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Brighton and Sussex University Hospitals

C081 – RSCH Adult Trauma Call Policy

Version: 1

Category and number: C081

Approved by: Clinical Policies Steering Group/TEC

Date approved: May 2019

Name of author: Clinical Lead, Major Trauma Centre

Name of responsible committee/individual: Trauma Committee

Name of responsible director: Nurse Director

Date issued: May 2019

Review date: May 2022

Target audience: Trustwide

Accessibility This document is available in electronic format only

Linked documents BSUH massive transfusion Policy

BSUH Paediatric Trauma Call Policy

PRH Trauma Call Policy

BSUH Helideck operational Policy

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Contents

Section Page

1 Introduction 3

2 Purpose 3

3 Definitions 3

4 Responsibilities, Accountabilities and Duties 4

5 Policy 5-11

6 Training Implications 11

7 Monitoring Arrangements 11

8 Due Regard Assessment Screening 12

9 Links to other Trust policies 12

10 References 14

Appendices

Appendix 1

Appendix 2

SECAmb Major Trauma Decision Tree

Silver Trauma Triage Tool

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Appendix 3 Adult ASHICE sheet 14-15

Appendix 4

Appendix 5

Appendix 6

Appendix 7

ED reception pathway for registration of trauma patients prior to arrival

Prompt cards for trauma patient pre-registration

Trauma Team Composition Table

Due Regard Assessment Tool

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18-22

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Appendix 8 Dissemination and Implementation Plan 26

Appendix 9 Paediatric Trauma Call Guidelines 27

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1. Introduction

1.1 A Trauma Call policy is required to support the effective delivery of trauma services and is a requirement of the standards for Major Trauma Centres1

2. Purpose

2.2 The policy covers:

Indications and process for instigating a trauma call

The clinical team required to attend

Documentation requirements and standards

2.3 The policy does not seek to specify the clinical management or pathway of individual patients.

3. Definitions

3.1 Trauma Call

The trauma call notifies the trauma team that the arrival of a potentially major trauma case(s) is imminent or has arrived. It will be activated by the Emergency Department and put out by Switchboard.

3.2 Major Trauma Case

Patients with an Injury Severity Score (ISS) score of 8-15 is considered moderate. Patients with an ISS score >15 are considered major trauma cases.

3.3 National Confidential Enquiry into Patient Outcome & Death (NCEPOD)

NCEPOD's purpose is to assist in maintaining and improving standards of medical and surgical care for the benefit of the public by reviewing the management of patients, by undertaking confidential surveys and research, and by maintaining and improving the quality of patient care and by publishing and generally making available the results of such activities.

3.4 Trauma Audit and Research Network (TARN)2

3.4.1 The purpose of TARN is to collate information on the treatment of trauma patients from time of injury to discharge, regardless of the institution or organisation providing that care in order to assess the overall treatment of patients from time of injury to discharge.

3.4.2 TARN, the independent monitor of trauma care in England and Wales, is committed to making a real difference to the delivery of the care of those who are injured. One of the ways they do this is by promoting improvements in care through national comparative clinical audit.

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3.5 Injury Severity Score (ISS)3

3.5.1 Those who are injured may have one or many injuries and the Injury Severity Score (ISS) is an anatomical score that measures the overall severity of injured patients.

3.5.2 All injuries are assigned an Abbreviated Injury Scale (AIS) code and score from an internationally recognised dictionary that describes over 2000 injuries and ranges from 1 (minor injury) to 6 (an injury that is thought to be ‘incompatible with life’). Patients with multiple injuries are scored by adding together the squares of the three highest AIS scores in three predetermined regions of the body.

3.5.3 This is the ISS which can range from 1 to 75. Scores of 7 and 15 are unattainable because these figures cannot be obtained from summing squares.

3.5.4 The maximum score is 75 (52+52+52). By convention, a patient with an AIS6 in one body region is given an ISS of 75. The injury severity score is non-linear and there is pronounced variation in the frequency of different scores; 9 and 16 are common, 14 and 22 unusual.

3.5.5 The assignment of AIS codes and scores are undertaken post-discharge by trained coders within TARN.

4. Responsibilities, Accountabilities and Duties

4.1 Chief Executive

Whilst ultimate responsibility is vested in the Trust Board, executive responsibility is delegated to the Chief Executive for managing health and safety.

4.2 Lead Executive Director

Overall responsibility for this policy rests with the Medical Director

4.3 Directorate Management Teams

It is the responsibility of the Directorate management teams to ensure that (i) this policy is brought to the attention of relevant staff and (ii) staff rotas and job plans within each specialty/service are organised in a way that enables staff to attend and participate in trauma calls as required on a 24/7 basis.

4.4 Ward Managers/ Heads of Service

Ward/Department Managers and other Clinical Managers are responsible for ensuring that (i) staff rotas and job plans within each specialty/service are organised in a way that enables staff to attend and participate in trauma calls as required on a 24/7 basis, (ii) any resulting scheduling conflicts are escalated to the Divisional Management Team as required and (iii) associated local procedures (eg. for making the trauma call) are in place and that staff are appropriately trained.

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4.5 All staff

All staff, including locum and agency staff, are required to comply with this policy.

5. Policy

The following information is for trauma patients arriving at Royal Sussex County Hospital (RSCH) as the designated Sussex Major Trauma Centre. South East Coast Ambulance Service (SECAmb) has instructions and protocols to divert trauma from the Princess Royal hospital (PRH) which is a local emergency hospital only. These have successfully operated for a number of years. However, there may be instances when patients arrive at PRH and there is a procedure in place for this which involves rapid airway management if required and transfer to the Sussex Major Trauma Centre with SECAmb and an attending doctor if required. (Appendix 1 Major Trauma Decision Tree, PRH Trauma Call Policy).

5.1 Types of Trauma Calls

5.1.1 On the basis of pre-hospital information provided to ED prior to the patient’s arrival (“ASHICE call”), there are three tiers of response:

Code Red trauma call

Advanced trauma call

ED (Emergency Department) trauma call

The type of trauma call (Code Red/Advanced/ED) activated must be annotated on the Trauma Booklet.

5.1.2 Criteria for differentiating between ED and Advanced trauma calls are at the discretion of the Emergency Medicine Consultant in charge who fulfills the Trauma Team Leader (TTL). However, as general guidance:

Mechanism plus normal physiology and anatomy = ED trauma call

Mechanism plus abnormal physiology or anatomy = Advanced trauma call

5.1.3 CODE RED hospital trauma calls are activated at the discretion of the ED consultant response to pre-hospital information that indicates that activation of the massive transfusion protocol (MTP) is required.

5.1.4 It is recognised that trauma call criteria have a poor evidence base and mechanism alone is a poor predicator of injury burden. These activation criteria are a clinical guide but should be determined by the TTL on a case-by-case basis.

5.2 ED Trauma Call Activation

An ED trauma call should be activated in cases of: “Significant mechanism

but normal physiology and anatomy”

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N.B. Patients over the aged of 65 presenting with a fall <2m require screening with the silver trauma tool. (Appendix 2)

5.2.1 Significant mechanisms of Injury

Fall over 3 metres

Pedestrian or pedal cyclist hit by motor vehicle

RTC over 40mph, or ejection from vehicle, or death to another occupant of the vehicle

RTC with rollover, extensive damage to vehicle, or extrication time more than 20 minutes

Patients over the aged of 65 presenting with a fall <2m require screening with the silver trauma tool.

5.2.2 Normal Physiology (values for adults)

Pulse 50–100 beats per minute

Respirations 10–20 per minute

Systolic Blood Pressure above 100 mmHg

Head injury with GCS 14 or 15

Interpretation of ‘normal physiology’ should be done in the context of clinical correlation, the above figures are based on the available clinical evidence.4-5

5.2.3 Anatomy

Penetrating injury to limb, or single femoral fracture

Potential spinal injury but no abnormal neurology

5.3 Advanced Trauma Call Activation

An Advanced Trauma Call should be activated in cases of: “Significant mechanism plus abnormal physiology or anatomy”

All HEMS calls must routinely be at least an Advanced Trauma Call

5.3.1 Significant mechanisms of Injury

Fall over 3 metres

Pedestrian or pedal cyclist hit by motor vehicle

RTC over 40mph, or ejection from vehicle, or death to another occupant of the vehicle

RTC with rollover, extensive damage to vehicle, or extrication time more than 20 minutes

Patients over the aged of 65 presenting with a fall <2m require screening with the silver trauma tool.

5.3.2 Abnormal Physiology (values for adults)

Pulse < 50 or > 100 beats per minute

Respirations < 10 or > 20 per minute, or cyanosis

Systolic Blood Pressure < 100 mmHg

Head injury with GCS < 14

Paediatric patients with shock, respiratory distress, or reduced conscious level

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Interpretation of ‘abnormal physiology’ should be done in the context of clinical correlation, the above figures are based on the available clinical evidence.4

5.3.3 Abnormal Anatomy

Airway problems

Flail chest

Penetrating injury to head, neck or torso

Severe pelvic injury

Major crush injury to torso or upper thigh

Limb amputation

Two or more long bone fractures

Abnormal neurological examination in context of suspected spinal cord injury

Burns over 20% BSA or potential airway burns

5.3.4 Special Circumstances

Multiple patients

5.4 Code Red Trauma Team Activation

A Code red trauma call should be activated if is deemed likely the patient will require blood transfusion within the ED or require emergency transfer to theatre or interventional radiology for haemorrhage control.

5.4.1 The decision activate a code red trauma call is at the discretion of the trauma team leader (usually the ED consultant) who should be guided by the code red policy and the following criteria:

5.4.2 Either two or more of:

Penetrating injury

FAST Scan – abdominal fluid positive

HR >120

SBP <90

Or: major trauma and senior clinician’s suspicion of on-going bleeding

Or: activation on pre-arrival advice of a Critical Care Paramedic or HEMS team

5.5 Paediatric Trauma Calls

Paediatric trauma calls are covered by the Paediatric Trauma Call policy

5.6 Trauma Team Activation Process

Requests to activate the trauma team are guided by physiological, anatomical and mechanism of injury criteria. Activation of the trauma team can be initiated in three ways:

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5.6.1 Prior to the arrival of an injured patient in the ED on notification of a pre-hospital ‘pre-alert’ (priority or “ASHICE” call), information about which should be added to the Emergency Department ASHICE Form (Appendix 2)

5.6.2 In the case of patients fulfilling criteria for an Advanced or Code Red trauma

call based on pre-hospital information given in the ASHICE call, these patients will be pre-registered onto Symphony prior to their arrival. The process for this is described in Appendix 3.

5.6.2 On arrival of the patient in the ED based on mechanism of injury,

physiological, and anatomic criteria as reported by pre-hospital or ED personnel.

5.6.3 Patients over the aged of 65 presenting with a fall <2m after screening with

the silver trauma tool 5.6.4 The ambulance service pre-hospital triage decision tree is used as a guide for

pre-alerting of trauma patients. 5.6.5 It is the responsibility of the person receiving the priority call to liaise with the

ED Consultant, to clearly document all information received and activate the appropriate trauma team

5.6.6 All HEMS calls must routinely be an Advanced Trauma Call 5.6.7 All secondary trauma transfers (Local Emergency Hospital/Trauma Unit to

MTC) must have an appropriate trauma team activation on arrival at RSCH 5.6.8 Regardless of level of trauma call, every patient requiring a trauma team

response should have a trauma call activation via the ‘2222’ system even when the core team is in the ED with another patient.

5.6.9 Non-core team members (e.g. neurosurgery, cardiothoracic surgery, vascular)

are alerted via ‘fast bleep’ through switchboard on 2222 as necessary

5.7 Switchboard

5.7.1 The Resus Nurse will phone Trust Switchboard using the priority phone number 2222 and will inform Switchboard of the nature of the call. The phrase used will be depend on the level of trauma call as given below:

‘Adult ED Trauma Call’

‘Adult Advanced Trauma Call – Sex – ETA’

‘Adult Code Red – Sex – ETA’ 5.7.2 Trauma call activation should be performed when the patient is estimated to

be 10 minutes from arrival at ED for ED and Advancded level calls, and 15 minutes from arrival for Code Red calls.

5.7.3 In the case of Code Red Trauma calls, if we are alerted greater than 15 mins

prior to arrival, this information should be passed at the earliest opportunity to

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the theatre co-ordinator to allow the maximum time for appropriate planning (ext 4172, bleep 8061). Out of hours, early calls should also be made to the specialty consultants.

5.7.4 Paediatric Trauma Calls are covered by the Paediatric Trauma Call policy 5.7.5 Switchboard will log the details in the Cardiac Arrest Book on the Trauma

Pages. This should be forwarded to the Trauma Practitioners for clinical governance.

5.8 Staffing at Trauma Calls 5.8.1 Trauma team composition is described in the table in Appendix 5 5.8.1 All trauma patients should have consultant led care.

5.8.2 ED trauma and advanced trauma calls may be led by an ED registrar, middle

grade doctor or ED consultant but there must be ED Consultant presence and oversight. This must be clearly documented on the trauma booklet.

5.8.3 CODE RED trauma calls will be led by an ED consultant. 5.8.4 The on-call SHO in Anaesthetics/General Surg/T&O may attend ED Trauma

Calls for education if operational demands allow

5.8.5 The T&O team are responsible for all secondary surveys in all Advanced and Code Red trauma calls. The ED team is responsible for secondary surveys in ED Trauma calls.

5.8.6 The T&O and General Surgical registrars must update their consultant if

appropriate within 30 minutes of patient arrival for all Advanced Trauma Calls. This also applies for Code Red Trauma Calls if the consultant has not presented to ED Resus.

5.8.7 For Code Red Trauma Calls switchboard will notify Specialty Consultants

(Anaesthetics [out of hours], General/Damage Control Surgery) at point of Trauma Call Activation and other consultants at the request of the ED Consultant (TTL).

5.8.8 If for any reason a team member cannot attend they should inform the ED

Consultant/TTL immediately by phone on Ext. 4218

5.9 Trauma Call Team Response

5.9.1 The TTL must respond immediately

5.9.2 The rest of the core team must attend

Immediately if they are on site

Within 30 minutes if they are off site

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5.9.3 If for any reason a team member cannot attend they should inform the ED Consultant/TTL immediately on extension 4218

5.10 Trauma Documentation

5.10.1 Clinical notes will be kept in the form of the Major Trauma Centre record (‘Trauma Booklet’). This will be used for all trauma patients. This documentation includes the minimum dataset required for TARN reporting and the Trauma Booklet must routinely be checked for completeness by the TTL prior to the patient leaving ED.

5.10.2 The Trauma Team Leader is responsible for ensuring the required sections are completed fully in line with minimum dataset requirements: Primary Survey, Secondary Survey, Summary of Injuries, Team Leader Summary and Plan. A drug chart including adequate analgesia provision as wells a ensuring the tranexamic acid, fluids and blood products have all been accurately documented.

5.10.3 All specialties attending are responsible for recording their actions and onward management plan in the Trauma Documentation and communicating this to the Trauma Team Leader BEFORE leaving the Resuscitation room.

5.10.4 The ED Resus Nurse is responsible for ensuring the nursing notes and observations are completed fully.

5.10.5 The ED Resus Nurse is responsible for ensuring that a copy of the Trauma

Documentation is made before the patient’s notes leave ED, and is stored in the designated way.

5.11 Clinical Governance of Trauma Teams 5.11.1 Request for consultant attendance

Notification or escalation to consultant level for additional in-patient specialties is via switchboard.

5.11.2 Upgrading of Trauma Call

Decisions to upgrade trauma calls from ED to Advanced to Code Red Trauma call should be communicated formally via switchboard (2222) as soon as TTL decides to upgrade. When upgrading a trauma call from (for example) a Advanced to Code Red call, the notification via switchboard should be: “PREVIOUS (ADVANCED) TRAUMA CALL UPGRADED TO (CODE RED) TRAUMA CALL IN (A&E RESUS)”

5.11.3 Escalation of trauma team issues

Non-attendance of ‘must attend’ trauma team members should be escalated via a repeat call to switchboard:

Notification to switchboard of “REPEAT xxxx TRAUMA TEAM TO A&E RESUS” Recording via DATIX (select major trauma tab) should be made for non-attendance by any essential speciality.

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5.11.4 Multiple trauma calls

Trauma patients arriving in the ED simultaneously should be activated individually via switchboard:

Notification to switchboard of “2nd/3rd (etc) [ADULT/PAEDIATRIC] ADVANCED TRAUMA CALL TO A&E RESUS”

5.11.5 Changes to trauma team notifications

Any changes to bleep notifications must be approved by the MTC Clinical Lead.

5.11.6 Major Trauma Clinical Governance

A structured debrief should take place after a Trauma Call if the TTL identifies issues that need immediate input and/or escalation. It is reasonable that this could be in the form of an After Action Review (AAR).

Attendance at trauma calls will be audited yearly with feedback to Trauma Committee and individual specialities as appropriate:

6. Training Implications

All new staff in trauma related specialties (Emergency Medicine, Trauma & Orthopaedics, General Surgery, Vascular Surgery, Anaesthetics, and Critical Care) will be made aware of the trauma call process

6.1 Staff attending trauma calls will be expected to have obtained certification in the Advanced Trauma Life Support (ATLS) course as a minimum

6.1 The BSUH trauma team leader course (1 day) is available and recommended for those staff working in the role of Trauma Team Leader

7. Monitoring Arrangements

Measurable Monitoring / Frequency Responsibility Where is monitoring reported

Policy Audit for performing & what groups/committees Objective Method monitoring Are responsible for

progressing & reviewing action plans

Attendance at trauma calls

Notes review Annual MTC Clinical Lead and MTC team

Trauma Committee

National Best Practice Tariff returns

Finance record

Quarterly/yearly MTC Clinical Lead and MTC team

Trauma Committee & Financial oversight committee

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TARN Dashboard

Dashboard report

Monthly MTC Clinical lead and

MTC Team

Trauma Committee, Trauma Network. Trust Board

Trauma Morbidity and Mortality meetings

Presentation and audit

Quarterly MTC Trauma Committee

Trauma Committee Network Board Trust Board

8. Due Regard Assessment Screening

BSUH NHS Trust has a statutory duty to assess and consult on whether planning, policies and processes impact service users, staff and other stakeholders with regard to age, disability, gender (sex), gender identity, marriage or civil partnership, pregnancy and maternity, race (ethnicity, nationality, colour), religion or belief and sexual orientation. It recognises that some people may face multiple discrimination based on their identity. A review of the assessed impact of this policy against these criteria can be seen (Appendix 7).

9. Links to other Trust policies

BSUH massive transfusion Policy

BSUH Paediatric Trauma Call Policy

C088 PRH Trauma call Policy

BSUH Helideck operational policy

10. References

Trauma: Who Cares? National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) 2007, available at: https://www.ncepod.org.uk/2007t.html

NICE Guideline NG39 February 2016. Major Trauma: assessment and initial management, available at: https://www.nice.org.uk/guidance/ng39/evidence/full-guideline-2308122833

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Appendix 1 – SECAmb Adult Major Trauma Decision Tree

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Appendix 2 – Emergency Department ASHICE Form

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Appendix 3 – Silver Trauma Triage Tool

Adapted from work by HECTOR elderly trauma triage criteria and also by work by D Peel, A Osmond, H Tucker (2018) as part of the London Major Trauma System: Management of elderly major trauma patients – Second Edition, published in December 2018.

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Appendix 4 – ED reception pathway for registration of trauma patients prior to

arrival

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Appendix 5 – Prompt cards for trauma patient pre-registration

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Appendix 6 – Trauma Team Composition Table

Role: Team: ED Trauma

Call Advanced

Trauma Call Code Red Trauma

Call

Trauma Team Leader (TTL)

ED Registrar / Consultant

ED Registrar / Consultant

ED Consultant

Primary Survey

Airway

ED / Specialty

SHO or SpR

Anaesthetic Registrar

Anaesthetic Registrar / Consultant

Breathing General Surgery /

T&O / ED Registrar

General Surgery / T&O / ED Registrar

Circulation

Disability

Exposure

Scribe ED Resus SHO

Monitoring

ED Nurse

ODP

Circulation ED Resus Nurse / Anaesthetic SHO

Drug Nurse ED Resus Nurse

Transfusion Services For info only – no action Activation of MTP

Porter - ED Porter ED Porter

Radiographer - Radiographer as

liaison for CT

Radiographer with portable XR machine

and liaison for CT

Trauma Line inserter - - Anaesthetic/ED SpR/Consultant

eFAST Doctor - - ED SpR

Rapid infuser nurse 1 - - ED Resus Nurse /

Nurse in Charge / ODP

Rapid infuser nurse 2 - - ED Resus Nurse /

Nurse in Charge / ODP

Additional Mandatory Attendance

- -

General Surgery/DCS Consultant

Anaesthetic Consultant (T&O SpR to contact

T&O Consultant)

Secondary Survey Responsibility

ED SHO / Registrar

T&O SHO / Registrar

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Appendix 7 – Due Regard Assessment Tool

Yes/No Comments

1. Does the document/guidance affect one group less or more favourably than another on the basis of:

Age No We base severity of injury on the Injury Severity Score and we know that older patients can sustain severe injury as a result of more minor mechanisms of injury compared to younger patients. Therefore we know that historically older patients with severe injury have been far more likely not to be treated initially by the trauma team. Changes to the way we triage and recognise significant injury in patients over 65 years in this new policy mean that the criteria for putting out a trauma call differs for those older or younger than 65. This difference is designed to reduce the inequality in initial assessment between younger and older patients but will mean there is a difference in the way we approach these two age groups. This mirrors similar changes at other Trusts and at present there is no better way we know of to do this.

Disability No

Gender Yes We recognise that a patient’s gender is that with which they identify. In our process for switchboard alerting the teams we have included only two options for sex – male and female. The rationale for this information being included in the call via the bleep system is to alert the transfusion laboratory about whether pre-prepared Rhesus negative or positive blood may be required. This decision is based on the genetic sex of the individual and due to this and in order to prevent confusion that might lead to clinical risk, we have left only the binary option

Gender identity No

Marriage and civil partnership No

Pregnancy and maternity No

Race (ethnicity) No

Religion or Belief No

Sexual orientation, including lesbian, gay and bisexual people

No

2. Is there any evidence that some groups are affected differently and what is/are the evidence source(s)?

Yes See above regarding age criteria for trauma calls. Nil else

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3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable?

Yes See above

4. Is the impact of the document/guidance likely to be negative?

No

5. If so, can the impact be avoided? N/A

6. What alternative is there to achieving the document/guidance without the impact?

This is the best option we are aware of

7. Can we reduce the impact by taking different action and, if not, what, if any, are the reasons why the policy should continue in its current form?

No See above

8. Has the policy/guidance been assessed in terms of Human Rights to ensure service users, carers and staff are treated in line with FREDA principles (fairness, respect, equality, dignity and autonomy)?

Yes

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Appendix 8 - Template Dissemination, Implementation and Access Plan

To be completed and attached to any policy when submitted to Corporate Governance for consideration and TEC approval.

Dissemination Plan Comments

1. Identify:

Which members of staff or staff groups will be affected by this policy?

1. Consultants, junior doctors, nursing and theatre staff in:

Emergency Medicine

Trauma & Orthopaedics

General Surgery

Vascular Surgery

Anaesthetics

Transfusion

2. Reception staff in the Emergency Department

How will you confirm that they have received the policy and understood its implications?

Cascade via trauma committee to clinical leads for trauma in specialties above and to team leaders in theatre and ED reception

How have you linked the dissemination of the policy with induction training, continuous professional development and clinical supervision as appropriate?

As above; via clinical spuervision

2. How and where will staff access the document (at operational level)?

Major trauma intranet site

Yes/No Comments

3. Have you made any plans to remove old versions of the policy or related documents from circulation?

Yes Removal of prior version from major trauma uintranet site

4. Have you ensured staff are aware the document is logged on the organisation’s register?

Yes Via trauma committee

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Appendix 9 – Paediatric Trauma Call Guidelines