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Mon Nov 20 18:38:10 GMT 2006

Pret,

I have attached our activation criteria for adults and kids.  And you
are correct - resident staff are surgical residents, until they have hit
their 80 hours, and then this PG-30 intern takes over with the MLPs.... 
;-)

Take care,
Ron

>>> "Bjorn, Pret" <pbjorn at emh.org> 11/20/2006 11:43 AM >>>
Thanks.  I'd enjoy knowing your criteria for activated/non-activated
traumas.  And am I correct that your "resident staff" (under
non-activated) are surgical residents?

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Ronald Gross
Sent: Sunday, November 19, 2006 1:25 PM
To: trauma-list at trauma.org 
Subject: Re: Hospital Triage: Trauma Team Activation

Pret,
If it ain't broke.......
We here have a 3 tiered system:
--Activated Trauma - seen immediately by the world as they roll
through
the doors, including the trauma attending, trauma housestaff,
radiology,
ED doc and resident for airway control (or/and anesthesia as per the
desire of the trauma doc), etc, etc.  based on physiologic criteria. 
--Non-activated trauma - seen immediately by the ED attending and
resident staff as they roll through the doors.  W/U done by EM staff
and
consult called as needed.  Can be elevated to activated status on the
discretion of the EM attending
--Trauma consult - usually the result of the w/u by the EM staff, on a
prn basis.
All over or under triage cases are reviewed by our PA/PI process.

Hope that helps,
Ron

>>> "Bjorn, Pret" <pbjorn at emh.org> 11/17/2006 3:04 PM >>>
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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