Preparing Your Team for Trauma Triage
At the recent American Animal Hospital Association annual meeting, Lee Palmer, DVM, MS, DACVECC, NRP, EMT-T, WEMT, CCRP, TP-C, led a discussion about trauma triage, emphasizing that “time is of the essence” when a client whose pet has suffered a traumatic injury calls or comes to your practice.
Emergencies happen every day in veterinary medicine, and they are challenging for veterinary teams because of their often unpredictable nature. An animal suffering a serious injury may be in obvious immediate distress or may not present with clinical signs until days after an incident occurs.
At the recent American Animal Hospital Association annual meeting in Nashville, Lee Palmer, DVM, MS, DACVECC, NRP, EMT-T, WEMT, CCRP, TP-C, led a discussion about trauma triage, emphasizing that “time is of the essence” when a client whose pet has suffered a traumatic injury calls or comes to your practice.
Triage: The Danger of Not Knowing
“In human medicine,” Dr. Palmer noted, “prehospital emergency medical services may limit or even halt the cascade of events that would otherwise lead to death or permanent disability. In animals, the cascade of systemic events goes unchecked until the animal arrives at the veterinary hospital.” It is for this reason, he said, that all veterinary team mem- bers must understand and be trained on how to deal initially with trauma cases.
“If anyone on the hospital team—from front desk staff to technicians to veterinarians—is not trained or does not understand how to triage a patient, then many serious conditions may be missed that could further jeopardize the patient’s condition and chance of survival,” said Dr. Palmer, who is chair of the K9 Tactical Emergency Casualty Care Working Group; assistant professor of emergency and critical care medicine at Wilford and Kate Bailey Small Animal Teaching Hospital in Auburn University, Alabama; and an adjunct instructor in the Emergency Medical Services Program at Southern Union State Community College in Opelika, Alabama.
“Often, the first contact a veterinary facility has with a client is via a phone call that is received by the front desk staff, similar to that of a 911 dispatch center,” Dr. Palmer warned. Although front desk personnel are not expected to have extensive medical knowledge, they should be equipped with enough training and education to recognize the need for immediate emergency care and when to alert the team that an emergent patient is on its way. (See Vital Triage Questions and Answers.) A well-trained and educated receptionist who can prioritize patients and reduce waiting times can help close the time gap between the onset of injury or another life-threatening medical condition and the reception of medical care, ultimately providing the patient with a greater chance of survival.
Reception triage is a vital component of hospital-based triage because receptionists serve as the hospital’s “first responders” when trauma patients are presented. Because nonmedical staff are not trained to perform a hands-on physical exam or assess a patient’s vital parameters, it is easy to miss conditions that are not obvious from the patient’s outward appearance (eg, internal bleeding such as hemoabdomen, non-opened fractured bones, pneumothorax).
Developing a list of common injuries or conditions classified by triage categories (eg, red, yellow, green) as well as checklists and standard operating procedures for triaging patients can all enhance the reception staff’s ability to triage quickly and effectively. “Implementing organ- and condition-specific questions, flow charts, or algorithms for the reception staff to refer to when talking on the phone with clients may further facilitate their success with providing appropriate phone triage,” said Dr. Palmer. “The key is to develop protocols that your staff must follow in relation to telephone triage and face-to- face contact with patients, similar to the triage guide cards developed for human 911 emergency medical dispatchers.” Consider training front desk staff to listen for common key words or phrases that would indicate a potentially severe condition, suggested Dr. Palmer. Examples may include “nonproductive” retching in a German shepherd or “straining to urinate” with no urine production in male cat. “For gross observation,” he said, “the team should understand the dire urgency of more serious conditions, such as spurting red blood from a traumatic wound, unconsciousness in a patient that was hit by a car, and extreme difficulty breathing in a Labrador retriever that presents with blue mucous membranes and high-pitched breathing sounds.” (See Table.)
One of the best ways to foster a positive training environment is through teamwork and a positive work environment, said Dr. Palmer. “Promote training as a team to develop cohesiveness and to allow everyone the ability to understand the triage process and flow fully,” he said, “thereby allowing the triage process and patient admission to flow smoothly and seamlessly.”
Training should not be a chore, he noted. Rather, it should be fun and relevant. Promote buy-in from the staff by letting them know the vital role they play in helping the patients they admit and how important they are to the team. Dr. Palmer suggested showing the reception staff examples of how the training they receive will increase their ability to help patients and the team overall.
To assess what your staff has learned and, better yet, how effectively they can apply their training to real-life scenarios, Dr. Palmer recommended conducting mock practice scenarios with both phone triage and walk-in emergencies. “Consider implementing a quality assurance program that includes an anonymous 360° constructive review from all members of the hospital team. A quality assurance program may help identify gaps in care as well as be able to provide constructive feedback to team members on how they can improve their performance,” he said.
Training refreshers and performance evaluations given periodically throughout the year are helpful as well. “Let people know how they are doing, highlighting both the good points as well as areas that need improvement,” he suggested. “Incorporate all hospital staff into the development process.”
A primary tenet of trauma triage is to identify and treat any grave conditions as soon as possible. Without training and guidelines, front desk staff may easily miss a grave situation that could ultimately lead to a patient’s death. Each case is different and unique, however, and it is difficult to cover all possible situations that front desk staff may encounter. “Any trauma case may have a myriad of hidden injuries,” said Dr. Palmer, “and there is only so much that can be determined through a phone conversation—even for the most experienced emergency veterinarian.”