Okay. We're going to go in another direction with my presentation. Not quite as clinical, but in another direction. We're going to look at trauma care, and we're going to take it from chaos to concise. One of the things that bothers me most about my trauma room is when anybody refers to it as chaotic or as chaos. And the reality is, if we're doing it right, to the untrained eye, it may look like chaos, but to the trained eye, it should look like a well-organized dance. And so we're going to go ahead and talk about going from chaos to concise. My name is Lisa Schwing. I'm the trauma program manager at Dayton Children's. I've been there for about 20 years. I did 17 years of adult ED before that. I'm a board member and officer of the Ohio Society of Trauma Nurse Leaders. I'm the vice chair of our regional trauma system, SORTS, TNCC state faculty, and the recipient of the Emergency Nurses Association National Education Award in 2016. So what we're going to do is we're going to put it all together for the trauma patient and talk about why we're doing it. My objectives are, I have no disclaimers, my objectives are we're going to discuss the importance of a systematic approach to trauma care. We're going to identify two ways to improve communication in the trauma room and between services, list how a trauma nurse leader program helps with staff engagement, and also patient care. And we're going to identify one evidence-based process that could be, could benefit your trauma patients, discuss how patient advocacy drives change. So really, if your nurse is in this room, you're advocates for your patient and you're also advocates for your staff. So we're going to try to talk about some game changers in trauma process. And who are we doing it for? We're doing it for Max. This is Max. He's a trauma patient at my facility, and if I didn't say it, we are a pediatric trauma center, level 2 ACS pediatric trauma center. And this is Max on his 10th birthday with 10 candles. And we'll get back to Max at the end of the presentation and talk about the significance of him on his 10th birthday. But before the pager goes off, it's time to get our ducks in a row. There's a lot of things that have to be right about your trauma system before you get started, before you can do the best for your patient. Good intentions, they're not enough. So we're going to talk a little bit about the equipment and training, taking your nursing care in the trauma room and beyond to the next level, some processes that may need tweaked, team members and their roles, pre-hospital partners, going to talk about collaboration, the use of videos in your trauma room, goals for loop closure, and also some communication. When things go wrong, communication is always at the root. It's always at the root of that. So we're going to talk about these things. So to get started, we're going to talk a little bit about equipment. Like I said, we're a standalone pediatric facility. So having tools to help us with pediatric care, because our kids are some are this big, and some are this big. And sometimes we even get adult patients, staff members that have had an accident or an injury, or grandparents that are there with a patient who have an event and end up going to ground. So we do occasionally get adults. So we do have a pediatric code cart, Braslo cart, Braslo tape, but we've created our own chart. And this chart that's up on the wall tells by age, exactly what equipment the patient needs, what ET tube, what energy tube, what doses for seizure medications, how we're doing fluid resuscitation and burn patients. And so this chart, it helps us in our trauma room. But this chart also is given to all the adult facilities in our region. Not so foolish to think that we're getting all the kids brought to us, at least not initially. 49% of my trauma patients are seen in an adult facility first. And so we know in delay of care or in not doing care correctly, we know that there's a cost in that. So we want our adult facilities in our region to have the advantage of having our recommendation for trauma care for kids as well. And so we also stock, check our stock daily in the trauma room, we check to make sure every single size of every single piece of equipment is right. And we put those in a Broslow cart. So even though we're a pediatric place, we are also living by Broslow a bit as well. So for our equipment, we talked about hypothermia and the dangers of hypothermia. And we have an entire room that's between our two trauma rooms. It's really all about keeping the patient warm. We have fluid warmers, blanket warmers, French fry lights in there, we have bear huggers. And we know that especially in pediatric patients, they lose heat fast, they have really immature hypothalamus. And so keeping that patient warm is really paramount. Same thing with old people, thin skin and get cold really easy, more responsive to the to the temperature in the room. So I tell my residents when they walk in the door, if you're not sweating in my trauma room, the heat's not up high enough, they should be sweating for every reason. We all know we've seen in our presentations this morning that hypothermia and hypotension lead to DIC and for pediatric patients even faster. So for our equipment, we've got our equipment in cabinets, it's they're very clearly marked. They've all got laminated colored labels with large print on them. So if you need a surgical tray, a chest tube tray, you need to open somebody's chest in the trauma room, the equipment, we don't do it very often. But if we need to, the equipment is incredibly easily identified, they're clearly labeled, stocked and checked daily. We make every attempt to streamline equipment. And so when a patient comes in in a C-collar from the field, that if they're well immobilized, and we think we can clear them in the trauma room, they may stay in that collar during their trauma room resuscitation, which is generally only 30 minutes or less in the trauma room. And if not, no patient goes past the trauma room in a field collar, not the one piece or the Philly collar or any other collar. When they get past the point of our resuscitation room, they're switched out to a single collar. For us, it's the Miami-Jade, but we're training, everybody in the ICU is trained on that collar. Everybody on their step down floors are trained on that collar specifically. And so when you standardize your equipment, you're also making it easy, like we saw in the previous talk where the patient had their collar up around their face and their neck and stuff, you're making it easy for your staff to identify issues if they happen at the bedside and fix them. So we also collaborate on equipment. It doesn't make sense to put the ICU through competencies on the rapid infuser. The ED staff is very well trained on the rapid infuser. If we have a patient that goes to the ICU with the rapid infuser, an ED nurse goes with them. The ED nurse may follow them to the OR to run that equipment as well. So we train our staff with a focus of being able to remain competent and not make people train on stuff that they may only touch once a year. And that's something that's understood. So when we're training for our competencies, we all do ACLS and we do PALS at our hospitals required as well. ATLS, TNCC, and ENPC. But the funnest training that we do is Trauma Olympics. Has anybody heard of Trauma Olympics? No. We take all of our trauma equipment and we put it out in an area where staff can get their hands on it. Then the staff picks teams of four or five, depending on the equipment that we're reviewing. And they have to review all the equipment because they're competing for time and accuracy against all the people in the ED. And whichever team then does the best job of the fastest art line setup, the fastest center line setup, the fastest rapid infuser setup, they win Trauma Olympics. They get all the kudos. It goes out on Focus, which is our hospital's kind of electronic magazine thing. And they also get a free educational conference as well. So it becomes fun and it becomes a great competition. So training in mock traumas, you've got to make them fun. If you don't, nobody's going to really want to do them. So we do them all the time and it is fun. And so here's another picture of our group training, doing training and competencies in mock traumas as well. The group on the left is doing a CPR training infant. The group on the right just got finished with their trauma competencies. Now that you've done a lot of mock traumas, it's time to let everybody else know what you really do. It occurred to us, one of our physicians that has to do with trauma, she's one of our intensivists, is also on the board of trustees. And she suggested that the board maybe come and see a trauma because what happens in the trauma room and the trauma service is really all about collaboration. There's a lot of different services involved. And so we actually did mock traumas for the board of our hospital. It helped our trauma service. They support us completely. They understand now what we do. They have an understanding. The gentleman in the very back corner of this room, he's one of our board members. We took the board members, put them at the bedside, told them what their roles were and kind of walked them through a trauma scenario. And then we allowed them to step back and see us do a mock trauma. And it really made a huge difference for them. So now we're going to take nursing care in the trauma room to a whole new level. And how did we do that? We did it by developing a trauma nurse leader program. We didn't make this up. We got this from nationwide children who had gotten it from Cincinnati children who had gotten it from someplace in Texas. And so I'm sure there are programs out there that have trauma nurse leader programs. But when we developed our trauma nurse leader program, one of the things we heard from our ED staff is that nobody got really good at trauma resuscitation. So we started looking at the numbers. In our trauma room or in our hospital ED, we see just over 80,000 patients a year. Between traumas, about 140, 150 traumas, and 1,302 major resuscitation. So lots more codes than traumas. And then three nurses per resuscitation. Or if you don't have any control over your trauma room, maybe 10 nurses. And you've all seen those big bad cases where everybody flocks in there and nobody's taking care of the other patients. And then three nurses per resuscitation if it's going well. And on average then each nurse gets in the trauma room 39 times. That's three times a month. That's not enough to get really good at what you're doing in there. So nobody was really good. So we took this core group of 12 nurses and we trained them on everything in the trauma room. On massive transfusion, on labeling blood and banding patients, on the equipment that's in the trauma room, on the processes, on our expectations, on our goals, on our PI indicators. They are part of our trauma service. Now these 12 trauma nurse leaders and they facilitate care in the trauma room. So really what's a trauma nurse leader? They're a trauma super user. Everybody's used that term before when you introduce something that's new or something that you're not doing very often. You end up with a nurse who's a critical thinker who's highly, highly, highly, highly trained in trauma care. And what we didn't really expect was that this group keeps the rest of the ED engaged. The rest of the ED thought, oh, only those people are going to be in the trauma room. We're not going to get to go in there. And so they thought that they were going to lose some skill. But what's really happened is these people become the go-to people for the rest of the staff. They keep the trauma, everybody trained. They pull out the equipment when it's maybe not as busy and we're just coming out of a busy season. So we'll be doing that more this spring. But they pull out equipment and they keep everybody moving forward and helping with training for trauma. They've done a huge, huge amount of work. They've also recreated the entire electronic medical record for trauma so that it's more user friendly. It's more like the everyday charting. It's set up like that. And so we're charting on electronic medical records. The TNL directs care in the trauma room. And if they're really good at what they do, you don't even know that they're there. They're not bossy. They're not loud. But they're two steps ahead of the physicians when they're in that ATLS, A through I algorithm. And they've already called CAT scan. They know that CAT scan's ready before somebody says, let's go to CAT scan. Are we ready for CAT scan? The TNL already knows the answers. They're ready for us in CAT scan. So training this nurse to that level has really, really not just improved those 12 nurses, but has improved our staffing, our care, and our documentation overall. So some of the things this group has accomplished is the development of an evidence-based pediatric massive transfusion protocol. Took us a year to do it, but we're there. Evidence-based poster on the TNL group themselves. So while we were creating this poster, we were also teaching these 12 the evidence-based process. Complete redo of the electronic medical record, trauma documentation, modules for staff. So when we did our last staff, previous staff engagement survey, what we were told was they didn't feel comfortable documenting. So the Commoner's leaders created five different documentation modules for them. And they are doing them at their annual competencies. So monthly we're getting some done. We did a pre-questionnaire on documentation before. We're going to do a post-questionnaire afterwards. Maybe we'll actually write that one up. We'll see how our results are. They've taken our trauma room length of stay now from over 60 minutes to well under 60 minutes for our top-tier trauma patients. And I don't mean out of the trauma room in 60 minutes. I mean finished with CAT scan in 60 minutes and to the ICU if the patient's going to the ICU. So this group has created a process called a ticket to trauma that completely limits the number of people in the trauma room. People have specific roles. They get a ticket or a sticker when they walk in the door for what role they are. If you don't have a ticket, you aren't in the trauma room. And so we don't have 20 people in there. We have 11 people in there. We are a teaching hospital. So we created three tickets for observer tickets. But that's it. I can't have everybody with a student in there. We can't be good. So they've done trauma symposiums that they've hosted. And I can't tell you how many more projects they've done. So trauma nurse leaders. Now the pre-hospital partners. What do your medics have and what do they need? For us, we have two EMS coordinators that go out and do education for our people. Also multiple trainings every week for EMS if they want it that are all CE'd. EMS, we do performance improvement for them. So every single EMS run, every single run that comes in, we provide feedback to them. Most of it's kudos. Most of it's great job. Everything according to protocol. Every once in a while, we have that Monday morning quarterback where he said, you know, this might have been done a little bit different. But mostly, we're developing a good relationship with them. This is Mike. He's one of my EMS coordinators that goes out and does the training. And this is a PD bag. We've provided all the EMS in our 20 county region with one of these bags. They have in it everything that you need to care for a kid. One of our area hospitals got a hold of one of these bags and referred to it as a pediatric trauma room in a bag. So every airway, adjunct, every size of IV catheter are kept in these bags. There's little pouches in these bags that are by weight. And this is Heather. She's my other EMS coordinator, Tiny Heather. And she's holding one of the pouches that's by weight. So when EMS comes in, if they've used the 5 to 15 kilo pouch out of that bag, they just dump it in that can there and grab a new one out of the PIXUS or out of the cabinet and back on the road. And that was one of the things that they like about our system is that they don't have a lot of downtime. Okay, so now we're ready for the pager to go off. And when the pager goes off, you need to know exactly who your team is. You need to know exactly where they stand in that room. So when I take the residents into orientation, if they're on the left side of the bed, they're in trouble for me. They live on the right side of the bed at the patient's shoulder. That's it. Okay. I don't expect everybody in somebody else's space. Everybody knows exactly where they're supposed to be. If they forget what they're supposed to do, it's all posted along the top edge of the wall, exactly what your role is. There are 11 roles in that room, and you have bullet points, and you do the first one first. So we've made it very easy that if you're a little out of your element, if you're a newer nurse, you know exactly what your personal goals are for that room. So one of my favorite quotes from the movie Sabrina is more isn't always better. Sometimes it's just more. And we never want our trauma room to look like this. So we did create this ticket to trauma where we have a page of stickers. Actually, it's two pages of stickers and like one and a half. And each person who has a role in that room has a sticker. You get your sticker as you walk in the door. You know exactly who everybody in the room, regardless if you have a gown on, a barrier, a lead apron, you put it on your arm, everybody knows who you are and what your role is in that room and who's supposed to be talking and who's really not supposed to be talking. We do allow Child Life to be part of that team. Their job is, and if you can imagine this, to normalize what's happening to the patient in the trauma room. There is nothing normal about getting stripped naked and having 11 people working on you at one time. So they do a lot of distraction and they help these kids a lot. And if the child is not alert enough, they turn their attention to the siblings. So some processes. We really looked at our group who was making the call to activate traumas, who was best at it. And what we found through an evidence-based study is when minutes count, who's really the right person to make that decision? The nurse. The nurse is the right person to make that decision. Nurses are in short supply. We do have a communication center. Nurses came out 10% more efficient than physicians and over 25% more efficient than just people who were trained to do it. And so we had kind of a trade-off, even though nurses kind of won that evidence-based practice study done by the trauma nurse leaders. The best that we can do is paramedics in that space. So we've standardized the people in our comm center. We've also tried to make it easy. We've standardized their documentation in our electronic medical record so they know exactly what questions to ask the medic. They don't want to be kept on the line. They're busy in the back of that box. So I want my people in our comm center to know exactly what information we need. We've also made our alpha and bravo criteria extremely clear. And we've made a rule that it can't be altered until the patient is seen. So there's no, let's wait until we see what they look like when they get here. Everybody knows that if it meets criteria, it's an activation, that's it. There are also some other people that we're collaborating with. So people that have the trauma pagers that never show up to the trauma room include our blood bank, our lab, our ICU, anesthesia, and CAT scan tech so that they know when we have a top tier or second tier trauma, they're going to be expected to be available to us immediately. And they always are. We take our labs, our lab is pretty close to our trauma room. We hand carry them over there, announce these are the trauma labs, and somebody takes them right from us. They go directly to the benches. And we get our labs back in less than 10 minutes, except for that PT, PTT, it takes a little bit longer. So communication in the trauma room. We keep it quiet in the trauma room. That's the first thing that they say before the patient gets there, is that they want quiet to hear the EMS report, and LMA looks very much like a king airway. We need to hear what the EMS has to say, what they saw at the scene, what they did, what they gave, so that we can build our care on that. Our comm center is trained to ask only the key questions that we need to activate our trauma team, and a hush falls over the room when the trauma patient comes in. It is truly very quiet. We have the participation in that room of an ICU nurse and an intensivist. This is a huge addition to our team. The ICU nurse counts as one of the three nurses. When they come down to the trauma room, they're there for the EMS report. They've heard everything from the very start. They hear what's going on with the trauma patient, what's going on, what they've gotten, what kind of fluid they've gotten, and they know everything that's happened in the trauma room. They stay with the patient through CAT scan. They go up to the ICU, and that's the nurse that's going to take care of the patient then in the ICU. It's a seamless handoff. There's no playing telephone. I don't think the ER told me that. The ICU nurse has heard everything there is, because we know that if we're doing a good job, the patient isn't staying in the ED very long. They're getting lines and airways, and then they're off to CAT scan in less than 30 minutes. So 100% of our orders, we make sure the TNLs make sure that 100% of the orders match what's been documented, and we do that by reviewing videos with our trauma nurse leaders, and that's open to staff as well. There's always some place you can improve. So everybody wants to see themselves, but really I think there's also value in seeing others so that you can see, oh, that went easier, that was quieter, that was better. Let me emulate that. So communication and performance, it's not intended ever to be performance improvement, not intended to be punitive at all, ever. The Trauma Record Review Committee looks at all of the records for trauma and makes a decision on whether follow-up's needed. We're going to give feedback to our transferring EMS people, again, not intended to be negative, and compare our facilities then to national benchmark. Were we surprised when we got our TQIP report back and this following data was there, we thought we saw a lot of abuse, but what we didn't realize is that our hospital, our region sees double the amount of abuse of all the other 73 pediatric trauma centers on average. We see double. What are we doing about it? You don't know what you don't know until you compare not just your care, but you compare it to other people and their statistics, and what's going on in my region that this is the case, and how can we as a hospital have an effect on this community? So big, big deal. So we look closer. We look at our videos to help close the loop, and one of my husband's favorite sayings is you must inspect what you expect. So I'm down in the trauma room watching the traumas as we go, helping people, not correcting. If something needs to be corrected, that happens later. We look at processes, blood labeling, team members that stay in their role or don't stay in their role. The length of attempt for intubation, you'd be really surprised that the documentation says one intubation attempt, and it really doesn't say anything more, but when you look at it on the video, it took two and a half minutes. That's too long. That's too long, especially for a kid. And then we review staff concerns and allow everybody the opportunity to watch their own performance on these videos, and it's not about individual performances. It's about fixing the processes that aren't working. Everybody, including my TNLs, is aware of our goals. So for our trauma attendings, they're getting to the ED within 15 minutes for our highest level activation, and then for life and limb surgeries, we're getting there within 15 minutes, and we monitor those every month. For our alphas, we're getting to the ICU in less than 60 minutes, and our second tier traumas in less than 20 minutes, and then that our documentation is 100% correct at least 90% of the time. So if you don't have specific goals for your trauma, then you're going to stay stagnant and not improve. So now we started out with Max, and I mentioned him because I wanted to come full circle and come back to him and do a little trauma scenario. And Max's case really relied on everybody doing everything exactly right at exactly the right time, otherwise Max would have had a very, very different outcome. So now that we've got our ducks in a row, we're going to talk a little bit more about Max. You'll notice that Max has 10 candles on his birthday cookie. When we first met Max, he was nine. It was his ninth birthday. And for his birthday, he and his friend got to go out and ride ATVs. And Max turned around and looked over his shoulder at his friend and hit a bump, lost control, flipped the ATV that weighed 700 pounds, and it landed on nine-year-old Max. And it actually landed right on his head, neck area, and jaw. Max was unconscious. He was bleeding orally. His friend that was with him wasn't big enough to move the ATV, smart enough to get back on his ATV and go get Max's mom. And she understood how badly this child sounded like he was hurt. She called 911, who they also got the message. They called our local helicopter group because we were pretty sure he was in a remote location and might need some extrication and some help getting to him. So with this ATV crash, we found that he had bruises and abrasions on his face. He was responding to pain only, suctioned by EMS for a lot of blood. He had a Glasgow of 11. CareFlight, who's our local helicopter service for our level one in Dayton, Ohio, responded to the scene, and they got there at 1033. He was intubated by 1045. They were off the scene by 1055. And then C-spine protection for him was a towel roll. Not everybody's got exactly the right equipment for little kids. And he was immobilized on a backboard. He got two IVs, not running at bolus rate, just at keep open rate. And his vital signs really looked fairly reasonable, so not too terribly worried. He arrives at our hospital by 1119, fully immobilized with this towel roll in place, and was sedated and chemically paralyzed, had a size six ET tube, and good bilateral breast sounds. So all sounds reasonable so far. This is Max's chest film. His ET tube's at C5, and so had to be advanced a little bit. No pneumothoraxes. Good so far until this is Max's lateral C-spine film. Anybody see any issues here? C1 and C2 are supposed to sit on top of each other. They aren't. They aren't, and they aren't even close. So Max has a high level spinal injury, and he's unconscious, and he's sedated now. And so we really aren't sure exactly what we're dealing with. And Max has a towel roll for C-spine immobilization. So we get him out of that towel roll and into one of our collars that everybody's trained on. So he has an alanto-occipital dislocation, and this is just a slide that kind of defines what that is. It's more common in kids. They have ligamentous weakness, or not as strong of ligaments in their neck. Up to the age of 10, they got bigger heads than adults. So they tend to be a little head heavy and lead with their head if they're falling or getting thrown from an ATV. This is Max's one cut of his facial head CT. You can see the ET tube in place, but you can also see that Max's mandible is fractured in at least three areas. He has also dental fractures as well. And the reason that CareFlight intubated him on the scene with that glass gowl of 11 was because they felt like his face was not stable. His mandible was in trouble. So he has an alanto-occipital disassociation, or an internal decapitation, concussion with prolonged loss of consciousness, bilateral mandibular condyle fractures, facial lacerations, and broken teeth. Max is in trouble. So on day two, he goes to the ICU, he gets stabilized, they make a game plan. And on day two, he goes to the operating room with three different surgeons, no, four different surgeons. First to work is our trauma surgeon, who gives Max a tracheostomy, because we know we're going to need that airway for quite a while. Neurosurgery, we have a brand new neurosurgeon and a very seasoned neurosurgeon. So both of them together went and put Max in this halo, in halo traction. He got mandibular fixation by the plastic surgeons, and then a peg insertion by the trauma surgeons. And this is Max immediately post-op. You can see his teeth are wired together. He's got a fixator on his mandible. His C1, C2 are still really not aligned, and he's in halo traction. And so 10 days later, Max is off to the OR again. He's getting cervical fusion of C1 through 4, and you can see that. And he's still in the halo. And he's now conscious, and he's oriented, and he's neurologically intact, which is the most amazing of all. And then this is Max going home. 32 days after his trauma, he's going home with his trach in place, with his halo traction. He's got thumbs up. He can walk. He can talk. He's alert and oriented. So a very amazing outcome for him. He's still having difficulty swallowing. So in follow-up, he's still in the C collar. He's out of the halo. He's in the collar, and it took multiple, multiple swallow studies before he could actually pass a swallow study. So just to kind of talk in general about motorized wheeled vehicles. We saw 48 kids the same year with injuries, critical injuries, from motorized wheeled vehicles. Kids, they don't really have the judgment to control these, nor do they have the strength. We see riders and drivers as young as four on these vehicles. So it's important to do a little safety, a little outreach, a little prevention as well, because the numbers are significant. This is Max and his partner in crime. This is the kid that was with him when he was riding his ATV that tried to roll the ATV off of him. And he and Max are climbing a rock wall. This is post-injury. Made us a little sick at the hospital to see that. This is Max on his 10th birthday, which based on the injuries on day one, we were not sure he was ever going to see. This is Max with his 4H calf that he raised for the year. And this is Max saying, I can do all things. This wheel has little tiny glass beads in it, and it turns outside of our ICU. And his parents walked by this wheel over and over and over in that 32 days that we had Max in the ICU. And so why do we do this? In a word, Max. And I know you guys have Max's too. So that every single process that we look at regarding our trauma patients is completely as thought through as we possibly can. They have every opportunity to survive and do well. And we do it for Max, his parents, his friends, his sisters and brothers. And we do it because we're advocates for the patient. And this is our best advocacy, is to be ready for them when they come. Because they're coming. Questions? All right. Sure. So speaking of trauma, the trauma nurse leader, do you have a bunch of those in here? The trauma nurse leader program, right this second, is only in the emergency department. However, Nationwide came to kind of introduce us to this program and give a talk on it. And at that time, their trauma nurse leaders had been up and running for about five years. And they were now taking a trauma nurse, developing a trauma nurse leader program in the ICU and then out to the floors. So that's our next step, is to create those super users in the ICU. Because most of the patients in the ICU are sick, not hurt. And so it's really nice if you've got trauma super users in the ICU and then on to the floor as well. What format are you giving your EMS follow-up in? Are you making phone calls? Are you sending letters? We have a couple of formats. For our trauma ones, we have, am I allowed to say what trauma system we use? We use TraumaBase. It's our trauma computer system. And through TraumaBase, we can create a follow-up letter for them that gives them the date of service, the patient's age, so they can identify who they are. And then we follow up with them by providing all the procedures that were done and all the treatments, the patient's length of stay, the survivability. Also then, when my EMS, and they get that on every patient that's a trauma patient, when my EMS coordinators go out to, say, West Carrollton, which is one of our smaller towns in the area, we'll pull a report for them of all the kids in our TraumaBase since they did their last training that came from that area, so that they can kind of focus feedback and discussion on the cases that that EMS group has had. So that's what we're doing for follow-up. Also, my EMS coordinators are also doing follow-up on not trauma patients, and they have created their own kind of standalone computer base that they keep that data in and then provide the follow-up on code resuscitations and everything else that comes in. So part of it's on my EMS coordinators, and part of it's on my trauma team. Great, thanks very much. Can I ask you something? Oh, sorry. Sorry, I've got a question. Sure. So your trauma nurse leaders, is that a clinical designation? Is that just a provider designation? Is there a pager for any of those, or is there a calendar or something like that? When somebody wants to be a trauma nurse leader, and they become a trauma nurse leader, they're automatically on the first rung of that clinical ladder. So they get a rung no matter what. They don't get a pay raise. It's not a paid position, but it's a position that they apply for, and generally we expect them to have two years experience in ED nursing and at least one year experience with us. The biggest problem that I have with trauma nurse leaders is attrition. These are people who are taking a first step up that rung. In the last five years, I've lost one to be the ED assistant manager, two have gone on to be nurse practitioners. One is now a nursing director of one of our smaller outside facilities. So as you enable them, and they get really good at what they do, and they get confidence, then those people kind of tend to continue stepping up. So attrition in that direction, it's a good thing, but then I have to replace them, so it's a little harder for me. Anybody else? Thanks very much. Thanks, Lisa. The evaluations are on our app. If you haven't downloaded it yet, if you go to the app store and look for guidebooks and look for TCAA, and I'll also be sending out an email later today or tomorrow inviting you to do the link. As I said before earlier, this is a pilot series that we started this year, and we would like your feedback on this. Please do not leave without turning in your CME form, CEE form, and I'll meet you in the back.

trauma care

systematic approach

communication

patient advocacy

evidence-based processes

case study

medical interventions

collaborative efforts