Trauma (Blue) OR Schedule


1	Falls KPI
2	Goal:	100% of eligible patients discharged from the Trauma Service after having experienced a fall, will be referred to the CP Falls Prevention Pilot Program; as evidenced by diagnosis of Fall in Problem List and Contact info into AVS
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5	1	Ensure the problem list is up to date at the time of tertiary survey
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7	2	Fall" is to be listed as a hospital based problem on the Problem List within Epic
8	3	Please include in all fall patient AVS the DCHOMEPILOT or DCFACILITYCPPILOT dot- phrase. This can be entered by choosing "ADT" then "Discharge" then "Patient Education." The dot phrase may be entered here
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15	Medical Reconciliation KPI
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17	Goal:	All patients will have a completed medication reconciliation within 24 hours of admission
18	1	Call patient’s pharmacy to verify meds, doses and frequency.
19	2	In ADT in the Admission section, click on “Med Rec-sign” in the sidebar.
20	3	Click on “Review Home Medications.”
21	4	Enter medications, doses and frequency and when last taken. If already entered, check for accuracy. If not accurate, please correct by choosing delete (not discontinue).
22	5	Click “next” which will bring you to “Reconcile Home Medications”
23	6	Click on “order, don’t order, or replace” One must be chosen for each medication.
24	7	On the bottom left of the screen there is a drop box for “Med List Status” Choose “Complete”, “In process”, or “unable to assess.” If unable to complete, fill out the "add note" tab. This must be followed up, until reconciled.
25	8	Please add the medical reconciliation column to your working trauma list so you can see when this has been completed
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27	Foley Catheter KPI
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29	Goal:	All patients with a foley catheter as designated by the "foley" column on the patient list home screen will be discussed on morning rounds, including indication
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32	Tertiary Survey KPI
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34	Goal:	All patients will have a tertiary survey complete within 24 hours of admission to include accurate medication reconciliation, identification of PCP and obtain any available records, and complete appropriate tertiary survey documentation
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36	Daily Report KPI
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38	Goal:	During morning report every day, the following will be discussed:
39		1. Presence of central lines and daily attestation
40		2. Updated estimated date of discharge
41		3. Foley catheters in place
42		4. Need for outpatient DVT prophylaxis on discharge
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44		In order to complete the above, the following dot phrase should be placed on the sign off report for all trauma and soft tissue patients:
45		.traumachecklist
46		[ ] Foley? [ ] Updated discharge date [ ] Outpt DVT ppx? [ ] CVC? [ ] tertiary


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2	Post-Discharge DVT Prophylaxis for Trauma Patients
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4	Patients who remain significantly immobilized at the time of discharge, such as those with spinal cord injury, pelvic fractures or long bone fractures, remain at risk for DVT and PE. A prophylactic regimen should be maintained until full mobility is resumed with full mobility being defined as the patient being weight bearing as tolerated on both lower limbs, or for a period of at least 4-6 weeks. A low molecular weight heparin (LMWH), such as enoxaparin, is preferred given its efficacy in the trauma population. If a patient has contraindications to LMWH (e.g. renal dysfunction) or chooses not to use LMWH, an alternate therapy should be considered. Alternatives may include aspirin, warfarin, or subcutaneous heparin (in the rehabilitation setting). Follow up and decision to stop prophylaxis will remain the responsibility of the trauma service unless positively handed off to the primary care provider.
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6	A. Patient selection for post-discharge anticoagulation:
7	Patients who remain significantly immobilized due to injury will continue anticoagulation after discharge from the hospital, regardless of their disposition (i.e. home, skilled nursing facility, acute rehab). Specific subgroups are as follows:
8	1. Spinal cord injury (complete or incomplete motor paralysis)
9	2. Pelvic fractures requiring operative repair with prolonged immobility (>5 days)
10	3. Complex long bone fractures that limit mobility (i.e. open fractures, more than one fracture in same extremity, or multiple fractured extremities) or any fracture (including non-op pelvic fracture) that results in the patient being other than WBAT on bilateral lower extremities as their weight bearing status.
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12	B. Medication selection for post-discharge anticoagulation:
13	Provided that there continues to be no contraindications to anticoagulation, extend current approach for inpatient DVT prophylaxis with modifications as noted below. With the exception of spinal cord injury, patients may be discharged home on enoxaparin 40 mg SC daily to improve adherence. Patients with SCI are most likely being discharged to a rehab facility where they will have support for twice daily injections.
14	Enoxaparin:
15	SCI: Enoxaparin SC, 30 mg twice a day
16	Pelvic Fractures: Enoxaparin SC, 40 mg once a day
17	Complex Long Bone Fractures of Lower Extremities: Enoxaparin SC, 40 mg once a day
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19	C: Monitoring for enoxaparin:
20	Platelet count within 1 week of discharge if patient has been on enoxaparin <14 days at discharge to assess for heparin-induced thrombocytopenia.
21	BMP two weeks after discharge if patient has any history of renal impairment.
22	Note: Coagulation monitoring (e.g. PTT, Anti-Xa levels) is not recommended
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24	D: Contraindications to enoxaparin:
25	Contraindications to enoxaparin will have been considered during the patient’s hospital course and should be reviewed at discharge as well, and include:
26	- Familial bleeding disorder
27	- Thrombocytopenia (Platelets <100,000)
28	- Severe renal impairment (CrCl <30mL/min)
29	- History of heparin induced thrombocytopenia
30	- High likelihood of noncompliance
31	- Unsuitable home environment to support self-management
32	For patients who have contraindications to enoxaparin or choose not to use enoxaparin after risks and benefits are explained, consider aspirin 160 mg PO daily.
33	The reason for alternative therapy to enoxaparin should be documented in the patient’s medical record.
34	Spinal cord injury patients who have contraindications to enoxaparin or choose not to use enoxaparin should be treated with dose-adjusted Coumadin therapy with target INR between 2.0 and 3.0.
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36	NOTE:
37	· Anticoagulation medications should be given until adequate mobility (WBAT bilateral lower extremities) is regained. Spinal cord injury patients should be treated for 3 months.
38	· If patient has a contraindication to anticoagulation, consider inferior vena cava filter placement if risk of PE is considered to be extremely high. See appendix.
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40	References:
41	Bridges GG, Lee MD, Jenkins JK, et al. Expedited Discharge in Trauma Patients Requiring Anticoagulation for Deep Venous Thrombosis Prophylaxis: The LEAP Program. J Trauma 2003; 54:232-5.
42	Rumbaugh K, Gondek S, Davis, S. Vanderbilt University Medical Center Multidisciplinary Surgical Critical
43	Care: Venous Thromboembolism Prophylaxis Guidelines. 2015. Retrieved from https://medschool.vanderbilt.edu/trauma-and-scc/files/trauma-and-scc/public_files/Manual/VTE%20Prophylaxis%20Guidelines%20Final%202-10-15.pdf on 1/8/2016.
44	Gould MK, Garcia DA, Wren SM et al. Prevention of VTE in Nonorthopedic Surgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141; e227S-277S.
45	Pulmonary Embolism Prevention (PEP) Trial Collaborative Group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) Trial. Lancet 2000; 355: 1295-302.
46	Guillamondegui O, Hamblin, S. Vanderbilt University Medical Center Practice Management Guidelines for Venous Thromboembolism Prophylaxis, Division of Trauma and Surgical Critical Care. 2014. Retrieved from https://medschool.vanderbilt.edu/trauma-and-scc/files/trauma-and-scc/public_files/Protocols/Trauma%20DVT%20Prophylaxis%20Guidelines%202014.pdf on 1/8/2016.
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48	Appendix:
49	Consideration of IVC filter for very high risk patients. Very High Risk patients include: SCI; greater than 3 long bone fractures; severe pelvic fracture (post elements) & long bone fracture (upper or lower); AIS (head and neck) greater than or equal to 3 & long bone fracture (upper or lower) (Vanderbilt).


1	Week Of 10/2-10/6			Trauma:	Carter		Burn/wound:	Sawhney		Residents:	Alex, Astrid
2		OR	Time	Attending	Procedure	Case Coverage	Clinic	Attending	Clinic Coverage
3	Monday						Monday
4			06:30 - 07:00		Morning Report		AM clinic:
5			07:00 - 08:00		Resident Conference		PM clinic:
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7			1110	Hallagan	PEG tube	Jamie or Alex
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11	Tuesday						Tuesday
12			06:30 - 07:00		Morning Report		AM clinic:
13			07:00		PIPS		PM clinic:
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20	Wednesday						Wednesday
21			06:30 - 07:00		Morning Report		AM clinic:
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23			1310	Carter	R BKA	Alex
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25							PM clinic:
26	Thursday						Thursday
27			06:30 - 07:00		Morning Report		AM clinic:
28			07:00 - 10:00		Resident conference		PM clinic:
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30	Friday						Friday
31			06:30 - 07:00		Morning Report		AM clinic:
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38							PM clinic:
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40				Attending	Pager		APPs	Pager
41				Ciraulo	741-6192		Erin Bacon	741-6148
42				Eddy	741-8415		Darlene Lessard	741-6156
43				Grindlinger	741-8413		Heather Lawler	741-7643
44				Hallagan	741-8101		Courtney Minzy	741-6744
45				Sihler	741-1415		Gail Cloutier	741-8198
46				Rappold	741-6256		Eric Beaver	741-3350
47				Sawhney	741-6259		Kim Henriques	741-1067
48				Carter	741-6475		Rose Paine	741-0358
49				Cheung	741-8287		Valerie Nye	741-1438
50				Chung	741-1515		Reid Holland	741-1595
51				Turner	741-1589		Mollie Bash	741-1434
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53							Social Work	Phone #
54							David Schwarz	662-1072
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1	Week Of 12/5-12/9			Trauma:	Hallagan		Burn/wound:	Carter		Residents:	Jamie Tung, Isabel Bernal
2		OR	Time	Attending	Procedure	Case Coverage	Clinic	Attending	Clinic Coverage
3	Monday						Monday
4	Heather, Rose, Eric		06:30 - 07:00		Morning Report		AM clinic:
5			07:00 - 08:00		Resident Conference		PM clinic:
6			07:20	Carter	EUA, I&D Labia Abscess	Isabel
7			?	Carter	Foot Ray vs. TMA	Isabel?
8			?	Carter	Burn Excision	Jamie?
9			?
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12	Tuesday						Tuesday
13	Heather, Gail, Rose		06:30 - 07:00		Morning Report		AM clinic:
14		3	10:45-12:25	Eddy	Ins PEG tube/G-tube	Isabelle	PM clinic:
15		14	11:00-13:10	Carter	Rt Flank Burn Exc; Stsg to Rt Flank	Isabelle
16		14	13:30-15:10	Carter	Rt Posterior Knee Non Healing Wound	Jamie	Isabel appt 1430
17		14	15:30-17:40	Carter	Foot Wound Debridement Vs Amp	Jamie
18		3	15:50-17:00	Hallagan	PEG tube insert	Jamie
19		14	18:00-19:10	Carter	Sacral Decubitus Debridement	Isabelle
20	Wednesday						Wednesday
21	Darlene, Gail, Heather		06:30 - 07:00		Morning Report		AM clinic:
22	Orient: Valerie						PM clinic:
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31	Thursday						Thursday
32	Darlene, Rose		06:30 - 07:00		Morning Report		AM clinic:
33	Orient: Valerie		07:00 - 10:00		Residen Conferences		PM clinic:
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42	Friday						Friday
43	Darlene, Erin, Eric		06:30 - 07:00		Morning Report		AM clinic:
44	Orient: Valerie						PM clinic:
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55				Attending	Pager		APPs	Pager
56				Ciraulo	741-6192		Erin Bacon	741-6148
57				Eddy	741-8415		Darlene Lessard	741-6156
58				Grindlinger	741-8413		Heather Lawler	741-7643
59				Hallagan	741-8101		Courtney Minzy	741-6744
60				Sihler	741-1415		Gail Cloutier	741-8198
61				Rappold	741-6256		Eric Beaver	741-3350
62				Sawhney	741-6259		Kim Henriques	741-1067
63				Carter	741-6475		Rose Paine	741-0358
64				Cheung	741-8287		Valerie Nye	741-1438
65				Chung	741-1515		Reid Holland	741-1595
66				Turner	741-1589		Mollie Bash	741-1434
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68							Social Work	Phone #
69							David Schwarz	662-1072
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1
2	Morning report
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4		8-9 AM	Wound care nurses will come during rounds, usually at 8:00	When present (and ideally when skin soft tissue attending is present, these patients will be discussed
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6	"Trauma" Service	Place all patients on the MMC Surgery, Blue list on admission
7		All patients require tertiary exams within 24 hours of admission
8		Please see KPIs tab for current and former KPI instructions
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10	"Burn, Skin/Soft Tissue" Service ("Red")	Place on both Trauma and the Burn lists if primarily ours (ie if trauma CMs will be involved)
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12	ICU "White Surgery" Service	ICU Functions indepnendently
13		Trauma patient's managed by White in the unit, then become blue when they come out
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17	Clinic	Mixed bag with general surgery, consider sending people
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19	Protocols	DVT prophylaxis & screening	DVT US weekly for all trauma patients	Lovenox prophylaxis unless contraindication
20		Head trauma
21		Anticoagulation reversal
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25	Wound care Rounds	4th Tuesday of the month 12-1 pm. Bean 2 conference room (confirm with wound care providers)


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2	1. Admission ECG and another at 8 hours should be performed in any patient suspected of having BCI
3	2. If admission ECG results are normal, pursuit of diagnosis can be terminated. However, if they are abnormal then the patient should be admitted for cardiac monitoring for 24-48 hours
4	3. If the patient is hemodynamically UNstable then an imaging study such as an echocardiogram should be obtained
5	4. The presence of a sternal fracture does NOT predict the presence of BCI and thus does not mandate continuous monitoring in the face of a normal ECG
6	5. Neither CPK-MB nor troponin T are useful in predicting which patients will have BCI


1	Burn Documentation
2	1	All Patients will have the estimated or extact TBSA in the assessment on daily notes and admission note (NOT a range)
3	2	All Patients will have the mechanism of injury outlined in the assessment on daily notes and admission note (ie flame, scald, etc)
4	3	All Patients will have the location of their burns (and depth) described in the assessment on daily notes and admission note
5	4	All admission notes for burn patients will include photo documentation of burns pre and post debridement
6	5	"Burn Man" image will be placed in the body of all burn admission notes
7		1	go to "more activities" on the bottom left of your epic window
8		2	select "images," a picture of a person with arrows
9		3	search "burn" at top left by the green plus sign
10		4	Select the adult or child burn as appropriate
11		5	choose appropriate colors or patterns
12		6	use the rhomboid shape tool (far left, third row) to outline the areas of burns. Use different colors or different patterns for varying depths
13		7	Use the "#" tool to add comments
14		8	Close the image, it will save automatically
15		9	To insert in your note, select "add images." A warning may pop up but simply move on
16		10	Double click your burn image to insert and adjust size as needed