Tag Archives: trauma team

Prehospital

Prehospital To Trauma Team Handoff: A Solution

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I’ve written about handoffs between EMS and the trauma team over the past two days. It’s a problem at many hospitals. So what to do?

Let’s learn from our experience in the OR. Best practice in the operating room mandates a specific time out process that involves everyone in the OR. Each participant in the operation has to stop, identify the patient, state what the proposed procedure and location is, verify that the site is marked properly, and that they have carried out their own specific responsibilities (e.g. infused the antibiotic).

Some trauma centers have initiated a similar process for their trauma team as well. Here’s how it works:

  • The patient is rolled into the resuscitation room by EMS personnel, but remains on the stretcher.
  • Any urgent cares continue, such as ventilation.
  • The trauma team leader is identified and the EMS lead gives a brief report while everyone in the room listens. The report consists of only mechanism, all identified injuries, vital signs (including pupils and GCS), any treatments provided. This should take no more than 30 seconds.
  • An opportunity for questions to be asked and answered is presented
  • The patient is moved onto the hospital bed and evaluation and treatment proceed as usual.
  • EMS personnel provide any additional information to the scribe, and may be available to answer any additional questions for a brief period of time.

Bottom line: This is an excellent way to improve the relationship between prehospital and trauma team while improving patient care. It should help increase the amount of clinically relevant information exchanged between care providers. Obviously, there will be certain cases where such a clean process is not possible (e.g. CPR in progress). I recommend that all trauma programs consider implementing this “Trauma Activation Time Out For EMS” concept.


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Prehospital

EMS Handoff: Comments

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I received quite a bit of feedback from yesterday’s column. Obviously this topic strikes a chord with my readers. Here was one well thought out comment from Tim Kaye in California:

I have worked for 15 years as a paramedic in a very busy EMS system in Northern California. When I was new, I used to fight to make myself heard in the trauma room, only adding to the din and chaos, which was usually – and rightly so – squelched by a decisive bark from the trauma team leader for quiet as they assesed the critical patient. What I came to realize was that if I wanted to benifit my patient, I needed to re-invent how I was taught to give my reports. Instead of trying to include everything in a minutes-long speech, I would instead follow this pattern:

1) Ask as I was walking in who I would give report to, thereby establishing clear communication and not just shouting to no one in particular.

2) A very brief, one sentence explination of MOI, and I forced myself to hold fast to the one sentence rule.

3) Critical findings/life-threats were reported next, followed by any interventions. This gave the trauma team leader an idea of where to focus their exam for similar life-threats.

4) I would give only selected vital signs in my rapid report. These included anything aberant or concering, followed by heart rate, respiratory rate and end-tidal CO2 on all patients.

5) I would conclude by asking the trauma team leader specifically if they had any immediate questions.

Because I structure and practice this method, my reports typically last about 20-30 seconds. Realizing that there are major gaps in the initial report, I then go and speak directly to the scribe and fill in those gaps with such information as further description of MOI, a complete set of vital signs and trends, blood glucose, IV sites, etc.

This method allows for rapidly communicating vital information quickly, and detailed information to the appropriate staff member at the appropriate time.

To tie up any loose ends, after I completed my charting, I ALWAYS stop by the trauma bay and check one last time with both the trauma team leader and the scribe and ask if they have any more questions. As I made this my practice, ER attendings, trauma surgeons and nurses all came to expect this final check-in to clear up any last questions. This worked in a most excellent fashion to provide continuity of care, to develop relationships with all of the staff at our two Level-1 and one Level-2 centers, and for personal education as I checked in to what the diagnosis and course of treatment was for the patient.

I would argue that the handoff is really a two-way process. Tim has found a way to do the right thing in an environment where the other half of the team is too busy / not listening / not aware.

Tomorrow I’ll share what I think is the best approach to this process. Hint: it involves active participation by both sets of trauma professionals.

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General

The Handoff: Opportunity for Improvement

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Handoffs occur in trauma care all the time. EMS hands the patient off to the trauma team. ED physicians hand off to each other at end of shift. They also hand off patients to the inpatient trauma service. Residents on the trauma service hand off to other residents at the end of their call shift. Attending surgeons hand off to each other as they change service or a call night ends. The same process also occurs with many of the other disciplines involved in patient care as well.

Every one of these handoffs is a potential problem. Our business is incredibly complicated, and given that dozens of details on dozens of patients need to be passed on, the opportunity for error is always present. And the fact that resident work hours are becoming more and more limited increases the need for handoffs and the number of potential errors.

Today, I’ll look at information transfer at the first handoff point, EMS to trauma team. Some literature has suggested that there are 16 specific prehospital data points that affect patient outcome and must be included in the EMS report. How good are we at making sure this happens?

An observational study was carried out at a US Level I trauma center with video recording capabilities in the resuscitation room. Video was reviewed to document the “transmission” part of the EMS report. Trauma chart documentation was also reviewed to see if the “reception” half of the process by the trauma team occurred as well. 

A total of 96 handoffs were reviewed over a one year period. The maximum number of elements in the study was 1536 (96 patients x 16 data elements). The total number “transmitted” was 473, but only 329 of those were “received.” This is not quite as bad as it seems, since 483 points were judged as not applicable by the reviewers. However, this left 580 that were applicable but were not mentioned by EMS. Of the 16 key elements, the median number transmitted was 5, with a range of 1-9. 

This sounds bad. However, the EMS professionals and the physicians have somewhat different objectives. EMS desperately wants to share what they know about the scene and the patient. The trauma team wants to start the evaluation process using their own eyes and hands. What to do?

Bottom line: EMS to trauma team handoffs are a problem for many hospitals. EMS has a lot of valuable information, and the trauma team wants to keep the patient alive. They are both immersed in their own world, working to do what they think is best for the patient. Unfortunately, they could do better if the just worked together a bit more. 

Tomorrow I’ll share a solution to the EMS-trauma team handoff problem.

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Reference: Information loss in emergency medical services handover of trauma patients. Prehosp Emerg Care 13:280-285, 2009.

Procedures

How Do You Dress YOUR Trauma Team?

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Over the years, I’ve seen the trauma teams at quite a few hospitals in action. One thing I have noticed is that most just don’t pay attention to what they wear. I’m talking about wearing personal protective equipment again. It’s one of those things, like hand washing, that everyone knows that they are supposed to do.

There are two reasons to put all that stuff on:

  • To keep potentially contaminated body fluids from getting on you
  • To prevent you from contaminating your patient’s open wounds

The minimum equipment that MUST be worn is a cap of some sort (to keep your hair from falling on the patient), mask and eye protection (mucus membrane protection), gown (protects your clothes), and gloves (obvious). Shoe protection is optional, in my opinion, unless you wear Christian Louboutin to work.

So you’ve been lax with your team. How do you get them to put everything on now? It’s like getting your child to wear a bicycle helmet when they are fourteen.

  • Create an expectation that everyone wear it and empower everyone to point it out. No exceptions. Physicians, this means you.
  • Put all equipment just outside the trauma room door. The farther away it is, the less likely it is to be used.
  • Assign an enforcer. Everyone entering the room must be dressed, or this person will speak up. Ideally, they should be a physician. If not, one of the docs must back this person up.
  • Occasionally, a badly hurt patient gets rolled into the room with little advance notice. In this case the fully dressed people need to relieve those who are not as soon as they dress and walk into the room.

The top picture shows part of our trauma team assembling before a trauma activation. Everyone is dressed. They know that someone will call them on it if they aren’t. Also, note the little pink sticker on the chest of physician at the head of the bed. We have a sticker for every role in the room (bottom picture). At the beginning of a resuscitation I scan the room to make sure everyone has one. It helps identify everyone and makes extraneous personnel stand out so they can be asked to leave the room.

Bottom line: Everyone has to wear their personal protective equipment on every trauma resuscitation. No exceptions.

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General

Why Did The Trauma Team Cut Off My Clothes?

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The fifth highest priority taught in the ATLS course is exposure. This generally means getting the patient’s clothes off so any hidden injuries can be identified. Early in my career, I was called to see a patient who had a gunshot to the chest that had been missed because the consulting physician had neglected to cut off her bra. A small caliber wound was found under the elastic strap in her left anterior axillary line after a chest xray showed a bullet in mid-thorax.

The usual trauma activation routine is to cut off the clothes. There are several tips and tricks we use to do this quickly. And a number of commercial products are out there to make it even easier.

But do we really need to cut everyone’s clothes off? I’m not disputing the fact that it’s important to be able to examine every square inch. But do we need to destroy everything our patient is wearing? I once saw a sequined wedding dress cut off (it’s almost as bad as cutting off a down jacket).

The answer is no. The key concept here is patient safety. Can you safely remove the clothing in a less destructive way? For most victims of major blunt trauma, we worry a lot about the spine. Unfortunately, it’s just not possible to allow the patient to wriggle out of their clothes and protect their spine. The same goes for fractures; it may be too uncomfortable to remove clothing because of fracture movement so scissors are required.

Penetrating trauma is a bit different, and in many cases it’s a good idea to try to get the clothing off intact. Once again, if spinal injury is a consideration (gunshots only), the involved clothes should be cut off. A patient with a gunshot to the chest can probably have their pants safely and gently pulled off, but their shirt and coat must be cut.

The police forensic investigators like to have intact clothing, if possible. This is another good reason to try to remove clothing from penetrating injury victims without cutting. 

Bottom line: Think before you cut clothes! Major blunt trauma and bad injuries require scissors. Lesser energy blunt injury may allow some pieces of clothing to be removed in the usual method. Most penetrating injury does not require cutting. But if you must (for patient safety), avoid any holes in the fabric so forensics experts can do their job.