Introduction
Deteriorating trauma patients
The early recognition and response to clinical deterioration is vital in order to prevent adverse events in the patient care episode including: avoidable morbidity, cardiac arrest, unplanned ICU admission and death. There is clear evidence that changes in physiological vital signs precede these events and research indicates that failure to appropriately manage these deteriorations directly leads to adverse outcomes for the patient.
Data from the Victorian government from 2010-2011 show that of the admissions direct to ICU from the ED, 70% were recognized as critically ill or injured on arrival, with 30% assessed as moderate to low acuity who then had an unplanned ICU admission.2
Early recognition of clinical deterioration is essential for timely escalation of care, clinical response and appropriate management of the patient’s condition.3
Medical Emergency Teams (MET) in hospitals are designed to review patients in the early stages of deterioration in order to attempt to reduce serious adverse events, cardiac arrests and unplanned ICU admissions. That same principle applies to the ED with a similar team based approach to trauma management. 4(See below)
| Similarities and differences between MET services and trauma team | ||
| Variable | Trauma team | MET service |
| Location of patient | Emergency department or trauma centre | Hospital ward |
| Team leader | Typically emergency department doctor | Typically intensive care unit registrar |
| Patient profile | Young with few co-morbidities | Elderly with multiple co-morbidities |
| Presenting problem | Trauma | Hypoxia, hypotension and tachycardia |
| Need for early intervention | Concept of “golden hour” | Shown for sepsis, myocardial ischaemia, stroke |
A fundamental feature of emergency care is managing that risk of clinical deterioration. Trauma patients, however, can be more complex and the sudden deterioration of any particular vital sign may be the result of the complex interaction of several injuries.
Trauma patient management requires careful observation in the period from arrival at the healthcare facility with a focus on two key outcomes of traumatic injury:
- Primary injury: the outcomes of the initial mechanical forces that occur from the traumatic event.
- Secondary injury: not mechanically caused outcomes of traumatic injuries that may be superimposed on the primary injuries already identified.5
Key to successfully managing a deteriorating major trauma patient is rapid assessment and intervention with escalation of care to external resources where there are no local resources available, or when patient care is beyond the capacity of the health service.6
Early communication with ARV clinicians and using tele/videoconference facilities may provide additional support and guidance to clinicians.
ACSQHC. (2017, Spetember 4). NSQHS Standards (second edition). Retrieved from Australian Commission on Safety and Qaulity in Health Care: https://www.safetyandquality.gov.au/our-work/assessment-to-the-nsqhs-standards/nsqhs-standards-second-edition/
Track and Trigger
The Australian Commission on Safety and Quality in Health Care (ACSQHC) recommend that all patients in acute care settings have access to a standardised system of response to guide healthcare providers. Track and Trigger systems actively promote the early recognition of clinical deterioration through regular assessment of vital signs (tracking) and aid in supporting clinical decision making via identification of predetermined physiological criteria (triggers) that indicate when to escalate care. The implementation across all health services of Recognising and responding to clinical deterioration (Standard 9) is now fundamental to health service accreditation7. This approach uses standardised, colour-coded charts with ‘track and trigger’ mechanisms to guide escalation of care, reflecting approaches required under the essential elements of the standards. In the 2nd edition currently being introduced across Australia, this standard is now changing to Recognising and responding to acute deterioration (Standard 8). The new standard builds on the existing Standard 9 from the first edition. The main changes are that the new standard recognises that deterioration can be physiological, mental or both. Therefore systems need to be in place to recognise and respond to patients’ physical and mental deterioration.8
Click to enlarge
Click to enlarge