Trauma Emergency Department Management
Trauma Emergency Department Management includes the organization and processes surrounding the care provided to trauma patients in the emergency department of an acute care facility. It is part of the more encompassing trauma system that includes injury prevention, prehospital care and posthospital rehabilitative services.
The American College of Surgeons Committee on Trauma categorizes trauma centers into four levels. Trauma centers that provide the highest level of care and are staffed with trauma teams on-site 24 h a day are designated as level I trauma centers. Level IV trauma centers provide initial care and transfer patients to a higher level trauma center when necessary. According to the CDC (2010), there is a 25 % decrease in mortality rate for severely injured patients treated at a level I facility as compared to patients treated at a non-trauma center. While it is impossible for every acute care facility to be a level I trauma center, it is possible for every facility to provide the best care possible for trauma patients within their limitations. This includes putting protocols into effect that include provisions for transferring patients to higher care centers when necessary.
The CDC (2010) advocates that communities strive to provide the right care at the right place at the right time for trauma patients. This is an idea introduced decades ago by Donald D. Trunkey, MD, an internationally renowned trauma surgeon and the father of modern trauma systems. While the idea applies to trauma systems as a whole, acute care facilities certainly strive to be the right place and provide the right care at the right time for trauma patients. The organization and management of these centers is vital to accomplishing these goals. In fact, the American College of Surgeons offers a course in “Optimal Trauma Center Organization and Management” to assist acute care facilities in creating strategies and operations to care for trauma patients with local factors and issues in mind (American College of Surgeons 2011b).
Trained personnel are key to providing appropriate care to trauma patients. Since 1978, the American College of Surgeons has taught Advanced Trauma Life Support (ATLS) as a method of ensuring a common language and systematic approach to the care of trauma victims. The 8th edition of the course was developed to be multidisciplinary, international, and evidence-based (American College of Surgeons 2011a). Providers trained in ATLS are essential to providing care in trauma centers. Whether the clinicians are part of a designated trauma team or an emergency department, it is essential to have an individual designated to make decisions and delegate roles to other team members. Ideally, this individual uses a team approach for making clinical decisions. Physicians, physician assistants (PA), and nurse practitioners (NP) are trained to play this lead role in trauma centers. Supportive roles may also be assumed by these clinicians or may be filled by nursing staff. In addition to clinicians and nurses, phlebotomy/lab and radiology personnel are needed to perform a complete initial assessment. The complete list of personnel needed to provide all the necessary functions for trauma patients within an acute care facility is quite extensive. It is noteworthy that in addition to medical training for personnel, the literature supports educating trauma team members in leadership, team management, interprofessional teamwork, conflict resolution, and effective team communications (Crichton 2006).
Continuity of Care
Providing continuity of care for trauma patients is a well-recognized challenge throughout the healthcare environment. As no single individual can provide 24/7 care, patients are inevitably cared for by many providers. Trauma patients present a unique challenge due to the multisystem nature of their injuries. While specialist are consulted and can assume primary care of the patient, other medical specialties may need to remain involved in the acute care of patients. For this reason, many trauma teams will continue to provide care for patients as the primary service and act as a liaison between other services also caring for the patient. This is a difficult task and requires diplomacy and excellent relationships among hospital staff members. While it is easy to see how important this role is for the trauma patient, it is not viewed as a very desirable role for surgical residents or surgeons who prefer to be in the operating room. As a result, many trauma centers now employ midlevel providers (PAs and NPs) to provide continuity for their trauma patients.
Up-to-date and accurate information
A process for verification
An opportunity to review any relevant historical data (Joint Commission Center for Transforming Healthcare 2011)
Administrative data (e.g., patient’s name, medical record number, and location) must be accurate.
New clinical information must be updated.
Tasks to be performed by the covering provider must be clearly explained.
Illness severity must be communicated.
Contingency plans for changes in clinical status must be outlined, to assist cross coverage in managing the patient overnight.
While each institution has its own unique methods for handing off patients, the development and implementation of these methods remain vital in the care of trauma patients.
Debriefing is a valuable learning tool in medicine. Most facilities debrief by using a formal mortality and morbidity conference. The focus is on improving processes and is never intended to be punitive. Some trauma centers have also instituted formal debriefing after every trauma resuscitation. Important elements reviewed may include the timeliness of procedures such as intubation or chest tube placement, team communications, team cooperation, care coordination, and situational awareness. There is evidence that this type of debriefing not only can improve patient safety but also improve team performance and outcomes thereby acting as a valuable learning tool (Griswold et al. 2012).
The Role of Protocols
Straightforward and concise
Amenable to implementation at natural pause points in the clinical workflow
- American College of Surgeons (2011a) History of the ATLS program. http://www.facs.org/trauma/atls/history.html. Accessed 1 July 2012
- American College of Surgeons (2011b) Trauma programs. http://www.facs.org/trauma/education/optimal.html. Accessed 3 July 2012
- Centers for Disease Control and Prevention (2010) Injury prevention and control: trauma care. http://www.cdc.gov/traumacare/access_trauma.html. Accessed 11 Oct 2012
- Department of Health & Human Services Agency for Healthcare Research and Quality Patient Safety Network (2012) Handoffs and signouts. http://psnet.ahrq.gov/primer.aspx?primerID = 9. Accessed 15 June 2012Google Scholar
- Griswold S, Ponnuru S, Nishisaki A, Szyld D, Davenport M, Deutsch ES, Nadkarni V (2012) The emerging role of simulation education to achieve patient safety: translating deliberate practice and debriefing to save lives. Pediatr Clin North Am 59(6):1329–1340. doi:10.1016/j.pcl.2012.09.004PubMedCrossRefGoogle Scholar
- Joint Commission Center for Transforming Healthcare (2011) Facts about hand-off communications. http://www.centerfortransforminghealthcare.org/projects/about_handoff_communication.aspx. Accessed 15 June 2012
- World Health Organization (2013) Trauma care checklist. http://www.who.int/patientsafety/implementation/checklists/trauma/en/index.html. Accessed 17 Jan 2013