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Policies,Clinical,UW Health Clinical,Emergency Response/Management

Pediatric Trauma (5.1.11)

Pediatric Trauma (5.1.11) - Policies, Clinical, UW Health Clinical, Emergency Response/Management

5.1.11


UW HEALTH CLINICAL POLICY 1
Policy Title: Pediatric Trauma
Policy Number: 5.1.11
Category: UW Health
Type: Inpatient
Effective Date: March 10, 2016

I. PURPOSE

To direct the optimal and expeditious management of pediatric trauma patients (age 17 and under)
according to criteria set forth by the American College of Surgeons Committee on Trauma (ACS-COT). This
policy only applies to the University Hospital and American Family Children’s Hospital.

II. POLICY ELEMENTS

American Family Children’s Hospital is an American College of Surgeons Level I Pediatric Trauma Center.
As a Level I Pediatric Trauma Center, w e provide facility resources and personnel available for trauma
patient care, in addition to education and research. These include, but are not limited to: neurosurgery,
complex orthopedic surgery, cardiac surgery, hand surgery, infectious disease, microvascular replantation
surgery, pediatric surgery, neuroradiology, cardiopulmonary bypass, operative microscopy, acute
hemodialysis and burn care. The trauma service actively engages in: performance improvement, injury
prevention, public education, trauma research, outreach and professional education programs. University
Hospital also serves as the South Central Regional Trauma Advisory Council’s (SCRTAC) lead hospital and
actively supports the State Trauma System.

UW Health provides optimal care for patients experiencing traumatic injury according to the guidelines of the
ACS-COT, regardless of race, creed, sexual orientation, gender identity, or the ability to pay.

III. ARRIVAL/ADMISSION PROCEDURE

All injured patients presenting to the Emergency Department (ED) at the University Hospital/American
Family Children’s Hospital, regardless of mode of arrival, or accepted through the Access Center, w ithin 24
hours of initial presentation follow ing injury, w ill be evaluated according to this policy. Patients requiring
transfer after 24 hours of initial presentation w ill be considered on an individual basis by the appropriate
admitting service.

Patients w ith multiple system injuries w ill be evaluated by the Pediatric Trauma Service (admission code
"STC"). Patients may be admitted and/or transferred to a subspecialty service after appropriate evaluation
by the trauma provider and the receiving service.

ED trauma evaluation of patients diagnosed w ith a single-system injury may be directly performed by the
Pediatric Emergency Department/Emergency Department (PED/ED) physician and the subspecialty service
and admitted to the appropriate subspecialty surgical service.

Patients w ith suspected child maltreatment and suspicion of physical injuries requiring medical evaluation
and treatment are to be evaluated in the ED and the Child Protection Program notif ied (UWHC policy #4.52,
Abuse, Neglect and Domestic Violence). All patients w ith acute injuries suspected to be from non-accidental
trauma that require inpatient admission for any reason need to be seen by the pediatric trauma team before
leaving the emergency department. If after consultation w ith the pediatric trauma team, injuries do not justify
further trauma surgery, critical care, or other surgical surveillance, including orthopedic or neurosurgery, the
patient may be admitted to a non-surgical service. If a patient w ith suspected child maltreatment is directly
admitted for other than injury-related purposes, and found to have actual injuries requiring further medical
evaluation and treatment, a trauma evaluation w ill be obtained w ithin an hour. Refer to Pediatric Non-
Accidental Trauma Guideline (available in the Trauma Manual on U-Connect).

Trauma patients requiring admission to the Pediatric Intensive Care Unit (PICU) w ill be co-managed by
Pediatric Trauma and Pediatric Critical Care services w ith the trauma attending surgeon leading the team.
Prior to admission to the PICU, the Pediatric Critical Care physician on call w ill be notif ied. All patient care
concerns w ill be addressed initially by the Pediatric Trauma Service.

For specialized trauma care of a pregnant patient please refer to UW Health clinical policy #5.1.3, Care of



UW HEALTH CLINICAL POLICY 2
Policy Title: Pediatric Trauma
Policy Number: 5.1.11

the Pregnant Trauma Patient in the Emergency Department at the University Hospital.

American Family Children’s Hospital w ill not be closed to or divert trauma patients unless the institution is in
an internal disaster mode. If every licensed bed is full, patients w ill be cared for in the ED and in the main
Surgical Services Post Anesthesia Care Unit (PACU). The decision to divert trauma patients w ill be made
collaboratively by the Pediatric Trauma Medical Director, Emergency Medicine (EM) physician and hospital
administration on-call after consultation w ith the AFCH Director of Pediatric Nursing. For additional
information please see Pediatric Diversion Policy (add reference)

IV. PEDIATRIC TRAUMA COMMITTEES

American Family Children’s Hospital Pediatric Trauma Management Committee (AFCH PTMC)

The AFCH PTMC is a combined committee encompassing the functions of the Trauma Program Operational
Process Performance Committee and Trauma Multidisciplinary Peer Review Committee. The committee is
dedicated to addressing, assessing, and correcting global trauma program and system issues and w orks to
correct overall program deficiencies to continue to optimize patient care. The members must attend at least
50% of the meetings. This committee must approve all other hospital protocols or policies that interface w ith
trauma care delivery.

Non-physicians are excused and the physician group review s select deaths, complications, and sentinel
events using objective data to identify issues and recommend appropriate responses.

Chairperson: Pediatric Trauma Medical Director
Members:
Pediatric Trauma Program Manager
Pediatric Medical Director
Pediatric Surgeon-in-Chief
Pediatric Trauma Surgeons
Pediatric Trauma Nurse Practitioner/Physician’s Assistant
Pediatric Neurosurgeon
Pediatric Orthopedic surgeon
Pediatric Emergency Medicine physician (PEM)
Pediatric Anesthesiologist
Pediatric Critical Care Physician
Children’s Hospital Emergency Transport Ambulance (CHETA) Pediatric Transport Coordinator
Med Flight Physician
Pediatric Director of Nursing
Pediatric Radiology
Pediatric Rehabilitation Medicine Physician
Pediatric Hospital Administrator
Pediatric Respiratory Therapist
Pediatric Intensive Care Unit Nurse Manager
Pediatric (P5) Clinical Nurse Manager
Pediatric Health Psychologist
Pediatric Case Manager
Pediatric Emergency Care Coordinator
Pediatric Child Life
Child Health Advocacy Program Director
Access Center Manager
Pediatric Trauma Registrar

V. MEDICAL COMMUNICATIONS

A. Referring Hospital Emergency Department Transfer:
i. The call is received by the Access Center and once identif ied as a trauma, according to policy, the
call is immediately connected w ith the Pediatric On-call Trauma Surgeon. If the Pediatric Trauma
Surgeon on-call is not available w ithin 5 minutes, the referring Provider is connected w ith the



UW HEALTH CLINICAL POLICY 3
Policy Title: Pediatric Trauma
Policy Number: 5.1.11

Emergency Department Administrative physician.
ii. If a head injury is suspected, the referring Provider is connected w ith the Pediatric Neurosurgeon
on-call. If the Pediatric Neurosurgeon on-call is not available w ithin 5 minutes, the referring
Provider is connected w ith the Emergency Department Administrative physician.
iii. If Med Flight is requested, the Access Center w ill immediately add Med Flight Dispatch (MFD) to
the call. Med Flight w ill follow their protocol for patient transfer.
iv. The Pediatric On-call Trauma Surgeon w ill be connected w ith the referring Provider to, determine if
transfer is w arranted solely based on the needs of the patient, offer recommendations for continued
care, and discuss transportation mode.
v. The Access Center nurse w ill connect the accepting surgeon w ith the Emergency Department
physician to give notif ication of the acceptance of a trauma transfer.
vi. The Access Center nurse w ill instruct the referring facility to send all imaging either w ith the patient
or by the PACS system and other documentation as indicated. Hospitals are encouraged to send
images via the PACS system, but if unable, a CD or hard copy must accompany the patient.
vii. The Access Center nurse w ill send a text page to the trauma chief residents to notify them of the
trauma w ith an approximate ETA and if images are available in PACS.
viii. The Access Center nurse w ill send a FYI page to the Pediatric Trauma Attending Surgeon w hen
the ED accepts a patient w ith “ED Accepted Trauma pt w ith multiple injuries, pt is/is not intubated,
MRN Last Name, First Name, Mechanism of Injury, ETA”
ix. The Emergency Department Care Team Leader (ED CTL) w ill determine the level of activation
follow ing the Pediatric On-call Trauma Surgeon report, referring facility nursing report, and/or
ambulance report and communicate the activation level to the Emergency Department Coordinator
(EDC).
x. The EDC w ill page out all patients arriving by ground or air ambulance w ith the appropriate
information as described below .
B. Scene/Ground/Air Ambulance Arrivals excluding Med Flight:
i. The PEM/EM physicians and/or the care team leader/charge nurse receive this call in the
Emergency Department.
ii. The ED CTL w ill determine the trauma activation level based on policy. The PED/ED physician,
Med Flight physician, or Pediatric Trauma Surgeon may upgrade at their discretion.
iii. The PEM/EM physician or care team leader/charge nurse w ill notify the EDC to page the trauma
w ith the required information as listed below .
C. Scene/Transfer requests for Med Flight:
i. Request for a f light w ill be received by Med Flight Dispatch and Med Flight policy and procedures
w ill be follow ed.
ii. Report must be communicated w ith the ED CTL prior to patient arrival.
iii. The ED CTL w ill determine the trauma activation level. The PEM/EM physician, Med Flight
physician, Pediatric Trauma Surgeon, Trauma Resident, or CTL may upgrade at their discretion.
iv. Required information for Pediatric Trauma Pages:
a. Beginning w ith the letter A (and cycling through the alphabet)(Trauma A)
b. The level (I or II)
c. Scene or transfer
d. Age/gender
e. Any airw ay, breathing or circulatory problems (indicate if intubated)
f. Mechanism of injury
g. Estimated time of arrival to our facility
Example: Trauma A, Level 1, scene, 13 yo male, intubated, high speed roll over, ETA 2030.

There w ill be instances that patients w ill arrive by ambulance or helicopter from the scene w ith a very short
notice. In these specif ic cases, the trauma page w ill be implemented ASAP w ith the ETA given of patient
arrival.

VI. STANDARD PRECAUTIONS

All personnel in the Trauma Bay must w ear personal protective equipment (PPE). This includes non-sterile,
latex-free gloves, impermeable gow ns, caps, and eyew ear plus mask or face shield to protect mucous
membranes of eyes, nose and mouth.




UW HEALTH CLINICAL POLICY 4
Policy Title: Pediatric Trauma
Policy Number: 5.1.11

Only trauma team members w ill be in the Trauma Bay. Other personnel may only enter at the request, or
w ith permission of the Trauma Chief Resident, PEM/EM and/or trauma staff.

Pre-hospital personnel, w hich include ambulance and aero medical staff, w ill transfer the patient to the
trauma team and then re-enter the Trauma Bay w ith proper PPE.

Refer to: UWHC policy #13.07, Standard Precautions & Transmission-based Precautions (Isolation) for
Inpatient Settings, and UW Medical Foundation Policy, MF Standard Precautions.

VII. DEFINITION OF LEVELS OF RESPONSE

The PEM/EM physician w ill be informed of all potential trauma admissions to the Emergency Department
regardless of mode of transportation. The ED CTL w ill determine the level of trauma activation for patients
arriving through Triage, via interfacility transfer, or from the scene. The initial level may only be upgraded by
Trauma Resident. This change in status must be communicated to all members of the trauma team via the
paging system.

Level I Trauma:

Trauma patients w ith any one of the follow ing pre-hospital physiologic abnormalities require an emergent trauma
team evaluation and activation as a Level I Trauma.

A. Cardiopulmonary Arrest
B. Intubated patients
C. Unstable airw ay – Respiratory distress/compromise/obstruction
D. Flail chest
E. Unstable VS (age specif ic)

AGE Respiratory Rate Heart Rate Systolic Blood Pressure (SBP)
0-6 months <40 or > 60 >180 <70
6-24 months <25 or > 50 >160 <72
3-7 years <20 or > 30 >140 <76
7-10 years <10 or > 30 >120 <84
11-17 years <10 or > 30 >120 <90

F. Transfers receiving blood to maintain VS
G. GCS < 8 or deteriorating by 2, w ith mechanism attributed to trauma
H. Gunshot or other penetrating w ound (stabs, impalement) to head, neck, torso, or proximal to elbow or knee
I. Amputation or crush proximal to w rist or ankle
J. Pulseless extremity/threatened limb
K. Transfer w ith intracranial bleed and GCS < 13.
L. Open or depressed skull fracture and GCS < 13.
M. Lateralizing neurologic signs or w orsening neurologic exam
N. Unstable pelvic fracture
O. 2 or more proximal long bone fractures
P. Hangings if meet any of the above criteria

Trauma Level II Activation Criteria Guidelines:

A. GCS 9-12
B. Trauma w ith full thickness burns > 10% TBSA
C. High voltage injury including lightning (excluding household electrical injuries)
D. Spinal cord injury w ith persistent neurological S/S and/or unstable vertebral fracture
E. Paralysis or focal neurologic deficit
F. Stable pelvic fracture
G. Ejection
H. Death in same passenger compartment
I. Extrication time > 20 minutes



UW HEALTH CLINICAL POLICY 5
Policy Title: Pediatric Trauma
Policy Number: 5.1.11

J. Vertical falls over 10 ft or 2-3 x’s the child’s height
K. Transfer w ith intracranial bleed and GCS 13-15
L. Open or depressed skull fracture and GCS 13-15
M. Abdominal injury w ithout hemodynamic compromise (distended/tender abdomen, abdominal bruising,
abdominal seatbelt mark)
N. High speed auto crash (> 40 mph)
O. Pedestrian vs auto, bike vs auto
P. Motorcycle/ATV/snow mobile etc crash > 20 mph
Q. Drow nings or near drow nings if suspected fall/trauma component
R. Rollover Motor Vehicle Collisions
S. Surgeon/Physician/CTL discretion (does not include dow ngrading)
*Consider upgrade by at least one level if on anticoagulants, hemophiliac, other bleeding disorders

Trauma Evaluation:
Any injured patient that does not meet Level I or II Activation Criteria and/or has been evaluated at a referring
hospital’s emergency department and is being transferred to the University Hospital/American Family Children’s
Hospital Emergency Department for further evaluation. These patients can not exhibit physiological abnormalities and
should have only suspected single system injuries. ED trauma evaluation of patients diagnosed w ith a single-system
injury may be directly performed by the Emergency Medicine physician and the subspecialty service and admitted to
the appropriate subspecialty surgical service.

VIII. TRAUMA TEAM ACTIVATION/EVALUATION ASSIGNMENTS

The Pediatric Trauma patients (age 17 years and below ) w ill be assessed by the follow ing:

LEVEL I LEVEL II TRAUMA EVALUATIONS
Pediatric Trauma Staff PEM or EM Physician PEM or EM Physician
Pediatric EM (PEM) or EM
Physician
Chief Resident EM Resident
PICU Attending or Fellow EM Resident Trauma Resident
Anesthesia Team Member Trauma Resident ED Nursing Staff
Chief Resident X-ray techs Child Life#
EM Resident Respiratory Therapist ED Social Worker#
Trauma Resident Medical Students*
X-ray techs ED Nursing Staff
Respiratory Therapist ED Social Worker
Orthopedic Surgery Child Life#
Neurosurgery
OR Charge Nurse
Medical Students*
ED Nursing Staff
ED Social Worker#
Child Life#
*= Observer
#= As available
Refer to “Guidelines for Response to Trauma Activations” in the Trauma Manual found on U-Connect.

IX. TRAUMA TEAM ACTIVATION/EVALUATION RESPONSIBILITIES

Pediatric Trauma Staff:
A. Attends all Level I Trauma patients w ithin 15 minutes of patients arrival time
B. Evaluates all Level II Trauma patients w ithin 12 hours of patient arrival time
C. Ultimate responsibility over all trauma patients
D. Observe and supervise
E. Attend multiple traumas

Pediatric Emergency Medicine Physician or Emergency Medicine Physician:
A. Attends all Level I, II, Trauma Evaluations



UW HEALTH CLINICAL POLICY 6
Policy Title: Pediatric Trauma
Policy Number: 5.1.11

B. Responsible for airw ay management w hen anesthesia team not present
C. Ultimate responsibility in Level I until trauma staff arrives
D. Ultimate responsibility for all Level II, Trauma Evaluation patients until arrival of trauma staff, hospital
admission and/or discharge from the ED
E. Will contact the Pediatric Trauma On-call surgeon to determine ED discharge (home) eligibility for all Level II
patients

Pediatric Critical Care Physician
A. Attends all Pediatric Level I Traumas and by request from the Trauma Chief Resident or PED/ED physician
w ill attend Level II Traumas
B. Works in collaboration w ith surgery and EM staff physicians to observe and supervise
C. Responsible for ventilatory management and sedation post intubation
D. Assist w ith vascular access, as needed

Trauma Chief Resident (PGY-4 or 5):
A. Attends all Pediatric Level I and II trauma activations
B. Direct responsibility under supervision (Trauma staff or EM physician)
C. Receives report from pre-hospital providers
D. Directs and orders major procedures
E. Monitors patients response to resuscitation
F. Does not perform or assist in procedures except for a deep peritoneal lavage (DPL), open thoracotomy, or in
situations w here multiple procedures are required
G. All orders from subspecialties must proceed through the Trauma Chief Resident
H. Communicates w ith patients families
I. Communicates w ith trauma staff prior to admission to PICU
J. Authority to surgically intervene w hen attending is en-route

Emergency Medicine Resident (PGY-2 or 3):
A. Primary evaluator for all traumas, alternating w ith General Surgery PGY-2-5
B. Verbalizes assessment for team aw areness
C. Performs procedures as directed by the Trauma Chief Resident
D. Responsible for documentation and orders
E. Remains w ith patient (or assigns PG-1) in CT or radiology as patients conditions dictates

Trauma Service Resident (PGY-2 or 3):
A. Primary evaluator for all traumas, alternating w ith Emergency Medicine Resident PGY -2 or 3
B. Verbalizes assessment for team aw areness
C. Performs procedures as directed by the Trauma Chief Resident
D. Responsible for documentation and orders
E. Remains w ith patient (or assigns PGY-1) in CT or radiology as patients condition dictates

Trauma Service Intern (PGY-1):
A. Secondary evaluator, rotating w ith EM PGY-1 residents
B. Performs procedures as directed by the Trauma Chief Resident
C. Responsible for documentation and orders
D. Remains w ith patient in CT or other diagnostic procedures outside the ED as patients condition dictates

Emergency Medicine Resident (PGY-1):
A. Secondary evaluator, rotating w ith Trauma PGY-1 residents
B. Performs procedures as directed by the Trauma Chief Resident
C. Responsible for documentation and orders
D. If Child Life not available, provides support to the pediatric patient and family
E. Remains w ith patient in CT or other diagnostic procedures outside the ED as patients condition dictates

Trauma Nurse Practitioner (NP)/Physician Assistant (PA):
A. Assists w ith order entry and patient supervision
B. Assists w ith procedures




UW HEALTH CLINICAL POLICY 7
Policy Title: Pediatric Trauma
Policy Number: 5.1.11

Anesthesia Team Member:
A. Responds to Level I Trauma activations
B. When requested by the Trauma Chief Resident or EM physician w ill attend Level II Trauma activations
C. Airw ay management in Level I/II Traumas under supervision of the EM physician or surgery attending if
other than an attending level anesthesiologist
D. Expanded role in multiple trauma scenario

Radiology Resident:
A. Review s all f ilms
B. Notif ies Trauma Chief Resident of any changes after Radiology staff reads

ED Primary Nurse:
A. Receives pre-hospital report, prepares room, begins documentation
B. Collaborates w ith Trauma Chief Resident and communicates tasks to team members as indicated
C. Obtains and communicates initial vital signs including f irst manual pressure, serial vital signs, CMS checks,
serial Glasgow Coma Score
D. Applies monitors/NBP cuff/pulse ox
E. Administers IV meds
F. Verbalizes vital signs, interventions, response to interventions
G. Accompanies patient out of the ED for diagnostic procedures
H. Provides support to patient and family w hen appropriate
I. Responsible for completeness of Trauma Flow Sheet and charge forms, IV labels
J. Pediatric RN w ill serve in this function w hen available to respond to Pediatric Traumas

ED Secondary Nurse:
A. Assists w ith removal of patients clothing
B. Temperature (post rectal exam)
C. NG and Foley as directed by the Trauma Chief Resident if not done by PGY-1
D. Administers and regulates blood products w ith blood w armer and rapid infusers as necessary
E. Administers tetanus prophylaxis, antibiotics and other medications as ordered
F. Anticipates procedures and prepares equipment as necessary
G. Checks and verbalizes lab results to the Trauma Chief Resident
H. Labels all f luid bags and IV sites

ED Care Team Leader:
A. Collaborates w ith trauma team regarding admission
B. Communicates w ith the OR care team leader/charge nurse
C. Provides crow d control
D. Interacts w ith EMS personnel and directs their activity
E. Assists in locating and notifying family members or delegates to social w orker, ED case manager or trauma
coordinator

Operating Room Charge Nurse:
A. Responds to the Trauma Bay to assist w ith coordination of the operating room if needed
B. Will not be involved in direct patient care but serves as a direct communication contact w ith the Trauma
Chief Resident
C. For a patient requiring an emergent trauma bay thoracotomy, the OR charge nurse w ill assist or assign a
scrub tech to assist
D. Patients w ho require emergent surgical intervention w hen the OR is at maximum capacity w ill be managed
as outlined in Surgical Services Departmental policy 2.29, Operative Triage of the Trauma Patient
E. Ensures communication w ith the trauma team is given to the anesthesia team especially w hen the patient
w ill be going to the OR from the Trauma Bay

ED Tech:
A. If Level I Trauma: prepares cooler, receives initial three units O negative packed red blood cells and one unit
of fresh frozen plasma, completes Blood Bank cooler validation form
B. Communicates w ith Blood Bank to process more products ordered by physicians
C. Responsible for receiving and delivering all blood products to the Trauma Bay



UW HEALTH CLINICAL POLICY 8
Policy Title: Pediatric Trauma
Policy Number: 5.1.11

D. Assists w ith unloading from Med Flight
E. Assists w ith removal of Med Flight stretcher
F. Places ID band
G. Establishes IV access, assess patency of existing lines
H. Foley placement
I. Compression (CPR) if needed
J. Label and send labs/urine
K. Assists w ith clothing removal
L. Collects and documents patients clothing, valuables
M. Assists w ith patient transportation
N. Assists w ith preparation of supplies and tray set-ups as needed

ED Recorder:
A. Records arrival times of personnel
B. Records primary and secondary assessments
C. Records vital signs, interventions and response to interventions
D. Records medication and f luid administration
E. Records times to and from CT or other diagnostic procedures
F. Records lab results
G. Receives ID band from registration and gives to ED Tech
H. Calls OPO if indicated for a GCS
I. Level I, II and Trauma consults must be documented using the Trauma Flow Sheet

ED Coordinator:
A. Notif ies PEM/EM staff of trauma patient’s arrival
B. Obtains and enters demographic information ASAP
C. Will implement Unidentif ied Patient if information not readily available (refer to UWHC policy #8.29,
Unidentif ied Patient)
D. All Level I Trauma patients w ill be registered as a Unident patient
E. Delivers trauma admission pack and ID band to the recorder ASAP
F. Directs EMS, policy, and family members and notif ies Care Team Leader of families arrival
G. Obtains identifying information for registration purposes from personal effects received from trauma team
members

Respiratory Therapist:
A. Document PSI on portable oxygen tank on the Trauma Flow Sheet
B. Reports ETT size, location, initial SaO2 and end tidal CO2
C. Assists w ith airw ay management, including assisting w ith all aspects of intubation
D. Sets ventilator or other oxygen delivery systems w ith setting provided from Trauma Chief Resident or Peds
Intensivist
E. Ensures pulse oximeter and end-tidal CO2 monitors are available
F. Must be present for all Level I Trauma patients and intubated patients and may be excused only upon the
approval of the Trauma Chief Resident

Radiology Technologist:
A. Respond to the Trauma Bay w ith f ilms
B. Develops initial f ilms before taking other f ilms
C. After CT, trauma patients can have additional f ilms taken in the radiology room

Social Worker:
A. Communicates w ith patient’s family
B. Liaison betw een trauma team and family
C. Support to patient and families

Child Life Specialist:
A. Provides support to the pediatric patient and family
B. Communicates w ith the patients family




UW HEALTH CLINICAL POLICY 9
Policy Title: Pediatric Trauma
Policy Number: 5.1.11

Pharmacist:
A. Prepares medications as directed by the Trauma Chief Resident
B. Records medications given during resuscitation

Trauma Program Manager:
A. Resource for trauma team
B. Assist w ith communication

X. MULTIPLE VICTIM TRAUMA RESPONSE GUIDELINES

A. The Multiple Victim Trauma Response Guidelines should be implemented by the ED CTL if multiple trauma
victims (Level I or II) arrive simultaneously to the ED but not necessarily from the same incident.
B. Implementation of the Multiple Victim Trauma Response Guidelines should take into consideration ED
overcrow ding status, patient acuity, ED staff ing, physician discretion and/or any other situations w here
needs outw eigh resource availability.
C. Additional assistance from the Trauma Surgery team should be requested immediately by paging the
multiple victim trauma paging list.
D. The multiple victim trauma page w ill include the follow ing communication: “Multiple victim trauma”, Adult
and/or Peds (all that are appropriate), estimated number of patients, patient location (here now , in route, at
scene), and estimated time of arrival.
E. Each trauma patient w ill be paged out individually according to the leveling criteria met via the appropriate
paging list (Adult Level I, Adult Level II, Peds Level I, Peds Level II).
F. Staff ing assignments w ill be at the discretion of the Trauma Attending Surgeon and EM/PEM Attending.
G. Additional personnel w ill be assigned to the Emergency Department as needed by nursing administration.

Follow ing consideration by the ED Attending, Trauma Attending Surgeon or Trauma Program Manager, ED
CTL, and Nursing Coordinator, the External or Internal Disaster plan may be activated (refer to UWHC policy
#12.04, Emergency Management Plan).

XI. BLOOD BANK PROCEDURES

Level I Traumas w ill have three units of O negative packed red blood cells and one unit of fresh frozen
plasma dispensed w ith a Typenex band, to the Trauma Bay. The blood w ill be sent via the pneumatic tube
and placed in a labeled cooler w ith ice or w ill be delivered in a cooler to the Trauma Bay by a carrier. Blood
w ill remain w ith the patient at all times including any transports to the CT scanner.

Blood arriving w ith the trauma patient from an outside hospital that is not being infused, w ill be sent to Blood
Bank for evaluation and testing.

Massive Transfusion Protocol (MTP):

If a trauma patient requires multiple units of blood products, the ED Attending or Trauma Attending Surgeon
may implement the MTP. This is done by calling the blood bank and implementing the MTP order in Health
Link. Refer to UW Health clinical policy #2.2.2, Massive Transfusion Procedure.

Operating Room and Blood Products:

If MTP is activated, the Primary Nurse w ill communicate w ith the OR care team leader/charge nurse the
number of units of blood being sent w ith the patient. This w ill also be documented on the Trauma Flow
Sheet.

XII. PERFORMANCE IMPROVEMENT AND PATIENT SAFETY

Performance improvement is a continuous process of monitoring, evaluating and correcting clinical
performance, outcomes and systems related to trauma care delivery.

The Trauma Medical Director in collaboration w ith the Trauma Program Manager develop quality f ilters,
perform audits, identify case review s, track trends and/or sentinel events, recommend actions to improve



UW HEALTH CLINICAL POLICY 10
Policy Title: Pediatric Trauma
Policy Number: 5.1.11

trauma care and peer performance. The systematic Plan - Do - Check - Act model adopted by UW Health is
used to identify, prioritize and operationalize program improvement efforts.

Deaths, complications, peer or systems issues and cases are review ed each w eek at the Trauma Program
Improvement Conference. The Trauma Medical Directors, Surgical Trauma Staff physicians, Trauma Chief
Resident, Residents, Medical Students, Physician Assistants, and Trauma Program Managers attend this
conference.

The Pediatric Trauma Management/Peer Review Committee meets quarterly to review selected deaths,
complications and sentinel events. Representatives from orthopedic, neurosurgery, emergency medicine
and anesthesia along w ith the trauma surgeons must attend at least 50% of these meetings.

The Surgical Morbidity and Mortality Committee is a multidisciplinary peer review body that determines
peer performance for the Trauma Service. Deaths and complications are referred to the committee for
review of preventability, disease process or provider relationship.

The AFCH Quality Coordinating Council review s the Pediatric Trauma Program Performance
Improvement activities on a bi-annual basis.

XIII. FORMS

Blood Bank cooler validation form

XIV. COORDINATION

Author: AFCH Pediatric Trauma Program Manager
Senior Management Sponsor: SVP, Medical Affairs
Review ers: Pediatric Trauma Medical Director; ED Clinical Operations Committee
Approval committees: Pediatric Trauma Management Committee; UW Health Clinical Policy Committee;
Medical Board
UW Health Clinical Policy Committee Approval: February 15, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

XV. APPROVAL

Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

XVI. REFERENCES

American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient:
2006. Chicago IL, American College of Surgeons, 2006.
Surgical Services Departmental policy #2.29, Operative Triage of the Trauma Patient
UWHC policy #7.44, American Family Children’s Admissions
UW Health clinical policy #5.1.3, Care of Pregnant Trauma Patient in the Emergency Department at the
University Hospital
UW Health clinical policy #2.2.2, Massive Transfusion Procedure
UWHC Administrative policy #12.04, Emergency Management Plan
UWHC policy #13.07, Standard Precautions & Transmission-based Precautions (Isolation) for Inpatient
Settings



UW HEALTH CLINICAL POLICY 11
Policy Title: Pediatric Trauma
Policy Number: 5.1.11

UWHC policy #8.29, Unidentif ied Patient
UWHC policy #4.52, Abuse, Neglect and Domestic Violence
Pediatric Non-Accidental Trauma Guidelines
Guidelines for Response to Trauma Activations

XVII. REVIEW DETAILS
Version: Revision
Next Revision Due: March 10, 2019
Formerly Know n as: Hospital Administrative policy #8.21