Trauma Telemedicine Transfer Guidelines

1. D. Lee Binnion, MD Trauma Telemedicine Transfer Guidelines

2. Trauma Current standards-Resources for the Optimal Care of the Injured Patient-2006 Best practice for treatment Golden Hour Based on ABC�s Obtaining consultations Arranging transport

3. Key Concepts Patient�s condition is time-sensitive Minimize hospital time by expediting the transfer of care to the transport team at the sending facility Safety is a top priority Predictors of success Effective communication Proper patient packaging & preparation Secure helipad Controlled patient loading

4. Current ACS Standards Four Levels of Trauma Centers-Established by ACS-COT Level I-Usually population dense areas 1200 admissions/year or 240 with ISS>15 24 hr in-house surgeons-dedicated to Trauma Response In ER within 30 minutes of patient arrival �Surgically directed� Critical Care Service Residency training affiliation Research and outreach programs

5. Current ACS Standards Level II-less population dense areas Lead Trauma Facility for a geographic area No admission number criteria 15 minute response time Dedicated to the Trauma patient with established BU Works closely with rural facilities to improve care

6. Current ACS Standards Level III- Capability to manage the majority of initial trauma patients Transfer Agreements with Level I or II centers for patients that exceed their resources Continuous general surgery coverage Field activation criteria 30 minute response time from arrival Need well established criteria for initiating transfers Injury prevention, outreach and education

7. Current ACS Standards Level IV- Rural facilities Limited resources Supplements care within a larger trauma system Provides initial evaluation and resuscitation 24 hour ER coverage by a physician May or may not have specialty coverage Need well organized resuscitation team Well defined transfer plans and agreements in place

8. SARMC Pre-Hospital Leveling Criteria: Level 3 Death of same car occupant Rollover Fall or jump 2x patient�s height Auto vs bike Auto vs pedestrian Motorcycle/ATV/snowmobile/jet ski �crashes� Horse rollover/ejection >12� intrusion into occupant space/vehicle

9. SARMC Pre-Hospital Leveling Criteria: Level 3 �Star� any window Broken/bent steering wheel Assault w/change in LOC Second or third degree burns < 10-20%. Drowning Amputation�one or more digits

10. SARMC Pre-Hospital Leveling Criteria: Bump from 3 to 2 if: Pregnancy (strongly consider) Extremes of cold or heat w/prolonged exposure(strongly consider) Extremes of age <12 or >55 Co-morbidities (COPD, diabetes, CHF, etc) Presence of intoxicants or illicit drugs Transfer from another facility.

11. SARMC Pre-Hospital Leveling Criteria: Level 2 Ejection from enclosed vehicle Glasgow Coma Scale 9-13 Chest tube Pelvic fracture (suspected) Two obvious long bone fractures (femur/humerus) Flail chest Spinal cord injury or limb paralysis Cervical fracture Burns > 20% or involving face, airway, hands, feet, or genitalia

12. SARMC Pre-Hospital Leveling Criteria: Level 1 Confirmed Systolic Blood Pressure of 90 or less. Respiratory rate > 24, Tachycardia >120 at any time in adults. Age specific hypotension in children:<70 mmHg + 2 X age HR > 200 or < 60 Respiratory compromise/obstruction. Intubation. Inter-facility transfer patients receiving blood to maintain vital signs.

13. SARMC Pre-Hospital Leveling Criteria: Level 1 GCS 8 or less with mechanism attributed to trauma. Major limb amputation. Trauma Arrest. Pregnancy > 20 weeks gestation with vaginal discharge or bleeding or abdominal pain that also meets Level 3 criteria. Hanging with LOC or any neuro deficits. Near drowning. Penetrating injury to abdomen, head, neck or chest.

14. Transfer Criteria Suggestions:Immediate Transfer BP < 90mmHg, or Respiratory rate >24, Tachycardia >120 at any time in Adult trauma patients Age specific hypotension or tachycardia in children <70 mmHg + 2 X age HR >200 or < 60

15. Transfer Criteria Suggestions:Strongly Consider Respiratory compromise/obstruction Intubation Patients receiving blood to maintain vital signs GCS <8 with mechanism attributed to trauma Major limb amputation Pregnancy >20 weeks gestation with vaginal discharge or bleeding or abdominal pain that also meet a mechanism attributed to trauma.

16. Transfer Criteria Suggestions:Strongly Consider Hanging with loss of consciousness or any neurological deficits Near drowning Penetrating injury to abdomen, head, neck or chest. Trauma arrest

17. Transfer Criteria Suggestions:Strongly Consider GCS 9 to 13 Chest tube in place Pelvic fracture (suspected) Two obvious long bone fractures (femur/humerus) Flail Chest

18. Transfer Criteria Suggestions:Strongly Consider Spinal Cord injury or limp paralysis Cervical Fracture Ejection from an enclosed vehicle Burns >20% or involving face, airway, hands, feet, or genitalia

19. Transfer Criteria Suggestions:Strongly Consider Patients involved in a serious mechanism and also have the following; transfer should be strongly considered: Extremes of cold or heat with prolonged exposure Extremes of age <12 or >65 Co-morbidities (Anti-coagulant use, COPD, diabetes, CHF, etc.) Presence of intoxicants or illicit drugs

20. Initial Call1-877-367-8855 Advise of major injuries If outside scope of SARMC, we will give referrals to appropriate facilities and offer to arrange transport with MAC We will determine if resources available at time of receiving patient ICU availability OR availability Specialist availability

21. Best Practices for Treatment Golden Hour of Trauma Dr. Cowley-MIEMS Initial evaluation and resuscitation begun within 1 hour of traumatic event (may be pre-hospital) Improved outcomes in almost every study Based on the ABC�s Airway control with C-spine precautions Breathing effectiveness Circulation Disability Evaluation of entire patient

22. Stabilization ABCs If potential for airway compromise, suggest intubation If uncomfortable with intubation, Life Flight can do it on their arrival Follow ATLS protocols 2 large bore IVs, supplemental O2 for everyone

23. Emergent Interventions Tracheal Intubation Inadequate oxygenation Inadequate Ventilation Clinical need Protection of the cervical spine Emergent stabilization of head trauma Prevention of secondary head injury Aggressive treatment of neurogenic shock

24. Emergent Interventions Decompression of tension pneumothorax Decompression and control of open pneumothorax Stabilization of flail chest Decompression of massive hemothorax Decompression of cardiac tamponade

25. Emergent Interventions Aggressive resuscitation of shock Recognition of potential aortic dissection and other severe thoracic injuries Recognition of massive intraperitoneal bleeding Stabilization of open book and severe pelvic fractures Prevention of hypothermia Prevention of pressure ulcers

26. Suggested Studies X-Rays CXR, especially if planning to fly Pelvic X-Ray All others not necessary Labs H/H

27. Patient Packaging: Multi-System Trauma Flight team will assess patient in the ED Peripheral IV access x 2 Supplemental oxygen Backboard and c-collar re-apply c-collar if removed If already off the backboard, it does not need to be re-applied

28. NG/OG Foley Preflight meds PRN Nausea In-Flight anxiety Flight team may request return to the ED for further stabilization Patient Packaging: Multi-System Trauma

29. Multi-System Trauma Reversal of anti-coagulation Medically necessary? Vit K 10 mg IV or IM FFP, if available PRBC (O-neg or cross-matched) to accompany patient Sometimes Life Flight will bring extra blood if requested

30. Obtaining ConsultationsArranging Transports For All Emergency Transfers Call Saint Alphonsus Access Center for �one stop shopping� 1-877-367-8855

31. Obtaining ConsultationsArranging Transports Decision to transfer is based upon your decision If you know early, call early If results of studies reveal need to transfer, call as soon as it is determined If you are not sure, we can arrange robotic consultations No need to contact a specialist Trauma or Neurosurgeon if transfer is demanded by patient status For patient consults if immediate transfer is not available for weather or other reasons Contact the Access Center at Saint Alphonsus They will obtain connection with specialists for consultation

32. Robotic Consultations New service with Saint Alphonsus Trauma Services Contact the Access Center at Saint Alphonsus Will be routed to on call Trauma Emergency Consultant Robotic consultation will then ensue with ability to assist with any patient that may require more than the usual resuscitation and transfer

33. Special Situations Burns If meet criteria for a burn center, should go directly there We can handle some burns, but in transfer we will discuss with the trauma doc first Plastics Major tissue loss that would require plastic surgery should be referred elsewhere

34. Special Situations Ocular trauma Dr. Boerner is the only oculo-plastic specialist. Potential transfers should be discussed with him. Hand injuries If there is no vascular compromise, most can be seen the next day. Discuss with the on call before emergent transfer.

35. Contact Information:Emergency Services Brian Boesiger, M.D., FACEP Medical Director, Emergency Services (208) 322-1730 Po Huang, M.D., FACEP Medical Director, IDN (208) 322-1730 Ted Ryan, MBA, RN Service Line Director (208) 367- 3219 Linda Martin, RN Emergency Services Director (208) 367-7223

36. Contact Information:Medical Access Center and Life Flight David Kim, M.D., FACEP Medical Director, Life Flight (208) 322-1730 Ted Ryan, MBA, RN Service Line Director (208) 367- 3219 Rita Schaeffer, RN Access Center manager� (208) 367-8186

37. Contact Information:Stroke Services Dr. Mary River Medical Director, Stroke Program (208) 367 � 7272 Nichole Whitener, RN CNRN Service Line Director, Neuroscience (208) 367- 2233 Jane Spencer, RN Stroke Coordinator (208) 367 - 2937

38. Contact Information:Cardiology Services Dr. Steven Writer Medical Director, Cardiac Service Line (208) 367 � 7272 Dr. Donald Stott Cardiologist (208) 367 � 8484 Paula Coulter Service Line Director, Cardiology (208) 367- 3115

39. Contact Information:Trauma Services Rick Foss, MD, FACS Medical Director, Trauma Program (208) 367�6803 Jana Perry, RN Service Line Director, Trauma Program (208) 367-3079 Bill Morgan, MD, FACS George Munayirji, MD Steven Casos, MD

40. Referral Resources Salt Lake City, Utah University of Utah Burn Center 801-581-2700 University of Utah main number 801-581-2121 Portland, Oregon Oregon Health Science University main number 503-494-8311 Emanuel Hospital and Health Ctr Portland (burn center) 503-413-2200

41. Referral Resources Seattle, Washington Harbor View Medical Center main 206-731-3000 U. of Washington Burn Center 1-888-744-4791 ext 43597 -Transfer Center Sacramento, California Shriner�s Burn Unit 1-866-714-7123. 18 years-old and under

42. Effective Communication Pre-planning Managing expectations (today) ETA notification Flight team will provide a 5-minute heads-up prior to arrival Is 5-min enough time to get the patient to the helipad? Essential clinical info What does the flight team need to know to provide care? Clinical information form: short & sweet