Trauma Tertiary Exam
7-13% of patients have injuries that are missed during the initial evaluation. A tertiary survey helps identify these occult injuries before they are truly “missed.” Patients at highest risk for a missed injury are those with severe injuries (ISS>15) and/or impaired mental status (GCS<15) or who do not speak English.
1. ALL trauma patients admitted to SGT will receive a tertiary exam at the time of the writing of the first progress note following injury. The tertiary exam may be performed by the intern, resident, PA, NP or attending and will include:
a. History and physical exam
b. Review of imaging (must read the ENTIRE report, not just the impression)
c. Review of lab testing
d. Updated order set including:
I. pain control
II. diet
III. mobility
IV. spine clearance
V. IVF
VI. review of consultant notes
VII. bracing or PT consults (if necessary)
2. The post-op mobility order changes with regards to limb trauma will be adjusted by ORF/ORR/NS team in Epic.
3. ORF operative dressings can be removed by the bedside nurse for evaluation and replaced daily and PRN starting POD 2.
How to do a trauma musculoskeletal exam:
http://www.youtube.com/watch?v=3lwHmxgmIGE
Transfer of Service
1. SGT admits some isolated orthopedic trauma patients according to mechanism:
a. All femur fractures
b. All pelvis fractures
c. MVC > 40 mph
d. Motorcycle crash > 20 mph and/or separation of rider
e. Pedestrian vs auto
f. Fall > 15 feet
g. Crush between 2 hard objects.
2. After the tertiary exam (morning, first progress note following injury) and further non-ortho/non-specialty trauma has been ruled out or found to be insignificant (ready for discharge), SGT will transfer the patient to Ortho or other specialty service as appropriate (ENT/PLA/OMS/NS/Etc).
A. These potential transfers can be identified on admission.
B. An attending, NP or PA will write a note in Epic documenting clinical appropriateness to transfer.
C. The Ortho or Specialty chief will be notified preferably in the morning (6a-12p) of patient’s readiness for transfer to ORF or Specialty service.
D. ADT change will be made by the SGT APP or intern for the ORF or Specialty attending noted by the Ortho or Specialty chief.
E. If unable to contact the Ortho/Specialty chief after 2 pages, an email will be sent to the attending by the SGT APP, Chief, or attending, the Ortho/Specialty intern will be contacted and the transfer will occur.
F. The transition in actual patient care will occur at the time of verbal agreement.
G. The SGT team is available to discuss any medical concerns for transfer and is always available for reevaluation after transfer.
H. If the patient is ready and able for discharge at the time of tertiary exam, SGT will discharge.
I. If the patient is ready but unable to discharge at the time of tertiary exam, the patient will transfer to the Ortho or Specialty service for future discharge.
3. If a patient was admitted to Trauma service overnight but then requires ongoing hospitalization but not trauma level care, they may be transferred to GME service if they meet the following criteria (same as admission criteria):
a. isolated fragility fracture of the LE, > 65 yo with or without active medical condition, OR
b. isolated fragility fracture of the LE with cirrhosis (no age requirement).
c. Patients not meeting these criteria can go to ortho service with GME co-management. If there are questions, please call the GME attending directly (numbers listed in Provider on Call) so that an appropriate transfer may be made.
4. If the patient has isolated orthopedic or specialty injuries (face, spine, etc), the patient may not require a blue surgery follow-up appt. In these cases:
a. Pain medication refills and patient phone calls will go directly to the orthopedic or Specialty service.
b. Trauma surgery will be available on an outpatient basis to evaluate any patient with new/ongoing non-orthopedic/non-specialty issues.
Revised/Reviewed 1-31-23
