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Trauma Center and the OR A COOPERATIVE APPROACH TO CARING FOR THE MASSIVELY INJURED

Timothy Morgan, RN; Pamela Berger, RN; Sharon Land, RN; C. William Schwab, MD

ach year more than 140,000 Americans die from traumatic injuries; one person in E three suffers a nonfatal injury.' Since the

Vietnam War, more emphasis has been placed on applying the lessons learned in wartime to the development of civilian trauma care systems. The success of such systems depends on rapid transport of the victim to an appropriate trauma facility, early resuscitation and stabilization by trained personnel, a multidisciplinary team approach to resuscitative and definitive care, and rapid surgical intervention?

The development of trauma centers in the United States has reduced the mortality rate of trauma patients.' Care of the trauma patient should begin with initial field treatment by well-trained and experienced emergency medical technicians and paramedics. It includes extrication of the patient, initiation of life-saving measures, and

expedient evacuation to an appropriate facility. The hospital phase of trauma care must include

an integrated approach to the care of the massively injured patient. Rapid a m to trained surgeons, nurses, and support personnel is important in reducing death and disability.

A cooperative relationship is needed between the trauma center and operating room. Through a preplanned system, operating room personnel are notified immediately of an incoming victim. Within minutes of arrival, the patient is assigned a trauma care level which succinctly commun- icates the need for an operating room. The early notification system allows time for operating room personnel to clear a room, prepare it with a versatile trauma cart, and, if necessary, call in additional personnel. This coordinated approach allows the trauma

team to proceed to the operating room minutes

llmothy Morgan, RN, CCRN, ii trauma nurse coordinator, Southern New Jersey Regional Trauma Center, Cooper HospitaNUniversity Medical Center, Camden, New Jersey. He received an associate degree in applied science in nursing from Gloucester County College, Sewell NJ.

Pamela Berger, RN, CNOR, is assistant nurse manager-trauma OR services, Southern New Jersey Regional Trauma Center, Cooper Hospital/University Medical Center, Camden, New Jersey. She received her associate degree in applied science in nursing from Dabney South Lancaster Community College, Clifton Forge, Va.

Sharon Lam4 RN, BSN, is director of nursing/ operating room Southern New Jersey Regional Trauma Center, Cooper HospitaNUniversity Medical Center, Camden, New Jersey. She received her bachelor of science degree in nursing from the University of Maryland Baltimore.

C. W d h m Schwab, MD, FACS, is head of the division of trauma and emergency medical services, Southern New Jersey Regional Trauma Center, Cooper Hospital/ University Medical Center, Camden, New Jerfey. He received his doctor of medicine degree from State University of New York Upstate Medical Center, Syracuse.

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Fig 1. The trauma admitting area is staffed 24 hours a day.

after arrival. A recent study showed that approximately 6% of patients amving at a large trauma center required surgical intervention within 10 minutes to control hemorrhaging?

The need for trauma care systems has been well documented: prompt resuscitation, diagnosis, and treatment by experienced trauma professionals have substantially reduced both mortality and morbidity of severely injured ~atients.~ Conversely, delays in care at any level have accounted for unnecessary deaths, usually from hemorrhage (intraabdominal or intrapleural) or untreated hypoxia (airway obstruction, pneumothorax)?

Types of Trauma Centers

he American College of Surgeons has developed standards for Level I, 11, and T 111 trauma centers.’ Some standards for

nursing have also been developed that pertain strictly to trauma centers?

All trauma centers, regardless of level, have the responsibility to provide sophisticated, up-to-date care. Level I, which is a regional trauma center, is usually found in a university setting and tends to have more resources and a wider capability to manage life-threatening situations. The Level I center must have adequate personnel and equipment in-house 24 hours a day. It has a “waiting for the injured” philosophy with surgeons, anesthesiologists or anesthetists, nurses, and operating room teams for around-the-clock trauma care.

The Southern New Jersey Regional Trauma Center (SNJRTC) has been a part of Cooper HospiWUniversity Medical Center in Camden, New Jersey since November 1982. The center functions as the regional center of nine counties with a population of over 2 million. The SNJRTC consists of a three-bed trauma admitting area and a 10-bed trauma intensive care unit, and is staffed by in-house attending traumatologists, trauma

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Table 1 Inshumentation for a Trauma Cart

aortic compressor liver clamp extra hemostats cotton spears adhesive sterile plastic drapes colostomy bags peritoneal lavage catheter cassette drapes C-arm drapes jejunostomy kits normal saline irrigation 2,000

viscera retainer mL/bag

suction reservoirs closed-suction drains chest tubes suction kits sump drainage tubing wire twister sternal wires closed-suction chestdrainage unit

vascular ligating clips one 50 cc syringe umbilical tape

vessel loops

Teflon'" felt 5 Ib mallet Lipske knife

sutures No. 5 braided coated Dacron'" 3-0 nylon No. 0 braided nylon 3-0 silk 4-0 polypropylene on a Keith

No. 1 polyglycolic acid retention bridges

needle

fellows, residents, nurses, technicians, and support personnel to care for the seriously injured patients (Fig 1).

The SNJRTC treated 536 seriously injured patients from July 1984 to July 1985. Eighty percent of the patients had blunt wounds and the other 20% had penetrating wounds; there was an average overall injury severity score of 17.9 An injury severity score classifies the severity of injury in the various body regions. It is calculated by taking patient diagnoses from discharge or postmortem data and classifying injuries from minor to critical on a scale of one to five in each of the six body regions. A score of 16 and above is considered serious injury.

Of those seriously injured patients, 188 (35%) had acute injuries and were taken to the operating room. The average surgical time was 3% hours.

The regional trauma center is projected to treat more than 900 patients in 1986. The trauma program is structured by the various phases of trauma care, which are:

discovery, prehospital care, transport and advanced life support, resuscitation and operation, acute care, and rehabilitation.

Trauma Alert Team

he three-bed trauma admitting area is used solely as a trauma resuscitation area. It is T separate, both physically and administra-

tively, from the emergency department. Adminis- tratively, it is part of the surgery department and has a trauma surgeon as its medical director.

This area is staffed around the clock by an RN who coordinates the trauma services and resuscitation of injured patients. The RN is notified that an injured patient is en route to the center, either from an accident scene or from a referring hospital. The nurse then notifes the trauma alert team via the overhead page and team beepers. Team members respond to the trauma admitting area and prepare intravenous lines, intubation equipment and ventilators, and monitors. A trauma alert team is composed of:

an attending traumatologist/trauma fellow, two trauma residents for surgery and

an anesthetist or anesthesiologist, a primary trauma admitting nurse, a trauma nurse from trauma intensive care unit, a respiratory therapist, two x-ray technicians,

emergency medicine,

SEPTEMBER 1986, VOL. 44, NO 3 A O R N J O U R N A L

-ps 10 hemostat 5 Kelly 5 long Kelly 2 Allis 2 long Allis 2 Babcock 2 long Babcock 3 right angle (one medium, one

2 sponge stick 5 tonsil

long, one long fine-tip)

Needles 2 %inch general closure

Table 2 Bask Trauma S t

1 12-inch general closure 2 French eye

Retractors 2 Army-Navy 2 vein 1 Balfour with blades 2 medium Rich 2 long Rich 1 malleable (medium) 3 Deaver 2 Hamngton

Forceps 2 1 1-inch Debakey

2 7-inch Debakey 2 plain long 2 Adson 1 1 x2tissue

scissors 1 curved Mayo 1 straight Mayo 2 Metzenbaum (regular) 2 Metzenbaum (long)

MisceIlaneous 4 knife handles (No. 3, No. 3

long, No. 4, No. 7)

a blood bank technician, a trauma head nurse or charge nurse, a trauma technician, and a social worker.

The trauma team, led by the attending traumatologist, resuscitates the patient using prearranged protocols that deal with specific types of injuries, such as blunt versus penetrating, peritoneal lavage, burn protocols, and exsangui- nation. As more dugnostic information becomes available, the traumatologist notifies appropriate subspecialists, sets priority for their intervention, and arranges for procedures such as computer- assisted tomography (CAT scan) and angiography, if needed. The attending traumatologist also determines whether the patient will proceed to the operating suite or go directly to the trauma intensive care unit.

Developing a Trauma Unit

or trauma care, the operating room is used on a nonscheduled, urgent basis. Our center F schedules nurses and anesthesiologists or

anesthetists on a 24-hour basis. The OR staff consists of 33 full-time and part-time RNs and 13 technicians. An OR assistant nurse manager

is responsible for developing, implementing, and integrating the trauma program. All nursing personnel are trained to care for the trauma patient requiring surgical intervention, including those needing cardiopulmonary bypass procedures.

In addition to training the personnel, we developed a system that allows any of our ORs to be used for a trauma procedure.

Trauma cart A standard supply cart is stocked with surgical equipment, instruments, and supplies necessary for a trauma case (Table 1). It can be moved quickly from a central location to the assigned surgical room when needed. The trauma cart saves the circulating nurse valuable time in finding supplies and instruments. The basic supplies allow the trauma team to be in control of any operative emergency; extra instruments are added as needed. Instrumentation. A basic instrument pan was

developed to provide instruments needed to stabilize the trauma patient with major hemor- rhage (Table 2). It combines a basic abdominal set, vascular instruments, long instruments, large retractors, and an abdominal retractor (Fig 2). Additional instruments for specialty surgery (eg, orthopedm, neurosurgery, urology, thoracic) are added as needed.

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AORN JOURNAL SEPTEMBER 1986, VOL. 44, NO 3

Fig 2. The basic trauma tray is designed for quick access and rapid hemastasis.

Because the basic set requires minimal set-up time, the scrub nurse can count the instruments rapidly and have time to assist the surgical team. The circulating nurse counts sponges and needles during the initial setup and throughout the case.

The trauma OR setup is standard for all emergency trauma cases. It includes ring stand with basin, Mayo tray and stand, back table with laparotomy drape pack, two suction cannisters, a dual electrocautery, and basic trauma instru- mentation. The operating room bed is equipped with an x-ray top and has a warming blanket.

Patient Classification

trauma/operating room classification system was developed to relay the A patient’s condition, priority, and expected

time of amval. This system was needed because

the trauma admitting area and the operating suite are separate areas; the penoperative n u m report to the OR, not to the site of the trauma alert.

The primary advantage of the classification system is that it allows the charge nurse to plan the use of rooms, equipment, and personnel. The system allows better communication and coop- eration between the trauma resuscitation team and the OR staff. Thus, OR personnel can be better prepared for a patient. The system also saves critical minutes that can be lost when a patient amves without warning.

Level I. The patient is unstable and needs surgical intervention as soon as possible. The patient is physiologically unstable, usually in hypovolemic shock. No injury evaluation is needed (eg, gunshot wound of the abdomen with evisceration).

Level II. The patient is unstable leaning toward

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stable and there is a hlgh probability of surgical intervention within 15 to 30 minutes. The patient is stabilizing physiologically; he or she may be in shock but returns to a normotensive state with administration of intravenous fluids. A quick injury evaluation, such as a peritoneal lavage, is needed (eg, stab wound of the back).

LeveUZZ. The patient is stable with a probability of surgical intervention within two hours. He or she is physiologically stable. A complex injury evaluation is needed (eg, multiple x-rays, CAT scan, angiography).

Level I K The patient is stable with a slim probability of surgical intervention. He or she has minor injuries and a quick injury evaluation is sufficient.

Summary

ommunication must be established between the operating room and trauma C center. At SNJRTC, perioperative nurses

rotate through the trauma center and are part of nursing grand rounds on trauma patients. This system has improved interdepartmental

relations, educational development, and most importantly, established a system in which patients have the best chance of survival as a result of the cooperative approach to the care of the massively injured.

Notes 1. National Research Council, Injury in America A

Continuing Public Health Problem (Washington, Dc: National Academy Press, 1985) 1.

2. Dennis Law et al, “Trauma operating room in conjunction with an air ambulance system: Indications, interventions, and outcomes,” Journal of Trauma 22 (September 1982) 759.

3. R J Lowe, R J Baker, “Organization and function of trauma care units,’’ Journal of Trauma 13 (April

4. C W Schwab et al, “The impact of an air ambulance system on an established trauma center,” Journal of Trauma 25 (July 1985) 580-586.

5. R Mullner, J Goldberg, “The Illinois trauma system: Changes in patient survival patterns following vehicular injuries,” Journal of the American College of Emergency Physkbns 6 (September 1977) 393-396;

1973) 285-290.

J G West et al, “Systems of trauma care: A study of two counties,” Archives ofsurgery 114 (April 1979) 455-460.

6. J G West, “An autopsy method for evaluating trauma care,” Journal of Trauma 21 (January 1981) 32-34; D D Trunkey, R C Lim, “Analysis of 425 consecutive trauma fatalities: An autopsy study,” Journal of the American College of Emergency Physicians 3 (November/December 1974) 368-371.

7. American College of Surgeons Committee on Trauma, “Hospital and prehospital resources for optimal care of the injured patient,” Bulletin of the American Colfege of Surgeons 68 (October 1 983) 1 1-2 1.

8. Linda Carl, “Nursing criteria for trauma center site review,” Journal of Emergency Nursing 9 (March/

9. Lowe, Baker, “Organization and function of trauma care units,’’ 285-290, S Baker et al, “The injury severity score: A method for describing patients with multiple injury and evaluating emergency care,’’ Journal of Trauma 14 (March 1974) 187-196; G Kane et al, “Empirical development and evaluation of prehospital trauma triage instruments,” Journal of Trauma 25 (June 1985) 482-489.

April 1983) 74-77.

Implantable Contraceptive Tested in United States An implantable device designed to protect against pregnancy for five years is being tested in the United States, according to a report in the June 9 issue of Medical World News.

According to the report, 1,500 women have undergone clinical trials using a reversible contra- ceptive that is implanted under the skin of the upper arm. An earlier version is being used in Finland, Sweden, Thailand, Indonesia, and Ecuador.

The 3 cm device releases 30 p g levonor- gestrel, a progestin used for many years in oral contraceptives, per day. The implantable device has a side effect of irregular bleeding or spotting in about 15% of the users.

The device had a failure rate of 0.3 pregnan- cies per 100 women per year for the first five years.

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