Guidelines

Use of A-WPTAS and GCS for patients with MTBI
The A-WPTAS combined with a standardized GCS assessment is an objective measure of post traumatic amnesia (PTA).

Only for patients with current GCS of 13-15 (<24hrs post injury) with impact to the head resulting in confusion, disorientation, anterograde or retrograde amnesia, or brief LOC. Administer both tests at hourly intervals to gauge patient’s capacity for full orientation and ability to retain new information. Also, note the following: poor motivation, depression, pre-morbid intellectual handicap or possible medication, drug or alcohol effects. NB: This is a screening device, so exercise clinical judgement. In cases where doubt exists, more thorough assessment may be necessary.

Admission and Discharge Criteria:

• A patient is considered to be out of PTA when they score 18/18.
• Both the GCS and A-WPTAS should be used in conjunction with clinical judgement.
• Patients scoring 18/18 can be considered for discharge.
• For patients who do not obtain 18/18 re-assess after a further hour.
• Patients with persistent score <18/18 at 4 hours post time of injury should be considered for admission.
• Clinical judgement and consideration of pre-existing conditions should be used where the memory component of A-WPTAS is abnormal but the GCS is normal (15/15).
• Referral to GP on discharge if abnormal PTA was present, provide patient advice sheet.

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.

Introduction

About 10% of the population is injured annually, and 100,000 are injured so seriously that they need treatment in hospital. Annually, 2,500 mostly young and previously healthy people die from injuries. Injuries are the most frequent cause of death in the population under the age of 35-40. The quality of the treatment of serious injuries matters a lot for the outcome in terms of survival and sequelae. The treatment will most often be time-critical, and depends on immediately available and well-prepared expertise. A trauma system is an organization of all resources in the chain that treats the seriously injured patient, where seamless overlapping and information flow is sought in a system without thresholds or bottlenecks. The trauma system therefore encompasses all stages, from prevention to first aid at the scene of the injury to rehabilitation, it includes patient experiences and the implementation of monitoring systems such as the national trauma register.

In 2007, the specialist directors of the regional health undertakings adopted the document "Organisation of the treatment of seriously injured patients - Trauma system". The document was prepared by a group set up by the regional health organizations in 2005, with broad representation from various professional environments. In the document, CEO wrote. Bente Mikkelsen, Helse Sør-East RHF, on behalf of the four regional health undertakings that "The document will be used as the basis for a joint presentation of the case which can possibly be supplemented with necessary additions specifically for the individual regional health undertaking, before it is submitted for board consideration in all the regional the health institutions. The goal is to achieve as great a degree of coordination of the trauma systems as possible."

It still took years before decisions were made in the four RHFs, and the implementation was less coordinated than originally hoped. One of the points in the plan was the creation of a competence center for traumatology. In the work, a number of areas have been identified where it is necessary to prepare proposals for national standards. There is also a need for a body that will be a driving force in practically related trauma research. Therefore, the group believes that a national competence center must be established which, in collaboration with others, will work on the following tasks:

• Guiding standards for how the AMK staff should guide in connection with calls regarding injured patients.
• Develop uniform, national guidelines for the correct requisition of air ambulances for use in all AMK centres.
• Develop national guidelines for trauma care for ambulance services.
• Requirements for documentation of pre-hospital findings and establishment of a standard ambulance record.
• Criteria for activation of trauma teams.
• Criteria for transfer from acute hospital to trauma center (indicative, agreed regionally).
• Criteria for transfer to departments with a national function.
• Guidelines for Content in Transmission Services.
• Education.
• Trauma-related research and quality control.
• Coordination of international collaborative projects.
• Rehabilitation.
• Follow-up of quality assurance at the hospitals.
• On the basis of the inequalities in Norway and the fact that major challenges lie outside the largest cities, the group recommends that such a competence center be organized as a network with representatives from all regions and all levels of trauma treatment.

The National Competence Service for Traumatology (NKT-Traume) was opened on 15 May 2013. The Competence Service made quick contact with the specialist directors to offer to oversee a roll-out of the national trauma plan, and the specialist director meeting on 18 November 2013 commissioned the National Competence Service for Traumatology (NKT-Traume) to lead a revision of "Organisation of the treatment of seriously injured patients - Trauma system' from 2006. The mandate was drawn up after consultation with the Norwegian Directorate of Health, and was decided in March 2014, and delivery was agreed for winter 2015. The working group was appointed by the professional director's meeting following input from NKT-Traume.

Notification Routines
From the scene of the accident, reports are made to the Emergency Medical Communication Center (AMK) and to the coordinator in the Emergency Department in accordance with specified criteria. The coordinator notifies the trauma team through a group search with key words on the calling display. The team members acknowledge via the calling. In the case of early warning, the team leader, who is responsible for communicating, among other things, to the chief anesthesiologist (862) / coordinator for intensive care units (581-73600) and to the interventional radiographer / radiologist / operating nurse, is informed about the use of Trauma-OP.

Graded Trauma Alarm
If physiology is affected, a large trauma team (Stort Team, ST) is called. In the case of serious injury without affected physiology, and accidents with high energy, but physiologically normal patients, a limited team (Lite Team, LT) is called. If the patient assigned to the Lite Team turns out to be more seriously injured or additional resources are needed, additional resources are called in. Personnel resources are graduated as early as possible after the primary survey. Both 833 and 832 should be present if the patient is critically ill. However, the vast majority of patients are not physiologically affected and must be handled by either 833 or 832 (by agreement between them), together with another LIS (829, 830, 831), who has passed the ATLS, as examining surgeon. This ensures a broadening of expertise, as well as flexibility, which means that other emergency operations are affected as little as possible. Transfer of a physiologically stable patient with presumed isolated head injury from another hospital is accepted by 833 or the one 833 delegates the task to, together with on-call neurosurgery (which fills in the trauma record and writes the income record). Patients who do not meet the criteria for admission to a trauma team can be seen by a surgeon in reception (832 or 833), and a trauma alarm can be triggered if necessary. For anaesthesia, separate individual assessments are made of whether to provide 2 nurses and/or doctors.

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.

1976 was a key year in the evolution of care of the injured patient. In that year, Dr. Donald Trunkey and the American College of Surgeons Committee on Trauma (ACS COT) laid out the first list of criteria to define the essential elements of a trauma center. This simple optimal resources document led directly to the development of the ACS COT’s Verification Review and Consultation (VRC) program, which has grown to 510 verified trauma centers across the United States. The same year, orthopaedic surgeon Dr. James Styner and his family were tragically injured in a plane crash in a rural Nebraska cornfield. The lack of trained personnel and resources available to care for his family compelled Dr. Steiner and his colleague, Dr. Paul “Skip” Collicott, to develop “Advanced Trauma Life Support (ATLS)”, with the goal of ensuring that surgeons providing injury care would know what to do when confronted with an injured patient. ATLS was quickly adopted and aggressively promulgated by the ACS COT, and has grown to become a global movement. The first course was held in 1980, and since that time ATLS has been diligently refined and improved year after year, decade after decade, with more than a million students taught world-wide.

These two programs, the VRC and ATLS have transformed the care of injured patients across the globe, resulting in hundreds of thousands of lives saved. Although ATLS was intended as an educational program, and the VRC was intended to be a set of standards, ATLS has standardized the care of trauma patients and the VRC educated the trauma community in the US on how best to provide optimal care for trauma patients. Now 60% of ATLS classes are held outside of the US, taught by local faculty based on the same central principles. By contrast, the concept of trauma center verification established by the VRC as not been established outside of the US.

Ultimately, reducing injury death and disability at a public health level requires a multifaceted, integrated approach, one that includes prevention, prehospital care, a network of definitive care facilities, and resources for rehabilitation. While training providers in injury care is an essential step, trained providers have limited impact without the other essential elements of a trauma system, especially a network of capable trauma centers. The development of a trauma system cannot be driven by ATLS education alone; an organized trauma center verification program, such as the VRC, is equally critical.

In 2015, Dr. Maria Fernanda Jimenez, the Chair of the International Injury Care Committee (I2C2), reached out to the ACS COT asking to move forward with a translation of the current Optimal Resources for Care of the Injured Patient 2014. This initial aim of translating the document led to a discussion involving the ACS COT Executive Committee, the Trauma Systems Evaluation and Planning Committee (Robert Winchell) and the Verification, Review and Consultation Committee (Rosemary Kozar) to discuss the strategy and goals of the project. Following these discussions and with the unanimous support of the ACS COT Executive Committee, a pilot program in Region 14 (Latin America and the Caribbean) moved forward with three primary goals: 1) translate the Optimal Resources document to Spanish and Portugese; 2) use the translated document as a framework to establish a verification system relevant to Latin American and the Caribbean; and 3) pilot a verification process and structure in the Region. It was recognized that the Optimal Resources for Care of the Injured Patient 2014 standards could be literally translated; however, the processes and requirements would not be directly applicable to another country or region outside the US due to a wide variety of cultural and societal differences (e.g. laws, professional certifications, culture, and specific resource availability). Although the ACS COT Executive Committee and the leadership of Region 14 recognized not all the specific criteria would be directly relevant or applicable to the Region, Dr. Jimenez and the surgeons in I2C2 and Region 14 committed to a trauma center/system verification process modeled on exactly the same principles established in the United States: 1) setting relevant, high standards which elevate care; 2) ensuring the right resources, structure, processes and leadership are present; 3) using clinical data (ideally risk adjusted) for performance Improvement and outcome assessment; and 4) verifying that the standards are being met by an independent, rigorous and objective external review by clinical experts.

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).