Trauma Team Roles and responsibilities



Canberra Hospital and Health ServicesClinical Procedure CCADS & SAOH Trauma Team Roles and ResponsibilitiesContents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc505686796 \h 1Purpose PAGEREF _Toc505686797 \h 2Alerts PAGEREF _Toc505686798 \h 2Scope PAGEREF _Toc505686799 \h 2Section 1 – Team members and team conduct PAGEREF _Toc505686800 \h 2Section 2 – Team organisation PAGEREF _Toc505686801 \h 4Section 3 – Communication and common pitfalls PAGEREF _Toc505686802 \h 8Implementation PAGEREF _Toc505686803 \h 9Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc505686804 \h 9References PAGEREF _Toc505686805 \h 9Evaluation PAGEREF _Toc505686806 \h 10Definition of Terms PAGEREF _Toc505686807 \h 10Search Terms PAGEREF _Toc505686808 \h 11PurposeThis 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 Back to Table of ContentsAlertsThe 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 <90mmHgAdministration of blood productsWhen consensus relating to treatment/ definitive care is not able to be met within the trauma teamBack to Table of ContentsScopeThe 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.Back to Table of ContentsSection 1 – Team members and team conductTeam MembersMedical Team Leader/Nursing Team LeaderAirway Doctor / Airway NurseCirculation doctor / Circulation NurseProcedure Doctor / Procedure NurseRadiographerWardsperson Subspecialists who may be allocated to the teamAnaesthetic RegistrarIntensive Care RegistrarNeurosurgical RegistrarCardiothoracic RegistrarPlastics RegistrarOrthopaedic RegistrarWhile 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 gownsDesignation stickers - to be worn on the chestIntroduction to the Medical/Nursing Team Leader and your nursing role equivalentTeam 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 minutesStable 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 LeaderIf the Team Leader is required to leave the resus bay they must clearly transfer the responsibility to another senior team memberAt the completion on the initial assessment phase, the Team Leader will hand over the care of the patient to the surgical registrarSection 2 – Team organisationTeam Organisation and floor planMedical Team LeaderPerformed by: ED Staff Specialist/ RegistrarRole: To co-ordinate and direct trauma responseTasks:Identify nursing Team Leader (TL)Allocate roles and ensure protective clothing/equipment/name badges are wornIdentify self as medical T/L to ACT Ambulance Service (ACTAS)Obtain “MIST”Direct primary surveyCo-ordinate trauma team to facilitate rapid stabilisation of Airway, Breathing, Circulation, Disability attending Exposure & Environment (ABCDE) to facilitated the secondary surveyOrder drugsOrder trauma radiology series/FAST/CTLiaise with specialty registrars (give handover)Complete Trauma SheetConsultant 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 bayRole: 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 requiredObtain ‘MIST’Document continuous record of vital signs, intravenous fluids (IVF) /drugs administered/ procedures and investigationsArrange immediate transfer of specimensCommunicate with Medical T/L regarding priorities of ongoing careCo-ordinate telephone communications, including # specialist registrarsLiaise with Social workers and family in attendanceAirway DoctorPerformed by: Anaesthetic/ED/ICU Registrar/Staff SpecialistRole: To assess and manage airway and cervical spine and ventilatory supportTasksIdentify airway nurse and ask name – all requests for equipment should be directed to this nurse or the medical team leader as appropriateAssess and secure airwayEnsure and maintain Cervical spine precautions at all timesOverview administration of anaesthetic drugs and application of cricoid pressureOrder ventilation parametersInsert orogastric tube (OGT)Provide medical management during transferAirway NursePerformed by: RN experienced in airway managementRole: Nursing management of airway and cervical spine & ventilatory supportTasksIdentify and work with airway doctorPrepare equipment and anaesthetic drugs prior to patient arrivalEnsure adequate oxygenation (15 litres/ minute NRM until directed otherwise)Ensure cervical spine is adequately stabilisedAssist airway doctor with intubation Perform rapid neurological assessment (Glascow Coma Score (GCS)), pupil size & response)Ensure endotracheal tube (ETT) is tied in effectivelyAttach to mechanical ventilator and check setting with airway doctorAssess airway and breathing as per standard observationAssist with orogastric/ nasogastric tube insertionWhen 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/LTasks:Identify Circulation Nurse and ask name – all requests for equipment and preparation should be directed to this nurse or the medical team leader as appropriateControl external haemorrhageEstablish size and function of pre-existing IV lines. Ensure 2 large bore IVCTake bloods G&XM, FBC, coags, EUC and BALComplete and sign formsEstablish invasive haemodynamic lines if requiredWhen 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 supportTasks:Identify & work with the Circulation DoctorAssess 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 oximeterAssist Circulation Doctor in securing Intravenous (IV) lines & attach warm IV fluidsDraw up non-anaesthetic drugs (analgesia, antibiotics, ADT)Continue to monitor circulatory status including haemodynamic parameters, fluid input and outputAssist with invasive haemodynamic monitoring when requiredAssist with logrollThe 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 Tasks:Identify procedure nurse & ask name – all requests for equipment and preparation should be directed to this nurse or the medical team leader as appropriateAssess Breathing, Circulation and Deficit at the discretion of the Team LeaderPerform the E-FASTPerform the secondary surveyLiaise with the Team Leader regarding the need to perform the following proceduresIntercostal catheterNeedle thoracentesisPericardiocentesisDiagnostic peritoneal lavageThe 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 proceduresTasks:Identify and work with procedure doctorExpose the patient, either by cutting or carefully removing clothingEnsure patient privacy and warmthInitiates wound managementAssists with the following proceduresChest tube insertionUrinary catheterisationLimb stabilisation (Donway splint)Haemorrhage control (direct pressure/ suturing)ThoracotomyNeedle thoracentesisPericardiocentesisWhen 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 leaderDon high visibility vestCollect blood products from the transfusion lab at the direction of the team leaderAssist in the transfer to definitive careSection 3 – Communication and common pitfallsCommon pitfalls for Sub-speciality RegistrarsNot identifying yourself to the Trauma Team LeaderCalling out orders directed at no one particular personTo facilitate prioritisation, use your allocated nurse or refer requests to the medical team leaderPoor prioritising of interventionsE.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. While invasive monitoring may be required it can be achieved in OT whilst haemorrhage is controlledNot using your allocated nurse for information about equipment and the trauma processAlthough 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 leaderTrauma 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 LeaderLosing the big picture by becoming involved in proceduresFocusing on resuscitation rather than facilitating surgery or embolisation of arterial bleeding to control haemorrhageFailing to repeat the primary survey when the patient’s condition changesAllowing the patient to become hypothermicLosing control of the trauma teamCommunicationCommunication 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.Back to Table of Contents Implementation 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. Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesHealth Directorate Nursing and Midwifery Continuing Competence PolicyConsent and TreatmentProceduresCHHS Healthcare Associated Infections Clinical ProcedureCHHS Patient Identification and Procedure Matching PolicyCHHS Trauma Team Activation ProcedureGuidelines CHHS Fasting Guidelines – Elective and Emergency SurgeryLegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsReferencesA 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):364-367P. 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):226-233D. Tiel Groenestege-Kreb, O. van Maarseveen, L. Leenen, S. J. Howell (2014) Trauma Team, British Journal of Anaesthesia, 113(2):258-265Clements, 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, 23:3–7Back to Table of ContentsEvaluationOutcome MeasuresAppropriate 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 minutesTime critical OT < 30 minsLaparotomy < 2 hours Craniotomy < 4 hoursJoint relocation reduced within < I hr Debridement open long bone # < 6 hrs MethodThe Trauma Coordinator will be responsible for auditing compliance, storing all identified issues on the Major Trauma Database; reporting monthly to the Hospital Trauma Committee.Back to Table of ContentsDefinition 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 vaccinationBack to Table of ContentsSearch Terms Trauma, Trauma team, Trauma team roles, Roles, ResponsibilitiesBack to Table of ContentsPolicy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval This document supersedes the following: Document NumberDocument Name ................
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