Sunday, November 3, 2013

Multi-Trauma/Mass Casualty Plan & Code Yellow


UK Healthcare

Adult and Pediatric Multi-Trauma Casualty Plan


The details delineated in this document provide guidance for the initial response of the trauma team in a multiple casualty situation.

Activation: 

There are 2 Activation types:      1) Multi-Trauma               2) Code Yellow

The Trauma Attending or Pediatric Surgery Attending (rounder during day and call person at night) may activate Multi-Trauma Response per the Event Report given by the ED Charge Nurse or the ED Attending.  The Trauma Attending or Pediatric Surgery Attending may delegate a surrogate to activate Multi-Trauma Standby as well. 

Upon patient arrival or Event Report confirmation, the Trauma Attending or Pediatric Surgery Attending and the ED Attending together will 1) Deactivate Standby or 2) Initiate Multi-Trauma or 3) Initiate Code Yellow.  See Diagram.  Since Multi-Trauma Response is not a Code Yellow, it does not activate the Hospital Incident Command System (see Code Yellow policy # A12-055 for more details).

Consider multi-trauma activation with 5-6 Adult or 3-4 Pediatric Trauma Alert Reds or more within an hour or at the discretion of the Trauma Attending or Pediatric Surgery Attending based on the Event Report and Resource Assessment.  The ED Attending and/or HOA may consider elevating or activating Code Yellow based on the likelihood of a larger casualty load or when ≥ 3 trauma surgeons (or ≥ 2 pediatric surgeons) are required to respond.

The ED Clerk will page:  “Multi-Trauma Alert” or “Multi-Trauma Alert Standby” to both the adult and pediatric trauma pagers.  Code Yellow is a hospital-wide overhead page.

Awareness:

The Trauma Attending (or surrogate) or Pediatric Surgery Attending (rounder during day and call person at night) will notify the following of Multi-Trauma Standby and relay the Event Report:

 Backup Trauma Surgeon

Pediatric Surgery Attending (rounder during day and call person at night)

The ED Charge Nurse PCA (or surrogate) will ensure notification of the following:

OR Front Desk (323-5631)

HOA (797-9219) or digital pager (330-6855)

ICU Charge Nurse (218-8100 or 218-8200)

The Pediatric Surgeon is notified by the trauma pager of the multi-trauma/code yellow.

The PICU Team Leader (notified by the trauma pager alert) will notify the following of the Multi-Trauma Activation:

                                PICU Attending

                                Pediatric DCN   

The OR Front Desk will notify the following of Multi-Trauma Standby, Activation, or Code Yellow: 

1.       Anesthesia Attending on Call (AOC)—who will notify the following:

a.        Anesthesia Chandler OR Director

b.        Anesthesia Chairman

2.       OR Medical Director

3.       Perioperative Enterprise Administrator

Preparation:

Multi-Trauma Standby:

<Emergency Department>          

The Charge Nurse will coordinate with the HOA for bed assignments for patients needing admission.  The ED Attending will evaluate patients for discharge.  Patients in the ED Trauma Bays will be facilitated first and further movement will be defined by the Event Report and Resource Needs.

<Operating Room>         

The OR will assess Resources:  OR Space and Staff.  The OR will HOLD Selected Scheduled Preop Patients from entering the OR if able until further determination of the Alert   

 <Trauma/Surgical Adult 7th Floor Intensive Care Unit>

Trauma/Surgical ICU Charge Nurse presents the HOA with a list of patients for discharge home/transfer to another ICU/downgrade to the floor or progressive.  This Triage List should be generated with physician input at the beginning of each shift and adjusted as needed.

<Trauma ICU and Ward Provider Teams>

Bed capacity on trauma ward and ICU will be needed for any mass casualty response, particularly in a Code Yellow response. On-duty providers, especially APP's, should report to 00.123 for staging the immediate response. Providers should rapidly assess the ward and ICU census for potential discharge and begin working with patients, families, nursing and case managers to facilitate any possible discharges and create bed capacity. APP's should be prepared to be deployed to perform initial clinical assessment and care (in ED), ICU care (in PACU), preop care (in holding) or continued inpatient care (ED observation or inpatient units. 

<PICU>

The Pediatric DCN with the HOA will evaluate the list of patients for discharge home or transfer within the pediatric hospital by downgrade. 

 

Multi-Trauma Activation or Code Yellow:

Back-up Personnel Notification:

The Blue Surgery Backup system will be utilized for a Multi-Trauma Alert.  During the day, trauma surgeon responders:  1. Trauma Floor Surgeon, 2. EGS ICU Surgeon, 3. Other Backup Surgeons.  During the night, trauma surgeon responders:  1. Blue Night Surgeon, 2. Trauma Day Floor Surgeon, 3. EGS ICU Surgeon.  For event notification, we will use the UK alert system with rosters tailored to the level of response needed (faculty only, faculty + residents, faculty + residents + APP’s).

During the day, the Pediatric Surgery rounding attending will be the first responder followed by the add-on PDS surgeon, followed by blue surgery back-up.

At night, the Pediatric Surgery on-call attending will be the first responder, followed by blue surgery back-up.

 

The ED will utilize the ED personnel call tree (including techs, nurses, and physicians) as needed and contact security to notify of the event (3-6152).

The OR Front Desk and Anesthesia will utilize their Personnel Call Tree as needed.                            

The Blue ICU Charge Nurse will activate the ICU personnel call tree and setup another ICU if necessary in the PACU staffed with current ICU nurses after reassigning patient ratios.  Responding ICU nurses may then staff the PACU ICU and stay for the length of a regular shift or until relieved by another nurse.

Personnel Response:

Trauma surgeons can park behind security and should notify security on arrival.  Additional surgical support should report to A.00.123.  Security should only allow ED staff and trauma surgeons into the Adult Trauma Bay unless otherwise authorized.   A PRA and/or Radio will assist in communicating responding surgical resources to the ED Controller for allocation.  All responding personnel should report directly to their patient care areas as directed by their supervisors and avoid the ED Trauma Bays.   

Triage:

Please see ED Policy #ED 12-02 for details.  Triage should occur outside the ED preferably in the Direct Admit Ambulance Bay by the SORT nurse and ED chief resident or attending.    The triage process will also determine whether decontamination should occur.  If so, this would occur prior to entry into the ED and the SORT team will manage through their normal process.

Initial Assessment Location and Responding Physician Service:

Red Patient—ED Adult or Pediatric Trauma Bays—Trauma Surgery Services

Yellow Patients—ED Trauma Bays—ED Services.

Green patients—Hold in ED Lobby until after Red/Yellow disposition complete, then ED Services to evaluate in the following areas.

Adult Trauma—ED Main Treatment Rooms

Adult Psych—ED Behavioral Safe Rooms

                                Pregnant Females—Obstetric: Labor and Delivery

Pediatric—Pediatric ER including Results Pending ED Room

Expectant Black—ED Treatment Rooms (40s/50s)—Trauma Surgery Services to evaluate after Red disposition complete

                Black:  Morgue

Disposition Areas:

Needs OR:  Preop Holding or PACU if not OR directly

Needs ICU:  7th Floor ICU/PICU or PACU

Needs Floor/Progressive:  ED OBS

 

Patient Tracking:

Standard patient registration with Greek names will occur.  Once the first round of greek names is exhausted, we will add numbers to the name (Alpha 2).  Internal movement will be tracked using markers on the trauma bay work area window.   The event will be recorded by paper charting and scanned into the record post-hoc.  We will utilize the paper Trauma H&Ps in the trauma bay for the medical charting which will travel with the patient.

 

Orthopaedic surgery trauma mass casualty response:

1.   Critical personnel include the orthopaedic surgery attending on call, the chief resident, and the junior resident. UK is one of the busiest fracture centers in the nation, and thus maintains a high degree of day-to-day preparedness for fracture care. Fracture stabilization and surgical care are available 24/7 with three OR’s dedicated every day Monday through Friday.

2.   The orthopaedic trauma team is usually stationed in the trauma suite charting area. They can be immediately contacted by use of the orthopaedic surgery consult pager. Additional orthopedic surgical resources in the form of faculty and residents, can easily be summoned through a call tree employing the orthopedic chief residents and orthopedic trauma faculty.

3.   Initial triage is performed by the orthopaedic surgery junior resident and/or the orthopaedic surgery chief resident. The established mass casualty incident trauma plan would be used, including ambulance bay triage by an emergency physician. Priorities are examination, timely administration of antimicrobial therapy for open fractures, splinting, timely wash out of open wounds and then prioritization based upon severity. The emergency department physicians in conjunction with the orthopedic trauma service manage a large volume of fractured patients at baseline so readiness is maintained.

4.   Coordination of secondary procedures is done through daily checkout rounds held at 0630 in person and via zoom.

Code Yellow Response Only:

Overflow Treatment Areas:

                Red/Yellow:   Critical Care Bays then Preop holding area.

                Green:  Wait in Pav A Lobby (by Registration) for a larger group

                                Peds:  Results Pending ED Room

Consider  APP or Medicine Services to assist in the evaluation of Green patients or existing ED patients.  

Code Yellow Admin Areas (see Code Yellow policy # A12-055 for more details)

                Hospital Command Center           N102

                ED Resource Center                        ED Conference Room  (A.00.415)

                Inpatient Discharge Point             Pavilion H Lobby

                Family Center                                    Pavilion A Auditorium

                Media Center                                    CTW 315

                Surgical/ED Physician Pool            A.00.123

Patient Care Roles and Responsibilities (Multi-Trauma or Code Yellow)

ED Surgical Controller:  Initially the On-call Trauma Attending with Blue Surgery Residents will assess the initial Reds for Disposition.  The Trauma Attending or Surrogate will remain in the ED Trauma Bays until relieved by another Responding Trauma Attending. 

·         Rapidly assess and move patients to the OR, ICU, Floor, or Admission Holding Area.

·         Ensure minimal diagnostic resources utilized. 

o   Avoid MRI, CT, and Xrays.

o   Ultrasound will be the tool of choice (3-4 in the ED)

·         Ensure minimal laboratory resources are utilized.

·         Deny any Backward Flow into the ED

·         Communicate with the OR Controller and ICU Controller regarding Patient Needs

·         Communicate Resource Needs with the ED Resource Center

OR Controller:  The OR Director, Trauma Surgeon, or Surrogate who is ideally not directly involved in patient care.   This may be the Anesthesia Attending On Call.

·         Prioritize Operative Interventions in the Casualty Staging Area (PreOp)

·         Encourage Damage-Control Surgery Only

·         Communicate with the ICU Controller for Postop Patient Needs

·         Communicate Resource Needs with the ED Resource Center

ICU (Trauma/Surgical) Controller:  Critical Care Surgeon or Surrogate.  May consider the Trauma/Surgical ICU Charge Nurse or a surrogate.

·         Assess Current ICU patients for discharge/transfer

·         Assess Resources: Space, Personnel

·         Manage Patients in the ICU and PACU (after the OR)

·         Communicate Resource Needs to the ED Resource Center

ED Resource Center Team:  The Representatives from the following departments will report to A.00.415 which will serve as the Resource Center.  The goal of this team is to assess current resources, receive requests from clinical staff, and distribute personnel/equipment as needed.  This team will determine when activation of a full enterprise response is indicated.   The ED Director will notify the following services to staff the ED resource center.   Appropriate personnel from the ED resource center would assume their role within the incident command system as defined per policy.

                ED Director

                Trauma/Surgical Services Nursing Director

                HOA

                                Materials Supervisor  (ADD PHONE NUMBERS)

                                EVS Supervisor

                                Transport Supervisor or designee

                                Security

                                Respiratory Supervisor

                                OR designee

                                Family liaison- to be assigned based on resources available

               

Security:

Restriction of entry:  Security personnel will control points of entry around the ED including the ambulance bay, ED lobby, and trauma bay Pav A doors.  Security personnel will allow Trauma Attendings and ED personnel through the doors.  Other surgeons or personnel will be directed to report to A.00.123 for further instructions and standby.    Further security resources will be distributed based on event needs at the direction of the Security supervisor in the ED Resource Center.

Communication/Radios:

For purposes of direct communication and in the event of cell phone signal loss, the radios currently held in the ED will be utilized.  Voceras will be utilized for communication amongst ED personnel and OR personnel if available.  The following groups will hold a radio provided by the ED:

1.       ED Resource Center

2.       ED Surgical Controller

3.       OR Controller

Event Debrief:

Patient Tracking Debrief:

To be held in A.00.123 at the conclusion of the event.  The Trauma Attending will notify the ED Clerk to page a message to the adult and pediatric trauma pagers.  For example, “Multi-Trauma Debrief at 0900 in A.00.123”.  The goals are to review the event patient census including location, injuries, and pending procedures.  The Multi-Trauma and Code Yellow debrief for patient census will be the same process.

Event Process Debrief:

This is especially for a Code Yellow but may include Multi-Trauma Activation.  To be held in Pavilion A Auditorium a few days after the event and de-escalation.  All participants in the event will receive email or phone communication regarding details of the debrief time and location.   The goals are to review casualty load, outcomes, event process, and lessons learned.

 

Drafted 2013 C Talley/A Bernard/L Fryman. Updated 10/6/14 S Priest. Updated 11/12/23 A Bernard/A Van/C Reynolds; Revised 9-25-24 by A Bernard/C Reynolds/A Doud


Available Surgery Resident Inventory

In-House Trauma Team:
Blue Chief  330-0911
Blue Junior 330-0912
Blue Intern 330-0913
Blue Intern Intensivist 

Surgery Residents In-House
ESS Junior
4 In-House Interns covering other services: 
                  SGG/SGO
                  Peds/PLA
                  VA/CT
                  Vasc/TXP

Non General Surgery Residents In-House
Ortho Junior  330-6946
Neurosurgery Junior 330-2958

Home-call chiefs covering other services:
Backup Trauma Chief / SCC Fellow (s)
SGG Chief
SGO Chief
GSH Chief
Vascular Chief
VA Chief
The Monthly General Surgery Schedule will be printed and available at the ED Charge Nurse desk and include:  Rotation Assignment schedule, Chief schedule, and Intern schedule

Resident Surge Response (as needed):
Call Tree Notifications:
Trauma chiefà ESS Junior, Backup Chief, and SCC Fellow(s)
ESS JunioràIn-House Interns
Backup ChiefàHome-call chiefs
Home-call chiefsà service juniors
No residents should report to an event for a surge without being first called to respond.

Response Location:  A.00.123 Conference Rm with Parking Location in the Limestone Garage

Patient Care Teams: 
Option 1:                  Patient-centered
The patient care teams stay with the patient along the continuum of the stay: 
Trauma bayàOR or ICU. 
Option 2:                  Geography-centered
The patient care teams stay in the ED, OR, or ICU and send/receive patients between areas.
àThe option used will be tailored to each event and will be determined by the ED Controller.
Patient Care Team Definition:
  OR:  Chief/junior or Chief/intern, +/- attending
  ICU:  2 MDs per 5-7 Acute Resusc pts.
  ED:  2 MDs, RN, tech per each Red Patient
The patient care teams will debrief their patient findings and f/u on final imaging at the post-event meeting.

Debrief Information:
                  Greek name, age/sex, actual name if confirmed
                  Trauma Bay presentation:  HPI, Initial vitals, Physical Exam Injuries, Minimal Imaging
                  Disposition
                  OR procedure/findings
                  ICU management
                  To Do:  Any additional scans after the event.  Final reports if scans performed.
                  Work with the chaplain or family liaison to connect patient and minimal family