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CHHS13/334

Canberra Hospital and Health ServicesClinical Procedure CCADS & SAOH Trauma Team Roles and ResponsibilitiesContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Team members and team conduct.........................................................................2

Section 2 – Team organisation..................................................................................................4

Section 3 – Communication and common pitfalls.....................................................................8

Implementation........................................................................................................................ 9

Related Policies, Procedures, Guidelines and Legislation.........................................................9

References................................................................................................................................ 9

Evaluation............................................................................................................................... 10

Definition of Terms................................................................................................................. 10

Search Terms.......................................................................................................................... 11

Doc Number Version Issued Review Date Area Responsible PageCHHS13/334 1 01/03/2009 01/07/2018 STS 1 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Purpose

This Clinical Procedure outlines the priorities for managing the seriously injured or potentially seriously injured patient according to ATLS guidelines. This is a framework for the ongoing assessment and evaluation, although it must be recognised that deviations will be necessary according to the patient’s haemodynamic status and ongoing re-evaluation. This Clinical Procedure is meant to serve as a framework for practice and in no way is meant to replace sound clinical judgment

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Alerts

The on-call surgical consultant for trauma and emergency staff specialist must be notified by the surgical registrar and emergency registrar respectively, of all trauma patients who meet the following criteria: Systolic blood pressure <90mmHg Administration of blood products When consensus relating to treatment/ definitive care is not able to be met within the

trauma team


Scope

The trauma team is responsible for carrying out this Clinical Procedure and refers to a multidisciplinary group of health care professionals who aim to provide the multi-trauma patient with immediate, expert assessment, resuscitation and treatment. Patients who are defined as having injuries or potential injuries for which these guidelines apply are those who meet trauma Code or Trauma Alert criteria as defined in the “Trauma Team Activation” Procedure, and are treated in the resuscitation bay.


Section 1 – Team members and team conduct

Team MembersMedical Team Leader/Nursing Team LeaderAirway Doctor / Airway NurseCirculation doctor / Circulation NurseProcedure Doctor / Procedure NurseRadiographerWardsperson

Subspecialists who may be allocated to the teamAnaesthetic Registrar



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Intensive Care RegistrarNeurosurgical RegistrarCardiothoracic RegistrarPlastics RegistrarOrthopaedic Registrar

While not necessarily involved as a part of the trauma team, these members act as consultants in care, and facilitate the progression to definitive care.

Upon arrival to the ED, team members are to present themselves to the medical team leader (Emergency Department (ED) consultant of registrar) and identify themselves by name and designation. The team leader will consider all available resources, and then assign the appropriate role for each member. This may mean being assigned a role in the trauma team, or asked to stand back behind the red line in the resuscitation bay, or informed that your services are not required at this time.

Trauma Team ConductTo facilitate communication and team cohesion, trauma team members must be easily identifiable. This is achieved through use of the following: Donning of impervious gowns Designation stickers - to be worn on the chest Introduction to the Medical/Nursing Team Leader and your nursing role equivalent

Team members must be familiar with their individual role and its designated responsibilities. All members must understand that the Team Leader is in charge of the resuscitation, therefore all questions and information should be directed to them.

The team must work together and be mindful of each other’s role, as well as being aware that there may be overlapping between initial assessment and definitive care. This being said, initial management is the responsibility of the trauma team leader, definitive care is the responsibility of the surgical registrar.

The following goals of care should be recognised: Unstable trauma patients should receive definitive care/ treatment within 30 minutes Stable patients should receive definitive care/treatment within 1 hour (note: This may

only mean transferring the patient within the Emergency Department) Trauma team members may only leave the resus bay once they have been stood down

by the Team Leader If the Team Leader is required to leave the resus bay they must clearly transfer the

responsibility to another senior team member At the completion on the initial assessment phase, the Team Leader will hand over the

care of the patient to the surgical registrar

Section 2 – Team organisation



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Team Organisation and floor plan

Medical Team LeaderPerformed by: ED Staff Specialist/ RegistrarRole: To co-ordinate and direct trauma response

Tasks: Identify nursing Team Leader (TL) Allocate roles and ensure protective clothing/equipment/name badges are worn Identify self as medical T/L to ACT Ambulance Service (ACTAS) Obtain “MIST” Direct primary survey Co-ordinate trauma team to facilitate rapid stabilisation of Airway, Breathing,

Circulation, Disability attending Exposure & Environment (ABCDE) to facilitated the secondary survey

Order drugs Order trauma radiology series/FAST/CT Liaise with specialty registrars (give handover) Complete Trauma Sheet Consultant notification of unstable patients (as per protocol)

Nursing Team Leader (Scribe)Performed by: Registered Nurse Level 2 (RN2)/Clinical Development Nurse (CDN)/Clinical Nurse Consultant (CNC) experienced in trauma management allocated to the resus bay



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Role: Co-ordination of the nursing team, prioritising procedures, documentation and communication.

Tasks: Identify Medical T/L Ensure ALL team members wear a ‘role sticker’ Ensure ‘resuscitation’ stickers available if required Obtain ‘MIST’ Document continuous record of vital signs, intravenous fluids (IVF) /drugs administered/

procedures and investigations Arrange immediate transfer of specimens Communicate with Medical T/L regarding priorities of ongoing care Co-ordinate telephone communications, including # specialist registrars Liaise with Social workers and family in attendance

Airway DoctorPerformed by: Anaesthetic/ED/ICU Registrar/Staff SpecialistRole: To assess and manage airway and cervical spine and ventilatory support

Tasks Identify airway nurse and ask name – all requests for equipment should be directed to

this nurse or the medical team leader as appropriate Assess and secure airway Ensure and maintain Cervical spine precautions at all times Overview administration of anaesthetic drugs and application of cricoid pressure Order ventilation parameters Insert orogastric tube (OGT) Provide medical management during transfer

Airway NursePerformed by: RN experienced in airway managementRole: Nursing management of airway and cervical spine & ventilatory support

Tasks Identify and work with airway doctor Prepare equipment and anaesthetic drugs prior to patient arrival Ensure adequate oxygenation (15 litres/ minute NRM until directed otherwise) Ensure cervical spine is adequately stabilised Assist airway doctor with intubation Perform rapid neurological assessment (Glascow Coma Score (GCS)), pupil size &

response) Ensure endotracheal tube (ETT) is tied in effectively Attach to mechanical ventilator and check setting with airway doctor Assess airway and breathing as per standard observation Assist with orogastric/ nasogastric tube insertion



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When the airway and Cervical spine are secure liaise with the Nursing Team Leader. The airway nurse will be released if no longer required. The aim is to release the nurse after the primary survey is complete.

Circulation DoctorPerformed by ED Registrar (Anaesthetics/ICU if assistance required)Role: Assess and manage the patient’s circulatory status in collaboration with T/L

Tasks: Identify Circulation Nurse and ask name – all requests for equipment and preparation

should be directed to this nurse or the medical team leader as appropriate Control external haemorrhage Establish size and function of pre-existing IV lines. Ensure 2 large bore IVC Take bloods G&XM, FBC, coags, EUC and BAL Complete and sign forms Establish invasive haemodynamic lines if required

When the circulatory is stabilised, communicate with the Medical Team Leader. The Circulation Doctor will be released if no longer required.

Circulation NursePerformed by: Nurse allocated to resus bayRole: Responsible for providing circulatory support

Tasks: Identify & work with the Circulation Doctor Assess circulatory status- temperature, capillary return, central pulse, external bleeding

(apply direct pressure) Attend Blood Glucose Level (BGL) Attach monitoring & equipment e.g. electrocardiograph (ECG) electrodes, Blood Pressure

(BP) cuff, pulse oximeter Assist Circulation Doctor in securing Intravenous (IV) lines & attach warm IV fluids Draw up non-anaesthetic drugs (analgesia, antibiotics, ADT) Continue to monitor circulatory status including haemodynamic parameters, fluid input

and output Assist with invasive haemodynamic monitoring when required Assist with logroll

The circulation Nurse will remain with the trauma team until the endpoint is achieved.

Procedure DoctorPerformed by: Surgical or ED RegistrarRole: Responsible for performing the secondary survey and related procedures



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Tasks: Identify procedure nurse & ask name – all requests for equipment and preparation

should be directed to this nurse or the medical team leader as appropriate Assess Breathing, Circulation and Deficit at the discretion of the Team Leader Perform the E-FAST Perform the secondary survey Liaise with the Team Leader regarding the need to perform the following procedures

o Intercostal cathetero Needle thoracentesiso Pericardiocentesiso Diagnostic peritoneal lavage

The surgical registrar is responsible for organising definitive care for the patient. This includes team admission and OT.

Procedure NursePerformed by: Extra RN (Subacute/Paeds)Role: Assist with invasive/non-invasive procedures

Tasks: Identify and work with procedure doctor Expose the patient, either by cutting or carefully removing clothing Ensure patient privacy and warmth Initiates wound management Assists with the following procedures

o Chest tube insertiono Urinary catheterisationo Limb stabilisation (Donway splint)o Haemorrhage control (direct pressure/ suturing)o Thoracotomyo Needle thoracentesiso Pericardiocentesis

When the primary survey is complete and all invasive procedures have been completed liaise with the Team Leader. The Procedure Nurse will be released if no longer required.

WardspersonTasks:

Present to the Trauma Team leader Don high visibility vest Collect blood products from the transfusion lab at the direction of the team leader Assist in the transfer to definitive care



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Section 3 – Communication and common pitfalls

Common pitfalls for Sub-speciality Registrars Not identifying yourself to the Trauma Team Leader Calling out orders directed at no one particular person

o To facilitate prioritisation, use your allocated nurse or refer requests to the medical team leader

Poor prioritising of interventionso E.g. arterial lines are rarely indicated in the initial stages of a trauma and particularly

not in an unstable patient where priority is transfer to OT. o While invasive monitoring may be required it can be achieved in OT whilst

haemorrhage is controlled Not using your allocated nurse for information about equipment and the trauma process Although with the best intentions, many registrars attempt to take control of the

situation by assuming a team leader role, rather than communicating their concerns with the medical team leadero Trauma resuscitation can be highly emotive, and controlling adrenalin and remaining

calm as you walk/run into an unknown situation has the potential to be quite difficult. ED staff have the benefit of five minutes of preparation time via ACTAS priority call notification. They are also working within their own environment and have not just run down 6 flights of stairs! Taking cues from ED staff can assist subspecialty registrars in remaining calm and facilitate communication

Common pitfalls for the Medical Team Leader Losing the big picture by becoming involved in procedures Focusing on resuscitation rather than facilitating surgery or embolisation of arterial

bleeding to control haemorrhage Failing to repeat the primary survey when the patient’s condition changes Allowing the patient to become hypothermic Losing control of the trauma team

CommunicationCommunication within the trauma team is essential for the integration of information, critical thinking and the ability to make timely decisions. A team approach in itself is a statement that communication is the essential component to providing patient care. Management of internal and external stressors in crisis situations is inevitable in human behaviour and this is often intensified for trauma team members, given the common age and injury demographics of patients affected by trauma. With this in mind, all team members must be aware that communication styles vary greatly among individual team members and that team members can change daily.


Implementation



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This clinical procedure will be implemented and communicated to the affected staff. It will incorporated into existing training programs, orientation plans sent to staff via email and placed in work rooms.


Related Policies, Procedures, Guidelines and Legislation

Policies Health Directorate Nursing and Midwifery Continuing Competence Policy Consent and Treatment

Procedures CHHS Healthcare Associated Infections Clinical Procedure CHHS Patient Identification and Procedure Matching Policy CHHS Trauma Team Activation Procedure

Guidelines CHHS Fasting Guidelines – Elective and Emergency Surgery

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011


References

1. A Kehoe, JE Smith (2015) An evaluation of the use of a two-tiered trauma team activation system in a UK major trauma centre, Emergency Medicine Journal, 32(5):364-367

2. P. A. Cameron, B. J. Gabbe, K. Smith, B. Mitra (2014) Triaging the right patient to the right place in the shortest time, British Journal of Anaesthesia, 113(2):226-233

3. D. Tiel Groenestege-Kreb, O. van Maarseveen, L. Leenen, S. J. Howell (2014) Trauma Team, British Journal of Anaesthesia, 113(2):258-265

4. Clements, A., Curtis, K., Horvat, L., Shaban, R.Z. (2015) The effect of a nurse team leader on communication and leadership in major trauma resuscitations. International Emergency Nursing, 23:3–7


Evaluation

Outcome Measures



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Appropriate documentation will be audited as a part of major trauma systems analysis, as will time to clearance and any complication associated with delayed / inappropriate clearance.

Current Key Performance Indicators Trauma team activation (According to activation criteria) Trauma team response, and trauma sheet present and complete Head CT scan < 30 mins (GCS 13 or less) GCS < 9, intubation within 10 minutes Time critical OT < 30 mins Laparotomy < 2 hours Craniotomy < 4 hours Joint relocation reduced within < I hr Debridement open long bone # < 6 hrs

Method The Trauma Coordinator will be responsible for auditing compliance, storing all identified

issues on the Major Trauma Database; reporting monthly to the Hospital Trauma Committee.


Definition of Terms

‘MIST’: Mechanism of injury, suspected injuries, prehospital vital signs, treatment given‘E-FAST’: Extended Focussed Assessment with Sonography in Trauma‘ABCDE’: Airway, Breathing, Circulation, Disability, Exposure & Environment ‘CT’: Computerised Tomography Scan‘NRB’: Non-rebreather mask‘G&XM’: Blood Group and Crossmatch ‘FBC’: Full Blood Count‘Coags’: Coagulation profile test ‘EUC’: Electrolytes, Urea and Creatinine‘BAL’: Blood Alcohol Level‘ADT’: Absorbed Diphtheria and Tetanus vaccination


Search Terms

Trauma, Trauma team, Trauma team roles, Roles, Responsibilities


Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval



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This document supersedes the following: Document Number Document Name



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