Local Procedure Wagga Wagga Health Service … Trauma Team and Expected Roles National Standards 1,...

WWHS Trauma Team and Expected Roles National Standards 1, 3, 9 April 2014 of 13

Local Procedure Wagga Wagga Health Service

WWHS Trauma Team Composition and Expected Roles

Relates to:

MLHD-PROC404 WWHS Trauma Team Activation Criteria

Local Version: WWHS 2014_033

PROCEDURE

Sequence of Actions The following Trauma team composition and roles were made in consultation with internal and external key stakeholders essential to the trauma care continuum. Trauma team composition & roles are detailed in the following document as well as Appendix 1 – Trauma Roles and Phases Table and Appendix 2 – Resuscitation Room Diagram. Team assembly prior to patient arrival depends on early notification by pre-hospital providers, and subsequently, to prompt trauma team activation. Trauma Team members should be present when receiving the patient and 1o Survey. The roles outlined in the following document are ideal to conduct a Trauma Resuscitation. Dependant on resources available the team composition and size may vary. With this in consideration all role descriptions should be accounted for by the team. Members should be allocated to their roles according to their ability and skill sets as per the Team Leaders instructions. This guideline encourages the use of the six non- technical tasks of a Trauma team being:

• Assemble the right team • Plan and Prepare • Manage resources • Manage People • Communicate effectively • Monitor and evaluate • Support each other

Wagga Wagga Base Hospital trauma team structure:

• Team Leader Doctor • Team Leader Nurse/Scribe • Airway Doctor • Airway Nurse • Procedure Doctor • Procedure Nurse • Circulation Doctor • Circulation Nurse • Radiographer • Orderly

http://gswagis001.gsahs.net/PPF/SearchFiles/MLHD-PROC404.pdf


The Trauma Alert Team is composed of the Emergency Department team with addition to the Surgical Registrar The Trauma Attend Team is composed of the Trauma Alert Team and the addition of the following members:

• General Surgical Registrar / ASU Consultant. • ICU Registrar/ Consultant. • Anaesthetics Registrar/ Consultant. • Critical Care Ward Staff

Pre Arrival of Patient:

• All team members should assemble. • Roles should be allocated Protective clothing and labels worn. • Any new team member MUST introduce him/herself to the team

leader. On Patient Arrival:

• “Hands Off/ Eyes On” • Listen to handover from the ambulance paramedic prior to starting

assessment and interventions. IMIST AMBO • The Whole team will assist in transferring the patient to the ED trolley.

Aim: The purpose of these trauma roles is to provide staff with descriptions of the responsibilities assigned to each role within the trauma team for the management of major trauma presentations

National Standard/Criteria: National Safety and Quality Health Service Standards, 2011 1.3 Assigning workforce roles, responsibilities and accountabilities to individuals for:

patient safety and quality in their delivery of health care

The management of safety and quality specified in each of these standards. 1.4 Implementing training in the assigned safety and quality roles and responsibilities 1.7 Developing and/or applying clinical guidelines or pathways that are supported by the best available evidence. Care 3.1 Developing and implementing governance systems for effective infection prevention and control to minimise the risks to patients of healthcare associated infections 3.1.1 A risk management approach is taken when implementing policies, procedures and/or protocols for:

standard infection control precautions

transmission-based precautions

aseptic non-touch technique

safe handling and disposal of sharps

prevention and management of occupational exposure to blood/body substances

environmental cleaning and disinfection

antimicrobial prescribing


outbreaks or unusual clusters of communicable infection

processing of reusable medical devices

single-use devices

surveillance and reporting of data where relevant

reporting of communicable and notifiable diseases

provision of risk assessment guidelines to workforce

exposure-prone procedures 9.4 Developing and implementing mechanisms to escalate care and call for emergency assistance where there are concerns that a patient’s condition is deteriorating Relates to the following: MLHD Trauma Team Activation Criteria

Scope: Team Leader Doctor Potential Role Position: Emergency Consultant, Senior Emergency Medical Officer, Surgical Consultant, Surgical Fellow, Director of Trauma, Retrieval Consultant. Pre Arrival of Patient:

• The team leader is allocated, this should be the Emergency department consultant/fellow/registrar. It is essential that the team leader stands back from the resuscitation to coordinate and should NOT be involved in clinical procedures.

• Allocates team roles. • Ensure all team members appropriately identified (stickers) and protected

(gloves/gowns/eye protection). • Documents pre-hospital information on the resus bay whiteboard. • Requests blood products on standby (if indicated). Considers activation of

Massive Transfusion Protocol.

Resuscitation: • Coordinates life support (directs primary & secondary survey) from foot of the

bed • Assures priorities of diagnosis Defines order of therapies. • Makes decisions regarding appropriate consultations, additional X-rays,

antibiotics and tetanus coverage and the need for surgical intervention. • Ensures the trauma documentation is complete • It is essential that the team leader liaise directly with the specialty services

involved. • Discusses patient progress with relatives and significant others. • Signs off on medications ordered. •

Diagnostics and Testing: • Coordinates Imaging. • Support CT Team. • Coordinate management post CT or imaging

Definitive Treatment:

• Liaise with care teams. • Liaise with Retrieval.


Post Resuscitation:

• Assumes primary Doctor Care for the trauma patient. • Conducts Hot Debrief if Required. • Documentation.

Team Leader Nurse and Scribe Potential Role Position: Resuscitation Nurse, CNE, CNUM, Emergency CNC, Trauma CNC, NP. Pre arrival of Patient:

• Identifies him/herself to team. • Applies personal protective equipment including: lead apron, impermeable

gown, eye shield and gloves • Confirms with medical team leader that a trauma page is to be activated and

activates page (if notification via batphone). • Prepares documentation, i.e. sees that Trauma Nursing & Trauma Medical

Documentation charts are ready on EMR. • Documents response from trauma team. • Communicates with ED CNUM re team requirements.

Resuscitation:

• Records arrival times and response of trauma team. • Records history from paramedics and Triage. • Scribes all observations, fluids, drugs, primary and secondary survey

completion and procedures. • Ensures family is being looked after. • Communicates with entire team. • Sends Orderly/scout for extra equipment or to blood bank, etc. • Ensures valuables are accounted for and secured in the ED safe. • Organises for additional departments to be contacted for consultation -

according to requests of team leader. Diagnostics and Testing:

• Coordinates Team and equipment for CT. • Accompany CT/Imaging team. • Definitive Treatment: • Liaises with OT/Ward. Liaise with Bed management and ED CNUM.

Post Resuscitation:

• Assumes primary nursing care for the trauma patient. • Conducts Hot Debrief if Required. • Documentation.

Airway Doctor Potential Role Position: Anaesthetic Consultant, Anaesthetic Registrar, Intensive Care Consultant Intensive Care Registrar, Emergency Consultant, Emergency Registrar Pre arrival of Patient:

• On arrival identifies him/herself to team.


• Applies personal protective equipment including: lead apron, impermeable gown, eye shield and gloves.

• Assembles necessary equipment for airway-management, including all intubation materials and difficult airway contingencies.

• Advises Airway nurse of medications that are required for intubation. Resuscitation:

• Takes up position at the head of the patient bed. • Role to assess and manage the airway and breathing. • Preforms intubation in discussion with Team Leader and confirms correct

placement of secure airway. • Protects Cervical Spine (C-Spine). • Conducts Survey of Head and Neck. • Feedback findings to team leader. • Liaises with team leader regarding necessary interventions. • Monitors central nervous system (CNS) status. • Ensures if patient intubated that orogastric tube is placed. • Works in cooperation with the entire team with a systematic approach. • Accompanies and cares for the intubated patient on transfer within the

hospital and during CT scan. • Diagnostics and Testing: • Escorts patient to CT/Imaging/Testing.


• Transfer to OT/Ward. • Package patient for Retrieval

Airway Nurse Potential Role Position: Resuscitation Nurse, CNE, CNUM, Emergency CNC, Trauma CNC, NP, Intensive care nurse Pre arrival of patient:


gown, eye shield and gloves. • Assembles necessary equipment for airway-management, including all

intubation materials and difficult airway contingencies and ensures ETCO2 monitoring is attached and warming up.

• Prepares and labels appropriate medications as per Airway Doctor: • Intubation drugs • Normal saline flushes

Resuscitation:

• Is responsible for nursing management of the airway and breathing. • Takes up position at the head of the patient bed. • Assists with intubation and airway management. • Maintains in-line cervical spine immobilization. • Assesses neurological status using AVPU. • If not already known confirms identity and contact details of NOK with patient

and relays information to nursing team leader (if possible prior to intubation). • Anticipates need for further intubation drugs. Draws up and labels. • Administers and announces to scribe all medications given.


• Ensures continuous assessment and monitoring of oxygenation and ventilation.

• Ensures ETT size, position at teeth, amount of air in cuff and ventilator settings have been communicated to nursing team leader and the medical trauma team leader.

• Ensures correct c-spine collar is fitted. • Ensures OGT is inserted and placement is confirmed via gastric aspiration

and auscultation. Inserts gastric tube if not already in situ. • Announces to scribe any gastric aspirate or vomitus. • Diagnostics and Testing: • Accompanies the intubated patient during transport. • Escorts patient to CT/Imaging/Testing.


• Transfer to OT/Ward. • Package patient for Retrieval.

Circulation Doctor Potential Role Position: Anaesthetic Consultant, Anaesthetic Registrar, Intensive Care Consultant Intensive Care Registrar, Emergency Consultant, Emergency Registrar, Surgical Consultant, Surgical Registrar Pre arrival of patient:

• Identifies him/herself to team. • Role is to assess and manage circulation. • Applies personal protective equipment including: lead apron, impermeable

gown, eye shield and gloves. • Assembles necessary equipment for circulation management with assistance

from circulation nurse. Resuscitation:

• Takes up position on the left side of the patient. • Obtains 2 x large-bore I.V. access or I.O. access. • Completes pathology request and obtains all blood specimens (FBE, group &

cross match, electrolytes, glucose & venous/arterial gas, BAL). • Monitors the haemodynamic status of the patient and commences

appropriate fluid resuscitation in consultation with the medical team leader. • Monitors ECG. • Gives all medications during an arrest sequence. • Completes X-ray request forms for trauma X-ray series and communicates

with radiologist. • Performs additional procedures, if required, at request of team leader. • Works in cooperation with entire team with systematic approach. • Informs the team leader of circulation status as appropriate.

Diagnostics and Testing:

• Documentation. • Cleaning and Restocking of resuscitation bay.


Circulation Nurse Potential Role Position: Resuscitation Nurse, CNE, CNUM, Emergency CNC, Trauma CNC, NP, Intensive care nurse, High Dependency Nurse Pre arrival of patient:


gown, eye shield and gloves. • Assembles necessary equipment for circulation management. • Prepares fluid warmers. • Sets up for I.V. line insertion (large-bore cannulas). • Assembles appropriate tubes for laboratory analysis.

Resuscitation:

• Takes up position on the left side of the patient. • Remove patient clothing and maintain warmth. • Assists with strapping I.V. Cannulae. • Administers blood products and i.v. fluids as prescribed. • Announces to Scribe all inputs to the scribe nurse. • Performs chest compressions during cardiac arrest until relieved by other

personnel. • Assists with other procedures, chest tube and Urinary catheter insertion. • Applies pressure-pad to significant haemorrhage; applies dressings to all

open wounds after documentation by surgical registrar. • Attends to rewarming procedures e.g. warming lights, space-blanket. • Monitors and announces to Scribe all outputs, i.e. blood, urine, vomitus. • Assists with exposure and log roll to expose back.


• Documentation. • Cleaning and Restocking of resuscitation bay.

Procedure Doctor: Potential Role Position: Intensive Care Consultant Intensive Care Registrar, Emergency Consultant, Emergency Registrar, Surgical Consultant, Surgical Registrar Pre arrival of patient:

• Identifies him/herself to team • Applies personal protective equipment including: lead apron, impermeable

gown, eye shield and gloves. • Prepares ultrasound for FAST exam. • Prepares likely procedural equipment in consultation with Procedure Nurse.

Resuscitation:

• Takes up position on the right side of the patient. • Starts primary survey on patient arrival. • Verbalises primary survey to the team when the paramedic handover is

complete.


• Performs FAST (if accredited) after primary survey and relays result to medical team leader. Ensures patient MRN is entered into FAST scanner and images saved to the disk.

• Performs secondary survey after FAST and relays results to medical team leader.

• Reviews CXR and pelvis X-Ray and relays results to medical team leader. • Assists with procedural interventions - surgical cricothyroidotomy, chest

decompression, ED thoracotomy. • Repeats primary survey as required


• Documentation. • Be prepared to do procedures post CT/Imaging/Testing.

Procedure Nurse Potential Role Position: Resuscitation Nurse, CNE, CNUM, Emergency CNC, Trauma CNC, NP, Intensive care nurse, High Dependency Nurse Pre arrival of patient:


gown, eye shield and gloves. • Prepares transport monitor and all monitoring equipment. • Attaches appropriate size, non-invasive BP Cuff, to monitor. • Prepares likely procedural equipment in consultation with Procedure Doctor.

Resuscitation:

• Takes up position on the right side of the patient • Remove patient clothing and maintain warmth. • Connects patient up to transport monitor (ECG leads, BP cuff & Oximeter

Probe, EtCO2). • Perform ECG/BGL/Temp. • Obtains and announces vitals every 5 mins x 4, then every 15 mins. • Attends to rewarming procedures e.g warming lights, space-blanket. • Apply splints as requires e.g. donway, pelvic binder. • Set up and assist with any of the following procedures:

• Insertion of chest tube. • Venous cutdown. • Emergency thoracotomy. • Insertion of central line. • Insertion of arterial line. • Insertion of IDC.


• Documentation. • Be prepared to do procedures post CT/Imaging/Testing.

Radiographer

• Responds to all Trauma Page. • Identifies him/herself to team. • Performs trauma series X-Rays as appropriate:

• Chest X-ray • C-Spine X-ray


• Pelvis X-ray • Acts as radiology liaison for organising any further medical imaging exams

that may be required in discussion with Team leader. Orderly

• Responds to all Trauma Page. • Transports blood specimens to and from appropriate labs and blood bank. • Collects blood transfusion products as directed by Team Leader Doctor • Collects further equipment as required by Trauma Team. • Assists with patient transport and remains with Trauma team until informed

they are no longer required.

Criteria: Meets MLHD Trauma Team Activation Criteria

Alerts: The final decision on who is to undertake a particular role during trauma resuscitation is to be decided by the medical trauma team leader based on staff seniority and availability

Safe Operating Procedures:

Back Care Hand Hygiene Clinical Competency Radiation Hazard Standard Precautions

Documentation: Attendee’s names and roles of the trauma team will be documented in the patients Firstnet notes

Outcomes: To assemble the right team, Plan and Prepare, Manage resources, Manage People, Communicate effectively, Monitor and evaluate and Support each other in order to provide effective and timely care to the traumatically injured patient.

Appendices: Appendix 1 - Trauma Roles and Phases Table. Appendix 2 – Resuscitation Room Diagram.


Consultation Process / List:

Title / Position Response received – Yes/No

Director of Critical Care Services - MLHD Yes

Director of Trauma Services – MLHD Yes

Emergency/Critical Care CNC MLHD Yes

Intensive Care CNC MLHD No

Director of Medical Services - WWBH Yes

Director of Nursing and Midwifery - WWBH No

Director of Emergency Department WWBH Yes

Nursing Unit Manager Emergency WWBH No

Director of Intensive Care WWBH No

Nursing Unit Manager Intensive Care WWBH No

Director of Surgery Services WWBH No

Chief Radiographer WWHS No

Director of Pathology Services WWBH No

Director of Anaesthesia WWBH No

Director of Acute Surgical Unit WWBH Yes

Acute Surgical Unit CNC WWBH No

Head of Security and HSA Services WWBH Yes

Created By:

Benjamin Hall

Trauma Clinical Nurse Consultant

Murrumbidgee Local Health District.

Approved by:

TITLE NAME SIGNATURE DATE

Acting Director of Medical Services

Dr Wayne McDonald

Signed by ADMS

10/4/2014


Appendix 1 – Trauma Roles and Phases Table


Appendix 2 – Resuscitation Room Diagram.

A

D

TLD

PD CD

A

N

TLN

C

N

PN

Air

way

Tro

lley

Moni

tor

Ventila

tor

Circu

lation

Tro

lley

Pro

cedu

re

Tro

lley

RAD ORD

Index

Team Leaders (TLD/TLN) – Red/Orange Airway Team (AD/AN) – Blue Circulation Team (CD/CN) – Yellow Procedure Team (PD/PN) – Green Radiographer (RAD) – Black Orderly (ORD) – Light Blue

Resus ZOL

and Transport

O2Tx

OBSERVERS ARE

TO STAY OUTSIDE

OF RED LINE

UNTIL INVITED

TO PARTICIPATE

IN TRAUMA.

US

/F

AS

T

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