Items tagged with NEW ZEALAND NATIONAL CLINICAL NETWORK

This guideline provides information on the resuscitative thoracotomy process in the Emergency Departments at Dunedin and Southland Hospitals.

Most patients with blunt thoracic trauma do not require surgery and are managed either with chest drainage and/or ventilatory support of some sort. Of those that do need an operation , the vast majority can be transferred rapidly and safely to the operating room.

Patients with penetrating trauma more commonly need surgical intervention but this should also be done in the operating theatre whenever possible.

Occasionally patients present in extremis with refractory shock or lose signs of life in, or just prior to arrival to, the Emergency Department. Some of these patients (notably those who have cardiac tamponade from a stab or other low energy penetrating wound) may survive if an Emergency Department thoracotomy is done and we need to be prepared for such an event, even though it is rare. An algorithm to guide decision-making is presented in Appendix 1.

1. Definition of TBI should include one of the following
   • Direct blow to the head or acceleration/deceleration mode of injury
   • Any head related injury (facial #s, mandible #, broken nose)
   • Significant mechanism (pedestrian vs car, bicycle struck or collision, RTC high speed – rollover, ejection, fall from height > 1m, thrown, head trampled on)
   • Patient has other major trauma injuries
   • Decreasing level of conscious at any time
   • Assault
   • Vague or no recollection of events pre or post injury
   • Active symptoms of concussion such as headache, blurred vision, sensitivity to light or noise, drowsiness, balance problems, nausea/vomiting, poor concentration, fatigue, poor sleep

2. **Discharge home criteria
   • No ongoing clinical indication for prolonged observation e.g no abnormal behaviour, severe post-concussive symptoms, no drugs and/or alcohol intoxication.
   • GCS 15/15
   • if has been tested A-WPTS 18/18
   • Responsible person at home
   • Patient or responsible person understands head injury instructions (provide printout MIDAS document 65632)

3. During assessment
   • Treat symptoms, hydrate and encourage rest and sleep between assessments

4. Referral to Concussion Clinic
   • Attach large patient sticker and patient’s ACC number to concussion clinic form (ACC883)
   • Sign and date form
   • Print clinical notes from EDIS
   • Email ACC883 form, clinical notes and Rivermead symptom evaluation to This email address is being protected from spambots. You need JavaScript enabled to view it.

5. Patients admitted to a ward prior to their concussion evaluation (eg for other significant injuries or illnesses)
   • These should have their assessment as an inpatient. Please document the need for this in patient’s notes and if possible let the admitting team know.

Patient handover from the Emergency Department (ED) nurse to the Southern Intensive Care Unit (ICU) nurse

The ED and ICU have been looking at ideas to improve the patient handover process and satisfaction between nursing staff. Patient handover from one unit to another represents a vulnerable time for communication of patient information. Both areas are fast-paced, unpredictable and clinical information can be lost during the patient handover process. The plan is to standardise the handover process, similar to the current process for cardiac surgery patients returning to the ICU, and use a handover tool.

The future plan for ED to ICU patient handover:

1. Clear identification of the ICU primary nurse to the ED nurse.
   The patient’s primary nurse should identify themselves to the ED nurse. When ICU staff wear plastic aprons it can be difficult to see names badges and identify who’s who. Ideally at the handover time if the patient’s condition allows the ICU primary nurse should not be task focused and therefore be in a position to clearly listen to the handover.
2. Handover PRIOR to transfer to the ICU bed (pitstop).
   We all know when a patients hits the ICU bed, it’s hard to stop the urge of ‘doing’ rather than ‘listening’ and ‘doing’ can be distracting for other team members to listen to a handover. Unless the patient’s condition requires urgent transfer to the ICU bed for immediate intervention an effective way of ensuring that everyone listens to the handover is to stop the ED stretcher next to the ICU bed and deliver handover PRIOR to transfer. In this way A. everyone listens, and B. everyone has a shared mental model from the outset, before individual task fixation occurs.
   
   The decision about handover prior to transfer verse immediate transfer is best made by the handing over team as they will know the patients condition.
3. Handover.
   The ISBAR form is currently used throughout the SDHB and we have made adjustments to it for ICU patients. It provides a structured framework for the ED nurse to write on and assists as an aide memoir. When information is handed over each time in a similar way it can reduce variability and important information is not forgotten.

We hope the use of the pitstop style handover and use of the ISBAR form will assist to improve the quality of patient handover and staff satisfaction, reduce variability, potential loss of information and result in improved quality of care and ultimately patient safety. Future feedback on the form and handover process will be sought for ongoing development.

These guidelines outlines the process of the completing the tertiary survey on trauma inpatients and who, how and when this should be completed.

Definitions

Tertiary Survey refers to the comprehensive general physical re-examination and review of all investigations, including diagnostic imaging and blood results, within 24 hrs and again when the patient is conscious and cooperative (Hajibandeh et al, 2015)

Missed injury detection are those that are not identified by primary or secondary surveys but are detected by tertiary survey (Hajibandeh et al, 2015).

Overview/Background

Missed injuries are considered an important issue in trauma patients and can lead to significant mortality and morbidity. The reported incidence of missed injuries is variable ranging from 1% to 40%. Risk factors for missed injuries include:

Altered level of consciousness such as:

• Central nervous system injury
• Intoxication and sedation
• A distracting injury
• Poly trauma patients
• Patients needing emergency surgery

The tertiary survey is widely used in the reassessment of trauma patients, reducing any missed injuries that may be overlooked at the initial time of presentation. The best available evidence demonstrates support in favour of tertiary survey in terms of missed injury reduction, and supports its use in management of trauma patients (Hajibandeh et al, 2015).

Introduction
In 2018 a working group of trauma nurses was set up to guide the development of this professional development framework. The group comprised representation from hospitals across the country, from small to large hospitals, and a range of experience from new to role to experienced (Appendix A).

The group identified four key areas of focus which form the basis of the framework:

1. Current state
2. Core trauma nursing skills and training
3. Advanced trauma nurse career options
4. Future trauma nursing state

This framework does have limitations and in particular we note the need to build the capacity and capability of the Maori trauma nursing workforce, incorporating Te Tiriti o Waitangi to address the burden of trauma for Maori across all aspects of the trauma system, and providing guidance on the level of resourcing in line with caseload. Future revisions of this framework should incorporate these aspects. This is the first time a trauma nurse professional development framework has been developed in New Zealand. We envisage this framework will be amended in time as our understanding of the role evolves and our trauma system matures.

Notwithstanding these limitations, this early work is an important step to building a high-performing trauma nursing workforce in New Zealand.

About major trauma in New Zealand
Major trauma accommodates those patients that incur injuries which have a threat to life. There are approximately 2,000 major trauma events per year and include injuries ranging from serious injury such as pelvic fractures, through to catastrophic injuries such as traumatic brain injury or mangled limbs which require intensive life-long care.

The burden of trauma is distributed unequally across New Zealand, and between population groups. Some regions have a disproportionally high incidence of major trauma and variation in the causes of injury. The burden of major trauma for Maori ais nearly double that for non-Maori, and the high incidence rate for young Maori males is of concern.

The National Trauma Network (the “Network”) was set up in 2012 to drive quality improvement across the trauma system and bring us into line with contemporary trauma systems internationally. Sponsored by ACC the Network has a strong clinical focus as the opportunity to improve outcomes for major trauma patient is largely in pre-hospital and hospital care. Best practice care results in fewer deaths and decreased life-long injury, and a more efficient health service.

There are variable levels of maturity in the trauma systems across the country, and many nurses and doctors are relatively new to role. The intent of this framework is to support a common understanding and consistent implementation of the trauma nurse role.