How To Measure Your Trauma Bay

In my last post, I detailed some standard info on trauma bay size. Today, I’ll describe what I found when I brought in my trusty tape measure a few years ago to check out the old trauma bays at Regions Hospital. I came up with several helpful measurements to help gauge the relative utility of the rooms.

Here are the indices that I came up with:

  • TBTA: Trauma Bay Total Area. This is the total square footage (meterage?) measured wall to wall.
  • TBWA: Trauma Bay Working Area. This is the area that excludes equipment carts next to a wall, and areas under countertops that extend away from the wall.
  • TBAA: Trauma Bay Available Area. This is the TBWA less any other unusable areas in the room. We have an equipment post near one corner that eats up 16.5  sq ft of space. Also remember to subtract the area taken up by the patient bed, as this area is not available to the trauma team, either.
  • TBSI: Trauma Bay Space Index. This value is derived by dividing the TBAA by the number of team members in the room. It gives an indication of how much space is available for each trauma team member to work in.

Values in the old trauma bays at my trauma center:

  • TBTA: 291 sq ft
  • TBWA: 220.5 sq ft
  • TBAA: 186.5 sq ft
  • TBSI: 15.5

What does it all mean? You’ll have to work out the details using measurements from your own resuscitation room. For my old rooms, it meant we each had a 4×4 foot square to move around in, on average. This was fairly tight, I would say. Fortunately, we’ve moved to new rooms with much, much more space.

Tune in to my next post this week on my thoughts on outfitting your resuscitation room.

How Big Should Your Trauma Bay Be?

Trauma professionals are never satisfied with the size of their trauma bay. Today, I’ll write about optimal trauma bay size. Next week, I’ll describe my system for quantifying the space in your trauma bay and address the equipment layout in your resuscitation room.

Trauma resuscitation rooms vary tremendously. They can range from very spacious…

to very tight…

Most trauma bays that I have visited were somewhere between 225 and 300 square feet (21-28 sq meters), although some were quite large (Rashid Hospital in Dubai at nearly 50 sq meters!).

Interestingly, I did manage to find a set of published guidelines on this topic. The Facility Guidelines Institute (FGI) develops detailed recommendations for the design of a variety of healthcare facilities. Here are their guidelines for adult trauma bays:

  • Single patient room: The clear floor area should be 250 sq ft (23 sq m), with a minimum clearance of 5 feet on all sides of the patient stretcher.
  • Multiple patient room: The clear floor area should be 200 sq ft (18.5 sq m) with curtains separating patient areas. Minimum clearance of 5 feet on all sides of the patient stretcher should be maintained.

The FGI “clear floor area” corresponds to my “Trauma Bay Working Area”, which is the area that excludes all the carts, cabinets, and countertops scattered about the usual trauma room. California’s guideline of 280 sq feet seems pretty reasonable as the “Trauma Bay Total Area”, if you can keep your wasted space down to about 30 sq feet.

Bottom line: Once again, don’t try to figure out everything from scratch if you are designing new resuscitation rooms. Somebody has probably already done it (designed a trauma bay, developed a practice guideline, etc). But remember, a generic guideline or even one developed for a specific institution may not completely fit your situation. In this case, the FGI guidelines say nothing about the trauma team size, which is a critical factor in space planning. Use the work of others as a springboard to jump start your own efforts at solving the problem.

Related link:

EAST Practice Management Guideline: Handoffs And Transitions Of Care

Medicine, in general, and trauma care, specifically, require frequent communication. These communications may be between two providers to maintain continuity of care or between providers and patients to explain it. Unfortunately, the Joint Commission has identified breakdowns in the process as a root cause of preventable events and a significant factor in preventable death.

To address this problem, many centers have sought to standardize this process, which may include some of the principles in my previous post. However, until now, there have been no evidence-based recommendations for this practice.

The Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the literature to develop a practice guideline. They focused specifically on handoffs for acute care surgery during perioperative interactions, patients arriving in the trauma bay, and patients transitioning to or from the ICU and floor. The goal was to reduce complications, handoff errors, medical errors, and preventable events.

The literature on this topic was searched from 1960 to 2021, and only observational and randomized studies were included. This yielded only ten papers that met all search criteria. The reviewers then used these papers to answer three questions. These and their answers are outlined below.

Question 1.  Should perioperative interactions in the care of ACS patients (P) include a standardized handoff versus current process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

Patients who received a standardized handoff were significantly less likely to experience a handoff error.  However, the impact on medical errors and adverse events could not be gauged because only one paper covered these problems.

Question 2. Should EMS utilize a standardized handoff at the arrival of trauma patients versus the current process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

We instituted a trauma team EMS timeout process in 2012, which persists to this day. Please take a look at my post here. The prehospital providers like it because they feel like they are more a part of the team. The receiving team can listen to their report without distraction. But what does the literature say? Unfortunately, we don’t know yet. Only one published paper covered this topic, and it included only 18 patients.  Thus, no conclusions can be drawn.

Question 3. Should intra/inter floor and ICU interactions in the care of ACS patients include a standardized handoff versus currently process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

Significantly fewer preventable adverse events occurred when a standardized handoff was used. There was no difference in clinical complications. The impact on medical errors could not be evaluated because only one study assessed this.

Bottom line: The general belief is that using a standardized handoff is a good thing. But I think you see the theme here. As in most EAST systematic reviews, there is painfully little high-quality data available for us to prove it. Most of the mundane, day-to-day things we do and decisions we make as trauma professionals are too dull to perform a study about. 

From the few papers available for this guideline, standardized handoffs are a good thing. They decrease handoff errors and reduce preventable adverse events as well. The EMS to trauma team handoff is well-received and is subjectively valuable. Unfortunately, there is little real data to prove this.

Overall, the real data on this topic is weak, and much more work needs to be done. I would encourage all trauma professionals to develop and refine their handoff processes. I strongly recommend coupling that with your own study so you can teach the rest of us how good it really can be.

Reference: Handoffs and Transitions of Care: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma, Publish Ahead of Print
DOI: 10.1097/TA.0000000000004285

The Handoff In Damage Control Surgery

Damage control surgery is now over 30 years old! We continue to refine the techniques and closure techniques/devices, and have developed novel ways to speed closure of the abdominal wall in order to avoid pesky hernias. But the process itself is time intensive, and typically several days pass with regular returns to OR until closure is achieved.  This is one of the prime areas in which human error can occur, especially with modern service-style coverage of trauma patients.

In the old days, trauma patients were admitted by their surgeon, and that person provided their care nearly continuously until discharge. He or she rounded on them daily, took them back to the OR when needed, and then discharged them.

This is less practical (and desirable) in this day and age. And even if it seems possible, it’s not. No one can be on call 24 hours a day, and provide comprehensive care to every patient, around the clock. Many trauma programs have adopted a “service model”, where patients are admitted to a defined care team and managed by them. The team is led by a surgeon, but that person may change on a weekly (or in some cases nearly daily) basis. I call this the “interchangeable head” model, and to make it work there must be excellent handoffs during any leadership change.

In some cases, a patient may undergo a damage control procedure by one surgeon, but another must do the takeback and possibly the definitive closure. In this case, the handoff is critical! It is paramount that the next surgeon know everything about the first case so that they can perform the correct procedure.

How can this be accomplished? Here are some tips:

  • Do not rely on the medical record and previous operative note. It may not be available, and there is usually some loss of information in recording it anyway. Don’t believe it.
  • Ideally, meet face to face with the previous surgeon(s). Get the blow by blow description of exactly everything that was done and how. Also discuss what still needs to be done, and when. Try to maintain a uniform philosophy of patient care across surgeons.
  • If face to face is not possible, a telephone call is acceptable. The discussion is exactly the same.
  • If the surgery occurred at an outside hospital and was then transferred, you must call the initial surgeon to have this discussion before going to the OR!
  • If something unexpected is encountered during the case, make sure you have contact information so you can call during the case.

Applying these concepts will decrease the possibility of error, as well as the likelihood of any iatrogenic harm to these complex patients.

In my next post, I’ll review a new paper from the Eastern Association for the Surgery of Trauma (EAST) that performs a systematic review and meta-analysis of handoffs in acute care surgery (which includes damage control, of course) and proposes a practice management guideline.

Giving TXA Via An Intraosseous Line?

Seriously injured patients frequently develop coagulopathy, which makes resuscitation (and survival) more challenging. A few years ago, the CRASH-2 study lent support for using tranexamic acid (TXA) in select trauma patients to improve survival. This drug is cheap and has antifibrinolytic properties that may be beneficial if given for life-threatening bleeding within 3 hours of initial injury. It’s typically given as a rapid IV infusion, followed by a slower followup infusion. The US military has adopted its routine use at forward combat hospitals.

But what if you don’t have IV access? This can and does occur with military type injuries. Surgeons at Madigan Army Medical Center in Washington state tried using a common alternative access device, the intraosseous needle, to see if the results were equivalent. This study used an adult swine model with hemorrhage and aortic crossclamping to simulate military injury and resuscitation. Half of the animals then received IV TXA, the other half had it administered via IO. Only the bolus dose was given. Serum TXA levels were monitored, and serial ROTEM determinations were performed to evaluate coagulopathy.

Here are the factoids:

  • The serum TXA peak and taper curves were similar. The IV peak was higher than IO and approached statistical significance (0.053)
  • ROTEM showed that the animals were significantly hyperfibrinolytic after injury, but rapidly corrected after administration of TXA. Results were the same for both IV and IO groups.

Bottom line: This was a very simple and elegant study. The usual animal study issues come into play (small numbers, pigs are not people). But it would be nearly impossible to have such a study approved in humans. Even though the peak TXA concentration via IO is (nearly significantly) lower, this doesn’t appear to matter. The anti-fibrinolytic effect was very similar according to ROTEM analysis.

From a practical standpoint, I’m not recommending that we start giving TXA via IO in civilian practice. We don’t typically see military style injuries, and are usually able to establish some type of IV access within a reasonably short period of time. But for our military colleagues, this could be a very valuable tool!

Reference: No intravenous access, no problem: Intraosseous administration of tranexamic acid is as effective as intravenous in a porcine hemorrhage model. J Trauma 84(2):379-385, 2018.

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