The Reading Hospital and Medical Center Trauma Center earned level II trauma designation from the Pennsylvania Trauma Systems Foundation in October 2005 and, since that time, this team has had some shining, if challenging, moments. Whether providing expert care for one patient with a gunshot, or a group of patients who arrived simultaneously from an accident scene, the method remains the same: an expert group of trauma professionals at the ready to provide the highest level of quality care.
Susan Butler, MSN, RN, trauma program manager, said the commitment of a trauma center requires a 24/7 specialized trauma team. Roles within this trauma service line include trauma surgeons; emergency department nurses and physicians; advanced practice nurses; radiology, operating room and ICU staff; blood bank personnel; and a chaplain. A simultaneous, computerized paging system sets the team in motion.
"The whole point is we have the team here prior to the patient's arrival," Butler said, noting the system is activated based on information about the patient's condition relayed by the emergency medical services en route to the hospital. "There are set criteria [to determine] who is a trauma patient. [For instance, it could be] a motor vehicle accident, a gunshot wound or a fall."
All of the nurses meet trauma core educational requirements, and the core roles within the team are dedicated members of the trauma service, working exclusively with those patients. In addition, one trauma nurse is always on call with no other responsibilities to coordinate the triage process, obtain a history of the incident and participate in the patient resuscitation.
A Well-Honed Machine
It's the trauma expertise and role definition that creates a well-choreographed dance out of what might appear to outsiders as chaos. While these factors serve the clinicians during time of increased census, it's the daily use of the skills that keep them sharp. Recently, the team worked through a high-profile weekend during which they treated multiple serious injuries simultaneously, which brought their hard-earned teamwork into focus.
"[The circumstance] was exceptional in the sense there was a lot of publicity, but we see multiple trauma scenarios at least once a week, we are able to retrospectively recognize the benefit to the [trauma treatment] protocols," said Eugene F. Reilly, MD, trauma surgeon and surgical intensivist, and clinical assistant professor of surgery at the University of Pennsylvania, Philadelphia.
"We see 8-10 injured people a day every day, and in the summer that goes up measurably. The fact we provide this care all the time gives us the muscle memory to act instinctively. Even if patients are arriving in succession, one of the strengths of the program is how the nurses, medics, chaplain, blood bank and radiology work interactively."
Communication has proved an essential element of the trauma center's success. Helenmarie Waters, RN, division director for critical care services, explained how patient handoffs have been streamlined.
"The handoff between the ED nurses and surgical ICU (SICU) nurses we've put in place has helped with flow," Waters said. Previously, the ED staff was doing a lot of the transport, but they have a number of other patients they are taking care of - it's in the best interest of the patients to keep staff in the ED. We have a bedside handoff between ED and SICU nurses, and the SICU nurse will follow that patient up to the ICU."
SCENES OF AN ED: A specialized trauma team takes on the challenges of being a level II trama center at The Reading Hospital and Medical Center. Photos by Kyle Kielinski
Holistic Trauma Care
Addressing the psychosocial effects of a hospital stay is crucial to the well-being of patients and families, and even more so in the trauma unit. Butler explained the chaplain is an integral part of the trauma team, and typically makes the first contact with the family to discuss the gravity of their loved one's medical situation.
"The chaplain communicates between the trauma team and the family, until the trauma surgeon is prepared to meet with the family members," Butler said. "The chaplain also escorts the family to the patient's next location."
Reilly described the chaplain's role on the trauma team as invaluable.
"People instinctively expect the worst when they get called from the hospital," Reilly said. "We may be in the midst of the resuscitation and don't have information or lab results to communicate to the family; the chaplain can comfort them until we can go and have a more meaningful conversation."
Reilly explained that family presence during resuscitation is not currently encouraged during the acute resuscitative phase in the trauma bay. "During an acute resuscitation, we feel the trauma bay is more analogous to an operating room than an emergency room, thus family presence is not encouraged during that time."
During the difficult wait, Waters said staff tries to make families as comfortable as possible. "We have a patient care liaison in the waiting room 13 hours a day who visits with families and communicates information about the patient," Waters said. "The liaison escorts family members to the waiting room, or a private conference room if more appropriate, brings them food and beverages, and provides information about area hotels, restaurants or where they can order takeout."
Following the immediate crisis and treatment, the chaplain and a social worker with trauma-specific training visit with the family daily. Once the patient is stabilized in the ICU, the family is encouraged to visit and be present during rounds. The trauma surgeon also continues caring for the patient in the SICU.
"Maintenance of the critically ill patient requires a first-person presence, but it's not possible to be there all the time," Reilly said.
"We rely on the nursing staff in the SICU who are often better-informed than we are about what's happening with the patient minute to minute; [the nurses] know when the consultations come and go and when the family raises a concern. I rely on them for up-to-date information."
ALWAYS PREPARED:Team members like Susan Butler, MSN, RN, trauma program manager, communicate with EMS on the scene so everyone can be assembled and waiting for patients upon arrival at the hospital.
Waters noted the communication between nursing and trauma staff has been a point of ongoing improvement, and the team meets weekly to discuss quality in an honest and collegial manner she believes comes from the top down.
"When your leadership works together well, other departments work together well," she said. "Nurses are a respected part of the team and there is collegial discussion and interdisciplinary rounds. In the SICU, I have seen times where the cardiothoracic surgeon, nurses and trauma surgeon are standing with their heads together trying to do the best for their critically ill patient. Our camaraderie and that focused care is what we're most proud of."
Staff is also proud when patients are able to return to visit following their treatment.
A patient might spend the majority of their recovery progressing through The Reading Hospital's continuum of care, from the SICU, to the progressive care unit, then med/surg and on to rehabilitation.
"It's nice to see a patient come in using a walker, and you know they are on their way," Waters said. "It's a wonderful moment for staff."
Professional, But Still People
Of course, not every traumatic case has a positive outcome, and the team naturally comes together to cope.
"We don't have a formal debriefing, but will discuss cases that can be especially trying on us," Reilly said. Specific cases that came to mind involved a particularly violent suicide, and an accident that resulted in terminal injuries for two young children.
"In those situations and similar ones, we have had opportunities to gather the staff at the first available downtime," Reilly said. "The chaplain usually takes the lead in recognizing the need for a kind of spiritual reset."
Waters said the department is in the midst of developing a more formal process of debriefing and support but, for now, team members have been satisfied with handling grief amongst themselves.
"While it's less formal, it is part of what happens daily," said Amanda McNicholas, CRNP. "We talk about many things throughout the day. We need to talk about cases for clinical care, teaching and any areas for improvement."
Butler thinks this sort of comfortable communication is what makes The Reading Hospital Trauma Center so valuable.
"We are a community hospital, and a community trauma center, and that is what comes through for successful patient care," Butler said.
Barbara Mercer is managing editor at ADVANCE.