Lessons Learned for Trauma Preparedness and Responses

Abstract and Introduction

Abstract

The emergence of coronavirus disease 2019 (COVID-19) that is caused by the SARS-CoV-2 virus has led to an overwhelming strain on healthcare delivery. This pandemic has created a sustained stress on the modern healthcare system, with unforeseen and potential drastic effects. Although the initial focus during this pandemic has been preparedness and response directed to the pandemic itself, traumatic injury has continued to remain a common problem that requires immediate evaluation and care to provide optimal outcomes. The State of Washington had the first reported case and death related to COVID-19 in the United States. Harborview Medical Center, which serves as the sole Level-1 adult and pediatric trauma center for the state, was rapidly affected by COVID-19, but still needed to maintain preparedness and responses to injured patients for the region. Although initially the focus was on the emerging pandemic on institutional factors, it became obvious that sustained efforts for regional trauma care required a more global focus. Because of these factors, Harborview Medical Center was quickly entrusted to serve as the coordinating center for the regions COVID-19 response, while also continuing to provide optimal care for injured patients during the pandemic. This response allowed the care of injured patients to be maintained within designated trauma centers during this pandemic. This present report summarizes the evolution of trauma care delivery during the first phase of this pandemic and provides informative recommendations for sustained responses to the care of injured patients during the pandemic based on lessons learned during the initial response.

Introduction

As with all other components of healthcare, trauma centers have had to alter and reconfigure care delivery in response to the challenges of the COVID-19 pandemic. This devastating pandemic originated in Wuhan, China, in late December 2019.^[1] Rapid worldwide spread occurred with the first case in the United States diagnosed in Washington State.^[2] Despite isolation of the first case, subsequent cases were found in the community. An outbreak was detected in late February in a long-term care facility in King County affecting 129 individuals.^[3] This outbreak was followed by a number of public health measures to limit further spread and maintain public healthcare infrastructure for the 2.2 million residents of King County. However, it became evident that the SARS-COV-2 virus had been circulating throughout Western Washington for at least 3 to 6 weeks before the first documented case in late January.^[4]

Despite this pandemic, trauma and emergency care needed to continue. As the sole Level I trauma center located in King County and supporting the states of Washington, Idaho, Montana, and Alaska, Harborview Medical Center (HMC) needed to create a rapid and nimble process to treat COVID-19 patients and still maintain the essential care of severely injured patients for the region.^[5] The following report focuses on the initial and sustained responses developed to manage injured patients during the evolution of the COVID-19 pandemic.

Table 1. Recommendations to Maintain Optimal Trauma Care
Recommendation	Process
Establish a Regional Medical Operations Center (RMOC) to coordinate distribution of patient across all hospitals in the region	Contact local healthcare coalition and evaluate existing infrastructure to support RMOC
	Convene a meeting with leaders from all regional hospitals and healthcare systems
	Obtain agreements from all hospitals for open sharing of data regarding burden of COVID-19 cases, bed capacity, and critical resources such as PPE and ventilators
	Establish a software platform for real-time data collection from all hospitals
	Identify and preserve specialized emergency care with centers of excellence
	Monitor burden on facilities as pandemic progresses and distribute patients & resources equitably to meet demand & preserve access for time sensitive emergency care
	Monitor for outbreaks, and support testing operations
Maintain hospital incident command to focus on pandemic and trauma care	Works with local/regional department of health to track COVID-19 infections
	Evaluates, maintains and develops contingence for equipment and therapeutics
	Works with RMOC to prioritize COVID-19 patients not to overwhelm single systems
	Maintains ability by working with pre-hospital providers and referral centers to continue to focus on trauma care
Optimize ED COVID-19 and trauma responses	Maintain supply of PPE and essential equipment, and maintain in optimal location
	Evaluate and redesign staff and provider response to minimize exposure
	COVID-19 testing must be available for staff and patients
Universal COVID-19 testing for all admissions	Rapid screen patients for COVID-19 that are to undergo emergent or urgent surgery
	Real-time polymerase chain reaction testing for all patients not undergoing rapid test
	Protocolize subsequent inpatient testing around risk of false-negative and AGPs
Optimize emergent and urgent surgery for injured patients	Develop COVID-19 operating room
	Establish and maintain effective intraoperative communication tool (e.g. Walkie talkie)
	Create mechanism to convert operating rooms to COVID-19 rooms as needed
	Restrict or cancel elective surgery based on COVID-19 regional needs
Maintain care of trauma patient at prepandemic level	Create mobile supply carts that contain equipment for geographically displaced patients
	Cross-train bedside providers for both trauma and COVID-19 care
	Staff and provider education on appropriate PPE use
	Proticolize and review COVID-19 process during aerosol-generating procedures
Optimize discharge and post-discharge care	Early engagement of social work to focus on discharge needs, including skilled nursing center engagement and discharge
	Develop and optimize telemedicine for postdischarge care
Ensure patient and family emotional support	Provide support and encourage palliative care involvement to patients with severe critical illness, severe comorbidities and frailty, and end of life disease process
	Screen and treat post-traumatic stress disorder
	Engage and encourage chemical dependence evaluation for patients based on screening
	Encourage and establish telemedicine and teleconferences to provide patient information and engage families with patients
	Establish and refine telemedicine discharge visits
Focus on staff and provider resilience	Virtual town halls and messaging of protocols/policies to be occur based on need
	Transparence around rates of hospital acquired and staff infections
	Rapidly deploy resources to hospital outbreaks and areas of concern
	Establish programs of meaningfulness

Table 1. Recommendations to Maintain Optimal Trauma Care

Recommendation

Process

Establish a Regional Medical Operations Center (RMOC) to coordinate distribution of patient across all hospitals in the region

Contact local healthcare coalition and evaluate existing infrastructure to support RMOC

Convene a meeting with leaders from all regional hospitals and healthcare systems

Obtain agreements from all hospitals for open sharing of data regarding burden of COVID-19 cases, bed capacity, and critical resources such as PPE and ventilators

Establish a software platform for real-time data collection from all hospitals

Identify and preserve specialized emergency care with centers of excellence

Monitor burden on facilities as pandemic progresses and distribute patients & resources equitably to meet demand & preserve access for time sensitive emergency care

Monitor for outbreaks, and support testing operations

Maintain hospital incident command to focus on pandemic and trauma care

Works with local/regional department of health to track COVID-19 infections

Evaluates, maintains and develops contingence for equipment and therapeutics

Works with RMOC to prioritize COVID-19 patients not to overwhelm single systems

Maintains ability by working with pre-hospital providers and referral centers to continue to focus on trauma care

Optimize ED COVID-19 and trauma responses

Maintain supply of PPE and essential equipment, and maintain in optimal location

Evaluate and redesign staff and provider response to minimize exposure

COVID-19 testing must be available for staff and patients

Universal COVID-19 testing for all admissions

Rapid screen patients for COVID-19 that are to undergo emergent or urgent surgery

Real-time polymerase chain reaction testing for all patients not undergoing rapid test

Protocolize subsequent inpatient testing around risk of false-negative and AGPs

Optimize emergent and urgent surgery for injured patients

Develop COVID-19 operating room

Establish and maintain effective intraoperative communication tool (e.g. Walkie talkie)

Create mechanism to convert operating rooms to COVID-19 rooms as needed

Restrict or cancel elective surgery based on COVID-19 regional needs

Maintain care of trauma patient at prepandemic level

Create mobile supply carts that contain equipment for geographically displaced patients

Cross-train bedside providers for both trauma and COVID-19 care

Staff and provider education on appropriate PPE use

Proticolize and review COVID-19 process during aerosol-generating procedures

Optimize discharge and post-discharge care

Early engagement of social work to focus on discharge needs, including skilled nursing center engagement and discharge

Develop and optimize telemedicine for postdischarge care

Ensure patient and family emotional support

Provide support and encourage palliative care involvement to patients with severe critical illness, severe comorbidities and frailty, and end of life disease process

Screen and treat post-traumatic stress disorder

Engage and encourage chemical dependence evaluation for patients based on screening

Encourage and establish telemedicine and teleconferences to provide patient information and engage families with patients

Establish and refine telemedicine discharge visits

Focus on staff and provider resilience

Virtual town halls and messaging of protocols/policies to be occur based on need

Transparence around rates of hospital acquired and staff infections

Rapidly deploy resources to hospital outbreaks and areas of concern

Establish programs of meaningfulness