Trauma Systems

1. Trauma Systems and Accident Auditing Dr. Mohammad Hassan Naseri, MD. Associate Professor of Cardiovascular Surgery Baghiyatallah Medical Sciences University, Truama Research Center Winter, 2009

2. Trauma System Goal To get the right patient to the right hospital at the right time.

3. Trauma Statistics • Leading cause of death in people age 1-34 • #1: MVCs • #2: Firearms • #3: Falls • 5th leading cause of death overall • 1/3 intentional • 2/3 unintentional • Someone in NH dies of trauma every 20 hours

5. When Do Trauma Patients Die? Severe Head or CV Injury % of Deaths Major Torso or Head Injury Infection and MSOF

6. Organized Trauma Systems  Death & Disability Through: • Injury Prevention • System Planning • Evaluation & Monitoring • Communication / Collaboration / Teamwork

7. Trauma Systems Save Lives!

8. Trauma System Components • Prevention & Public Education • Hospitals & EMS Providers • Medical Direction: On-line & Standing Orders • Triage & Transport Guidelines • Rehabilitation • Evaluation What does that mean for me?

9. “Need to Know” Information • Hospital Assessment • Trauma Triage Guidelines • Communication Guidelines • Transport Guidelines • Resources available to you

10. Hospital Assessment • Performance Levels • Initial, Advanced, or Leadership • Roles • Area or Regional • Capability Levels • Adult & Pediatric; Level I, II, or III

11. Hospital Assessment:Process • Hospital Staff Self-Assessment • Site Visit by Members of TMRC • Confirmation • Consultative / Assistance

12. Contributing Factors MOI & Medical Conditions

14. Trauma Triage Steps: To Recap • Use Pathway Card to determine Pt Status • Trauma Triage Communication • Contact Medical Control • Relay enough info to aid in decision making • Transport Decision → Transport

15. Scenario 1

16. Scene Info • Motorcycle v. Pickup Truck • Truck traveling 40 mph, ? Cycle speed • 30 y/o male thrown 20 feet • Truck has damage • Rider’s helmet has few, minor scratches What does this information provide us? What additional information do you need?

17. Initial Assessment • Airway is open and clear • Opens eyes to loud verbal stimuli • Localizes painful stimuli • Confused verbal response to questions • RR=32, ≠ chest expansion, R. wall bruising • Strong radial pulses, no major bleeding • Skin pale, moist, cool Can you estimate GCS & RTS? What is the Patient Status?

18. Focused H&P • No obvious head injury, PERRLA • No JVD or tracheal tugging, C-spine non-tender • ≠ Chest expansion, crepitus,  lung sounds R. • Abdomen soft, but guarding; pelvis stable • Open L. femur fracture • Abrasions and small laceration on R. arm • Pulse = 100, BP 110/68, RR = 32 • Medic alert tag for Coumadin use Confirm or dispute your initial severity determination.

19. Trauma Communications What pertinent information will you communicate to medical control? “MIVT”

20. Transport Decision • Injury Severity • Hospital capability, location, driving time • Area Level III Trauma Hospital is 10 minutes • Regional Level II Hospital is 20 minutes • ALS intercept is unavailable • Helicopter is available and ETA to scene is 20 minutes What decision will Medical Control make? Why?

21. _____ ____________

22. "If it wasn't documented, it wasn't done."

23. General PCR Guidelines • Complete a PCR for every call and every pt • This includes when care or transport was: • Requested • Rendered • Refused • Cancelled This includes pts treated by one agency and transported by another. >1 PCR may be generated for the same pt/pt encounter.

24. General PCR Guidelines • A written PCR is: • Complete • Accurate • Legible • Professional • Be: • Objective • Brief • Accurate • Clear Legible Handwriting & Correct Grammar and Spelling are a must! “Poor documentation = Poor care”

25. Changes to the PCR • DO NOT use “white out” or any correction fluid/tape • DO NOT try to obliterate or destroy information • It gives the impression of trying to cover up malpractice • DO draw a single line through the mistake, write “error” above the mistake, date and initial it, and proceed with your documentation • DO NOT leave blank or empty lines or spaces!

26. What to Write in a PCR • Who started care before you arrived • How you found the patient • Anything you found during your assessment • Pertinent (+) and (-) findings • Anything you did for the patient & their response • Where you left the patient (& with whom) • Report given (to whom) & questions answered • Condition of the patient upon termination of care • PIVs patent? MAE=x4? ETT position verified? If you did it, you should write it (& vice versa)

27. “Within Normal Limits” Or “We Never Looked” ??????? Be detailed!

28. What NOT to Write in a PCR • Any foul or objectionable language • Anything that could be considered as libel • Example: “He was drunk.” • It is far better to write objective comments, such as: • “Patient had odor of intoxicating substance on breath.” • “Patient admits to drinking two beers.” • “Patient unable to stand on his own without staggering and visual hallucinations.” • Do not write on anything you have lying on top of a PCR because it will copy through onto the PCR, obscuring your report

29. Refusal Documentation • Patients ABLE to refuse care include: • Competent individuals – defined as the ability to understand the nature and consequences of their actions AND • Adult – defined as 18 years of age or older, except: • An emancipated minor • A married minor • A minor in the military

30. Refusal Documentation • Patients NOTABLE to refuse care include: • Patients in whom the severity of their condition prevents them from making an informed, rational decision regarding their medical care. • Altered level on consciousness (head injury, EtOH, hypoxia) • Suicide (attempts or verbalizes) • Severely altered vital signs • Mental retardation and/or deficiency • Any patient who makes clearly irrational decisions in the presence of an obvious potentially life or limb threatening injury, including persons who are emotionally unstable • Any patient who is deemed a danger to self or others (under protective custody) • Not acting as a “reasonable and prudent” person would, given the same circumstances • Under age 18 (except as denoted above)

31. Refusal Procedure • Perform a complete exam with vitals • If refused, document this • Determine if the patient is competent to refuse • Ensure the pt or responsible party: • Has been told of his/her condition • Understands the risks or refusal • Assumes all risk & releases EMS from liability • Understands he/she can call you back anytime

32. Narrative Charting "SOAP"

33. Subjective • Any information you are able to elicit while taking the patient’s history: • Chief Complaint (CC) • History of Present Illness (HPI) • “OPQRST – AS/PN” • Past Medical & Surgical History • Meds and Allergies

34. Objective • General Impression • Primary Assessment • ABCDE • Secondary Assessment • Head to Toe Exam

35. Assessment • Field Diagnosis • What you believe the problem to be • Working diagnosis • Example: “Chest pain, R/O MI”; “closed head injury with altered LOC”; “pelvic fracture”

36. Plan / Management • Treatment • Patient Response • Example: • “Patient placed on O2 at 4lpm by NC and placed on the cardiac monitor. Medical control contacted, and the following orders received from Dr. Smith: Nitroglycerine sublingual x3, 5 minutes apart for continued chest pain and BP >90/60. If no relief from nitroglycerine, administer morphine 2 mg SIVP, titrated to a maximum of 10 mg for continued chest pain and BP >90/60.”

37. Narrative Charting "CHART"

38. CHART • Chief Complaint • History • Assessment • Rx • Transport

39. ___ _________

40. Why do we collect data? • Benefit patient care • Provide feedback to the EMS agency/provider • Evaluate system performance • Determine if the patient treatment protocols are working for the patient population served • Design injury prevention programs • Perform quality assurance • Outline opportunities for improvement in data collection and the reporting system

41. Examples of Reports • Response time • Performance, such as ETI success rates • Procedures, such as number of IVs per provider per year • Number of CPR calls

42. Difficulties… “Garbage in…garbage out.” Information collected must be complete and accurate or it will not be useful.

43. 17 Key Trauma Data Fields • On Scene • Pt Status • Pulse • Resp Rate • Systolic BP • GCS Total • GCS Eye • GCS Motor • GCS Verbal • Diastolic BP • RTS Total • RTS GCS • RTS Resp Rate • RTS BP • Trauma Patient? • Temperature • Trauma Team Activated? Being monitored currently