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Brighton and Sussex University Hospitals
C081 – RSCH Adult Trauma Call Policy
Version: 1
Category and number: C081
Approved by: Clinical Policies Steering Group/TEC
Date approved: May 2019
Name of author: Clinical Lead, Major Trauma Centre
Name of responsible committee/individual: Trauma Committee
Name of responsible director: Nurse Director
Date issued: May 2019
Review date: May 2022
Target audience: Trustwide
Accessibility This document is available in electronic format only
Linked documents BSUH massive transfusion Policy
BSUH Paediatric Trauma Call Policy
PRH Trauma Call Policy
BSUH Helideck operational Policy
2
Contents
Section Page
1 Introduction 3
2 Purpose 3
3 Definitions 3
4 Responsibilities, Accountabilities and Duties 4
5 Policy 5-11
6 Training Implications 11
7 Monitoring Arrangements 11
8 Due Regard Assessment Screening 12
9 Links to other Trust policies 12
10 References 14
Appendices
Appendix 1
Appendix 2
SECAmb Major Trauma Decision Tree
Silver Trauma Triage Tool
13
Appendix 3 Adult ASHICE sheet 14-15
Appendix 4
Appendix 5
Appendix 6
Appendix 7
ED reception pathway for registration of trauma patients prior to arrival
Prompt cards for trauma patient pre-registration
Trauma Team Composition Table
Due Regard Assessment Tool
16
18-22
23
24-5
Appendix 8 Dissemination and Implementation Plan 26
Appendix 9 Paediatric Trauma Call Guidelines 27
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1. Introduction
1.1 A Trauma Call policy is required to support the effective delivery of trauma services and is a requirement of the standards for Major Trauma Centres1
2. Purpose
2.2 The policy covers:
Indications and process for instigating a trauma call
The clinical team required to attend
Documentation requirements and standards
2.3 The policy does not seek to specify the clinical management or pathway of individual patients.
3. Definitions
3.1 Trauma Call
The trauma call notifies the trauma team that the arrival of a potentially major trauma case(s) is imminent or has arrived. It will be activated by the Emergency Department and put out by Switchboard.
3.2 Major Trauma Case
Patients with an Injury Severity Score (ISS) score of 8-15 is considered moderate. Patients with an ISS score >15 are considered major trauma cases.
3.3 National Confidential Enquiry into Patient Outcome & Death (NCEPOD)
NCEPOD's purpose is to assist in maintaining and improving standards of medical and surgical care for the benefit of the public by reviewing the management of patients, by undertaking confidential surveys and research, and by maintaining and improving the quality of patient care and by publishing and generally making available the results of such activities.
3.4 Trauma Audit and Research Network (TARN)2
3.4.1 The purpose of TARN is to collate information on the treatment of trauma patients from time of injury to discharge, regardless of the institution or organisation providing that care in order to assess the overall treatment of patients from time of injury to discharge.
3.4.2 TARN, the independent monitor of trauma care in England and Wales, is committed to making a real difference to the delivery of the care of those who are injured. One of the ways they do this is by promoting improvements in care through national comparative clinical audit.
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3.5 Injury Severity Score (ISS)3
3.5.1 Those who are injured may have one or many injuries and the Injury Severity Score (ISS) is an anatomical score that measures the overall severity of injured patients.
3.5.2 All injuries are assigned an Abbreviated Injury Scale (AIS) code and score from an internationally recognised dictionary that describes over 2000 injuries and ranges from 1 (minor injury) to 6 (an injury that is thought to be ‘incompatible with life’). Patients with multiple injuries are scored by adding together the squares of the three highest AIS scores in three predetermined regions of the body.
3.5.3 This is the ISS which can range from 1 to 75. Scores of 7 and 15 are unattainable because these figures cannot be obtained from summing squares.
3.5.4 The maximum score is 75 (52+52+52). By convention, a patient with an AIS6 in one body region is given an ISS of 75. The injury severity score is non-linear and there is pronounced variation in the frequency of different scores; 9 and 16 are common, 14 and 22 unusual.
3.5.5 The assignment of AIS codes and scores are undertaken post-discharge by trained coders within TARN.
4. Responsibilities, Accountabilities and Duties
4.1 Chief Executive
Whilst ultimate responsibility is vested in the Trust Board, executive responsibility is delegated to the Chief Executive for managing health and safety.
4.2 Lead Executive Director
Overall responsibility for this policy rests with the Medical Director
4.3 Directorate Management Teams
It is the responsibility of the Directorate management teams to ensure that (i) this policy is brought to the attention of relevant staff and (ii) staff rotas and job plans within each specialty/service are organised in a way that enables staff to attend and participate in trauma calls as required on a 24/7 basis.
4.4 Ward Managers/ Heads of Service
Ward/Department Managers and other Clinical Managers are responsible for ensuring that (i) staff rotas and job plans within each specialty/service are organised in a way that enables staff to attend and participate in trauma calls as required on a 24/7 basis, (ii) any resulting scheduling conflicts are escalated to the Divisional Management Team as required and (iii) associated local procedures (eg. for making the trauma call) are in place and that staff are appropriately trained.
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4.5 All staff
All staff, including locum and agency staff, are required to comply with this policy.
5. Policy
The following information is for trauma patients arriving at Royal Sussex County Hospital (RSCH) as the designated Sussex Major Trauma Centre. South East Coast Ambulance Service (SECAmb) has instructions and protocols to divert trauma from the Princess Royal hospital (PRH) which is a local emergency hospital only. These have successfully operated for a number of years. However, there may be instances when patients arrive at PRH and there is a procedure in place for this which involves rapid airway management if required and transfer to the Sussex Major Trauma Centre with SECAmb and an attending doctor if required. (Appendix 1 Major Trauma Decision Tree, PRH Trauma Call Policy).
5.1 Types of Trauma Calls
5.1.1 On the basis of pre-hospital information provided to ED prior to the patient’s arrival (“ASHICE call”), there are three tiers of response:
Code Red trauma call
Advanced trauma call
ED (Emergency Department) trauma call
The type of trauma call (Code Red/Advanced/ED) activated must be annotated on the Trauma Booklet.
5.1.2 Criteria for differentiating between ED and Advanced trauma calls are at the discretion of the Emergency Medicine Consultant in charge who fulfills the Trauma Team Leader (TTL). However, as general guidance:
Mechanism plus normal physiology and anatomy = ED trauma call
Mechanism plus abnormal physiology or anatomy = Advanced trauma call
5.1.3 CODE RED hospital trauma calls are activated at the discretion of the ED consultant response to pre-hospital information that indicates that activation of the massive transfusion protocol (MTP) is required.
5.1.4 It is recognised that trauma call criteria have a poor evidence base and mechanism alone is a poor predicator of injury burden. These activation criteria are a clinical guide but should be determined by the TTL on a case-by-case basis.
5.2 ED Trauma Call Activation
An ED trauma call should be activated in cases of: “Significant mechanism
but normal physiology and anatomy”
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N.B. Patients over the aged of 65 presenting with a fall <2m require screening with the silver trauma tool. (Appendix 2)
5.2.1 Significant mechanisms of Injury
Fall over 3 metres
Pedestrian or pedal cyclist hit by motor vehicle
RTC over 40mph, or ejection from vehicle, or death to another occupant of the vehicle
RTC with rollover, extensive damage to vehicle, or extrication time more than 20 minutes
Patients over the aged of 65 presenting with a fall <2m require screening with the silver trauma tool.
5.2.2 Normal Physiology (values for adults)
Pulse 50–100 beats per minute
Respirations 10–20 per minute
Systolic Blood Pressure above 100 mmHg
Head injury with GCS 14 or 15
Interpretation of ‘normal physiology’ should be done in the context of clinical correlation, the above figures are based on the available clinical evidence.4-5
5.2.3 Anatomy
Penetrating injury to limb, or single femoral fracture
Potential spinal injury but no abnormal neurology
5.3 Advanced Trauma Call Activation
An Advanced Trauma Call should be activated in cases of: “Significant mechanism plus abnormal physiology or anatomy”
All HEMS calls must routinely be at least an Advanced Trauma Call
5.3.1 Significant mechanisms of Injury
Fall over 3 metres
Pedestrian or pedal cyclist hit by motor vehicle
RTC over 40mph, or ejection from vehicle, or death to another occupant of the vehicle
RTC with rollover, extensive damage to vehicle, or extrication time more than 20 minutes
Patients over the aged of 65 presenting with a fall <2m require screening with the silver trauma tool.
5.3.2 Abnormal Physiology (values for adults)
Pulse < 50 or > 100 beats per minute
Respirations < 10 or > 20 per minute, or cyanosis
Systolic Blood Pressure < 100 mmHg
Head injury with GCS < 14
Paediatric patients with shock, respiratory distress, or reduced conscious level
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Interpretation of ‘abnormal physiology’ should be done in the context of clinical correlation, the above figures are based on the available clinical evidence.4
5.3.3 Abnormal Anatomy
Airway problems
Flail chest
Penetrating injury to head, neck or torso
Severe pelvic injury
Major crush injury to torso or upper thigh
Limb amputation
Two or more long bone fractures
Abnormal neurological examination in context of suspected spinal cord injury
Burns over 20% BSA or potential airway burns
5.3.4 Special Circumstances
Multiple patients
5.4 Code Red Trauma Team Activation
A Code red trauma call should be activated if is deemed likely the patient will require blood transfusion within the ED or require emergency transfer to theatre or interventional radiology for haemorrhage control.
5.4.1 The decision activate a code red trauma call is at the discretion of the trauma team leader (usually the ED consultant) who should be guided by the code red policy and the following criteria:
5.4.2 Either two or more of:
Penetrating injury
FAST Scan – abdominal fluid positive
HR >120
SBP <90
Or: major trauma and senior clinician’s suspicion of on-going bleeding
Or: activation on pre-arrival advice of a Critical Care Paramedic or HEMS team
5.5 Paediatric Trauma Calls
Paediatric trauma calls are covered by the Paediatric Trauma Call policy
5.6 Trauma Team Activation Process
Requests to activate the trauma team are guided by physiological, anatomical and mechanism of injury criteria. Activation of the trauma team can be initiated in three ways:
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5.6.1 Prior to the arrival of an injured patient in the ED on notification of a pre-hospital ‘pre-alert’ (priority or “ASHICE” call), information about which should be added to the Emergency Department ASHICE Form (Appendix 2)
5.6.2 In the case of patients fulfilling criteria for an Advanced or Code Red trauma
call based on pre-hospital information given in the ASHICE call, these patients will be pre-registered onto Symphony prior to their arrival. The process for this is described in Appendix 3.
5.6.2 On arrival of the patient in the ED based on mechanism of injury,
physiological, and anatomic criteria as reported by pre-hospital or ED personnel.
5.6.3 Patients over the aged of 65 presenting with a fall <2m after screening with
the silver trauma tool 5.6.4 The ambulance service pre-hospital triage decision tree is used as a guide for
pre-alerting of trauma patients. 5.6.5 It is the responsibility of the person receiving the priority call to liaise with the
ED Consultant, to clearly document all information received and activate the appropriate trauma team
5.6.6 All HEMS calls must routinely be an Advanced Trauma Call 5.6.7 All secondary trauma transfers (Local Emergency Hospital/Trauma Unit to
MTC) must have an appropriate trauma team activation on arrival at RSCH 5.6.8 Regardless of level of trauma call, every patient requiring a trauma team
response should have a trauma call activation via the ‘2222’ system even when the core team is in the ED with another patient.
5.6.9 Non-core team members (e.g. neurosurgery, cardiothoracic surgery, vascular)
are alerted via ‘fast bleep’ through switchboard on 2222 as necessary
5.7 Switchboard
5.7.1 The Resus Nurse will phone Trust Switchboard using the priority phone number 2222 and will inform Switchboard of the nature of the call. The phrase used will be depend on the level of trauma call as given below:
‘Adult ED Trauma Call’
‘Adult Advanced Trauma Call – Sex – ETA’
‘Adult Code Red – Sex – ETA’ 5.7.2 Trauma call activation should be performed when the patient is estimated to
be 10 minutes from arrival at ED for ED and Advancded level calls, and 15 minutes from arrival for Code Red calls.
5.7.3 In the case of Code Red Trauma calls, if we are alerted greater than 15 mins
prior to arrival, this information should be passed at the earliest opportunity to
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the theatre co-ordinator to allow the maximum time for appropriate planning (ext 4172, bleep 8061). Out of hours, early calls should also be made to the specialty consultants.
5.7.4 Paediatric Trauma Calls are covered by the Paediatric Trauma Call policy 5.7.5 Switchboard will log the details in the Cardiac Arrest Book on the Trauma
Pages. This should be forwarded to the Trauma Practitioners for clinical governance.
5.8 Staffing at Trauma Calls 5.8.1 Trauma team composition is described in the table in Appendix 5 5.8.1 All trauma patients should have consultant led care.
5.8.2 ED trauma and advanced trauma calls may be led by an ED registrar, middle
grade doctor or ED consultant but there must be ED Consultant presence and oversight. This must be clearly documented on the trauma booklet.
5.8.3 CODE RED trauma calls will be led by an ED consultant. 5.8.4 The on-call SHO in Anaesthetics/General Surg/T&O may attend ED Trauma
Calls for education if operational demands allow
5.8.5 The T&O team are responsible for all secondary surveys in all Advanced and Code Red trauma calls. The ED team is responsible for secondary surveys in ED Trauma calls.
5.8.6 The T&O and General Surgical registrars must update their consultant if
appropriate within 30 minutes of patient arrival for all Advanced Trauma Calls. This also applies for Code Red Trauma Calls if the consultant has not presented to ED Resus.
5.8.7 For Code Red Trauma Calls switchboard will notify Specialty Consultants
(Anaesthetics [out of hours], General/Damage Control Surgery) at point of Trauma Call Activation and other consultants at the request of the ED Consultant (TTL).
5.8.8 If for any reason a team member cannot attend they should inform the ED
Consultant/TTL immediately by phone on Ext. 4218
5.9 Trauma Call Team Response
5.9.1 The TTL must respond immediately
5.9.2 The rest of the core team must attend
Immediately if they are on site
Within 30 minutes if they are off site
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5.9.3 If for any reason a team member cannot attend they should inform the ED Consultant/TTL immediately on extension 4218
5.10 Trauma Documentation
5.10.1 Clinical notes will be kept in the form of the Major Trauma Centre record (‘Trauma Booklet’). This will be used for all trauma patients. This documentation includes the minimum dataset required for TARN reporting and the Trauma Booklet must routinely be checked for completeness by the TTL prior to the patient leaving ED.
5.10.2 The Trauma Team Leader is responsible for ensuring the required sections are completed fully in line with minimum dataset requirements: Primary Survey, Secondary Survey, Summary of Injuries, Team Leader Summary and Plan. A drug chart including adequate analgesia provision as wells a ensuring the tranexamic acid, fluids and blood products have all been accurately documented.
5.10.3 All specialties attending are responsible for recording their actions and onward management plan in the Trauma Documentation and communicating this to the Trauma Team Leader BEFORE leaving the Resuscitation room.
5.10.4 The ED Resus Nurse is responsible for ensuring the nursing notes and observations are completed fully.
5.10.5 The ED Resus Nurse is responsible for ensuring that a copy of the Trauma
Documentation is made before the patient’s notes leave ED, and is stored in the designated way.
5.11 Clinical Governance of Trauma Teams 5.11.1 Request for consultant attendance
Notification or escalation to consultant level for additional in-patient specialties is via switchboard.
5.11.2 Upgrading of Trauma Call
Decisions to upgrade trauma calls from ED to Advanced to Code Red Trauma call should be communicated formally via switchboard (2222) as soon as TTL decides to upgrade. When upgrading a trauma call from (for example) a Advanced to Code Red call, the notification via switchboard should be: “PREVIOUS (ADVANCED) TRAUMA CALL UPGRADED TO (CODE RED) TRAUMA CALL IN (A&E RESUS)”
5.11.3 Escalation of trauma team issues
Non-attendance of ‘must attend’ trauma team members should be escalated via a repeat call to switchboard:
Notification to switchboard of “REPEAT xxxx TRAUMA TEAM TO A&E RESUS” Recording via DATIX (select major trauma tab) should be made for non-attendance by any essential speciality.
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5.11.4 Multiple trauma calls
Trauma patients arriving in the ED simultaneously should be activated individually via switchboard:
Notification to switchboard of “2nd/3rd (etc) [ADULT/PAEDIATRIC] ADVANCED TRAUMA CALL TO A&E RESUS”
5.11.5 Changes to trauma team notifications
Any changes to bleep notifications must be approved by the MTC Clinical Lead.
5.11.6 Major Trauma Clinical Governance
A structured debrief should take place after a Trauma Call if the TTL identifies issues that need immediate input and/or escalation. It is reasonable that this could be in the form of an After Action Review (AAR).
Attendance at trauma calls will be audited yearly with feedback to Trauma Committee and individual specialities as appropriate:
6. Training Implications
All new staff in trauma related specialties (Emergency Medicine, Trauma & Orthopaedics, General Surgery, Vascular Surgery, Anaesthetics, and Critical Care) will be made aware of the trauma call process
6.1 Staff attending trauma calls will be expected to have obtained certification in the Advanced Trauma Life Support (ATLS) course as a minimum
6.1 The BSUH trauma team leader course (1 day) is available and recommended for those staff working in the role of Trauma Team Leader
7. Monitoring Arrangements
Measurable Monitoring / Frequency Responsibility Where is monitoring reported
Policy Audit for performing & what groups/committees Objective Method monitoring Are responsible for
progressing & reviewing action plans
Attendance at trauma calls
Notes review Annual MTC Clinical Lead and MTC team
Trauma Committee
National Best Practice Tariff returns
Finance record
Quarterly/yearly MTC Clinical Lead and MTC team
Trauma Committee & Financial oversight committee
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TARN Dashboard
Dashboard report
Monthly MTC Clinical lead and
MTC Team
Trauma Committee, Trauma Network. Trust Board
Trauma Morbidity and Mortality meetings
Presentation and audit
Quarterly MTC Trauma Committee
Trauma Committee Network Board Trust Board
8. Due Regard Assessment Screening
BSUH NHS Trust has a statutory duty to assess and consult on whether planning, policies and processes impact service users, staff and other stakeholders with regard to age, disability, gender (sex), gender identity, marriage or civil partnership, pregnancy and maternity, race (ethnicity, nationality, colour), religion or belief and sexual orientation. It recognises that some people may face multiple discrimination based on their identity. A review of the assessed impact of this policy against these criteria can be seen (Appendix 7).
9. Links to other Trust policies
BSUH massive transfusion Policy
BSUH Paediatric Trauma Call Policy
C088 PRH Trauma call Policy
BSUH Helideck operational policy
10. References
Trauma: Who Cares? National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) 2007, available at: https://www.ncepod.org.uk/2007t.html
NICE Guideline NG39 February 2016. Major Trauma: assessment and initial management, available at: https://www.nice.org.uk/guidance/ng39/evidence/full-guideline-2308122833
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Appendix 1 – SECAmb Adult Major Trauma Decision Tree
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Appendix 2 – Emergency Department ASHICE Form
15
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Appendix 3 – Silver Trauma Triage Tool
Adapted from work by HECTOR elderly trauma triage criteria and also by work by D Peel, A Osmond, H Tucker (2018) as part of the London Major Trauma System: Management of elderly major trauma patients – Second Edition, published in December 2018.
17
Appendix 4 – ED reception pathway for registration of trauma patients prior to
arrival
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Appendix 5 – Prompt cards for trauma patient pre-registration
19
20
21
22
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Appendix 6 – Trauma Team Composition Table
Role: Team: ED Trauma
Call Advanced
Trauma Call Code Red Trauma
Call
Trauma Team Leader (TTL)
ED Registrar / Consultant
ED Registrar / Consultant
ED Consultant
Primary Survey
Airway
ED / Specialty
SHO or SpR
Anaesthetic Registrar
Anaesthetic Registrar / Consultant
Breathing General Surgery /
T&O / ED Registrar
General Surgery / T&O / ED Registrar
Circulation
Disability
Exposure
Scribe ED Resus SHO
Monitoring
ED Nurse
ODP
Circulation ED Resus Nurse / Anaesthetic SHO
Drug Nurse ED Resus Nurse
Transfusion Services For info only – no action Activation of MTP
Porter - ED Porter ED Porter
Radiographer - Radiographer as
liaison for CT
Radiographer with portable XR machine
and liaison for CT
Trauma Line inserter - - Anaesthetic/ED SpR/Consultant
eFAST Doctor - - ED SpR
Rapid infuser nurse 1 - - ED Resus Nurse /
Nurse in Charge / ODP
Rapid infuser nurse 2 - - ED Resus Nurse /
Nurse in Charge / ODP
Additional Mandatory Attendance
- -
General Surgery/DCS Consultant
Anaesthetic Consultant (T&O SpR to contact
T&O Consultant)
Secondary Survey Responsibility
ED SHO / Registrar
T&O SHO / Registrar
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Appendix 7 – Due Regard Assessment Tool
Yes/No Comments
1. Does the document/guidance affect one group less or more favourably than another on the basis of:
Age No We base severity of injury on the Injury Severity Score and we know that older patients can sustain severe injury as a result of more minor mechanisms of injury compared to younger patients. Therefore we know that historically older patients with severe injury have been far more likely not to be treated initially by the trauma team. Changes to the way we triage and recognise significant injury in patients over 65 years in this new policy mean that the criteria for putting out a trauma call differs for those older or younger than 65. This difference is designed to reduce the inequality in initial assessment between younger and older patients but will mean there is a difference in the way we approach these two age groups. This mirrors similar changes at other Trusts and at present there is no better way we know of to do this.
Disability No
Gender Yes We recognise that a patient’s gender is that with which they identify. In our process for switchboard alerting the teams we have included only two options for sex – male and female. The rationale for this information being included in the call via the bleep system is to alert the transfusion laboratory about whether pre-prepared Rhesus negative or positive blood may be required. This decision is based on the genetic sex of the individual and due to this and in order to prevent confusion that might lead to clinical risk, we have left only the binary option
Gender identity No
Marriage and civil partnership No
Pregnancy and maternity No
Race (ethnicity) No
Religion or Belief No
Sexual orientation, including lesbian, gay and bisexual people
No
2. Is there any evidence that some groups are affected differently and what is/are the evidence source(s)?
Yes See above regarding age criteria for trauma calls. Nil else
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3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable?
Yes See above
4. Is the impact of the document/guidance likely to be negative?
No
5. If so, can the impact be avoided? N/A
6. What alternative is there to achieving the document/guidance without the impact?
This is the best option we are aware of
7. Can we reduce the impact by taking different action and, if not, what, if any, are the reasons why the policy should continue in its current form?
No See above
8. Has the policy/guidance been assessed in terms of Human Rights to ensure service users, carers and staff are treated in line with FREDA principles (fairness, respect, equality, dignity and autonomy)?
Yes
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Appendix 8 - Template Dissemination, Implementation and Access Plan
To be completed and attached to any policy when submitted to Corporate Governance for consideration and TEC approval.
Dissemination Plan Comments
1. Identify:
Which members of staff or staff groups will be affected by this policy?
1. Consultants, junior doctors, nursing and theatre staff in:
Emergency Medicine
Trauma & Orthopaedics
General Surgery
Vascular Surgery
Anaesthetics
Transfusion
2. Reception staff in the Emergency Department
How will you confirm that they have received the policy and understood its implications?
Cascade via trauma committee to clinical leads for trauma in specialties above and to team leaders in theatre and ED reception
How have you linked the dissemination of the policy with induction training, continuous professional development and clinical supervision as appropriate?
As above; via clinical spuervision
2. How and where will staff access the document (at operational level)?
Major trauma intranet site
Yes/No Comments
3. Have you made any plans to remove old versions of the policy or related documents from circulation?
Yes Removal of prior version from major trauma uintranet site
4. Have you ensured staff are aware the document is logged on the organisation’s register?
Yes Via trauma committee
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Appendix 9 – Paediatric Trauma Call Guidelines