Trauma is the leading cause of death and disability in children (American College of Surgeons [ACS], 2012; Emergency Nurses Association [ENA], 2014). For these reasons, both accuracy and timeliness of trauma team activation are important for an organized, systematic approach to patient care (ENA, 2014). The primary objective of Advanced Trauma Life Support (ATLS) is to “assemble a team and prepare to resuscitate an injured patient” (ACS, 2012, p. 3), implying that all players should be in their role with a plan for resuscitation prior to the patient's arrival. Overactivation (overtriage) results in overutilization of the trauma team, impacting flow of care to other patients in the emergency department (ED), with a trickle-down effect to many other departments. Underactivation (undertriage) results in not having the correct team members needed and can delay lifesaving treatment; consequently, accuracy in triage is vital. The ACS recommends that the surgeon be present upon the patient's arrival, but no later than 15 min after the patient's arrival for top-tier (most serious) trauma team activations.
This article is both a review of the literature on which medical facility role can most accurately perform phone triage of patients and the quality improvement process one Level II pediatric trauma center went through to evaluate and implement best practices. This ACS Level II trauma center sees more than 900 trauma cases per year with an estimated 45 Tier 1 traumas and 145 Tier 2 (modified smaller team) traumas.
Historically, ED charge nurses and staff nurses answered the Emergency Medical Services (EMS) radio and no deficits in accuracy or timeliness of trauma team activation were experienced. However, because of the overwhelming number and nature of the calls affecting the ED flow of care, our hospital committed to the creation of a Communication Center (Com. Center). The Com. Center would create value by connecting outside physicians with needed resources in a timely manner and managing the many other calls that were a barrier to the ED flow. The ED also determined that the Com. Center staff would answer the incoming radio calls from EMS and activate trauma team pages based on standard criteria. Because of the high demand and clinical need of nurses in the ED, it was decided the Com. Center staff would not include nurses. The Com. Center staff had a mix of job experience and education including a 911 operator, an emergency medical technician (EMT) basics, a respiratory therapist student, a nursing student, a paramedic, and a lay person with no medical background.
After several years with the aforementioned Com. Center configuration, the Trauma Department had concerns about both the accuracy and timeliness of trauma activations that made up more than 13% of all Trauma Department's quality improvement opportunities. Follow-up with individuals involved through our quality improvement process did not change efficiency and, unfortunately, the accuracy issues were not isolated to just a few but were widespread among staff members. The Trauma Service set out to quantify both accuracy and timeliness deficits while also evaluating evidence-based practice for phone triage with the intent of sharing the data and improving processes.
Our first task in August 2014 was to complete an audit of all trauma team activations arriving via EMS from August 1, 2013, to July 31, 2014. The audit revealed that only 13 of 58 (22.4%) activations occurred within 5 min or less from the time of the end of the EMS report to the Com. Center. This audit was based on an analysis of all recordings of Com. Center calls and was shared with the management of the Com. Center staff. In review of the EMS calls and patient records, several barriers to timely activation were identified:
- Com. Center staff documenting the EMS call in the electronic medical record (EMR) prior to activation;
- Calling the ED physician to discuss the case or seek permission for activation;
- Notifying the ED charge nurse before activating the trauma team; and
- Dispatching the transport team needed to bring the patient from a transferring facility before placing the trauma team activation page.
The trauma program manager and the trauma performance improvement coordinator provided the Com. Center manager with monthly reports highlighting any error or delay in activation. Within 3 months, almost 50% of the activations were occurring in less than 5 min. Trauma Department members attended Com. Center staff meetings to provide scenarios and encourage feedback from the staff. This ongoing education was well received.
In December 2014, the Com. Center director then led a multidisciplinary group through the Lean process improvement methodology intended to systematically evaluate the trauma team activation process. The goal was to remove waste and reduce variation to streamline the workflow. Both the Trauma Service and Com. Center departments agreed the activation timing must take precedence over all other functions. A template was created in the EMR to standardize the documentation of EMS intake calls and reduce errors of data omission while the mean and median time to activation continued to be monitored by Trauma Service leadership.
Additional education was provided for the Com. Center staff. The trauma program manager met with all new Com. Center staff members during orientation. Trauma Service empowered the Com. Center staff to make the decision themselves and place the page based on criteria. Compliance with the activation plan was poor precisely because staff members were hesitant to make a wrong decision and relied very heavily on ED physicians to make the call with sometimes inaccurate results. Any call from the surgeons to gain additional information was seen as criticism, and surgeon calls were limited to confirming the page was received and the surgeon was in route. The Com. Center staff was comprised of people with multiple backgrounds including a patient care assistant, a prior 911 dispatcher, a nursing student, EMTs, and paramedics each with varying clinical judgment. Based on the ongoing data, the vice president of Medical Affairs, a member of the Trauma Planning Committee, indicated that despite best efforts, education was not going to be enough to correct this problem.
Phase II: Synthesis of Literature and Task Force Formed
The next step was to proceed to a more in-depth analysis of the problem beginning with a literature search for evidence-based practices (Tables 1 and 2). Also, at this time, we submitted our project to our institution's institutional review board, which formally reviewed it and determined that it was exempt as a quality improvement project. A search of Cochrane, PubMed, and CINAHL databases from 2000 to 2015 was completed with the following key words:
- Pre-hospital AND Notification
- Emergency Department AND EMS AND Triage
- Nurses AND EMS AND Triage
- Nurses AND Receiving Pre-hospital Report
- Emergency Department Triage by Nurses AND Ambulance
The results yielded identification of 13 articles on the topic of emergency triage, but only one article spoke specifically about triage of trauma patients arriving to an ED by EMS. The articles' level of evidence ranged from III to VII. One finding repeatedly appeared in 12 of the 13 articles:
- Patient safety was affected by triage accuracy sometimes directly impacting mortality and morbidity (Bost, Crilly, Patterson, & Chaboyer, 2012; Bruce & Suserud, 2005; Buschhorn, Strout, Sholl, & Baumann, 2013; Domagala & Vets, 2015; Göransson, Ehnfors, Fonteyn, & Ehrenberg, 2008; Hitchcock, Gillespie, Crilly, & Chaboyer, 2014; Jelinek, Fahje, Immermann, & Elsbernd, 2014; Kahveci, Demircan, Keles, Bildik, & Aygencel, 2012; Paulson, 2004; Ryb, Cooper, & Waak, 2012; Stanfield, 2015; Wheeler, Greenberg, Mahlmeister, & Wolfe, 2015).
Other findings are as follows:
- Nurses' triage skills were the most accurate compared with physicians and “others,” with physicians' accuracy scoring 9% lower than nurses' (Buschhorn et al., 2013; Hitchcock et al., 2014; Jelinek et al., 2014; Kahveci et al., 2012; Wheeler et al., 2015). The group of “others” was too low to evaluate (Wheeler et al., 2015). Meanwhile, a 1-year review of our nursing triage accuracy at the walk-in entrance to the ED exceeded 98%.
- When EMS has to repeat its report multiple times (Com. Center, charge nurse, bedside nurse), details become less complete with each subsequent report (Domagala & Vets, 2015; Jensen, Lippert, & Østergaard, 2013).
- Increased time to the provider increases the number of patients who left without being seen (Paulson, 2004; Wheeler et al., 2015).
A multidisciplinary task force was assembled. The chief nursing officer, who chaired the Trauma Planning Committee, assembled this team facilitated by a corporate education nurse. The team included the trauma program manager, trauma performance improvement coordinator, trauma medical director, manager and director of the Com. Center, EMR specialist, and a Com. Center staff member. A SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis was performed (see Figure 1). Through this analysis, a cause-and-effect diagram was made to review the process, people, culture, technology, education, and training with a goal of accurate timely trauma team activation required for ACS verification. Some of the barriers identified through this process included the following:
- Trauma versus medical activation rules;
- Seeking physician permission (support);
- Concern for surgeon questioning decision;
- Number of incoming calls;
- Number of people in a very small work space;
- Variability of clinical skills;
- Communication skills;
- Non-Com. Center staff in the space;
- Lack of accountability to the process;
- Not enough phones; and
- Lack of clinical information systems support with competing priorities.
The task force reviewed the findings of the evidence-based practice. Based on the outcomes synthesis table for this evidence-based review, the recommendations from this project were as follows:
- Involve a nurse in the triage of EMS calls to listen to the first report.
- Develop a nurse navigator for patients arriving by EMS.
- EMS intake calls to be managed by a triage-trained nurse.
- Trauma activation initiated per criteria as directed by a triage-trained nurse.
- Intake nurse receives patient information from EMS and upon arrival, greets EMS, and directs EMS personnel to the trauma room if trauma activation criteria were met. If criteria were not met, the intake nurse evaluates the patient, assigns a triage level, and determines the appropriate ED team destination for the patient.
Several changes were made as a result of the task force's recommendations:
- All future Com. Center hires would be paramedics. (Nurses were in high demand and could not be used to staff the Com. Center's other functions.)
- No outside staff would be permitted in the Com. Center.
- Additional phone lines were installed.
- Glass windows of the Com. Center were glazed to limit staff in the hall distracting the Com. Center staff.
- Trauma Service would continue to monitor all trauma-related calls and provide feedback to the Com. Center staff on timeliness and accuracy of all trauma activations.
- Training would include trauma triage simulations.
After implementation of the aforementioned intervention, the Com. Center performance revealed an improvement from 72.7% correct activations in 2015 to 89.3% correct activations in 2016 (see Figure 3). In addition, a staggering reduction in activation times of 90% was achieved. Mean activation time in January 2015 was 48.5 min before the intervention and 4.71 min postintervention in December 2016 (see Figures 2 and 3). A profound improvement in both accuracy and timeliness of trauma team activation was possible but required frequent training and constant reinforcement of the goals. The inability to continually sustain an acceptable level of success going forward was attributed largely to paramedic staff turnover that occurred frequently, as often as monthly. Accuracy deficits were often found to trend, unfortunately, among the new paramedic staff despite their training and orientation. This institution is now developing a plan to incorporate an ED float nurse in this process by making this nurse available on all EMS calls to hear the report firsthand, assist with activation decisions, and receive the incoming EMS patient on arrival.
- A profound improvement in both accuracy and timeliness of trauma team activation was possible but required frequent training and constant reinforcement of the goals. The goals included each trauma alert to contain standard information and to be sent within 5 min.
- Standardization of the process of Trauma Team activation alerts led to improved accuracy and times.
- The evidence-based practice review of related articles identifies the registered nurse as the most proficient at phone triage compared with the physician or others receiving information. The literature supported that nurses' experience level and critical thinking skills contributed to their accurate triage rates.
- Over time, standardization of the Com. Center staff to paramedics did not consistently improve trauma team activation time and accuracy, so future plans include incorporation of a nurse into this process.
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Keywords:Copyright © 2019 by the Society of Trauma Nurses.
Accurate communication; Ambulance triage; Trauma activation; Triage