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Direct to OR Policy

 Direct to OR Peds Trauma Activation  

Criteria for consideration of activating Direct to OR are:  

  • Thoracic injury with open cavity  
  • Evisceration of abdominal contents  
  • Penetrating injuries or impalement of neck, chest, abdomen, or pelvis with hypotension  
  • Profound shock with CT or US evidence or hemoperitoneum  
  • Massive blood loss on scene or en route with ongoing uncontrollable external blood loss (excluding GSW to head)  

  

While the process is not linear, the necessary steps are identified in a linear format. Multiple parties are involved in the process; therefore, each will be identified in a specific font and color for ease of tracking:   

Transfer Center

PICU Attending  

PEDS EM faculty OR Desk/Charge  

EMS crew OR Circulator  

EMS communications OR Scrub  

ED Charge RN ED Recording RN  

PDS Trauma Attending ED Tech  

Trauma Team (Chief, Junior, Intern/APP) ED X-ray  

Peds Charge RN (Peds ED TeamLead or TL) Blood Bank  

Anesthesia Attending Anesthesia Tech  

  

Decision to activate and activation of DIRECT TO OR, including notifications  

  1. Upon receiving the call regarding a pediatric trauma transfer, the Transfer Center connects the referring physician with the PEDS EM faculty.   
  2. IF the patient is local, the initial call will come through Dispatch (EMS communications) who take report and relay report to the ED Charge RN and PEDS EM faculty.   
  3. Upon receiving report of a pediatric trauma (≤15y) meeting any of the above noted criteria, PEDS EM faculty contacts the PDS Trauma Attending and confirms need to activate the Direct to OR Activation.  
  4. Once determination of Direct to OR candidate, EMS communications may be requested to connect the PDS Trauma Attending or PEDS EM faculty with the incoming EMS crew. In communication with EMS communications and PEDS EM faculty, the ED Charge RN activates “Peds TAR DIRECT TO OR” page.   
  5. PDS Trauma Attending notifies the OR Desk/Charge of anticipated DIRECT TO OR case and notifies the Trauma Chief  
  6. Trauma Chief notifies, or ensures notification, the Blood Bank of MTP activation, OR Desk/Charge, AND Anesthesia Attending  
  7. Upon receiving the activation page, all responders (PEDS EM faculty PDS Trauma Attending Trauma Chief, Junior, Intern/App Anesthesia Attending PICU Attending etc) respond per protocol and prepare for patient arrival either in the trauma bay or at the patient transport elevator. For patient arrival  
  8. via ground transportation, the team gathers in the ED trauma bay,   
  9. for air transport, the team gathers outside the ED at the patient transport elevator with the EMS communications rep standing ready to mobilize the team to the helipad.   
  10. For air transport, EMS crew will be directed to prepare for Trauma Team assessment in helicopter vestibule.   
  11. At the discretion of the PDS Trauma Attending, the Trauma Junior prepares the mobile US machine move to the patient elevator to proceed to the helipad with the team.   
  12. As the team collects at the patient elevator to move to the helipad, the Trauma Junior/Intern notes team member arrivals to be documented in H&P or significant event note.   
  13. The Peds Charge RN (Peds ED TL) collects the paperwork, sticker, and patient armband and delivers them to the trauma team gathering at the patient elevator.  
  14. ED Tech, or designated runner, is dispatched to the Blood Bank to retrieve the initial cooler of blood and is instructed to deliver the blood cooler to the appropriate location, based upon patient means of arrival (trauma bay or OR desk). Additional coolers will be retrieved and delivered to patient location per protocol.  
  15. The Blood Bank prepares coolers per protocol until directed to stop by trauma team.   
  16. Upon receipt of notification of anticipated DIRECT TO OR, the OR Desk/Charge confirms with Anesthesia Attending and activates the OR team (as potential or definite per PDS Trauma Attending direction).   
  17. The OR Desk/Charge identifies available OR room and designates the hold.   
  18. OR Circulator and OR Scrub report per protocol and await further instruction based upon patient arrival and assessment.   
  19. PICU Attending and/or Peds Charge RN notify ICU staff and identify and prepare ICU bed.   
  20. Peds ED TeamLead, or ED Charge RN, locate & inform family and contact PDS Trauma Junior to discuss patient condition, POC, and consent.  
  21. Of note, emergency consent implied if family cannot be located. Emergency consent documented per policy.    
  22. For patients returning to the ED as TAR, the ED Recording RN, records team arrivals and organizes the team per TAR procedure.   

  

  

PATIENT ARRIVAL, ASSESSMENT, AND DECISION TO PROCEED WITH DIRECT TO OR  

  1. ATLS Primary assessment will be completed per protocol with FAST being directed by the PDS Trauma Attending.  
  2. The Trauma junior/intern will include assessment details, including VS’s in Significant event note.   
  3. PDS Trauma Attending confers with Anesthesia Attending to make decision to proceed either DIRECT TO OR or return to ED trauma bay (i.e. remain in ED for ground arrivals).   
  4. NOTE: for decision to remain in, or return to, the ED, all TAR roles and functions resume per trauma activation policy   
  5. Upon decision to proceed with DIRECT TO OR, Anesthesia Attending notifies the OR staff  
  6. PDS Trauma Attending notifies the OR Desk/Charge and communicates instruments &/or trays to be prepped and opened.  
  7. Upon direction of the OR Desk/Charge, the OR Circulator and OR Scrub prepare the designated operating room as requested.   
  8. IF the US is taken to the helipad, the Trauma Junior IMMEDIATELY returns the US to the ED before proceeding to join the operating team in the OR.  
  9. The PDS Trauma Attending, Anesthesia Attending, as well as the Trauma and OR teams, escort the patient to the OR.   
  10. The OR Desk/Charge stops at the OR desk to verify the patient has an armband in place and places and verifies the armband as needed.   
  11. The ED Charge RN notifies the ED X-ray tech and directs him/her to the OR suite to prepare for trauma x-rays upon patient arrival.   
  12. The Anesthesia Tech ensures the MTP cooler is delivered to the designated OR room.   
  13. Anesthesia Attending or PDS Trauma Attending will notify Blood Bank to stop MTP.   
  14. The PDS Trauma Chief and PDS Trauma Attending will verify an appropriate MTP order was entered or complete order if not.   
  15. The ED Charge RN or the Chaplain will ensure the patient’s family is taken to the OR or ICU waiting area and communicate location to the Trauma Team.   

  

 

POST-OP CARE AND FOLLOW-UP  

  1. PDS Trauma Attending will communicate with the patient’s family.   
  2. At the end of the OR case, the patient will be escorted by Anesthesia Attending to the previously identified ICU bed.   
  3. Peds Charge RN and/or PICU Attending coordinate receipt of patient from Anesthesia Attending by assembling the ICU team and assisting as getting patient settled as needed.   
  4. The OR team (the OR Desk/Charge, the OR Circulator and OR Scrub) will remain in the OR to turn the OR room.   
  5. The Chaplain will verify family presence & location and ensure communication. 
  6. The Pediatric Trauma Coordinator will collect feedback from involved parties and prepare case for review at Peds IDTQA and/or PHQAC.  

Disclaimer

These guidelines are not intended as a directive or to present a definitive statement of the applicable standard of patient care.  They are offered as an approach for quality assurance and risk management and are subject to (1) revision as warranted by the continuing evaluation of technology and practice; (2) the overall individual professional discretion and judgment of the treating provider in a given patient circumstance; and (3) the patient’s willingness to follow the recommended treatment. 


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