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Fri Nov 17 20:04:08 GMT 2006

Since the list appears unusually quiet, maybe I can stir something up
with a project of mine: we're looking to upgrade and sensitize our
trauma team activation criteria, and would welcome advice.

Some of the older trauma-listers may recall my discussing EMMC's trauma
team activation sequence many years ago.  Long ago, our trauma service
was in its infancy, populated largely by private-practice surgeons whose
alacrity was inconsistent, as were the instincts and aptitudes of our
emergency clinicians (if only where trauma triage was concerned).  By
aligning our internal systems with prehospital assessment protocols, we
began to articulate three reliable stratifications of trauma response:

The highest level ("Tier I"), summoning the full trauma team and
clearing OR and ICU space immediately, was triggered by true physiologic
distress.  In its most recent iteration, that means GCS <9, any recorded
systolic BP <90, or respiratory rate >29 or <6 (or intubated for any
reason).  For pediatrics, the physiologic threshold was a pediatric
trauma score (PTS) of <7.

The second level, ("Tier II"), summoning the trauma team minus
anesthesia, and preparing OR and ICU space within 30 minutes, was
characterized by anatomic or kinematic markers in otherwise stable
patients: paralysis, limb amputations, penetrating head/neck/trunk
wounds, multiple proximal long bone fx's, unstable pelvic fx's, open or
depressed skull fx's, or burns associated with other injury.  Also
included were co-occupant fatality (MVC) and soft PTS (7 or 8).

The third level absorbed all other comers, who were evaluated and
treated by the EM clinicians, SOP, with trauma consults only at the
request of the ED docs.

A couple of points are worth making here: first, the system is much
simpler than it may appear in prose.  We developed a very basic "score
sheet" as part of our radio report document, which has very high
inter-rater reliability.  

Also, we admit that the algorithm yields much higher specificity than
sensitivity (for M&M and/or ICU/OR admission) - but again, the system
was developed before we hired all of our surgeons and enhanced our
training and processing.  At the time, specificity was a big
improvement.

Today we're an ACS Level II Trauma Center with round-the-clock employed
trauma surgeons who enjoy highly effective working relationships with
their EM service colleagues, supported by a hospital living up to its
mission as a trauma care leader.  Indeed, our trauma team responsiveness
has overtaken the old algorithm: three levels have effectively become
two (the first and second tiers have roughly identical, immediate,
full-team response).  

Moving forward, we think it's time to formally sensitize and simplify
the process.  What do you think of this:

All trauma patients (except, essentially, for uncomplicated
single-system orthopedics) will fall into one of two categories.

TRAUMA ALERTS would basically combine the criteria of Tiers I and II,
with a full trauma team and promptly available beds and resources.

TRAUMA CONSULTS would include everyone else.  For any inbound trauma
transfer, or any other prospectively identified trauma admission
(multisystem, significant comorbidities, or extreme mechanisms of injury
at the discretion of the EM clinician), the trauma surgeon will be
immediately contacted, with a thirty-minute callback window to discuss
and coordinate care with the EM service.  Within 60 minutes of that
conversation, the trauma surgeon will be expected in the ED to supervise
the admission process.

Simple questions for the group: how does this compare with what you do,
does it pass the ACS straight face test, and might you offer any other
recommendations - especially with regard to the patient selection
criteria?  

Being honest, the cases most prone to confusion are the elderly
fall-down-go-booms with soft neuro findings and few if any CT changes,
but multiple meds and co-morbidities.  Although these are typically safe
social admissions, needing little more than tuning-up and methodical
discharge planning, we still see a case or two a year slipping past the
trauma service with a brain or spinal injury, however clinically
trivial.

I'm rambling.  Surprise, surprise.

Anybody out there have any thoughts?

Pret Bjorn, RN
Eastern Maine Medical Center
Bangor, ME USA

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