Chapter 3 - The Emergency Department

Activation of the trauma team is based on anatomical and physiological parameters. Mechanism of injury does not form the basis of the activation triage tool. A trauma team can be called at any stage of a patient’s journey. There is an automatic acceptance policy (Page 13). A copy of the South West Ambulance Service NHS Trust Major Trauma Triage Tool can be found on Page 45. Indications for Trauma Team Activation Anatomy: Unsafe airway 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 Paralysis from spinal cord injury Burns over 20% or potential airway burns Abnormal Physiology: Respiration 30 or other signs of respiratory compromise Pulse 120 Systolic blood pressure <90 mmHg Systemic signs of shock Head injury with motor score ≤4 Special Circumstances Multiple patients Agreement between TTL and paramedics on scene Agreement between the TTL and Specialist Paramedics on SWAST’s Trauma Advice Line HEMS requested Secondary Transfer from Trauma Unit

The ethos is that this team manage the initial assessment, resuscitation, imaging and coordination of disposal be it theatre, ITU or ward for major trauma patients presenting to NBT. Each team member will have generic roles within this structure, as well as providing individual expertise. The aim is that a consistent and predictable trauma team response is provided to each trauma, where roles and responsibilities are well defined and adhered to by each member of the team. There is a switchboard test call at 10:00 and at 16:00 Call Activation 1. Following pre-alert from ambulance service the senior doctor and Band 7 on duty will decide whether trauma team is activated: decision supported by the use of trauma activation guidelines. 2. Ring x2222 3. State ‘trauma call’ 4. The TTL and Senior Nurse will carry out a situational appraisal of the department with the Duty ED lead to allocate appropriate bays and resources. 5. On arrival of patient the TTL must identify themselves to the lead pre-hospital clinician and receive handover. 6. The salient points of this handover will be written on the Trauma Board to prevent repetition of information, using the ATMIST handover formula – see Page 39. A sticker for ATMIST handover should be available and completed by the scribe. 7. Each member of the trauma team should fulfil their roles unless the TTL dictates otherwise. 8. Members of the trauma team must not leave resuscitation without discussion with the TTL.

Contact numbers for the trauma team at North Bristol Trust:

Trauma Team Leader Bleep 9745

Anaesthetist 3rd on Call Bllep 9033

ICU Registrar Bleep 9039

General Surgeon Reg on Call Bleep 9772 (Take) 9656 (Post-Take) Orthopaedic Reg On Call (SHO will hold bleep when SpR not on site) 9750 Radiology Registrar 9746 Haematologist 9433 Radiographer 9704 Trauma Nurse Co-Ordinator 9747, 9748, 9749 ED Nurse 1 ED Nurse 2 ED Nurse 3 ERA Porter 9567 Matron ED 9744 Senior nurse ED 9743 Receptionist 9742 Other specialities may be called as clinically indicated Neurosurgery Ext. 45726 Plastics 1311 Cardiothoracics Via switchboard @ University Hospitals Bristol and Weston

Present in ED or available within 5 minutes of notification. Start of Shift: Liaise with Lead Nurse, collect trauma bleep and TTL folder, take departmental situational report and meet with Trauma Team Nurse 1&2. Trauma Team Activation Pre-Hospital: Alert Call ‣ Take call / review call as details taken ‣ Take patient identifiers as available ‣ Decide with ED nursing shift lead whether to initiate trauma team activation ‣ Call Switchboard to initiate trauma call – an ETA is not required ‣ If patient is transferred by air then security and clinical site teams needs to be informed. In-Hospital Alert Call ‣ Can be initiated at any stage by the TTL for a patient within the Emergency Department. ‣ The decision to activate the trauma team is based on the expectation that the alerted team members will be present to receive the patient. There is no requirement for team members to ring the ED to discuss the case prior to the patient’s arrival. ‣ All team members receiving a trauma call are expected to alert their respective speciality teams of an incoming Trauma. ‣ (Thus theatre, radiology, ITU beds and blood product availability can be planned for by respective teams) Consider: ‣ Early notification to neurosurgery, plastic surgery, interventional radiology, cardiothoracic surgery, urology and vascular surgery as required. ‣ Massive transfusion protocol activation. ‣ Medical Photography

Pre-Arrival ‣ Add alert call details to Trauma Board and update trauma team. ‣ Lead resuscitation, coordinate staff and resources. ‣ Ensure personal introductions by team members and confirm roles. ‣ Ensure team wear personal protective equipment. Patient Reception ‣ Ensure resus clock started ‣ Co-ordinate ATMIST handover from Pre-Hospital Team – add details to Trauma Board. ‣ Co-ordinate transfer to Resus Trolley. ‣ Manage trauma team response. ‣ Make decisions in conjunction with team members and relevant specialists. ‣ Prioritise investigations and treatments. ‣ Ensure imminent life threatening conditions are treated and direct rapid transfer to CT or Theatre. Promote an environment of open communication with review of ongoing management priorities and plans, ensuring involvement of all team members. Aim for CT within 15 minutes unless reasons prevent this Consider CT in lieu of primary survey x-rays in some cases see - “Imaging in Trauma“ guidance. Consider early use of: Emergency blood Massive Transfusion Policy Tranexamic acid 1g over 10 mins. - The maintenance dose, 1g over 8hrs (given within 3 hours of Trauma) should be given on return from CT in order to minimise infusions needed in the CT scanner, and to focus the team on preparation for the CT scanner. Combat Application Tourniquet – use and management. Consider eFAST – if this would enhance and not delay ongoing patient care.

Arrival On arrival of the patient into resus the TTL will make a brief assessment of the patient (a ‘5 second round’) to ensure no immediate interventions are required The pre-hospital team will move to the patient right side of the stretcher and liaise with the TTL to move the patient from the ambulance stretcher to the hospital trolley with a trauma mattress. The ambulance stretcher should then be removed from the cubicle. Patients arriving by air will be wheeled in directly on a hospital trolley and no movement of the patient is required. The pre-hospital team will then give a verbal handover of the patient to the Trauma Team. This is an important handover of information; the whole hospital team should give this their full attention. No one should touch the patient during this process whilst the pre-hospital team continue to monitor the patient. This process should not be interrupted, unless critical, with questions held until the end, to prevent the loss of vital information. Patient Transfer Team members may be required to remain with the patient during transfer to CT or Theatre. Whilst sliding the patient up or down into the head cradle, the TTL should hold the trauma mattress fixed in position whilst the trauma team slide the patient. Trauma team members must remain with the patient until appropriate disposal is achieved. If any team member needs to leave the trauma team environment – this must be discussed and agreed by the TTL. Antibiotics, urinary catheter, arterial lines, tetanus, pregnancy test need early consideration but can be delayed if transfer to theatre for emergency surgery is required. Resuscitation is managed as a dynamic process which is not dependent on geographical location. Handover: The TTL determines the speciality to lead ongoing inpatient care. Inform Blood Bank: When patient transferred and likely ongoing blood product requirements. Speak to Relatives Documentation: Review completed Trauma case note documentation Complete Hot Debrief form Debrief team

Start of Shift Collect speciality trauma bleep and receive handover + relevant speciality situational report. Trauma Team Activation ‣ Inform respective Speciality team members / Consultant / Theatres of incoming trauma – thereby allowing for proactive planning of personnel, resources and theatre space. ‣ Attend Resus area of the ED as soon as possible on receipt of trauma call. The decision to activate the trauma team is based on the expectation that the alerted team members will be present to receive the patient. There is no requirement for team members to ring the ED to discuss the case prior to the patient’s arrival. On arrival to the Emergency Department: ‣ Identify yourself to the Trauma Team Leader. ‣ Give name, specialty and grade to the scribe ‣ Fill in your identification sticker and place in a visible place ‣ Confirm expected role ‣ Ensure adequate personnel protective equipment ‣ On arrival of trauma team, all team members should be on the patient’s left of the ED trolley, except the primary survey doctor, airway nurse, and anaesthetist. The paramedics will then be on the patient’s right. Remain with the patient until appropriate disposal is achieved If you need to leave the Trauma Team environment – this must be discussed and be agreed by the Trauma Team Leader.

Key Roles ‣ Catastrophic haemorrhage control ‣ Cervical spine and pelvic stabilisation ‣ Venous access ‣ Perform secondary survey ‣ Determine imaging requirements (additional to trauma CT) Patient Management ‣ Direct pressure haemorrhage control as required, in extreme conditions for extremity bleeds – consider tourniquet use. ‣ Ensure c-spine protection adequate ‣ Ensure pelvic splint in situ, correct size and placement ‣ Ensure legs aligned with internal rotation – bandage ankles to maintain position Venous Access ‣ Venous access – shared role – as directed by TTL ‣ Confirm patency of IV access ‣ Unless the patient has two patent IV access sites - Gain IV/IO access with 20mls blood samples for:- FBC, U&E’s, LFT’s, lipase, clotting screen, cross-match, venous blood gas and blood glucose ‣ If possible, free cannula to be placed in the back of the left hand for the IV contrast. ‣ If the patient has two patent i.v. access sites then gain 20mls blood for samples from a femoral arterial puncture ‣ Ensure samples are labelled correctly and dispatched to the appropriate departments. Neurological Assessment ‣ Perform baseline peripheral neurological examination, prior to anaesthesia if planned or just prior to logroll as directed by TTL ‣ Ensure c-spine protection in situ and placement correct if directed by TTL Orthopaedic Assessment ‣ Identify & splint long bone fractures ‣ Contribute to case discussion with the TTL, particularly where limb or lifesaving interventions are required

Once the primary survey and immediate lifesaving interventions have been achieved, the orthopaedic consultant must be informed of the likely case progression. This may require the attendance of the consultant to ED resus or to theatre as appropriate. Secondary Survey ‣ Carry out secondary survey, when deemed appropriate and verbally report findings to TTL and scribe ‣ Document all wounds, grazes and degloving directly into the trauma booklet ‣ Evaluate each joint and long-bone for dislocation / stability / fracture ‣ Neurovascular examination of all limbs ‣ Record presence or absence of peripheral pulses ‣ Identify peripheral injuries that need to be included in trauma CT scan ‣ Splint fractures as needed ‣ Repeat neurovascular examination after splintage Determine additional imaging requirements Any additional imaging requirements in addition to a CT Trauma series should be discussed (review “Imaging in Trauma” Guidance). Requesting of departmental films can impede the rapid progress of patients to definitive or staging care – and must be agreed amongst team members to ensure co-ordinated care. Patients who have anterior pelvic injuries may require a retrograde-urethrogram prior to insertion of urinary catheters – this is to be undertaken by the orthopaedic registrar. Discuss orthopaedic assessment / plan / needs / priorities with TTL. Case discussion should also consider the need for vascular or plastic surgery specialty attendance, dependent on injury patterns. Liaise with theatres, anaesthetic colleagues, bed manager and consultant for patients needing theatre and/or admission. Assist with sending/ordering tests, liaising with specialists or performing procedures as training and ability allows e.g. chest drains, urinary catheter. Post Trauma Call ‣ Document all actions and findings with a clear plan in patient notes. ‣ Remain with the patient until appropriate disposal is achieved ‣ If you need to leave the Trauma Team environment – this must be discussed and be agreed by the Trauma Team Leader.

Key Roles ‣ Assess Breathing and Circulation – On occasion Primary Survey Breathing and Circulation assessment may be performed by a senior Emergency Medicine Doctor at the discretion of the TTL ‣ Perform logroll examination ‣ Determine need for immediate surgical intervention in theatres Breathing ‣ Assess air entry, chest expansion, percussion and tracheal position to allow identification of significant chest pathology. ‣ Report findings to TTL, discuss, agree and institute appropriate interventions. Circulation ‣ Venous access – shared role – as directed by TTL ‣ Confirm patency of IV access ‣ Unless the patient has two patent IV access sites - Gain IV/IO access with 20mls blood samples for:- FBC, UE’s, LFT’s, lipase, clotting screen, cross-match, venous blood gas and blood glucose. If possible, free cannula to be placed in the back of the left hand for the IV contrast. ‣ If the patient has two patent IV access sites then gain 20mls blood for samples from a femoral arterial puncture ‣ Ensure samples are labelled correctly and dispatched to the appropriate departments. ‣ Complete abdominal examination ‣ Assess pelvis through visual examination and light palpation of bony prominences – work with orthopaedic registrar to ensure correct pelvic splintage ‣ Assess long bones as source of haemorrhage Perform examination on logroll – ensure full exposure. Assess for occipital head trauma, thoracic/ lumbar spinal injury, examine posterior chest including auscultation, palpate flanks, perform rectal examination and assess posterior aspect of limbs. Logroll may be delayed until after CT and indeed be part of secondary or even tertiary surveys when patients are expedited to surgical/interventional radiological management. Contribute to case discussion with the TTL. Discuss surgical assessment/plan/needs/ priorities particularly: decision on transfer to CT or Theatre - communication with theatres role is shared with ITU. Case discussion should also consider the need for vascular or plastic surgery speciality attendance, dependent on injury patterns. Once the primary survey and immediate lifesaving interventions have been achieved, the surgical consultant must be informed of the likely case progression if patient has initial SBP <90, has complex multisystem injury, or is likely to need early surgery. This may require the attendance of the consultant to ED Resus or to theatre as appropriate. Stay with the patient in Resus/CT until stood down by the TTL. Liaise with theatres, anaesthetic colleagues, bed manager and consultant for patients needing theatre and/ or admission. Assist with sending/ordering tests, liaising with specialists or performing procedures as training and ability allows e.g. chest drains, urinary catheter. Post Trauma Call ‣ Document all actions and findings with a clear plan in patient notes. ‣ Remain with the patient until appropriate disposal is achieved ‣ If you need to leave the TTL environment – this must be discussed and be agreed by the Trauma Team Leader.

Key Roles ‣ Ensure patient oxygenated and ventilated with no airway obstruction. ‣ Intubate when appropriate in discussion with the TTL – ensuring baseline neurological examination performed beforehand. ‣ Control patient logroll ‣ Ensure safe patient transfer Airway Intubated patients ‣ Take physical handover of ETT or LMA from pre-hospital team. Ensure end tidal capnography confirms placement. ‣ Assess effectiveness of BMV/ Mapleson C ventilation in conjunction with surgical registrar’s assessment of Breathing ‣ Attach to ventilator as soon as feasible – with confirmation of effective bilateral ventilation. Non-Intubated patients – requiring intubation ‣ Intubate when appropriate in discussion with the TTL – ensuring baseline neurological examination performed beforehand, orthopaedic registrar will assess peripheral limb response, anaesthetist to assess pupil response and formal GCS. ‣ Perform co-ordinated RSI with Nurse 1. ‣ Ensure end tidal capnography confirms placement. ‣ Assess effectiveness of BMV/ Mapleson C ventilation in conjunction with surgical registrar’s assessment of Breathing ‣ Attach to ventilator as soon feasible – with confirmation of effective bilateral ventilation. Non-Intubated patients ‣ Communicate airway patency and issues to TTL / scribe. ‣ Assess respiratory rate and inform TTL / scribe. ‣ It is usually appropriate for the anaesthetist to talk to the patient and provide ongoing assessment of GCS and pupil size. ‣ Reassure patient on arrival, explain what is happening, take AMPLE history and inform TTL/scribe ‣ Provide enhanced analgesia and sedation for patients that require procedures such as fracture/joint reduction/splintage and intercostal drain insertion

AMPLE History Allergies Medications Past medical history Last meal Everything else relevant Exposure Once primary survey completed and when directed by the TTL, the anaesthetist will control the log roll Consider need for endogastric tube (nasal or oral). Arterial lines may be indicated, to avoid delay to CT this can usually be done after CT or in the operating theatre. It should not delay either. Contribute to case discussion with the TTL. Case discussion should also address ongoing fluid management, blood products and inotropic support. Discuss massive transfusion protocol use in the ED and manage its implementation once in theatre, informing blood transfusion of any changes to contact name and telephone number. Once the primary survey and immediate lifesaving interventions have been achieved, the ITU Consultant must be informed of the likely case progression. This may require the attendance of the consultant to ED resus or to theatre as appropriate. Communicate any requirements with theatres - role shared with surgical registrar. Liaise with additional anaesthetist as appropriate if care to be handed over for theatre etc. Assist with sending/ordering tests, liaising with specialists or performing procedures as training and ability allows e.g. chest drains, urinary catheter. Post Trauma Call ‣ Document all actions and findings with a clear plan in patient notes. ‣ Remain with the patient until appropriate disposal is achieved ‣ If you need to leave the Trauma Team environment – this must be discussed and be agreed by the Trauma Team Leader.

Key Roles ‣ Assist 3rd on Anaesthetist with RSI/intubation and line placement as appropriate ‣ Liaise with TTL to ensure prompt access to ICU beds ‣ Liaise with TTL and ICU Consultant when additional resuscitative support is required on arrival Prior to Patient Arrival Speak with TTL prior to arrival of the patient(s). The ICU Consultant must be informed of the likely case progression. This may require the attendance of the consultant to ED resus or to theatre as appropriate. The TTL may request an ICU Consultant to attend for the initial resuscitation. Patient Arrival Assist with interventions (such as RSI and lines) as training and experience dictates. Arterial lines may be indicated, to avoid delay to CT this can usually be done after CT or in the operating theatre. It should not delay either. Contribute to case discussion with the TTL. Case discussion should also address ongoing fluid management, blood products and inotropic support. Make ICU nursing staff of the need for an ICU bed if required directly from ED or following theatre interventions. Post Trauma Call ‣ Document all actions and findings with a clear plan in patient notes. ‣ Remain with the patient until appropriate disposal is achieved ‣ If you need to leave the Trauma Team environment – this must be discussed and be agreed by the Trauma Team Leader.

Liaise with Trauma Team Lead, Senior ED Nurse and other Trauma Team Nurse. Review resus bays and ensure resus checklists are completed and signed. Highlight and address any deficiencies. Prior to Patient Arrival Responsible for supporting Trauma Team Leader. Prepare for the trauma call with level one infuser run through when indicated, warmed IV fluids run through, chest drain sets out if suggested, scoop stretcher and pelvic binder to hand. Ensure equipment for gaining large bore IV access and taking bloods is available. Ensure availability of emergency blood. Co-ordinate porters / transfer equipment – porters will need to meet patient’s transferred in by air at the helipad Patient Arrival ‣ Ensure clock started when patient arrives in resus bay ‣ Assist in transfer to the resus trolley ‣ Position yourself to the patients left side ‣ Have scissors ready, remove enough clothing initially to attach monitoring, ‣ Clearly state first observations to TTL & scribe as soon as available. ‣ Then continue to remove all clothing including underwear and store securely. ‣ Check temperature ‣ Cover with Bair Hugger / blankets ‣ Help with getting IV access and sending bloods off if required, set up intraosseus kit (ez-IO) if no/difficult IV access. Attach patient to level one infuser if required. ‣ Assist with log roll ‣ Draw up drugs / administer as prescribed ‣ Prepare for transfer to CT ASAP (within 10 minutes ideally) and/or theatre ‣ Help with procedures as identified e.g. catheter, chest drain, arterial line, dressings, and splints of open fractures / significant wounds. ‣ Ensure patient kept warm. Post Trauma Call Ensure you have documented all your interactions in the notes Ensure you have signed for any drugs Only leave the patient after liaising with the Trauma Team Leader

Liaise with Trauma Team Lead, Senior ED Nurse and other Trauma Team Nurse. Review resus bays and ensure resus checklists are completed and signed. Highlight and address any deficiencies. Prior to Patient Arrival ‣ Responsible for assisting with the initial assessment and management of airway supporting anaesthetist. ‣ Obtain an anaesthetic grab bag from the resus controlled drugs cupboard ‣ Assist in preparing any drugs requested by anaesthetist/TTL. ‣ Check all appropriate airway equipment is available and working ‣ Check suction available and working Patient Arrival ‣ Position yourself to patient’s right side ‣ Assist in transfer to resus trolley ‣ Reassure and establish a rapport with patient ‣ Assist anaesthetist with airway patency and ventilation passing adjuncts as necessary ‣ Prepare any drugs needed by anaesthetist (check drugs with them or Nurse 2). Assist during log roll ‣ Prepare arterial line equipment if requested Post Trauma Call ‣ Ensure you have documented any of your interactions ‣ Ensure you have signed for any drugs ‣ Only leave patient after liaising with the Trauma Team Leader

Key Roles ‣ Liaise with Theatres, TTL and surgical teams to ensure ready availability of operating space ‣ Provide additional skilled support if asked to do so – e.g. management of the Rapid Infuser alongside ED Nursing Team

A complex job but vital. Ensure you are being given the information you require and inform the TTL if you are not. Prior to Patient Arrival Ensure Receptionist is on-hand for rapid patient registration ‣ Ensure paperwork is available for documentation ‣ Ensure bags/documentation available for patient property ‣ Ensure team sign into Trauma Booklet on arrival ‣ Document team member’s presence in the Trauma Booklet: including speciality, grade e.g. ST3 and supervising consultant. ‣ Ensure role labels available – encourage members to place labels visibly in center of chest. Patient Arrival Ensure clock has been started when patient arrives in the Resus Bay. Ensure all patient details correct and NOK information is documented. Ensure patient wrist labels are secured on the patient. List and store safely any patient belongings Responsible for documentation of observations, events and interventions ‣ Document all pre-hospital drugs and fluids – times and amounts. ‣ Document initial vital signs and then every 5 mins in unstable patient and every 15 mins otherwise. This role continues into CT and until discharged from ED. ‣ Maintain a chronological record of all events e.g. time of venflon, CXR, FAST, move to CT etc. Inform the team leader if key observations have not been taken e.g. Temp or GCS. Inform the team leader every 15 mins that pass, the aim is to be in CT within 15 mins, when appropriate ask and document reasons for any delays. Keep a log of the running total of blood products transfused – this role may be done by a specified nurse member responsible for the level one infuser. In a massive transfusion after every 4-5 units prompt the TTL of need for adjuncts (such as calcium or insulin / dextrose). Post Trauma Call ‣ Ensure all documentation is complete ‣ Print out pre-hospital ePCR ‣ Liaise with police if any property handed over for evidence ‣ Ensure all drugs/fluids signed for by appropriate person ‣ Only leave the patient after liaising with the TTL

Key Roles ‣ Present to TTL, discuss plan for immediate CT imaging based on pre-hospital clinical information ‣ Work with trauma team to ensure CT performed within 15 minutes of patient arrival ‣ Ensure Radiologist available to review images as the patient is in the scanner

Key Roles ‣ Obtain plain film x-rays as required during trauma call ‣ Place cassettes under the trolley to speed up initial x-rays ‣ Liaise with TTL or nurse in charge if team members are not wearing lead. Liaise with TTL if team members are obstructing your chance to x-ray to prioritise actions.

Key Roles ‣ Liaise with CT radiographer to clear the CT Scanner and communicate with resus when scanner is likely to be available. ‣ Attend the trauma call whenever possible as your expertise will be valuable in reviewing x-rays, eFAST scans and early recognition of interventional radiology requirements and planning of imaging (CT vs US). ‣ Most trauma patients will need early CT, national guidelines are to complete the CT and have the initial report within 30 mins of arrival in ED. ‣ A standardised reporting proforma is used to ensure rapid reporting.

NEED TO ADD IMAGE

The Emergency Department drug bag should be stored in the locked controlled drug cupboard in resus. Contents of the ED Major Trauma Drug Bag:

The ED drug bag contents may change over time, but should contain all key drugs to safely perform emergency anaesthesia for all types of major trauma patients. The Emergency Department have a separate SOP covering the management of controlled drugs within the drug bag in the Emergency Department. Clinicians should familiarise themselves with this.

The Intensive Care Unit has two emergency drug bags in the Pod D Controlled Drug fridge. One of these bags should be taken to any in-hospital trauma. Contents of the ICU Emergency Drug Bag:

The Intensive Care Unit has a separate SOP covering the management of controlled drugs within the ICU Emergency Drug Bag. Clinicians working on the Intensive Care Unit should familiarise themselves with this.

Communication with Relatives Effective and timely communication with relatives is crucial. Key points include: Conversations with family members should take place in a room offering privacy and ‣ space with refreshment facilities and a telephone available The most experienced clinician involved with the patient should convey information ‣ to relatives to avoid conflicting information and mixed messages being given The doctor should be sensitive of religious, cultural or other needs of the family ‣ A good starting point is to find out what the family already know about the patient’s ‣ current condition. Bad news should be communicated in a timely and sensitive way, avoiding ‣ euphemisms and jargon. Listening is as important as talking when breaking bad news. ‣ A nurse should accompany the doctor when breaking bad news in order to support ‣ the family Following death, relatives should be allowed to ‘say goodbye’ ‣ Offer support from appropriate faith or religious leaders (available via switchboard). ‣ This may provide support to relatives whilst the patient is in theatre or following death It is good practice to provide follow up for the relatives of a deceased patient ‣ A letter of condolence to the family after the event is appreciated ‣ Departments should consider giving the name and telephone number of a ‣ Consultant that relatives can contact at a later date. Providing the family with an appointment a few weeks after the death to discuss the ‣ events has been shown to help families with their grieving process Staff Support After every death or incident staff should be encouraged to talk together about the ‣ event. In many cases a formal debrief can be valuable Further support should be available to staff through their supervisor or from occupational health

Where withdrawal of life sustaining treatment is being considered the following steps should be taken Communication with relatives Information should be provided in a timely and open manner by the most ‣ experienced clinician familiar with the patient including details of their relatives condition, possible outcomes, assurances their relative is not experiencing pain or distress and when appropriate, an indication when death is imminent Regular updates of a patient’s condition should be provided. Where indicated, ‣ interpreters should be used Communication between staff members is essential to prevent conflicting information ‣ being provided A named link nurse to support relatives and act as an advocate for the relative(s) is ‣ essential NBT supports the principle of witnessed resuscitation; this should be offered where ‣ appropriate Offer relatives the opportunity to spend time with the patient before transfer to ITU or ‣ theatre, even if this is only for a brief period. Children should not be excluded as they may imagine a situation far worse than the reality General Points Any patient where withdrawal of life sustaining therapy is being considered should be ‣ discussed with the on-call ICU Consultant so that an appropriate management plan and location can be agreed. All patients with a perceived devastating brain injury where no neurosurgical ‣ intervention is planned should be discussed with the on- call ICU Consultant regarding admission to ICU for a period of neuro-prognostication. This should be explained to relatives ‣ No discussion about organ donation should take place in the ED when an ICU admission is planned ‣ When withdrawal of life sustaining treatment is planned to take place in ED, a SNOD must be contacted by the Trauma Team Leader prior to discussing organ donation with the patient’s relatives. Every reasonable effort must then be made to wait for the SNOD to attend before initiating a discussion about organ donation with a patient’s relatives If an approach for organ donation is undertaken in the ED a planned, collaborative ‣ approach involving the senior doctor, SNOD, and named linked nurse should be undertaken.

Any discussion regarding organ donation must be separated from information ‣ regarding prognosis. This ‘de-coupling’ of ‘breaking bad news’ and an approach regarding organ donation allows relatives time to begin to understand the position their relative is in. Organ donation must not be raised until it is clear that relatives have understood and accepted the clinical situation. At NBT, SNODs are located in the ICU administration office during office hours and ‣ via 03000 20 30 40 at all other times. A green folder containing information relating to organ and tissue donation can be found in the office behind ‘see and treat’ in ED. Information is also available on the intranet or from the SNOD Staff Support After every death or incident staff should be encouraged to talk together about the ‣ event. In many cases a formal debrief can be valuable ‣ Further support should be available to staff through their supervisor or from occupational health

Verification of death must be completed as per NBT policy and documented on NBT ‣ verification of death paperwork. Where required, a death must be reported to the coroner as soon as possible. ‣ Nursing staff must complete a deceased patient record which ensures GP’s are ‣ notified and information collated for follow-up and audit In the event of a paediatric trauma/death, ‘Form A’ - notification of child death, must ‣ be completed. The consultant community paediatrician (contacted via BRI switchboard - 76100) and Ann Fry (named nurse for child protection- 0117 323 2363) must be contacted Tissue Donation must be considered in all patients after death. The completed ‣ referral form should be emailed to the National Referral Centre at National.ReferralCentre@nhsbt.nhs.uk Relatives should be given the ‘When Someone Dies’ leaflet. This contains practical ‣ guidance and details of support services. A member of the bereavement team will contact a deceased’s family for follow-up and support ‣ Any further information or guidance required please speak to the ED nursing team who are experienced and trained in ED bereavement care.

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