Introduction to the Blue Surgery Service


SECTION 1: INTRODUCTION BLUE SURGERY (TRAUMA/EMERGENCY) SERVICE

INTRODUCTION:
The Blue Surgery (Trauma/Emergency) rotation is sponsored by the Division of General Surgery, Section of Trauma and Critical Care. The length of the rotation depends on the year of post- graduate training. The rotation is designed specifically to provide all residents with experience and didactic knowledge in comprehensive care of the injured adult (≥ 15 years of age) and adults with trauma or requiring emergent general surgical intervention.

ROTATION OBJECTIVES:
1. Provide clinical experience, instruction, and knowledge in the initial assessment/evaluation, resuscitation, surgical intervention, and management of all injured adults.
2. Provide clinical experience, instruction, and knowledge in the initial assessment/evaluation, resuscitation, surgical intervention, and management of adults with emergent general surgical illness and/or requiring emergent surgical intervention.
3. Provide clinical experience, instruction, and knowledge in the management of critically ill patients.

ROTATION REQUIREMENTS:
I. Patient Care Responsibilities
A. Trauma Patients*
The majority of trauma patients are admitted via the Emergency Department (ED). There will be direct inter-facility transfer of injured patients from the referring hospital to the ICU or floor. Occasionally, direct admits to the OR will bypass ED evaluation. Trauma patients can present as a referral from another hospital and physician, direct from the accident scene via helicopter (scene call), or unannounced by ground ambulance from Fayette County or the surrounding county EMS. *Refer to attached "Trauma Admission Guideline"

Trauma Expect: Patients referred and accepted by the trauma service from another hospital (ground or air transport) are considered trauma expects. Trauma expects are often referred for EM evaluation. Unless referred for EM evaluation, the Trauma/emergency surgery residents will, in those cases, be consulted by the EM residents/faculty. Emergency general surgery referrals are more likely to require early assessment by the Trauma/Emergency Surgery residents and conveying this necessity to the EM residents/faculty is helpful to accelerate care.
Local EMS Transports: Patients transported by local EMS providers become the responsibility of the Trauma/emergency surgery residents by one of two mechanisms:
1.     Trauma consult called by the ED
2.     Trauma Alert RED* called by ED.
*The Trauma Alert system is discussed below under a separate heading.
Initial assessment and evaluation of the multiply injured patient should proceed according to ATLS protocol. A review of your ATLS provider manual is highly recommended. Resident roles and responsibilities during the initial evaluation are outlined in the attached documents. Role assignment is pre-designated depending upon experience, skill proficiency, and resident knowledge base. The chief surgical resident in house (PGY4 or PGY5) assumes responsibility for the timely evaluation, management, and disposition of the trauma patient. This responsibility also includes the timely notification of the attending physician. Patient disposition should be determined within 60 minutes of ED admission. The entire diagnostic evaluation/disposition should not exceed 120 minutes. Should it become obvious at any point during the initial evaluation that the patient will require surgical intervention, it is imperative that the OR be contacted immediately. A surgical resident will accompany hemodynamically unstable patients outside the ED for all diagnostic procedures (i.e., CT scan, angiography, etc.). Physicians are not required to accompany "stable patients". It is the responsibility of the ED nursing staff to insure that all trauma patients will be accompanied by an RN during procedures done outside the ED. There is a policy that governs the RN responsibilities for transport.

1. Trauma Alert System
The trauma alert notification system was designed to provide rapid and efficient mobilization of personnel and resources essential for resuscitation, evaluation, diagnosis and treatment of the multiply injured patient. The trauma alert system is divided into two levels in order to maximize the efficiency resource allocation.
Trauma Alert
A trauma alert will be called based on the outlined mandatory and/or potential criteria (http://uktraumaprotocol.blogspot.com/2013/11/trauma-activation-criteria.html). Patients receiving a trauma alert may be arriving via ground ambulance, air medical transport, or could be present in the ED and experience an acute deterioration in condition.
Trauma Alert Red
A second level of trauma alert called 'Trauma Alert Red' is present in order to provide immediate OR access for patients that have a high likelihood of requiring emergent life-saving surgical intervention. 'Trauma Alert Red' is reserved for injured patients with reported or measured hypotension (within the 1st hour after arrival) following blunt injury and for patients who have sustained penetrating injury to the neck, thorax and/or abdomen. An operating room will be held for 30 minutes after the trauma alert red has been called. The chief surgical resident is responsible for the decision to release the OR suite as soon as possible after patient arrival.
Trauma Alert Rotation
Responsibility for directing trauma alert resuscitations is the purview of the EM residents and faculty.
Trauma alert red supervision is the responsibility of the Trauma/Emergency Surgery residents and faculty.

2. Trauma Labs
There is guideline outlining laboratory tests that will be ordered (http://uktraumaprotocol.blogspot.com/2014/08/trauma-labs.html). The labs ordered are based on the severity of the injuries. Blood Alcohol and urine drug screens are mandatory for ALL trauma activations. Any questions regarding the necessity values should be clarified with the chief surgical resident and communicated to the nurse.

3. Documentation
Trauma Admission H&P
The trauma H&P is to be completed IN FULL on ALL injured patients admitted to the trauma service or receiving consultation from the trauma service. This includes ALL ED and OPERATING ROOM MORTALITIES. Critical errors and frequently missing data are as follows:
1.     Injury time.
2.     Thorough HPI
3.     Loss of consciousness
4.     Medications
5.     Family history
6.     Complete ROS
7.    Laboratory results including ETOH and urine drug screen results.
8.     Procedures.
9.     Primary diagnoses in detail (MVC is not considered an adequate medical diagnosis and will not be accepted).
10. Referring physician and referring hospital.
11.  For aeromedical scene work, the county where the scene work occurred.

The trauma admission H&P becomes the patient's medical record. It is used for clinical care, quality reporting, credentialing and verification and verification of the trauma center, billing, criminal prosecution, malpractice defense and other purposes. Any missing trauma H&P’s are the responsibility of the chief surgical resident on-call that day. Any trauma admission form submitted incomplete will be returned to the chief or junior resident for completion within 24 hours. Missing data elements will be noted for completion. Documentation of all injuries AND medical diagnoses must be accomplished under the SCM problem list. This list should be updated as new injuries and diagnoses are identified.

Documentation should not stop with the completion of the trauma H&P’. Any and all significant changes in patient condition while in the ED should be documented completely in the medical record.

Daily Census
A daily census will be the responsibility of the off-going chief resident and his/her team. Updated census information should be complete for morning rounds. All patients admitted to or consulted by the service should be represented on the census. The census must include the following: name, MR#, DOB, diagnoses, location. Procedures are optimal but optional. Discretion should be used when populating the paper census with data that is regularly changing and exists in SCM. ED and OR mortalities should be listed on the weekly M&M list.

Procedure Documentation
All procedures (deep lines, chest tubes, arterial lines, intubation, LP, laceration closures, bronchs, trachs, etc.) should have a procedure note completed in SCM in detail.
A.    The attending physician will be notified prior to performing a procedure. We realize there are emergent situations that necessitate immediate performance of procedures that would preclude prior attending physician notification.
B.    Procedure notes should be completed for all procedures regardless of whether the attending is present or absent.
C.    The supervising attending physician for after hours procedures is the attending on call.
D.    Please remember that the medical record is a legal document. Think before you write or finalize. Do not ventilate disagreements in the medical record. The attending faculty assumes the liability for your actions and your words. Daily progress, as well as any and all acute changes in patient condition should be documented in the chart completely, accurately and legibly with the appropriate date and time.

4. Trauma Admission Orders
Computer trauma order sets ARE TO BE USED FOR ALL trauma service patients. PLEASE INSURE THAT ORDERS ARE COMPLETED IN A TIMELY FASHION. It is appropriate to enter admission orders PRIOR to seeing the patient I the EM caller indicates that admission is a certainty (chest tube has been placed, CT-proven appendicitis, mechanical ventilation, etc). If admission is uncertain, wait until the patient has been evaluated by the Trauma/Emergency Surgery resident before writing admission orders. All emergent consults should be seen within 60 minutes of consultation.
ALL DIRECT ADMITS MUST BE SEEN AND ORDERS WRITTEN WITHIN 60 MINUTES OF ARRIVAL.

B. General Surgical Emergency Patients and UKMC Inpatient Consults
The vast majority of emergency general surgery patients are admitted via the UK Emergency Department (ED). Occasionally, there will be direct inter-facility transfer from referring hospitals to the ICU or floor that will bypass ED evaluation. Emergency general surgery patients present either as:
1. A referral from another hospital and physician. *Trauma/Emergency Surgery residents should see general surgery referrals accepted from another hospital as soon as possible after those patients’ arrival in the UK ED. * Patients accepted in transfer by other general surgery services (Green and Gold) or Green and Gold patients that present in the ED for evaluation are and remain the primary responsibility of the Green or Gold Surgery service chief resident.
2. A consult from the ED attending. The Trauma/Emergency Surgery service is responsible for the evaluation of ALL general surgery UK ED** consults in adults (generally ≥ 15, sometimes negotiated with Pediatric Surgery).
**The Trauma/Emergency service should and will evaluate all ED general surgery consults. It is permissible to triage appropriately to other general surgery services (Green and Gold) but only after appropriate evaluation and reasonable diagnostic possibilities have been established. The Blue surgery attending must approve such transfer. The triage or transfer of service should be arranged between the chief surgical residents and/or between service attendings not between junior house officers.
All ICU surgical consults and in house UK emergency consults (including emergent Kentucky Clinic consults) are the responsibility of the Trauma/Emergency Surgery service. Colorectal surgery consults involving nonemergency malignant disease, anal disease and IBD should be directed to the colorectal surgeon on call 24/7.
The chief surgical resident in house (PGY4 or PGY5) assumes ultimate responsibility for the timely evaluation, management, and disposition of all general surgery emergency patients. This responsibility also includes the timely notification of the attending physician. A Communication Guideline-When to Notify for call etiquette to/from the Chief Resident is provided (http://uktraumaprotocol.blogspot.com/2013/04/communication-guideline-when-to-notify.html).

NOTIFICATION OF CONSULTANTS
Consultant(s) evaluation is frequently required for the complete evaluation and treatment of the multiply injured patient. Timely consultant notification and patient evaluation are necessary to minimize emergency department length of stay and to insure high quality patient care. The Section of Trauma and Critical Care has established the following guidelines. We expect the Trauma/Emergency Surgery service residents to adhere to these guidelines. Consultants should be notified promptly following completion of the secondary survey (<20 minutes after patient arrival) or sooner if their services are required (acute neurosurgical, face team, cardiothoracic, or orthopedic intervention). Consultants should respond to a page within 10 minutes. Consultants should be present for patient evaluation within 20 minutes of notification. Consultation should be performed by an upper level resident (PGY2 or higher) or faculty. Interns should not be notified for ED patient evaluation unless all other members of the consultant team are involved in priority patient care that precludes their presence.

TRAUMA SERVICE WARD
A single geographic location for all trauma patients will improve patient care, facilitate rounds, reduce phone calls, and reduce housestaff workload. Pavilion A 7th floor and PavH 8th floor have been designated as the trauma/emergency surgery service wards. These wards also include Orthopedic trauma.

ADMISSION OFFICE NOTIFICATION POLICY FOR THE BLUE SURGERY SERVICE
The decision regarding hospital admission, level of care (ICU, progressive care, floor, telemetry), and admitting service can be made rapidly (<20 minutes) for the vast majority of patients. With the exception of patients taken directly to the OR, the trauma/emergency surgery service will insure that the admitting process is initiated at the completion of the secondary survey or within 20 minutes of patient arrival. Admitting office notification should occur as soon as possible for a patient taken directly to the OR. Prompt notification of the admitting office will allow bed hunting/assignment to proceed simultaneously with ED evaluation thereby avoiding needless bed assignment delays. A working diagnosis, sex, and hospital area (ICU, progressive care, telemetry, floor) are all the information needed to initiate a bed search. Once a bed has been assigned and before the patient is transferred from the ED, admitting must have the patient's name and the name of the admitting service attending physician. Admitting office notification can be accomplished by entering the information directly in the computer. Do not call admitting because this is time-consuming and inefficient!
Trauma alert reds who require ICU care should be moved to the ICU as quickly as possible. To facilitate this, an open ‘Trauma Bed’ is maintained at all times. Furthermore, the ICU Charge RN and the HOA will respond to TA Reds to communicate bed availability and facilitate rapid admission of the most critically injured to the Trauma/Surgical ICU.

II. Call Coverage Responsibility
Call coverage teams will consist of Senior Surgical Resident (PGY 4 or 5), a midlevel surgery resident (PGY2 or 3), and an intern. Night call and work hours will conform to the ACGME work hours and night call standards. During some months, additional senior, midlevel and first year residents (EM, Pulmonary, Anesthesia, OB/GYN, PM&R, Surgery, OMS) will rotate on the service. These additional resident resources will be integrated into the service to provide additional coverage in compliance with ACGME work hour standards.
A. Referring Physician Calls
Receiving referring physician calls is a necessary part of resident education. Calls from a referring physician (including UKMDs) are the responsibility of the chief resident (PGY 4 or 5). Any other resident or intern receiving such a call should immediately forward the call to his/her chief resident. The Call Center will AUTOMATICALLY accept all trauma referrals and immediately facilitate transfer without contacting the trauma chief resident unless they specifically request to do so OR it appears, at the discretion of the call center, that the patient may require immediate surgery. Brief patient info will be conveyed by digital pager to the trauma chief resident. The resident then has the opportunity to follow-up with the referring MD by phone thru UKMDs.

REMEMBER THAT THEY ARE ASKING FOR OUR ASSISTANCE. MANY REFERRING HOSPITALS DO NOT HAVE THE RESOURCES TO CARE FOR THESE PATIENTS. ALL patients referred by an outside physician are to be accepted in transfer by the chief surgical resident unless otherwise instructed by the Trauma/Emergency surgery service attending on call (NO EXCEPTIONS).

B. ICU Call
Primary ICU calls for Blue Surgery Service patients are the responsibility of the PG2 or PG3 on call. The Critical Care Nursing Staff have been instructed to direct all calls to the PG2 or PG3 on call. Interns receiving ICU calls will refer them to an upper level resident.

C. Floor Call
Primary floor calls are the responsibility of the Blue Surgery Intern on call. Monday to Friday 7a-5p, calls for patients on PavA 7-100 and -200 should be directed to Charles Spillman, PA-C or Yvonne Rice, APRN, respectively. Questions or problems regarding floor patients should be directed to the chief surgical resident on call.

III. Patient Rounds
Patients rounds should occur twice daily on all Trauma/Emergency Surgical Service patients and some consults. Patient Care Guides have been provided to facilitate communication on rounds and should be provided to all patients BY THE TEAM.
A. Morning Rounds
The chief surgical resident assumes primary responsibility for the timing and conduct of rounds. In general, daily morning rounds begin at 6:00 am with a brief handoff to include only new events of the night. The walking handoff for the ICU should occur while walking through the ICU. These quick handoffs should not exceed 30 minutes in most cases. Residents from each call team are to be present for rounds. Given that this is not always possible, a resident from each of the call teams should be present so that information transfer occurs in an orderly fashion. Formal work rounds should follow.
B. Attending Rounds
Daily attending rounds will be arranged between the faculty on service and the senior surgical residents. Residents should present patient information in a clear, concise, and detailed format facilitating the completion of rounds in a thorough but timely fashion. Presentations by students on rounds or at sign out is encouraged but requires a certain persistence and fortitude on the part of the student.
C. Discharge Planning Rounds for Ward Patients
Discharge planning with the Trauma Case Managers/Social Workers/Pharmacists/Dietitian/Others will occur EVERY DAY at approximately 9:30am in PavA 7th Floor Smart Rooms. These rounds are mandatory for the surgical intern on-call. These rounds are multidisciplinary, facilitate patient care, and insure timely patient discharge.

IV. Patient Discharges and Service Transfers
A. Hospital Discharge*
Patient discharge from the hospital should be timely and efficient. This process is facilitated by discharge planning rounds. Timely and cordial interaction with the nursing staff that provide discharge teaching and with the social worker who arranges extended care [i.e. Subacute Nursing Facility (SNF), Acute Rehabilitation, Home Health, etc.] is critical. The Trauma Case Manager will be responsible for coordinating discharge of the multiple injured patients to home. When patients are identified for discharge, the nursing staff should be notified on the day prior to discharge and an ANTICIPATE DISCHARGE ORDER should be written in SCM. Discharge orders and prescriptions will be completed the evening before or by 8:00am on the day of discharge. The following critical errors are often made in patient discharges:
1.     Patients are not scheduled for subspecialty appointments prior to discharge (i.e. Neurosurgery, Orthopedics, ENT, Plastics, etc.)
2.     Patients are not given adequate supplies or medication**. This is poor patient care, results in unnecessary patient calls, and is unfair to the patient and their family. Please make sure that patients are given adequate medication and supplies to make it to their first clinic appointment. Prescriptions should be written in SCM Rx Writer and electronically submitted to the patient’s pharmacy, filled thru meds-to-beds at UK Chandler Retail Pharmacy, or printed for attending signature during sign out.
3.     Appropriate labs and X-rays are not being ordered for the first clinic visit.
4.     The first blue surgery clinic appointment should be scheduled according the guideline (http://uktraumaprotocol.blogspot.com/2014/11/clinic-follow-up-sgb.html). Not all patients require a Trauma/Emergency Surgery service clinic appointment. Please check with chief surgical resident, attending physician, or case manager before scheduling a follow-up appointment.
5.     The attending physician of record for the discharge summary is the attending on service when the patient is discharged from the hospital.

**Trauma service residents will not prescribe narcotic pain medications after hours or on weekends. Patients should be instructed to contact the clinic during regular working hours for narcotic pain medications.

B. Service to Service Transfers
Multiple or single system injury patients can be transferred to an appropriate subspecialty service when they are stable. Coordination of the transfer process is the primary responsibility of the chief surgical resident. The Blue Surgery Service should function as a consultative service after transfer of the patient when consultation is appropriate for good patient care. See ED Triage-Determining Admission Dispo (http://uktraumaprotocol.blogspot.com/2014/08/ed-triage-determining-admission.html) See Trauma Tertiary Exam and Transfer of Service (http://uktraumaprotocol.blogspot.com/2013/05/trauma-tertiary-exam-and-transfer-of.html).

V. Clinic Responsibility
A. Trauma/Emergency Surgery Clinics
There are two clinics for the service. The main clinic for the service is Tuesday 8:30 am – 4:30. Residents are expected to attend in accordance with the resident duty hour restrictions. All patients seen by a resident should be staffed by an attending physician unless otherwise instructed.

B. Clinic Phone Calls
During weekday working hours, clinic phone calls that cannot be handled by the clinic staff will be referred to the Trauma Case Manager (TCM), the Social Worker (SW), the Chief Resident or the Attending. Residents will be contacted by the clinic for prescriptions or medication** renewals. If the patient needs to be seen by a physician, the clinic will try to accommodate the patient during clinic hours. This avoids long delays and unnecessary co-pays for our patients. During evening hours and on weekends all patient phone calls will be directed to the Chief surgical resident on call.

VI. OR Scheduling
A. Emergent
The booking of emergent surgical cases is the primary responsibility of the chief surgical resident.
B. Elective Inpatient*
The booking of elective surgical cases on Trauma/Emergency Surgery inpatients is the primary responsibility of the chief surgical resident. *The clinic personnel OR the O.R. Scheduling Office must be notified about elective inpatient booking so they can keep our schedule correct.
C. Elective OR Scheduling for clinic patients
The Surgical Residents are ultimately RESPONSIBLE for ALL ELECTIVE SCHEDULING OF O.R. CASES FOR CLINIC PATIENTS.
1.     All cases should be posted by completing the O.R. Case Posting form. The patient name, procedure, estimated time, CPT code, and attending on service at the time of surgery are the necessary information.
2.     Same Day Surgery Patients and Outpatients should have and H&P*, consent*, appropriate preoperative labs*, and a referral to anesthesia clinic (when appropriate) prior to the day of surgery. (*This should be given to clinic personnel).
3.     Completed O.R packets should be hand carried to the O.R scheduler prior to the patient leaving the clinic whenever possible.

The Trauma/Emergency Surgery service has elective operating room time every Thursday and Friday. Cases must be booked no later than 24 hours prior to Surgery. Do not wait until the last minute to book elective cases. The chief surgical resident is responsible for checking, verifying, and establishing case order. This should be accomplished along with the surgical attending on service. A daily O.R case list with resident surgeon and student assignments for the following day should be broadcast by the Chief Resident each night.

PERSONNEL
Trauma Nurse Coordinator (TNC) Name: Stephanie Devore, RN Phone: 859-257-1231 Pager: 330-2319
The TNC is responsible for program administration, quality assurance activities, and systems problem solving. The TNC maintains and facilitates the trauma registry for the purpose of research and quality assurance. Clinically, the TNC evaluates quality of care, especially during the initial assessment and resuscitative phase.
The TNC also coordinates ATLS and other education related activities.

Trauma Case Managers (TCM’s) Name: Amie Newell, RN. Office: 859-323-5318. The TCM’s are responsible for: 1. Discharge planning-determining patient disposition early and making appropriate referrals to outside agencies accordingly; directing consultation of Rehabilitation Medicine and Physical Therapy as necessary; serving as a liaison with Orthopedics and other specialty services; along with nursing, identifying patients needing Home Health Referrals, outpatient equipment needs, and teaching needs; teaching and guiding housestaff; serving as a liaison between the Blue surgery service and nursing-keeping nursing abreast of the current plan of care and keeping surgeons abreast of the nursing plan of care; along with nursing, making adjustments in the nursing plan of care to meet patient outcomes; developing and monitoring protocols related to the care of trauma patients.


Chemical Dependency Counselor- Our Professional Counselor, David C. Maynard, MA, LPCC (cut my credentials if they are cut for others) is available to trauma patients for a wide range of reasons, including alcohol and substance use, traumatic stress, and depression.  If you are a patient and in need of his services, he can be reached at 859-323-0881.

Trauma Outreach Coordinator-Amanda Rist, RN, BSN. Office: Cell: 859-779-8858. The Injury Prevention Coordinator works inside UK and in the community to educate the public and develop programs that reduce injury occurrence. The IP Coordinator is considered an expert in IP and is a resource for questions about preventing future injury in our patients.


Orthopedic Case Manager:  David Bartley, RN, BSN.  Office: 859-323-2029.  The Case Manager is responsible for discharge planning for the Ortho Fracture, Reconstruction, Hand and Sports Medicine services for the University of Kentucky Medical Center.  The Case Manager attends daily multidisciplinary rounds that include Physicians, Pharmacy, Social services, Physical and Occupational Therapy.  Discharge planning includes visiting patient to assess social situation and identify barriers to DC.  Case Management works closely with nursing staff to discuss issues, communicate Plan of Care and educate for timely discharges once patient is medically ready. 

Ortho PI Coodinator-Ellen Williams

A. Trauma/Critical Care Conference*
There is a mandatory trauma/acute surgery/critical care conference Monday and Wednesday at noon (time and topic to be confirmed by the faculty covering at VA). All team members are expected to attend unless patient care responsibilities preclude attendance.

LEGAL RESPONSIBILITY
Many trauma patients become involved in civil or criminal cases. Consequently, residents sometimes receive a subpoena to testify in these cases. Under most circumstances, the responsibility to testify in court belongs to the attending faculty member that supervised the case. Please bring all subpoenas involving testimony in these cases to the immediate attention of the Section Chief of Trauma and Acute Care Surgery (Phil Chang) or to the Medical Director (Andrew Bernard). All other medical practice/legal issues should be brought to the immediate attention of Trauma Medical Director.

TRAUMA/EMERGENCY SERVICE PROTOCOLS
There are a number of protocols that govern the treatment and care of Trauma/Emergency Surgery Service patients. The surgical residents are expected to be familiar with these protocols and to adhere to them. All of the protocols are located at uktraumaprotocal.blogspot.com.
DISCLAIMER
These guidelines are not intended as a directive or to present a definitive statement of the applicable standard of patient care. They are offered as an approach for quality assurance and risk management and are subject to (1) revision as warranted by the continuing evaluation of technology and practice; (2) the overall individual professional discretion and judgment of the treating provider in a given patient circumstance; and (3) the patient’s willingness to follow the recommended treatment.