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Trauma Nursing Conference

Cedars-Sinai Medical Center

Organized Chaos? What is really going


on when our trauma patients are in the ED!

Sam Torbati MD, FAAEM, FACEP

Co-Chairman and Medical Director


Ruth and Harry Roman Emergency Department

Associate Professor of Emergency Medicine


Department of Emergency Medicine
Cedars-Sinai Medical Center
Organized Chaos:

a complex situation or process that appears


chaotic while having enough order to achieve
progress or goals.

--English Dictionary

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Objectives

Discuss management issues of non-Trauma patients in


Level-I Trauma ED

Review challenges in ED flow of high volume complex


patients

Assess opportunities for collaboration between ED and


medical center

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Common Scenario today at 1:00

ED census 85, 20 in waiting room


15 admissions

1 Active Code Brain in hallway


1 STEMI 200 in room 8
1 Intubation in process in room 5
Pediatric sedation in Fast Track
Security paged to assist with restraints in Pavillion
Seizing patient in Triage

2 Trauma activations on the way.

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Etiology of Chaos:

Unscheduled visits
Unscheduled illness or injury

Unpredictable demand variation:


Seasonal, Day to day, Hour to hour

Rapid changes in complexity and acuity

Fixed capacity: space and staffing

Doors are always open


Trauma, STEMI, Stroke, BLS, Walk-in
EMTALA

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What causes all of the chaos? What makes the ED different than
the rest of the house?

Unscheduled visits
Unscheduled illness or injury

Unpredictable demand variation:


Seasonal, Day to day, Hour to hour

Rapid changes in complexity and acuity

Fixed capacity: space and staffing

Doors are always open


Trauma, STEMI, Stroke, BLS, Walk-in
EMTALA

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Unpredictable demand variation:
Seasonal, Day to day, Hour to hour

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What causes all of the chaos? What makes the ED different than
the rest of the house?

Unscheduled visits
Unscheduled illness or injury

Unpredictable demand variation:


Seasonal, Day to day, Hour to hour

Rapid changes in complexity and acuity

Fixed capacity: space and staffing

Doors are always open


Trauma, STEMI, Stroke, BLS, Walk-in
EMTALA

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ED Acuity

Acuity
3500

3000

2500

2000

1500

1000

500

0
Acuity 1 (0.5%) Acuity 2 (36.8%) Acuity 3 (44.9%) Acuity 4 (17.4%) Acuity 5 (0.8%)

Acuity 1: Life threatening


Acuity 2: Maximal resources
Acuity 3: Limited resources
Acuity 4: Minimal resources
Acuity 5: Least resources

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What causes all of the chaos? What makes the ED different than
the rest of the house?

Unscheduled visits
Unscheduled illness or injury

Unpredictable demand variation:


Seasonal, Day to day, Hour to hour

Rapid changes in complexity and acuity

Fixed capacity: space and staffing

Doors are always open


Trauma, STEMI, Stroke, BLS, Walk-in
EMTALA

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Fixed capacity

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What causes all of the chaos? What makes the ED different than
the rest of the house?

Unscheduled visits
Unscheduled illness or injury

Unpredictable demand variation:


Seasonal, Day to day, Hour to hour

Rapid changes in complexity and acuity

Fixed capacity: space and staffing

Doors are always open


Trauma, STEMI, Stroke, BLS, Walk-in
EMTALA

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Non-Trauma High Intensity Patient Types

STEMI

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Non-Trauma High Intensity Patient Types

Stroke/ICH

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Non-Trauma High Intensity Patient Types

STEMI
Stroke
Psych/Behavioral
Critically Ill:
Peds
Adult
Respiratory failure
Cardiogenic shock
OD
Sepsis

Sedation

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How different in Cedars-Sinai than other medical centers?
We take care of very complex patients

Tertiary/Quatrinary Care Facility:

Level 1 Trauma Center


Comprehensive Stroke Center
STEMI receiving Center
EDAP Approved for Children

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Whats in the future for the CSMC ED?

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Strategies to manage chaos

High functioning systems: Protocols and Personnel with


expertise and understanding of defined roles
Trauma Team
Stroke Team
Cardiac Cath Team
ECMO
PERT
PICU Team
L&D Team

Appropriate staffing, space and diagnostics


The ED is an advanced diagnostic center

Operational efficiency to optimize flow


Lessons from battle field

Removing botte necks

Pull vs push of admitted patients from ED

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Strategies to improve efficiency, capacity & flow

Space:
Hallway beds and even more hallway beds
Gray Team: Imaging overflow 4:00 pm daily

Flow:
Triage Phlebotomy
Provider (PA) assessment & order entry in Triage
EDCTSICU of critically ill Trauma patients

Imaging:
Imaging Flow Nurse
CT Coordinador
ED Flow Nurse
ED CT Suite

Communications:
ED to Inpatient Report/Nurse hand-off project

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We do organized chaos well

ED census 85, 20 in waiting room


15 admissions

1 Active Code Brain in hallway


1 STEMI 200 in room 8
1 Intubation in process in room 5
Pediatric sedation in Fast Track
Security paged to assist with
restraints in Pavillion
Seizing patient in Triage

2 Trauma activations on the


way.

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