VOL: 98, ISSUE: 37, PAGE NO: 34
Lee Turner, RGN, QARANC, is a major and trauma nurse coordinator, Royal Centre for Defence Medicine, Selly Oak Hospital, Birmingham
Gary Kenward, BSc, RGN, QARANC, is a major and A&E senior military nurse, Ministry of Defence Hospital Unit, Frimley Park Hospital, Surrey;Timothy Hodgetts, OStJ, MMedEd, FRCP, FRCSEd, FFAEM, FIMC, FRGS, L/RAMC, is a colonel, professor and defence consultant adviser in emergency medicine and trauma, Royal Centre for Defence Medicine, Selly Oak Hospital, Birmingham
One year after the September 11 terrorist attacks on Washington and New York, many health care professionals’ thoughts will return to the incidents in which thousands of people were killed in the USA. Although it is difficult to be prepared for events of such magnitude, it is vital to set up systems to manage patients with major trauma.
Trauma causes an estimated 10% of all deaths worldwide (Greaves et al, 2001), and road traffic accidents alone cause 40,000 serious injuries and result in 3,400 deaths in the UK each year (Coats and Davies, 2002). But not all deaths that result from trauma are inevitable and up to 70% of trauma-related deaths in hospital may be avoidable (Trauma Sub-committee of the British Orthopaedic Association, 1997).
The appropriate preparation of a trauma room and its staff before patients with major trauma are received will help to ensure the optimal clinical outcome.
Structures and systems required
It is essential to be able to communicate with the ambulance personnel at the scene of an accident before the casualties arrive (Committee on Trauma, 1999) as a good flow of information will enable the receiving hospital to be better prepared. Technological developments such as hand-held personal digital assistants and touch-screen computers support patient care at the scene and allow the transmission of real-time data to A&E departments.
Each acute hospital should be able to activate a trauma team (Royal College of Surgeons of England and British Orthopaedic Association, 2000). The make-up of this team will be influenced by the size and type of the hospital (Greaves et al, 2001; Scaletta and Schaider, 2001). However, all trauma teams need a leader who is qualified and competent to take control and guide the rest of the team through the resuscitation phase (Committee on Trauma, 1999). The team leader remains responsible for the patient’s care until this is taken over by the appropriate specialty.
The leader’s role has been defined by the British Trauma Society (1993). The specialty of the leader is not important as long as he or she is committed to the role. The Royal College of Surgeons of England and British Orthopaedic Association (2000) state that the team leader must be a consultant, although this is often not the case in practice. The allocation of roles within the team before the arrival of patients and knowledge of how the team will work are essential. The likely composition of a trauma team is outlined in Box 1.
Allocating time to prepare equipment may seem obvious, but it is important to have a system in place which guarantees that vital equipment is checked regularly and that disposable items are routinely stocked (Driscoll et al, 2000). A simple system is often the best. Many resuscitation rooms use a trolley with drawers to provide easy access to disposable items. A simple method to indicate that the drawer has been restocked is to place a thin strip of tape diagonally across the front of it, which is removed when items are used. Designated locations for essential items and kits, such as chest drain insertion kits and surgical airway kits, will improve efficiency - provided that staff know where to find them.
Fluids are an important part of resuscitation and should be warmed before use. A supply can be held in a warming cabinet but staff should be aware that this reduces their shelf-life, which is particularly important if items are used infrequently. Fluids can be connected to a giving set and run through to save time before the patient arrives, including the preparation of type O rhesus negative blood if the prehospital advance information suggests critical hypovolaemia.
A systematic approach to managing patients with trauma is important to ensure that no injury goes undetected. The accepted approach is provided by the following Advanced Trauma Life Support guidelines (Committee on Trauma, 1997):
- A Airway with cervical spine control;
- B Breathing with oxygen;
- C Circulation with haemorrhage control;
- D Disability;
- E Exposure.
Following these simple steps helps to prevent the team from being distracted by an injury that is not life-threatening (Hodgetts et al, 1997).
Significant technological advances in prehospital communication have aided the flow of information between the ambulance personnel and the receiving hospital. Direct communication without the use of a third party benefits all those involved.
Activation of the trauma team should be straightforward, both in terms of calling the team and the criteria for requiring their presence (Box 2). The use of call-out criteria will help staff to decide whether the team should be activated. This prevents unnecessary call-outs and ensures that the team is called when needed (Hodgetts et al, 1997).
Communication within the trauma team is the responsibility of the team leader, who must take control of the team and ensure that there is as little noise as possible. This helps to reduce patient anxiety and enables the team to hear clearly what is happening. It also allows the team to hear the details of the ambulance handover, preventing the need to repeat them when the patient arrives.
The MIST mnemonic (Box 3) will help ambulance personnel and A&E staff to achieve a clear and concise handover (Hodgetts et al, 1997).
Documentation is an essential part of the communication process. The role of scribe should be allocated before the patient arrives so that recording can begin as soon as the patient gets there. This role should not necessarily be given to the most junior nurse present. The scribe needs to understand what information must be recorded, and be able to record it accurately and thoroughly as it will be needed afterwards.
Monitoring and recording vital signs is an important part of the scribe’s role, and the ability to interpret and communicate any change in trends is essential. It also enables audits to be carried out more effectively, which is vital for the hospital to comply with recommendations. This is significant as it may determine whether a hospital is granted permission to receive trauma cases and be considered for trauma centre status (Royal College of Surgeons of England and British Orthopaedic Association, 2000).
Roles for nurses in the resuscitation room
In addition to their knowledge of where essential equipment is and how to operate it, nurses have key roles in the resuscitation room. Ideally, three nurses should join the trauma team for each seriously injured patient. This has resource implications for multiple casualty scenarios. The allocation of resources will be dictated by each individual incident, depending on the number of casualties and the severity of their injuries.
The three nurses should be allocated roles in the trauma team. The first nurse assists with all aspects of maintaining airway patency and breathing, providing an opportunity to communicate with the patient and establish a rapport if the patient is conscious. The second nurse focuses on the circulatory aspects of resuscitation, including the preparation and administration of intravenous fluids, and monitors the patient. The third nurse is the scribe. He or she records all interventions and acts as a runner.
Beyond these specific roles in the trauma team, experienced nurses also contribute in other ways, including:
- Controlling environmental factors;
- Pain management;
- Patient monitoring;
- Communication with the patient and his/her relatives;
- Pressure ulcer prevention.
Control of environmental factors
Staff should begin to prepare the environment by considering the health and safety regulations. Universal precautions (gloves, goggles, lead apron and plastic gown) should be mandatory for the trauma team and all staff who come into contact with such patients (Committee on Trauma, 1997). The disposal of sharps and contaminated waste poses a risk to the trauma team, which adequate and appropriately placed sharps bins will help to reduce.
Control of the patient’s body temperature must be a priority. On arrival in the resuscitation room, most patients’ clothing is removed so that a full assessment of any potential injuries can be made. The young, the elderly and the severely injured are less able to maintain their own body temperature so it is important to monitor this continually and take appropriate steps to prevent hypothermia. This includes keeping the resuscitation room at an adequate temperature, preventing draughts, removing wet clothing and warming the patient with regular or warm-air blankets.
Although much has been written about the management of pain, it may not always be considered a priority when a seriously injured patient arrives and each member of the trauma team focuses on his or her area of responsibility. Pain management requires the administration of appropriate analgesia and an antiemetic, the reduction of fractures and the application of splints, and where possible the alleviation of anxiety through appropriate communication.
Preventing pressure ulcers
Most trauma patients arrive in the resuscitation room strapped to a spinal board with a hard collar protecting the cervical spine. They are at varying degrees of risk for developing pressure ulcers, depending on age, severity of injury and length of time on the spinal board (Swartz, 2000). Spinal boards are intended for transportation and should be removed as soon as it is practical to do so.
During the ‘log roll’ to inspect the patient’s back an assessment of potential pressure ulcer areas can be made. Using a standardised assessment model, such as the Waterlow pressure ulcer risk assessment score, can improve continuity of assessment as the patient moves on to definitive care (Waterlow, 1998). This is particularly important for any patient with spinal injuries.
The care of patients’ relatives
The relatives of those who have been seriously injured need careful attention. They are usually psychologically unprepared because of the unexpected nature of traumatic injury. Where possible a dedicated ‘supporting nurse’ should be allocated to the patient’s relatives to establish a rapport and provide a focus for communication.
The support nurse liaises with the trauma team and informs relatives of the patient’s progress. If necessary, he or she will also prepare them to deal with the patient’s death. This requires an experienced nurse, particularly if the outcome is poor.
Planning for major incidents
When a unit’s resources are unable to cope with either the severity or number of live casualties presenting, this is classed as a major incident. Because of variations in size, resources, location and workload, each hospital will have its own criteria for a major incident.
Command and control enter a new dimension in such circumstances as trauma teams from several hospitals are activated and coordinated. Lines of communication become even more crucial. It is imperative that major incident plans are prepared in advance and tested to check that they work. It is too late to try them out for the first time on the day that they are needed.
Adequate preparation of the trauma room and trauma team provides the best chance for a trauma patient to receive life-saving definitive treatment. It is vital that the emergency department makes the process as effective and efficient as possible. For the hospital, this also provides an opportunity to reduce avoidable trauma mortality rates from the Trauma Sub-committee of the British Orthopaedic Association’s (1997) estimated rate of 70% of all trauma-related deaths occurring in hospitals.
The recommendations of the Royal College of Surgeons of England and the British Orthopaedic Association (2000) should be read by all those responsible for the care of the severely injured. They should also measure how closely their hospital’s system of trauma care adheres to the guidelines and aim to make it even closer.
Nurses have a pivotal role to play in the entire process of caring for trauma patients, from preparing for admission through to discharge, so they should participate in the development of trauma care in their units.
- For further information see the British Trauma Society’s website at: www.trauma.org.bts/