Tips for improving your trauma care

It’s a team effort

When mistakes are made during a trauma case, are these identified and discussed? Do nurses in your ED feel comfortable bringing their concerns to the attention of others during a resuscitation? Are new nurses given a chance to ask questions about trauma care?

These are all effective strategies for improving trauma care in your ED, says Margot Daugherty, MSN, MEd., RN, education specialist for trauma services at Cincinnati Children’s Hospital Medical Center in Cincinnati.

Here are ways to improve trauma education of ED nurses:

• Make trauma education mandatory.

ED nurses at Cincinnati Children’s are encouraged to participate in trauma rounds, attend trauma morbidity and mortality meetings, and become involved in the trauma performance improvement committee, says Daugherty.

In addition, nurses must obtain Trauma Nursing Core Course (TNCC) certification within a year of employment, and are paid to attend the classes, says Daugherty. "TNCC provides a systematic approach to the care of a trauma patient," she says. (To find a course near you, go to www.ena.org and click on "CATN II/ENPC/TNCC.")

An all-day trauma workshop is held annually that covers all phases of resuscitation. "We set up stations in the ED to orient nurses to the trauma bay, so they learn which equipment is located on the right and left side of the bed and what the role of each team member includes," says Daugherty.

• Focus on communication during codes.

Knowing the roles of each team member during a resuscitation is of the utmost importance to reduce errors, says Daugherty. "In a resuscitation bay, things can quickly become chaotic and confusing," she explains. "We respect that each team member has equal input, but there is only one conversation in the bay, with one team leader."

However, ED nurses are encouraged to point out concerns such as trends in vital signs that other team members might not notice in the flurry of activity, says Daugherty. It’s OK to say, "I can’t start this IV. You need to start a central line," she says. "It’s a team, and no one should be intimidated by the senior surgical attending physicians. If a team member notices something that isn’t quite right, it’s the team member’s responsibility to point it out."

• Pair new nurses with experienced trauma nurses.

"In our ED, we have a team of core trauma nurses who are present at every resuscitation," says Daugherty. These nurses are required to attend higher-level inservices such as running simulated resuscitations, and they act as mentors to new ED nurses.

"This provides a steady source of information from a single individual, which is less overwhelming to a new nurse," says Daugherty. "Sometimes it’s easier to ask questions when you have an established relationship with one particular nurse."

Real-life learning

• Videotape actual codes.

At OSF St. Joseph Medical Center in Bloomington, IL, traumas are digitally taped and reviewed by the ED team so nurses can identify mistakes and why they occurred, reports Staci Sutton, RN, BSN, TNS, emergency services manager. For example, nurses check to see that medication orders were read back and that nurses called out to the team after giving medications.

At first, nurses were resistant to the videotaping of resuscitations, says Sutton. "Many didn’t feel comfortable because they felt like they were being watched," she says. "We had to do a lot of education with the staff to explain that the only people who view the tape are the team members who were actually involved."

If possible, the debriefing occurs right after the case, and at minimum, staff are required to do a verbal debriefing, says Sutton. "Debriefing sheets are completed and turned into the ED manager or trauma coordinator for review," she adds. (See checklist used by ED nurses.)

Commonly observed mistakes include call outs that don’t get heard or information that is not relayed, says Sutton. "A patient may be getting intubated, but that information isn’t shared with the group, or a nurse didn’t yell out the vital signs so we don’t know the pulse oximetry, or the patient may fibrillate but no one calls it out," she says.

These errors are very easy to spot when watching the recordings, says Sutton. "It’s very easy to get caught up in doing your own task and fail to see the bigger picture, so it’s very important that debriefings are held," she says.

During debriefings after trauma cases at Children’s, one area of focus is preparation before the patient arrives in the ED, says Daugherty. "When we have notification and the team arrives, the expectation is that the nurses have the bay warmed up, checked all of the equipment, and any equipment is opened that they anticipate needing, such as a chest tube drainage system," she explains.

ED nurses also are asked to watch for instances of poor communication, says Daugherty. "What we are listening for is who is calling out the orders."

If orders are coming from the anesthesiologist, the ED physician, and the team leader, the tape is stopped to point out that three people are giving orders. "That increases the chance of a mistake," she says.

Sources

For more information on trauma education in the ED, contact:

  • Margot Daugherty, MSN, RN, Education Specialist, Trauma Services, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., ML 3019, Cincinnati, OH 45229-3039. Telephone: (513) 636-5543. Fax: (513) 636-3827. E-mail: Margot.Daugherty@cchmc.org.
  • Staci Sutton, RN, BSN, TNS, Emergency Services Manager, OSF St. Joseph Medical Center, Bloomington, IL. Telephone: (309) 662-3311, ext. 5114. E-mail: Staci.A.Sutton@osfhealthcare.org.