Zuckerberg San Francisco General Clinical Practice Manual for Trauma
Zuckerberg San Francisco General Hospital, Trauma Services
UCSF Department of Surgery
Version 2.0, November 2001
This manual has been prepared specifically for members of the surgical house staff at Zuckerberg San Francisco General Hospital providing care for trauma patients. It is designed to define and clarify service coverage issues, trauma team activations, admissions, transfers, initial evaluations, documentation, interactions with consultants, and issues related to performance improvement. Zuckerberg San Francisco General is the sole provider of organized trauma care for the City & County of San Francisco and northern San Mateo County. Patients are transported to Zuckerberg San Francisco General, not by choice, but by virtue of the actual and potential injuries they have sustained. Zuckerberg San Francisco General, operating as a Level 1 Trauma Center under the California Code of Regulations, Title 22, is obligated by regulatory law to provide specific services and responses to critically injured patients.
Many of the requirements included in this manual are based on this regulatory law, or requirements set forth by the American College of Surgeons Committee on Trauma. As in any complex organization involving patient safety, consistency & redundancy are critical elements. As a member of the health care (trauma) team at only designated Trauma Center in San Francisco, it is important that you appreciate the importance of the role you play in regional public safety and the overall emergency medical response, a role which is unlike any other in a surgical residency program.
The second portion of this document is a compendium of clinical management protocols for trauma. These protocols have been developed at Zuckerberg San Francisco General and reflect current practice at this institution. They are not intended to be used as a locked-in set of rules, but as guidelines which are applicable to most, but not all clinical situations. The list of protocols is not yet complete, and more are being added. Major deviations from these protocols, while occasionally necessary, should involve members of the Zuckerberg San Francisco General surgical faculty.
Every effort will be made to distribute this manual to each house staff member prior to their rotation at Zuckerberg San Francisco General Hospital. Each member of the resident staff will be responsible for reviewing the Clinical Practice Manual thoroughly. Each member of the junior and senior house staff will be responsible for also becoming familiar with the Clinical Management Protocols for Trauma and managing their practice on the surgical service in accordance with the guidelines & protocols set forth in this manual. Questions and suggestions should be directed to Carol Shagoury, but any of the surgical faculty will be willing to provide clarification as needed. The practice of Trauma Surgery is challenging, fast paced, and can be extremely rewarding. It is hoped that this manual will provide a framework around which you can better structure your clinical education during your time at Zuckerberg San Francisco General Hospital.
Robert C. Mackersie, M.D.
Professor of Surgery,
Division of General Surgery
Director, Trauma Service and Vice Chief of Surgery,
Zuckerberg San Francisco General Hospital and Trauma Center
CLINICAL COVERAGE : ATTENDING STAFF
The "Service Attending"
As the result of reductions in house staff and the implementation of work hours restrictions, it was necessary to eliminate the old system of multiple surgical services. All surgical inpatients are now admitted and cared for as part of a large, single surgical service, generically referred to as the "Trauma Service", although elective and emergency general, vascular, and thoracic patients will also be admitted to this service. The service is covered at all times by an attending physician, the ":service attending", who will make rounds with the surgical team (or individually with the senior or Chief resident) on a DAILY basis. The service attending will have primary responsibility for all patients hospitalized on the Trauma Service, and will be available 24 hours a day during the period of service coverage, unless substitute coverage arrangements are made. Any problems that arise on in-patients or established consults should be referred to the Service Attending. The service attending shall serve as the attending-of-record for service in-patients in need of operative procedures, unless other arrangements have been made. In the event that the service attending is not immediately available for acute emergencies that arise on service patients, the on-call attending should be contacted.
The "ON-CALL" Attending
For each 24 hour period (9am-9am), an on-call attending is assigned. This attending will be responsible for covering all new admissions, consults, trauma resuscitations, and trauma and emergency procedures. Most of the time, the on-call attending will be physically present in the hospital, and will be immediately available to respond to trauma and other surgical emergencies at all times. A card with attending contact numbers may be obtained from the administrative staff in the Department of Surgery at Zuckerberg San Francisco General.
The surgical staff member who attends at an elective operative procedure generally serves as the attending of record and the principal decision-maker for subsequent patient care, unless other arrangements have been made between individual attendings. The surgical staff member who attends at an emergent operative procedure may elect to have the service attending assume care of the patient post-operatively and act as the attending-of-record. In either case, the attending staff member acting as the principal decision maker should be clearly identified to the house staff.
Sub-specialty surgical attending consultants
Attending consultants are available for special problems involving burns, thoracic, vascular, pediatric surgery, and surgical critical care. All consultations for acute and in-patient trauma problems should be cleared with either the on-call attending or the service attending.
CLINICAL COVERAGE : HOUSE STAFF
The Chief Resident (PGY V)
The Chief Surgical Resident on the Trauma team will have clinical responsibilities similar to those of the ‘Senior’ surgical residents, but will also have overall responsibility for the service and all of the trauma in-patients at Zuckerberg San Francisco General Hospital. The ‘Chief’ will provide more senior supervision, as needed, for surgical resident team, and ensure its smooth operation. The Chief Resident will take in-house trauma & emergency call every third night and be responsible for responding immediately to all ‘911’ level activations. In the event the Chief is involved in elective surgery or some other non-emergent activity that might interfere with an immediate response to a ‘911’ trauma team activation (TTA), it is his/her responsibility to ensure that either the Trauma Attending or a PGYIV level resident will respond instead. Neither a PGYII nor a PGYIII level surgical resident may substitute for a Chief Resident or a Senior resident under these circumstances.
The Senior Residents (PGY IV)
The ‘Senior’ surgical residents on the Trauma service will take in-house call every third night, provide out-patient clinic coverage as needed on post-call days, and provide coverage for operative procedures, as needed, on pre-call days. The ‘Seniors’ will also respond immediately to all ‘911’ TTAs during their on-call periods, and respond promptly (within 15") to ‘912’ level TTAs. Both Chief and Senior residents will remain available at all times, either by phone or pager, for emergency call-back and multi-casualty incidents at Zuckerberg San Francisco General, unless specifically excused by the Chief of Surgery at Zuckerberg San Francisco General.
The Junior Residents (PGY II, III)
The ‘Junior’ surgical residents on the Trauma service will maintain a schedule similar to that of the ‘Senior’ residents and will also respond immediately to ‘911’ level resuscitations. ‘Junior’ surgical residents will respond as soon as possible, if not immediately, to ‘912’ level TTAs, and be responsible for communicating any urgent patient needs or serious condition immediately to the on-call Chief or ‘Senior’ resident. The ‘Junior’ residents will assist w/ trauma resuscitations under the direction of the ‘Chief’ or ‘Senior’ residents, including the transport & monitoring of patients to CT or angiography. The PGYIII level resident may not act as a substitute for the Chief or ‘Senior’ resident for ‘911’ level TTAs.
Interns (PGY I)
The surgical interns will respond to ‘911’ and ‘912’ trauma team activations, and assist with trauma resuscitations only as needed and directed by the more senior surgical residents, or the ED attending staff.
4th Year Medical Students ("Sub-interns")
Acting interns, "sub-I’s", may respond to ‘911’ and ‘912’ TTAs and assist in the same manner as interns, but generally should NOT be involved, unless specifically requested by a Senior or Chief resident, in trauma-related procedures conducted during the resuscitation.
3rd Year Medical Students
Surgery 110 students (3rd year) should be NOT be involved in trauma resuscitation except as observers. Exceptions may be made under unusual circumstances, but only as directed by the Chief, Senior residents or the Trauma Attending surgeon.
CLINICAL COVERAGE : TRAUMA NURSE PRACTITIONERS
Zuckerberg San Francisco General currently employs 3 trauma nurse practitioners. They are highly trained providers who function under the supervision of the Zuckerberg San Francisco General Trauma Medical Director and a Senior Hospital Administrator. Nurse practitioners are members of the Zuckerberg San Francisco General ancillary medical staff and are licensed and approved to independently prescribe medications and treat patients, within a defined scope of practice. Their primary responsibilities are to trauma patients. Depending on service needs, volume, and acuity, the NPs may admit and assume primary care of patients, assist with discharge planning, see clinic patients independently, and act as a consultative liaison to rehabilitation and other services. As of this writing, they may not care for ICU patients, direct trauma resuscitations, or assist in the operating room. These functions may be added at a later date. All NP in-patient care activities must be consistent and coordinated with the overall patient management plan as directed by the trauma attending or trauma Chief resident.
TRAUMA TEAM ACTIVATIONS
‘911’ and ‘910’ level activations
Criteria for ‘911’ and ‘910’ trauma team activations are attached. These activations require and immediate response on the part of the Chief or ‘Senior’ on-call surgical residents. Insofar as the majority of ‘911’ activations require hospital admission, these patients are assumed to be the primary responsibility of the Trauma Service upon ED arrival. Unless and until it is established that a ‘911’ patient will not require hospital admission, the senior members of the Trauma Service (Attending, Chief, or ‘Senior’ resident) will be the primary decision makers in the course of managing these patients. The ED staff will act as consultants and assist with the resuscitation as will members of other services including anesthesiology, neurosurgery, orthopedics, etc.
‘912’ level activations
Criteria for ‘912’ level activation is attached. These patients are at risk for sustaining major injury, but without evidence of significant physiological changes. These activations require a prompt response by the Trauma Chief or ‘Senior’ resident. If and when a ‘912’ patient presents with indications for hospital admission (e.g. long bone fractures), they become the primary responsibility of the Trauma Service. ‘912’ patients without obvious indications for hospital admission will be the primary responsibility of the ED staff. The Trauma Service, under these circumstances, will act as consultants. Conflicts that arise over diagnostic or treatment issues will be resolved between the senior ED and Trauma staff.
Any patient who presents to the ED with, or develops indications for, a higher level of TTA than was originally made, will automatically trigger a second, upgraded TTA. A TTA upgrade may be triggered, at any time, and regardless of the presence in the ED of senior trauma team members. It will be the responsibility of the ED staff and the trauma team members in attendance to ensure that the upgrade is recognized and a page sent.
Mandatory trauma attending response: the ‘900’ level activation
The American College of Surgeons guidelines for a Level 1 Trauma Center requires that a board eligible or certified, trauma-qualified surgeon be present in the ED for major resuscitations. A ‘900’ page is triggered by the ED charge nurse, based either on pre-hospital or on-arrival patient status. This page is received only on designated ‘900’ pagers, carried by the on-call trauma attending and sometimes by the on-call attending anesthesiologist. Trauma attendings will respond to the ED within 15 minutes of this page. ‘900’ level activations may be triggered at any time during the initial resuscitation, and are based on established hypotension, respiratory distress (or need for intubation), gunshot wounds to the neck or torso, or for multiple patients & mass casualty incidents.
Trauma activations with minor or unclear mechanisms
Patients presenting to the ED with seemingly minor or unknown mechanisms and altered (911-type) physiology will trigger a ‘911’ TTA if any reasonable suspicion of a trauma etiology exists. This determination will be made by either the ED attending or charge nurse.
TRAUMA RESUSCITATIONS: ROLES & RESPONSIBILITIES
Leadership, decision making, and the "team approach"
Each resuscitation must have a "team leader", who organizes the team and "conducts" the resuscitation, as well as someone, typically the most experienced physician, making the major diagnostic and therapeutic decisions. Occasionally this may be the same person, but more often not. Collaboration is critically important, and should involve all physicians providing care during a trauma resuscitation. The following guidelines apply to these roles and responsibilities:
For ‘911’ level activations involving patients with decompensated shock, respiratory distress, head-injury related obtundation or coma, and multiple GSWs to the chest or abdomen, the Trauma Chief or ‘Senior’ resident will act as the ‘team leader’. These are ‘900’ level activations, involving the Trauma Attending Surgeon who will typically be the principal decision maker. The ED Attending & resident will assist, as needed with these resuscitations.
For ‘911’ and ‘910’ activations that do not meet the criteria for a ‘900’ level resuscitation as outline above, the ED resident in conjunction with the ED Attending, will act as the resuscitation "team leader". The ED team must work collaboratively with the Senior or Chief trauma resident, who will be responsible for making or approving major therapeutic and diagnostic decisions. If, at any time and for any reason, the ED resident is unable to act as an effective ‘team leader’, the role will be assumed by the trauma Chief or Senior resident.
For ‘912’ level activations, the ED resident, in conjunction with the ED attending, will act as the resuscitation "team leader". Major diagnostic & therapeutic decisions will be made collaboratively by the ED staff for patients not requiring hospital admission and by the trauma Chief/Senior residents for patients requiring hospital admission.
Airway management, including tracheal intubations will be the responsibility of the anesthesiology team, working in conjunction with the Trauma team. All related medications administered during trauma rapid sequence inductions (RSIs) will be prescribed or administered by the anesthesiology staff.
Sub-specialty services, neurosurgery, orthopedics, pediatrics, are consulting services during trauma resuscitations working collaboratively with the trauma team. All major decisions based on sub-specialty consultation as well as any sub-specialty related procedures must be made or cleared by the principal decision maker.
The following guidelines apply to procedures performed during resuscitation in the ED by the trauma team or ED team:
All procedures must be supervised by an ED attending or Trauma Senior/Chief resident
Strict aseptic technique, including wide prep & draping, should be followed at all times.
Procedures in critically injured patients should not be performed, even if supervised, by house staff lacking complete familiarity and substantial experience with that procedure.
3rd year medical students should not be performing any procedures.
ED residents, both UCSF and non-UCSF, should be given priority, within the limits of their experience and capabilities, in performing trauma resuscitation procedures.
Resuscitative thoracotomies and cricothyroidotomies should only be performed by Trauma Senior of Chief residents or Trauma Attending surgeons
Endotracheal intubations should only be performed by a member of the anesthesiology team, unless specifically directed otherwise by the Anesthesiology Attending.
PATIENT ADMISSIONS & CONSULTATIONS
Basic Criteria for Admission To the Trauma Service
All patients requiring hospital admission on the basis of demonstrated or suspected acute traumatic injury will be initially admitted to the Trauma Service until a complete diagnostic evaluation is completed and appropriate service transfer arrangements, if needed, can be made. All ICU admissions for trauma patients should be initially to the Trauma Service.
Exceptions to this rule include the following:
Isolated orthopedic injuries to the extremities without suspicion of associated vascular or neurological injury may be admitted to the orthopedic service
Minor isolated head injuries, cleared by the Trauma service, and not requiring ICU or 4B admission may be admitted to the neurosurgery service.
Serious isolated head injuries, completely cleared of associated injuries by the Trauma service, seen & examined & cleared by the on-call Trauma attending, and seen & examined by the neurosurgery attending or Chief resident may be admitted to the neurosurgery service if OK’ed by both the Trauma Attending and Neurosurgical Attending or Chief.
Pediatric patients cleared by the Trauma service for discharge, but admitted separately by the pediatric service
On rare occasions, patients with severe or complex underlying co-morbidity (e.g. severe CAD, COPD) may require admission precipitated on the basis of a minor or moderate injury. Admission to a subspecialty service may be appropriate, but should be cleared with the Attending Trauma Surgeon on-call.
Trauma consults are requested by the ED staff or sub-specialty services, and involve non-trauma team activation patients. Patients meeting the following guidelines require evaluation by a Senior Trauma resident or above:
Any patient with a trauma-related mechanism requiring ICU or Step-down admission by a non-trauma service.
Any patient with major or minor mechanism with any complaints of abdominal pain or signs of abdominal injuries.
Patients with major mechanism trauma not resulting in TTA, who require hospital admission for any reason.
All trauma patients being transferred to Zuckerberg San Francisco General from out-of-region
Surgical sub-specialty consultations
Additional consults may be requested by the on-call trauma team, as needed.
Burn patients requiring admission: Mandatory notification of the on-call Trauma attending followed by notification of the on-call burn attending.
Blunt aortic injury: Mandatory notification of the on-call trauma attending followed by contacting the cardio-thoracic on-call surgeon. If Zuckerberg San Francisco General on-call staff are unavailable, then the UCSF-Parnassus campus on-call CT surgeon should be notified.
Axial spine injuries: Mandatory notification of the on-call spine team.
Complex pediatric trauma: Mandatory notification of the on-call trauma attending followed by notification of the pediatric surgeon on-call.
EMERGENCY DEPARTMENT DISPOSITION
Critical Care Patients (intubated and non-intubated)
Current hospital policy dictates that intubated patients will be physically admitted to an ICU bed within 30 minutes of ICU notification. The E.D. charge nurse is responsible for ICU notification. Approval by the Critical Care resident for intubated patients is not required. Patients requiring radiographic studies (e.g. CT scans or angios) should not return to the E.D., but should be transported directly to the ICU post-radiology. Non-intubated patients will be admitted within 30 minutes of ICU resident approval (verbal or otherwise). Under no circumstances should a critical care patient be held in the E.D. for prolonged diagnostic studies.
All trauma patients requiring critical care unit admission will be admitted to the Trauma Service except for clearly defined, isolated head injuries, which may be admitted to the neurosurgery service.
Monitoring of critical care patients in radiology
All patients requiring ICU admission should be attended by at least a junior resident (PGY2 or higher), while undergoing studies in radiology (CT/angio). The trauma senior staff (Senior, Chief, Attending) will be immediately available to these patients.
All patients for whom the trauma team is activated will be evaluated by the senior or chief resident. The senior or chief resident is also responsible for completing the Trauma Consultation (Evaluation) form on all trauma patients admitted to the hospital. The practice of junior residents routinely completing the form for the senior or chief resident's signature is unacceptable. Occasionally the demands of mass or multiple (>3) casualty events require that junior residents complete the form. Under these circumstances, however, the patient must be evaluated by a senior/chief resident and documentation to that effect provided on the form. In addition to the trauma evaluation form completed by the trauma Chief/Senior resident, all admitted patients must also have a complete history & physical exam completed by the PGYI, PGYII, or NP admitting the patient.
COMMUNICATION & THE ‘CHAIN OF COMMAND’
Poor communication constitutes one of the most common failures of the system of care for trauma patients and results in errors, delays, and even preventable deaths. Gaps in the continuity of care are thought to be a major cause of preventable medical errors and are often linked to poor communication. The house staff at Zuckerberg San Francisco General has historically been allowed a greater degree of autonomy and latitude in independent decision-making than exists at most other hospitals within the UCSF system. This "supervised autonomy" has also been an important and popular element in the UCSF resident educational program, and one in which the Zuckerberg San Francisco General faculty continues to be committed to. In order to prevent errors and sub-optimal decision making by house staff involved in learning & accruing experience however, it is critical that the "chain of command" and good communication be maintained. The following are a set of guidelines regarding physician to physician communication.
Communication with the on-call Trauma Attending
Timely notification / discussion with the trauma attending will be made for:
All trauma service patients requiring operative intervention for traumatic injury
All patients with acute findings on abdominal or chest (CT) scan, (+) DPL, or (+) FAST, cardiac echo, exam possibly suggestive of serious injury.
All patients requiring admission to ICU or step-down unit
Any request from an out-of-county facility for emergent trauma patient transfer
All cases requiring diagnostic or therapeutic angiography
All pediatric patients requiring hospital admission
Following the admission/operation of multiple high acuity trauma patients, and as soon as time permits, the senior/Chief resident should perform a brief but systematic review/discussion/re-evaluation of these patients w/ the on-call Trauma Attending
Any instance of a major change in clinical status:
Development of any shock state
Urgent / emergent need for intubation
Significant change in LOC or neurological status
Communication with the Service Attending & "Surgeon of Record"
Discussion RE scheduling, staffing, positioning, etc. of any OR case*
Courtesy call notifying attending of case start*, if not present in OR
For senior house staff starting an operative case: immediate notification of attending for any major unexpected findings
Immediate notification for change in patient physiologic status in OR or evidence of ongoing hemorrhage
Discussion with ‘surgeon of record’ RE any subsequent surgical complications
Daily discussion of all service patients and significant consultations (typically on rounds) w/ service attending
Prompt notification of service attending of major changes in clinical status for service patients
Communication & "sign-offs" between house staff members & nurse practitioners
For PGYII,III residents responding to trauma resuscitations prior to the arrival of the Senior/Chief resident: Immediate notification of senior house staff or attending staff for any abnormal physiology or potentially serious injuries.
Comprehensive review & sign-off for all patients admitted (new to the service) during the previous 24 hours
Comprehensive review & sign-off for patients waiting in the ED for admitted to the Trauma Service
Comprehensive review & sign-off for patients being evaluated in the ED whose admission has not yet been determined
Pending & completed diagnostic studies on all new patients
SERVICE TRANSFERS & REPATRIATION
Transfers IN, from other acute care facilities to Zuckerberg San Francisco General
Transfers to Zuckerberg San Francisco General may come from within the county of San Francisco, or from out-of-region. In-county transfers occur as a matter of policy and do not require prior approval. In most instances in-county trauma transfers will be indistinguishable from field triaged trauma patients.
Requests for transfers from out-of-region (e.g. Marin, Lake counties) may be accepted if: 1) There are beds available at Zuckerberg San Francisco General and 2) They involve a level of care (LOC) transfer [see attachments] regardless of insurance status OR they do not involve a LOC transfer and are covered by an acceptable form of insurance. The procedure for acceptance of out-of-county trauma patients in included in the attachments.
Transfers OUT, to other acute care facilities from Zuckerberg San Francisco General
When a patient is being transferred out to a non-trauma center (NTC) from Zuckerberg San Francisco General, it represents a down-grade in the level of care. Such transfers are generally discouraged, but may occur in the setting of patient/family wishes or as the result of HMO contractual arrangements. When the later occurs, it is termed "repatriation", and involves the transfer of a patient from a non-HMO hospital to an HMO hospital, typically for financial reasons. Insofar as "repatriation" transfers rarely are of much medical benefit to the patient, particularly when they involve transfer to an NTC, they occur only under certain circumstances, and only when the risks of the transfer is outweighed by the benefits. In all cases of transfers, approval by the trauma Service Attending and/or the surgeon-of-record must be obtained. The process and guidelines for transfers-out may be found in the attachments.
Zuckerberg San Francisco General Service Transfer Guidelines
As a general rule, all major mechanism trauma patients, and those with multi-system injuries admitted to Zuckerberg San Francisco General will be admitted initially to the trauma service.
CROSS COVERAGE & BACK-UP DURING HIGH VOLUME PERIODS
Due to the lack of other trauma receiving hospitals in San Francisco, Zuckerberg San Francisco General does not divert trauma patients except during disaster/mass casualty incidents. While the on-call attending and resident staffing is generally sufficient to mange a normal volume of trauma patients, this capacity is exceeded, usually 3-4 times each year, during high volume/acuity periods. For this reason, it is important that a back-up team be available to return to the hospital, usually for limited periods, during these situations. At the beginning of each Zuckerberg San Francisco General Trauma rotation, each house staff member (PGY II-V) will received a laminated card with contact numbers for the Zuckerberg San Francisco General surgical faculty, as well as the UCSF house staff. It is the responsibility of each member of the house staff, while on rotation at Zuckerberg San Francisco General, to remain available by pager, cell phone, home phone, or some other means, in the event that return to the hospital becomes necessary. Special arrangements for out-of-town travel may be made through the Zuckerberg San Francisco General Chief of Surgery’s office. The back-up schedule is as follows:
Primary team: Scheduled on-call attending & house staff team
1st back-up: Scheduled back-up attending & pre-call house staff team
2nd back-up: Pre-call / post-call attending & post-call house staff team
CONFERENCES & TRAUMA PERFORMANCE IMPROVEMENT (QA)
In order to continue to improve the trauma care provided at Zuckerberg San Francisco General and the performance of the surgical services, a variety of conferences and resources are available. It is recognized that the quality & consistency of care provided at Zuckerberg San Francisco General must take into account a constantly changing array of providers (house staff), who are in various stages of their surgical education. The overall goal of trauma-related conferences & performance improvement (PI) activity is the continuing development of a system that will provide optimal care to the injured patient, and yet still provide a rich educational environment for physicians-in-training.
Trauma videotape review conference
Each Tuesday 10-11am, Emergency Medical Services Conference Room. Videotaped resuscitations are review and management principals & algorithms are discussed. Led by a member of the surgical or ED faculty. All trauma house staff not in the OR involved in emergency patient care are expected to attend.
Departmental Morbidity & Mortality Conference
Each Wednesday 10-12am. All house staff not involved in emergency patient care are expected to attend. Led by the Trauma Chief Resident.
Trauma Program Coordinator & Trauma Case Managers
Carol Shagoury (TPC), leads a team of trauma case managers who assist in the management of the trauma program. One of their functions is to manage the trauma performance improvement program, and capture all significant errors, complications, and problems that occur in the course of providing trauma care at Zuckerberg San Francisco General. The case managers work closely with the Trauma Director on program development & monitoring. Any significant system or provider-related problems encountered in the course of patient management should be reported back to one of the case managers.
Clinical Management Protocols for Trauma
The purpose of the CMPs (attached), is to reduce undesirable physician-related variability (and errors) in the management of trauma patients. The principals learned on elective surgical rotations at other hospitals may not be applicable to the critically injured trauma patient, and the "making- it-up-as-we-go-along" approach is completely unacceptable and even dangerous in this environment. Surgical house staff responsible for making or formulating decisions in the management of trauma patients should be familiar with the relevant protocols contained in this document. Questions, comments, & critiques are welcome.
Appendix E: SCOPE OF ADMINISTRATIVE AND NON-DIRECT PATIENT CARE RESPONSIBILITIES
Trauma Attending Panel
- Board eligible or certified, general surgery.
- Demonstrated commitment and regular involvement in the care of injured patients.
- Demonstrated educational involvement in trauma care (e.g. lectures, ATLS instructor, etc).
- Ability and willingness to adhere to trauma regulatory requirements described in Article 1, and to the requirements of this performance agreement.
General responsibilities and on-call requirements
Immediately available by phone at all times for trauma-related problems in and out of Zuckerberg San Francisco General.
Will not become engaged in any non-emergent clinical or non-clinical activity that may act to diminish availability or decrease response time to provide care for the crucially injured patient in the absence of a formally designated and appropriately available back-up trauma surgeon.
Will not provide, nor be on-call to provide clinical care at any institution other that Zuckerberg San Francisco General while on trauma/emergency call.
Adherence to Zuckerberg San Francisco General policies and procedures in regards to trauma-related care.
Adherence to Dept. of Surgery and Trauma Program P&P related to trauma care including activation of back-up physicians.
Be available by phone or pager when on back-up trauma call.
Non-direct care responsibilities.
On call and immediately available to the ED, OR, or other patient care areas, as needed, for the care of the trauma patient when a PGY5 surgical resident is not similarly available.
On call and promptly available to the ED, OR, or other patient care areas, as needed, for the care of the trauma patient when a PGY5 surgical resident is immediately available.
Present and involved in important therapeutic decisions during major resuscitations. Presence and involvement must be suitably documented, and compliance must be at least 80%.
Participates on a regular basis in Trauma Multi-disciplinary Peer Review Conference. Attendance, (per ACS guidelines) must be at least 50% for each trauma panel member.
Participates, as needed, in TQA committee activities and trauma program performance improvement.
Participates in trauma-related outreach programs, including lectures and ATLS courses.
Participates in Trauma Video Tape Review conference.
Works with Emergency Department Physicians, nursing supervisors, and referring physicians in coordinating the transfer of patients from NTC facilities.
Works with the trauma clinical case managers and receiving physicians in the process of coordinating transfer OUT of appropriate patients to NTC facilities.
Performs periodic chart reviews for purposes of trauma performance improvement work & case evaluations.
Provides clinical supervision, as needed, for trauma NPs.
Assists in development and implementation of trauma protocols & guidelines.
Participates in targeted training relevant to Trauma Service objectives for nursing staff, NP, ancillary staff and other health care providers as necessary.
Supports trauma-related research & publication activities.
Works with the TMD and ‘business manager’ to help assure fiscally responsible patient management, as measured by the number of decertified days resulting from factors under control of the service, by facilitating timely discharge of inpatients, timely referral to rehabilitation services, and ensuring appropriate utilization of diagnostics and therapeutics.
Appendix F: SCOPE OF PATIENT CARE RESPONSIBILITIES
Trauma Attending Panel
Qualifications: As per Appendix E
General responsibilities and on-call requirements: As per Appendix E
On-call responsibilities: PGY5 surgical resident on call in-house
Responds promptly  to the emergency department for all major resuscitations as defined , and provides direct and/or supervisory care as needed.
Provide timely and substantive chart documentation for all major resuscitations , including initial critical care services.
Respond to all community and out-of-region requests for consultation.
Respond to requests for urgent consultations from the E.D. & other hospital areas as needed.
Be present in the OR, ensure adequate documentation, and directly supervise & provide instruction for the conduct of all major trauma operative procedures performed by General Surgery House Staff. 
Additional on-call responsibilities: PGY5 surgical resident not on call and available.
In addition to meeting all the obligations described in section III, on call trauma attendings will have the additional responsibilities when a PGY4 surgical resident is on call without a Chief Surgical resident:
Responds immediately to the Emergency Department (ED) for all major resuscitations and provides direct and/or supervisory care as needed. 
Responds immediately to the ED for patients with any evidence of major active hemorrhage, shock, transfusion requirements in the ED, or amputations/near-amputations.
Provide prompt and direct supervision and care for any patient requiring emergent arteriography for any reason, for any patient requiring ICU admission, or for any patient likely to need a major operative procedure. 
 The attending surgeon is expected to be present in the ED upon patient arrival in all patients meeting the hospital specific guidelines for defining a major resuscitation when given sufficient advance notification from the field OR within fifteen minutes of trauma team activation when the advance notification is short. Documentation of compliance with this requirement must be 80% or greater.
 The minimum criteria for the definition of a major resuscitation are as follows:
CONFIRMED Blood pressure < 90 at any time in adults and age specific hypotension for children
Respiratory compromise/obstruction and/or intubation or need for intubation.
Transfer patients from other hospitals receiving blood to maintain vital signs;
Gunshot wounds to the abdomen, neck, or chest;
GCS < 8 with mechanism attributed to trauma.
Triage code conditions (disaster activation: ‘999’) or other multiple casualty incident.
Emergency Department Attending Physician's discretion;
 Major operative procedures: thoracotomy, laparotomy, laparoscopy, median sternotomy, extremity (vascular) or neck explorations, amputations/ near amputations, cricothyroidotomy/tracheostomy