Trauma

MCE Trauma/ Surgical Critical Care Guide 

WELCOME: 

We are an ACS verified Level II Trauma center and we are excited to have you join our team. This material is intended to assist you in transitioning into your role as a Trauma APP or Surgical Resident. Please read through the entirely of this packet and utilize it during your orientation process. 

General Roles/Responsibilities: 

- Be a team player – we cannot function without this! The day to day clinical team made up of residents, NPs, PAs and the ATS. Residents and APPs function collaboratively and everyone reports to the ATS. 

- Carry the trauma phone at all times. This is the trauma lifeline and we are the first point of contact for ED, nurses, consultants, etc.  Residents AND APPs are responsible for consultations and for carrying a phone.

- ALWAYS have AMS Connect and your EPIC chat feature available when you are in house.

- Respond to all trauma alerts and see consults when called from ED. Consults must be seen within 30 minutes of notification by ED.

- Follow up on the entire census based on prior shift report/to-do list. Even during the day if you are not assigned to a specific patient – we help each other out and keep everyone in the loop about what is going on. 

- If a new patient arrives it is up to our services discretion to see them and determine to admit vs discharge and carry out that process either way. ED does not do discharges for us. We are the attending service when the patient arrives through our bay. 

First Day: 

- Attire: Green Surgical Scrubs, provided by the facility. Accompanied by black jacket (to be ordered when you begin), green scrub jacket, or white lab coat. 

- Trauma APP Office: Located in the BLUE Tower (N). Take Blue elevators to the 4rd floor. We are located on STICU off to the left hand side. door code is #154. 

- If you have not already, search Alyssa Gray under order sets and save the following: Emergency – Major Trauma (Pan Scan); GS – Trauma Intermediate Care Admit (NSG and SIMCU versions); GS – Trauma Critical care Admit (Poly Trauma).

Shifts: 

- Day shift – begins at 0530. RESIDENTS AND APPs should arrive for handoff at 530. You will arrive and get handoff/assignments from the prior shift. Day team includes 1 APP and 1-2 residents.  

o 0530-0800: Look up patients/Pre-round (residents in conference 07-08) 

o 0800-1100: Multidisciplinary rounds with Attending Trauma Surgeon (ATS) 

o 1100-1730: Notes, Orders, Discharges, Follow ups, Consults, Activations, etc. 

- Tuesdays – Trauma Clinic 1230-1400 or until done seeing patients. One APP and Both residents should attend clinic. The rest of the team is expected to stay and take care of in house issues. AT LEAST ONE person needs to be in house for inpatient alerts.

- Night shift – starts at 1730. You will arrive and get handoff from the prior shift. If able, briefly round on at least the ICU patients to ensure stability and follow up on any orders leftover from day shift. See any consults or activations that arrive. Help with prepopulating discharge/depart information for expected discharges the following day. 

How to admit a patient: 

· Manually add (drag/drop) patient to the EPIC list – MCE TRAUMA TEAM LIST 

· Right click and “Assign others” add McCe trauma as the Attending trauma surgeon. 

· See the patient in ED/TB 

· Determine need for ordering additional imaging/labs, Also consider a CXR and PXR for completeness if not already ordered. 

· Staff patient with the Attending Trauma Surgeon (ATS) 

· Write H&P – All note templates are saved under “.MCET … followed by H&P, PN, Tertiary, Brief, Discharge, SBIRT Etc. 

· Determine need for admission vs DC home 

· Place Admission orders (Specific Set – Search Alyssa Gray ordered sets) and add injury specific orders/plans 

All admitted trauma patients must have an Ethanol level drawn and a “Drug Screen urine 8” ordered. 

· Call all consultants in real time (All #’s in trauma phone); Call schedule listed on @MC 

· Consult a medicine team if patient has multiple comorbidities.

· Reconcile patients’ home medications 

· Update Epic Handoff: summary section = .SUMMARY; TODO section= - use .TODO which includes injuries and negative rad; TODO ON CALL Section= .TDOC includes a brief list of things to Follow up on in next 24h

· Bill for your service – (APP only)

Daily Progress Notes (Floor or Critical care): 

- PROBLEM LIST TAB:

o Update the HOSPITAL COURSE SUMMARY every day. This is a running summary of the patients course with significant events.

o Update the PROBLEM LIST with every diagnosis (traumatic injuries, active medical problems, ongoing issues.)

- If a patient is in an ICU room use .MCETPN and include a systems based exam in the Daily plan box.

- If a patient is not in the ICU, use .MCETPN and use an injury based assessment.

- **When a patient moves from ICU to the floor you must then transition them from one note type to the other*** No copy pasting, just start a new note at that time.

How to Discharge a patient: 

- It is the responsibility of the trauma service to determine disposition/discharge ALL of our patients (ED or floor). We are ALWAYS the attending unless otherwise discussed with medicine or ED physician. 

- If the patient came through the trauma bay and is slated for discharge, in addition to their H&P they will also need a separate tertiary exam and note. This entails another full head to toe assessment, ruling out any missed injuries and determining the need for any further imaging. 

- If discharging a non-admitted patient from ED, complete all necessary discharge instructions, education, prescriptions and follow up appointments. Once this is complete ask the ED physician to formally discharge the patient. 

Depart Process: 

Go to the UNIT NAVIGATOR Band

Click Discharge Tab 

Activity Tab : .ACTIVITYDC which populates possible instructions.

Diet Tab: .DIETDC

Notify Provider Tab: .NOTIFYPROVIDERDC

Under Education please include ALL the following under Patient Education for ALL patients: 

- .COTRAUMA – this is a general trauma aftercare instruction set 

- Injury Specific Education (Rib fx, SDH, ortho injuries, TLSO, collar, splint care, etc.) 

- Mechanism Specific Education (MVC, fall prevention, assault, etc.) 

Follow up Tab: Ensure patient has all of the correct follow up appointments – always include:  MCEMB Trauma Service Clinic – Always click follow up as needed unless specific follow up is desired 

- Any service line that saw patient in consultation that requires follow up (ortho, NSG, or PCP for incidental findings) 

Discharge Orders/Med Reconcilliation: Write prescriptions if applicable, otherwise always reconcile patients’ home medications 

- If patient is going to a facility (SNF, LTACH, ECF or needs homecare) – fill out a discharge order set so the facility is clear about restrictions/diet/etc. 

- Home/ Home with HC: Write/E-Scribe ALL prescriptions. Ambulatory referral to Home Care or outpatient PT/OT completed in DC orders set.

- SNF: HARD PRINT NARCOTIC/CONTROLLED prescriptions. You can ‘No Print’ the rest of the continued medications.

- IPR or LTACH: ‘No Print’/Continue all needed medications.

Alcohol Use Disorder/ Substance Abuse: 

- Every single patient (regardless of age or mechanism) is required by the ACS to have an ethanol level drawn on arrival/admission.  

- 100% of the patients with an Ethanol >10 or who are positive for substances in their urine tox (THC not included) needs an “SBIRT” prior to discharge. THIS IS MANDATORY.

- SBIRT: Situation, Brief Intervention, Response to Treatment: A proper SBIRT should be a therapeutic/ counseling intervention for the patient. Many have a “rock bottom” moment when faced with the consequences of their alcohol/substance use and are very receptive to assistance/resources. It includes: 

- Informing the patient of their alcohol or drug positivity 

- Asking them the CAGE questions (cards in trauma office) 

- Discussing how their alcohol has potentially contributed to their trauma/injuries 

- Offer resources (back of the card in office) for assistance with addiction, recovery, alcohol use 

- THIS IS THE PROVIDERS RESPONSIBILITY – do not rely on social work 

- Use .MCETSBIRT for documentation of the completed SBIRT.

Mental Health Screening/ ITSS:

- Any admitted category 1 trauma activation OR victim of violence needs an ITSS (Injured Trauma Survivor Screen)

- Usually completed by SW but ultimately our responsibility to ensure it is completed.

- Use .MCETPTSD and ask the questions it entails.

Standard Abbreviations for EPIC List: 

CXR      = chest XR 

PXR       = pelvic XR 

S/I          = superior/inferior 

R/L/B     = right/left/bilateral 

PR          = pubic rami 

Fx           = fracture 

D/L        = dislocation 

UE/LE    = upper extremity /lower extremity 

BLEDs   = bilateral lower extremity dopplers 

CT-H      = head/brain 

CT-N      = c spine/neck 

CT-F       = maxillofacial 

CT-C       = Chest (NOT c spine) 

CT-AP     = abdomen/pelvis 

CT-TL     = thoracic spine/lumbar spine 

CT-aC     = small a delineates CT angiography 

CT-rH     = small r delineates a repeat scan 

· You do not need modifiers like displaced, nondisplaced, comminuted, etc. Just put the laterality (R/L) and the injury. 

· Every injury should be followed by operative date (8/29) OR designate it is non-operative management (NOM) 

· Summary: .SUMMARY includes PMH, SBIRT/ITSS needs, VTE PPX

· To Do Column: .TODO Includes all injuries and additionally negative radiology below. 

· To Do - ON CALL: .TDOC should be a running of tally of things that need done/followed up on in the next 24-48hrs. It should not be used to communicate what is currently ordered. 

· Goal of the list is for someone to be able to pick it up and basically give themselves report – ACCURATE and up to date snapshot of what is going on with each patient. 

Important Phone Numbers: 

Trauma APP Phone: (614) 562-2593 

Allie Gray, Lead Trauma APP: (614) 361-9057 (cell) 

Andy Betz, Trauma Program Manager: (614) 946-1698 (cell)

Attending Trauma Surgeons:  

Consultants: (all in trauma APP phone) 

Neurosurgery APP Phone #1: (614) 746-4465 

Orthopedic PA Phone “Bone Phone”: (614) 507-7251 

Anesthesia on call/Airway emergency: (614) 981-2571 

Pulmonary Critical Care: pager (614) 303-3199 

Psych Answering Service: (614) 365-2548 

Plastic Surgery, ENT, Ophtho – ask ED front desk who is on call – each physicians’ number is in trauma phone 

Internal Medicine Groups: 

Sound Hospitalists: (614) 813-0134 – sees

Trauma discharges:

MCE TRAUMA DISCHARGE PROCESS

1. Is the patient medically stable for discharge?

2. Click - Unit Navigator Band – Discharge Tab

3. Left side bar menu items that need completed:

a. Activity

i. .ACTIVITYDC

b. Diet

i. .DIETDC

c. Notify Provider

i. .NOTIFYPROVIDER

d. Education

i. Add/Search education specific to ALL CATEGORIES:

1. Mechanism (MVC, Stab, Domestic Violence, Fall, etc.)

2. Injury (vertebral fx, rib fx, SDH, abrasion, concussion, etc.)

3. Trauma (.COTRAUMA) *free text into blank space*

4. Any new diagnoses/devices (IS, TLSO, Alcohol use disorder, Cervical Collar)

e. Medication Instructions

i. .MEDINSTRUCTION

ii. Please DC Blue text if patient is not allowed to have NSAIDS

f. Follow up

i. Enter follow up for ALL of the following:

1. MCEMB TRAUMA CLINIC – ALL PATIENTS:

a. UNDER 65: Unless we specifically need to see them (post op, suture removal, pain f/u, PTX) at the very least everyone gets follow up as needed. Clinic is on Tuesdays

b. OVER 65: EVERY ONE OVER 65 place this in their F/U instructions: 2 weeks. “ Please call to be seen in our geriatric clinic within two weeks (Preferrably 1 week) of discharge. You will see Sherilyn Elam,CNP. Our clinic is held on Wednesdays.”

2. Patients PCP – if no PCP, “call 614-234-LIFE if you need help obtaining a PCP”

3. EVERY CONSULT THAT SAW PATIENT IN HOSPITAL (Ortho, NSG, Cardio, Nephrology, Heme/Onc Etc.)