introduce yourself and let's get started talking about child life. My name is Barbara Romito. I am the director of the Child Life Department at the Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. And I oversee child life services and family centered care for the Children's Hospital. And I am trying to go backwards. Okay, here we go. All right, so I'd like to start by telling everybody what is the role of a child life specialist, and I'm hoping that many of the people here today participating are familiar and know the answer. So this is either a refresher, or for those of you who are not familiar with child life. The overall goal of a child life specialist is to support the emotional and psychosocial needs of children and families and enabling them to cope with the stressors of illness of injury of hospitalization. The training of a child life specialist, it's multifaceted but the basis really lies in growth and development. Knowing what to do, how to teach, how to interact, how to intervene and also support individual needs of the child based on their development and their cognitive level. So a child life specialist will help support the child by providing things like recreational and therapeutic activities, teaching them about their illness, their injury, preparing them for procedures in ways that are age appropriate, and also by initiating different methods of non-pharmacological pain management, so including things like guided imagery and relaxation. So that was a very basic definition of the role of a child life specialist. Their focus in a hospital will change depending on where they work within the organization. So for example, if a child life specialist does work in the oncology unit, their focus may be on helping the child to understand their illness, their diagnosis. Okay, so a child life specialist, if for example they are working in an oncology unit, like I said, they deal with helping the child to understand their diagnosis and their illness and long term coping of that illness. A child life specialist's main role is in the emergency department. Their job is to do a very quick assessment of the child and the family when they come in, establish a very quick report, a trusting relationship, and then providing interventions for that emergency department visit. So it might be preparing them for the x-ray or the CAT scan, or it might be showing them sutures on a doll and what that's going to be like. And it might just be doing the distraction, relaxation, breathing to calm them during the experience. Ideally, your child life specialist in the ED is going to be one of the very first people that the child and family meet, so that way they make sure that very first touch point is as atraumatic as it can be. So when you talk about a trauma center, many level one and level two trauma centers or institutions that do have a pediatric unit as well will have a child life specialist on staff. And when it's a level one trauma center, usually the child life specialist is part of the responding trauma team. They're usually stationed at the head of the child and their job is to talk to the child and calm the child. And depending on what the classification of that trauma is, it may include providing distraction or guided imagery, or simply being the person to talk to them in a calming voice to help them through the experience. And the child life specialist is also integral in this situation in supporting the other family members, whether there are caregivers or siblings involved, preparing everyone for the next steps. And if it is a situation where there is a bereavement, their role is really going to be helping to support the whole family during that time. In community hospitals, as we know, especially those without a pediatric service, such as the case that we're talking about today, there isn't a child life specialist on staff. But there still is a need to be prepared in case a child does arrive in your emergency department. The most important intervention in this case includes prior planning. And I know we've talked a lot about that in some of the other sessions, planning for everything that could possibly happen. So that prior planning, for the most part, should involve education for everyone who is going to be involved in care of that child, whether it's the pre-hospital providers, the nurses, physicians, or ancillary staff, helping them get the information ahead of time, so prepared when the time comes. So, for example, for pre-hospital providers, some of the transportation considerations, you know, if you can, limit the siren or the high speeds, having distraction items on the ambulance, things like bubbles or stress balls or stickers. What's most important in pre-hospital transportation is preparing the child for what will happen next. In age-appropriate ways, helping them understand what will happen when they arrive at the hospital. For all of those who are involved in the care, it's important to understand how children are going to typically respond to hospitalization. Age-appropriate care, communication, they're just a small part of this, and I'll go into detail in just a second. I do want to mention that the American Academy of Pediatrics recommends that in a community hospital, where there may not necessarily be a need or resources to have a child life specialist on staff, there is a recommendation that consultative services are arranged with child life specialists that not only can help provide this education ahead of time, but can also provide either part-time or on-call services, or even offer telehealth sessions with patients, with families, and with staff members when the need arises. I want to talk briefly about children's typical responses to hospitalization, and then I'll go into detail about what we need to do to ensure that psychosocial care for the two children in this case. When a child comes to the hospital or the emergency department, the number one feeling almost always is fear. That's fear of the unknown, fear of the unexpected, having a lack of control, not knowing the environment, and in many cases, separation from caregivers. Some children are going to respond to this with passive-responsive. Some children will see those overt and active responses. Almost always, we're going to see some type of regressive behavior. How the child actually responds, that's going to depend on a lot of different things, their age, their developmental level, their cognitive level, but also what their prior experiences are with healthcare, with death and dying, the reason they're coming to the hospital, as well as their, of course, individual and pre-hospital personality. Finally, children are going to respond based on how we communicate with them. What we say and how we say it makes such a big difference. We need to use very simple language with them. We need to avoid medical terminology that can be confusing and can be scary. An example, I'm going to take your vitals. We never want children to think we're taking something from them, and vitals, that doesn't mean anything to most children. Or telling a child, the nurse will be right in to flush your IV, that is really incomprehensible to most children and scary. What we say to them or in front of them matters, even if they don't appear to be listening, because what we do know is children hear everything. If it's something that is confusing, and they hear bits and pieces, they usually make up their own answers, which are generally much more frightening than reality. What do we do when we're working with children if there isn't a child life specialist present? First and foremost, please always be aware of age and developmental level, because it really guides everything we need to do, how we communicate with them, how we prepare them, and how we support them. Preparation. This really is one of the major roles of a child life specialist, including it here, because it's so important for all providers to do. We need to prepare children of all ages for what's going to happen next. Things to remember from the very start, get on the child's level. Introduce yourself. So, for example, my name is John, and I work on the ambulance, and my job today is to make sure you are safe and cared for, and I'll be giving you a ride to the hospital so you can see the doctor when you get there. You need to designate roles for everyone involved, and if at all possible, give the child choices when real choices do exist, and this involves just watching how you phrase things. It's very common for people to say things like, is it okay if I examine you? And the child says no, and then you continue to examine them. So give them choices when real choices exist, and don't make promises that you don't think you can keep. Pain management. We all know how important pharmacological pain management is, but so is non-pharmacological pain management. So with children, we want to do the guided imagery and distraction and relaxation. This is going to help children through that stress of a hospitalization. However, if you don't have professionals who can do that, very simple exercises such as deep breathing, counting, squeezing a stress ball, simple techniques like that will distract and calm most children. There's also a technique called one voice, and I'm not going to go into all the details right now, but it does involve ensuring that only one voice is communicating to the child, especially in a trauma situation where so many people are talking at the same time. Having one voice focused on the child is helpful. And positioning for comfort. Pupuses of the old days are not recommended, nor is utilizing multiple staff to hold a child down. So positioning for comfort allows a supportive person to hold the child in a secure way so that any procedure can be done with minimal discomfort, and especially allowing the child to sit up whenever that's medically possible. So on to today's case. And here is our polling question. So you are caring for multiple patients when the five-year-old arrives. What would you consider the top priority from a developmental standpoint? Giving the child a comfort item? Ensuring the child is not left alone? Checking on the condition of the parents to be able to inform the child or explaining to the child what will happen next? So the good thing is hopefully you read through them and thought they were all important, which they are. So I don't want to say there's one right answer, but one of your priorities, and obviously people were listening about preparing the child for what's here next because that was the most popular one, but really you want to make sure the child is not left alone. In a situation like this where the caregivers are also patients, you want to make sure that there is someone designated as the safe person and the support person. And in this case, if the grandmother is stable enough to be that person, that is great. If not, you need to designate ahead of time who will be your support person. And I would strongly recommend having a policy in your organization to designate who in a situation like this is that support person so you are not scrambling at the last minute. So today we have a five-year-old. Developmentally, they are a preschool child, and this age group is often the most difficult age group when it comes to experiencing stress during hospitalization. And that's because they're old enough to have an awareness of what's going on, but they're young enough to have a very limited cognitive ability to fully understand. They have that magical, egocentric thinking, so they cause everything. Real or imagined, everything is the result of what they have done. So they're in the hospital today, the accident happened because they didn't clean their room, or they didn't pick up their toys, or they had a fight with their sibling. So you do need to assure this age group over and over that it was not their fault, the accident is not their doing, and they didn't think it, make it happen. Generally, five-year-olds can tolerate brief periods of separation from caregivers, but when they are stressed in a situation like this, it is exacerbated. So that is likely going to be your biggest stressor for your five-year-old, not having their caregivers with them. Five-year-olds also tend to ask a lot of those why and what questions. So you want to give them very simple explanations that focus on their senses, what they're going to see, what they're going to hear, what they're going to smell, and then preparing them for what will happen next. And when you prepare them for a procedure, do it right away. This age group tends to really enjoy delaying tactics, and that ends up causing more stress. You also want to remember they have full awareness of their body parts. So if you have a bloody wound, you want to cover that up as soon as possible, because they might fear that all of their blood is going to run out through that wound. You want to be careful that you don't relate a child's self-esteem to behavior during procedures. Give them permission to cry. Don't use those words, be a big boy, be a big girl, be brave. They can be upset, and they can cry. And again, the non-pharmacological pain management. Five-year-olds are very easily distracted, so I would suggest use that to your advantage. Flowing bubbles can very easily come and distract a child of this age. So then we have our 17-year-olds. Very similar to a five-year-old, 17-year-olds usually have that egocentric thinking. You know, the world revolves around them. They have that personal fable that they are unique. They can't be harmed, and a situation like this often shatters that belief. They also have a very big focus on what other people will think. That, in this situation, might actually dominate feelings of guilt. They do have that imaginary audience. They're preoccupied with being different, what other people think. So there might be that combination of guilt, of anger, of fear, all wrapped up in one. They do have a different parental relationship. They might find comfort in their parents' presence. They might be embarrassed, and we have complications up here with the mother working in the ED. So we need to be sensitive to that, and also respecting boundaries in this situation. The psychosocial piece is really going to be prominent with a 17-year-old. Emotionally and developmentally, they're a child, although physically they might be an adult. So you might see a little flip-flop back and forth from adult-like behaviors to child-like behaviors, and a sense of self-esteem and self-worth being questioned. So it's really the emotional side for the 17-year-old that might be the dominating factor. So that leads me to what I'd like to close with, which relates to emotional safety in pediatrics. And I want to talk about that because emotional safety, we define that as an intentional interdisciplinary practice to promote resiliency, healing, and trust for pediatric patients and their families during medical experiences. In every hospital, every healthcare organization, we're all on our high reliability journey to become safer institutions. And this focus is usually on physical safety, but we need to include emotional safety. Emotional harm that is just as, if not more, potentially damaging to all patients, but especially children. So it really is our responsibility to ensure that we are implementing procedures and processes that will minimize this risk of emotional harm to everybody we are treating. So the key takeaways that I'd like to end with, first and foremost, when you don't have a child life specialist on staff, please plan ahead and provide that education to everyone who could at some point care for children and their families. Second, consult with a child life specialist for the education, but also pursue potential telehealth interventions when needed. Have those diversional and recreational supplies on hand. And finally, designate who will be that support person for that child ahead of time. And now I am actually, that is the end of my piece. So I am going to turn it over now to Karen Gutick, our social worker. Okay, Karen, if you could introduce yourself and jump right in. I am Karen. I am the emergency room social worker at Cardinal Glen Children's Hospital in St. Louis. So the benefits of an emergency room social worker are someone to gather information about the accident and the family members. It's really important that we don't have doctors and nurses trying to figure out exactly what happened and who was involved in the accident. So the social worker's role in the emergency room, either being an adult hospital or pediatric hospital, would be for us to gather that information and find out who is able to be present, who was in the accident, and just basically put a big, kind of a big piece together of what transpired. We also are there for immediate crisis intervention, especially if you have somebody who works in the hospital. So as in our scenario, we have that 17-year-old whose mother works in the emergency room. She is going to have learned about the accident and potentially be very upset since she doesn't know much. So in that situation, we would be able to help with the immediate crisis intervention for her and obviously her friends as well if they are also staff in the hospital. We do provide support to families and patients. In addition to Child Life, we work very well and closely with them here at Cardinal Glennon. We do provide community resources for families. We also act as a mediator sometimes between the medical staff and families, especially if there's a lot going on. We can help kind of answer some basic questions and go to doctors, residents, attendings, trauma surgeons, and say, hey, this is what's going on. These are some basic questions that the family has. Can you come in and ask them, or is it okay for us to answer them? We also handle, and I call it traffic control. It was said earlier as crowd control. We do lots of things with traffic or crowd control in the emergency room, especially in a small hospital when you have lots of things happening. People are going to be coming and going, especially if it's somebody like the local football player that's in this massive accident. You might have tons of high school people trying to come into that emergency room. So just as here at the Pediatric Hospital, we have kids who injure themselves, who are well known in the community. We have lots of people that we have to kind of control. We also answer phone calls, give out information to only who we can give out information to, and then direct other people to other sources. So what is our primary role in the emergency room? I believe it's communication. We want to communicate with the outside hospital, the police involved, and any family members that family gives us the permission to. So if I know that I'm getting a child from another hospital, I want to communicate with that other hospital about who is coming or not coming with that child. If the family, if a parent is able to talk, I want to potentially talk to them as well, just so that I can find out if there's a non-family member that wasn't in the accident, that we can reach out to that could be a support for that child. Especially if we have mom going to one hospital, dad going to another hospital, and grandma potentially staying there. We want to know is there anyone that we can call that can come be a support to that family. I also want to know the details of what potentially occurred in that accident. And so I'm calling the police department that was involved. And sometimes we get traumas and we have no idea who people are or what was going on. So reaching out to those local law enforcements or the highway patrol is very important. And we get a lot of kids here who are involved in these accidents with multiple other children. Some have driver's license, some don't. And so we rely on our outside sources such as our police to help us identify who people are and who we can call. So in this situation, we luckily have a mom and a grandma who were able to potentially communicate with us. So we can communicate with them at the other hospital. But again, is there anyone else we could call to get up here to be with the child? I believe this family was on vacation. So they weren't in their local area. So we're trying to figure out where their local area is and who potentially can come up. So communication, information gathering is very, very key to the role of the emergency social worker. We also deal with reunification, if it be in person or FaceTime and Zoom. If we have a child here that's small, and we have parents everywhere else, and we have another grandmother coming from out of state, we might not initially have somebody at the hospital for several hours. So we do utilize FaceTime, Zoom, anything else that we can get our hands on to show that kid that there are people out there that he's familiar with and he can communicate with. We also do in-person reunifications as well. When family members are not able to initially be present and then can come be present, we help reunify them when they're here. So we can kind of do a variety of things to assist with that reunification, and also to keep contact with that child. We had a child here not that long ago whose mom was in rehab, and the grandparents were here. We were able to work well with the rehab center to get them to have twice a day FaceTime so that the child could see the mom, the mom could see the child, and it really definitely helped with everybody's feeling comfortable here at the hospital. And also grandparents who would want to know how their mom, their daughter was doing when they were spending time here at the hospital with their grandchild. The other thing that is really, really important is understanding your local trauma counseling resources. So luckily for us in St. Louis, we have a really big area, and we have tons of trauma resources. We actually have a website that we can utilize here. It's called MissouriACTS.org, and it stands for Missouri Academy for Child Trauma Studies. And for us, we can utilize that website, put in a family's zip code, and be able to at our hands have local trauma counselors available. We also give all of our families information on trauma counseling, what acute stress is, and PTSD. So we provide that to them immediately upon arrival to the emergency room, and then we also follow up with them at discharge to make sure they still have those. If a family is not from this area, and we are trying to find trauma resources somewhere else, we do a couple of things. We either contact the local children's hospital where they reside and ask them if they have any resources that they can provide to them. We also utilize our child advocacy centers, and every state has a child advocacy center. I have contacted child advocacy centers out of state to ask them what the local trauma counseling resources are, and they have been super helpful in guiding me to the right direction. And the great thing about the local trauma, or the child advocacy centers, is that we do have them everywhere. So you can call them, say this is what's going on, I do need some trauma counseling resources, and they should be able to help you and guide you. The other thing that's also on our minds here is if the child gets admitted, how can we get them back to where they're from? So if they're not from St. Louis, and they were traveling through St. Louis, but they actually live in North Carolina, how can we get them back to a hospital or a rehab center closer to home? And a lot of that is communicating with other hospitals and rehabs in the family's area. So we'll, again, contact the hospital in their area, talk to them about what resources they have that are local for families close to home. Oops, sorry. So my first polling question is, how comfortable are you with having open discussions with family members about using proper child car seat usage? It's not a problem to have that conversation. You're uncomfortable, not sure what to say. I talk another co-worker into having the conversation for me. Sometimes I wish that was the answer for just about everything. So I'll wait to see what everybody says. But the most important key to this question in reality is understanding car seat usage. If you don't understand car seat usage, you're not going to be able to have a conversation with them. So if you don't know that a five-year-old should technically be in a booster seat versus just a lap belt, you're not going to be able to have that conversation, a comfortable conversation with them. And then the other question is, what is your protocol for discharging an infant or child involved in a motor vehicle accident? Discharge with car seat that was involved in the accident with instructions to get a new one. We keep a supply in the emergency room. We've never thought of it before or other options. So luckily for us here, we do have a program where we can obviously provide children car seats and have education regarding those car seats. So I'm glad to see that most people don't have a problem having conversations with people. And I'm also glad to see that it looks like a lot of people have car seats available. That's great. So again, it is important to understand what car seat safety is, and these are the recommendations of the American Academy of Pediatrics. But I also recommend that you not only know these, but you know what your state's car seats requirements are, because sometimes they are different. So I always want to make sure you understand both. And we do educate families frequently in the emergency room and upon discharge, if it's not in the emergency room, about what's appropriate car seat for a child. So when you're thinking about rear facing car seats, we always think of initially those kids who are in those pumpkin seats. Well, really in reality, we should at least have children rear facing for at least two years of age, if not more. So what you can start out with is those pumpkin seats, but realize those pumpkin seats definitely cannot hold a two-year-old. So you need to make sure that you're looking at the pumpkin seat, looking at the height and or age, sorry, height and or weight requirements, because many of those pumpkin seats don't go up to very much weight. So you might have to go from a pumpkin seat to an actual convertible seat and utilize that rear facing. Again, on most of these car seats, it tells you, you can rear face to this age and or this weight. So you can let, so once you go from rear facing, you go to forward facing in what is called a convertible car seat. And that convertible car seat has a harness, a five-point harness. It also has a weight and a height requirement on it as well. And usually that weight is about 65 to 80 pounds. So when you hit that weight and or that age, you then go to a booster seat and you can sit in a booster seat from age five, kind of forever in reality, because what you want to be able to do is go from that booster to a lap belt. So in our accident here, the child was only in a lap belt when in reality at five, he should have been in a booster seat. And so what gets you out of a booster seat is, is weight and or height, or if you can properly sit in a car seat in a car. So if you bent your legs bend and the seat belt hits you appropriately, then if you are at least five, at least over the 80 pounds, you can then sit in a, in a lap belt. We obviously recommend all children sit in the back seat. Twelve years of age before you sit in the front is a recommendation as well. So just make sure you look at the American Academy of Pediatrics website. Also know your state's requirements for car seats as well, because sometimes they are very different. I would now like to introduce Dr. Christmas. Great, thank you. So today I'll be speaking a little bit about a transfer up the chain, if you will, the level one and two centers. My name is Brick Christmas. I am currently the Section Chief and Trauma Medical Director for Atrium Health at Carolinas Medical Center and, and the former co-director of Pediatric Trauma. So I have kind of seen all sides of this with regard to the adults and the children. So starting off, you know, our basic tenet that we follow couldn't be said any better than what ATLS tells us. The decision to transfer a patient to another facility for definitive care is influenced by the identified and suspected injuries, expected progression of the injuries, and the capabilities on hand to expeditiously diagnose and treat. Now, when you look at trauma centers, as already mentioned by Dr. Rubano earlier, the designation of trauma centers is really based upon resources. You could take any one of us and put us at any level trauma center, but it really comes down to what do we have available. And in its most basic form, you can see the definitions for level one, two, three, and four, all the way down the, all the way down the chain. Now, the considerations you really have to look at is, does your facility have the necessary resources and expertise to adequately care for the patient? And at what point do you identify the need for transfer? And I think this is where a lot of places fall down, is that they don't adequately recognize that they need to get the patient out of there. And then once we decide that, is what is the method of transport going to be? And as we've already heard, especially in this scenario, this comes down to issues such as distance, how far, what is the weather? And especially over the last two years with COVID, what is the availability? As many of us found out, our EMS services were overwhelmed just like we were. So especially when we're talking about transferring a patient from a level three up to a level one or level two, we've got to depend on those EMS services having the availability for patient transport, which are issues that really pop up whenever the system gets strained. And then what are the critical care service needs that we're going to have? And this just be basic ambulance, or are we going to have higher level of care to get the patient from point A to point B? And we're looking at resuscitation, you know, what kind of labs do we have? What do we have availability for even on the front end? You know, for us at the level one, we're fortunate enough, we have point of care labs in the in the emergency department. I can, you know, I can have most of my panel figured out in about two minutes. But then what about all these others? What does it mean with the CBC, BMP, the COAGS, amylase, lipase, all that? And to tell you the truth, half the time when I received this packet of information that has the LFTs and everything else, as a receiving center, I don't care to tell you the truth. Because if I have a small liver lack or high LFTs, is it going to be clinically significant? Same thing with amylase, lipase. What I want to know is what is the clinical picture and that I'm going to have to act upon the quickest, and I figure it out from there. But what about the use of thromboelastography? Well, a lot, this isn't even at a lot of level ones. It's truly coming into play more and more often. But the question then becomes, when do you use it? Am I using it in the emergency department? Am I using it in the ICU in the operating room? And I can tell you from our experience, if we've got a patient we're giving a massive transfusion to that's just been transferred upstream, we're usually not going to check this until after that resuscitation because things are changing so fast with the MTPs that we can't, that I've already given more product, even as fast as I can get the tag back, that we're infusing so rapidly that we're already correcting issues and things are changing too quickly in the trauma base. So we use most of that in the ICU. What is your blood product availability? And Dr. Rovano mentioned this early on as well, is when you go and say, I'm going to activate an MTP. Well, how much blood do you have at that level three in this scenario? If you've got two ORs, you could potentially wipe out your blood bank in a night and what you would expect to have, which fortunately for us at the level ones and twos, we have a deeper bend to pull from. So those are even considerations, especially in this case, which patients are going to the operating room. And what are they going to need? And do we have enough blood to stabilize them and get them out of there? Imaging. And, you know, this gets into what x-rays do we need? Chest, pelvis, extremities, you know, your ultrasound. And at the level three, if you have a positive fast hypotensive patient, you're going to act on it. But then the question becomes at the referring facilities farther out, if you do get an ultrasound and it's positive, and you've got a hypotensive patient, where are you going to keep that patient in the first place? The patient needs to be packed up and gone. And then we get into the issue of CT scans. It was already mentioned. And the question really comes down to how are these studies going to affect the resuscitation and decision-making right then? And the reality is at smaller hospitals where you have less staff than what we're accustomed to, the radiology suite is a terrible place for your patient to decompensate. And we would like to say that this happens less than it does, but that is one of the biggest things that I can tell places referring upstream is if you know they're coming, stabilize them and get them out of there because the last thing you want is for a patient to crash in your CT scan. And then other considerations that we have are EMR and imaging platform considerations. Whenever you're trying to get everything ready to pack up, not all of our referring centers are within our system. So we've got to make sure that we have access to whatever information they're forwarding us. And then regarding that transmission of information, who's giving the information and who's receiving? Is it an attending physician, ED or trauma? Are they talking to a resident physician on the other side or an APP? And for us at the receiving end, whenever the calls are coming to me, we've taken it in our group at the attending level because our mindset is we are trying to pull patients into our system, that we don't want there to be barriers or a bunch of questions or a delay. But what we want is we know they're coming in. We want to try and help with a higher level decision, but then pull. But I also know on the other end, that's not always the case. We will occasionally speak to APPs and some others. And I think the thing to really communicate out in the system is when we are asking questions from the level one and two, it's not that we're trying to see, oh, do they really need to come? It's we are trying to triage. And I know some of the feedback we've gotten when we're asking a lot of questions, they feel like they're being grilled. But for me, I'm trying to put the entire clinical picture together in my head for what I'm going to need and how quickly I need to get them there. And then as was also mentioned earlier, whenever we're getting the report, we need the quick information, mechanism, pertinent findings, what the history is, especially more and more elderly patients regarding blood thinners and beta blockers and everything that could affect their outcome. And then your pertinent findings so far. And then interventions, right? We need to know, did you innovate? How many attempts? Did they desat? Splints, lacerations, chest tubes, and then pertinent radiology findings, because do we want to take a patient that has pneumothorax and throw them on a helicopter or put them in an ambulance for an hour ride without putting a chest tube? And then for us, I would say we actually have different communication expectations from our referring level threes than we do from even some of the other centers. Because if I've got a patient coming from a level three, I know they've been evaluated by one of our surgeons out there. And so I like to get that information from them because I know that is going to give me the most reliable picture of what is coming and why they are coming to the level one. And then prior to transfer, is your patient stable enough to make the trip? And if not, what's the cause? Is there something that we need to or can do now? And we've had instances on the other line where there's a patient, they're hypotensive to the 60s, and they did have a positive fast. And well, you know, what do you want us to do? And if you've got a surgeon standing at the bedside, the best you can, because that patient is going to bleed to death before they can get to me in an hour. And it's the do what you can to make sure the patient's going to survive and then pack them up and get them to us. And we'll take care of everything on the back end. Not ideal, but sometimes it's what has to happen. And it's actually the best option for that patient. And then we have to assess what are the availability of blood products during transport. You know, more and more we have EMS services, certainly the aeromedical transport services carrying blood products and ability to give. And then the need for the reversal agent. If I've got a patient that's coagulopathic out there at the outlying facility and they're transferring in, whether or not they get that reversal agent before they're transferred versus when they get to me, that can make a huge difference, especially in a traumatic brain injury. And if they can get the reversal agent and even hang it as the patient's going out the door, it will help us and the patient certainly on the back end. And then sedation on route. And the big thing for us, especially with head injuries, is we need to know the best GCS prior to intubation or the patient showed up. And then it's important to give right the air medical transport teams, especially you have to give enough sedation so you're not wrestling with a patient in the back of the helicopter. But at the same time, we have to get an adequate neuro exam when that patient shows up, because in some cases, if a patient shows up with a GCS of three and pupils are fixed and it's a true GCS three, then that patient won't receive an intervention. But if I've got a GCS of six, then that's a little different story with some of the neurosurgery decision making. So anything we can do to give us the best GCS that we can get. And then the thing is always please send all pertinent information and imaging. The last thing we want to do is find out the patient was there, you've got this and you send reports, but then I have no access to the images for spleen lax, liver lax. And as we know, all of these are different and I can't just rely on a written report or a verbal report. We need to see these images and anything you happen to have gotten. And then another very important part that we kind of overlook in a lot of these discussions is PI feedback. It's very important to have relationships all the way from your EMS providers, all the way up to your trauma medical directors and level one administration. If you look, I mean, you can see all the stakeholders here, your ED medical directors, hospital administrators, your state regional trauma system, right? Our trauma system is only as good as the cooperation among all those trauma centers and providers in the state. And you have to have a credible outreach coordinator. We have a tremendous outreach coordinator in Scott Wilson, who is a paramedic as well. So really understands all sides of the game. And when you're doing this, you're really trying to do your outreach to get loop closure and make sure you get systematic improvement. And don't forget to acknowledge successes. What we don't want to do and what we do too often is we're always sending the bad feedback, things that we think could have been done better or where we think the system fell down. But when you have providers anywhere in the chain that do a terrific job, we need to make sure we acknowledge that. So it's everybody's in it for the right reasons in patient care. And we can't forget that. And when somebody does a great job, remember to tell them. And this is the same thing for PI. We get patient like this, this is a needle decompression, right? This is, if you look medial to the nipples bilaterally, certainly in a very, very treacherous place. And I've got to have a mechanism to give feedback where if we need to go and go out and provide education and go downstream as a level one trauma center, we've got to do everything we can to improve that referral process. So polling question here, and granted, this is going to be some retrospective data, if you will, which group experiences the longest transfer times from referring facilities? We understand that you calculate your ISS on the back end, but I think this is very important to point out. Patients with ISS less than 15, followed by ISS of 15 to 30. And then this is what I wanted to see and exactly where I wanted to highlight it. So in looking at regional issues, if you will, our own facility, we looked at inter-facility transfer delays. And over the course of a year, received patients from 20 referring EDs and 13 surrounding counties and over a thousand inter-facility transfers. And what we found was pretty shocking that our ISS of 16 to 30 actually had the longest times from showing up and getting to our facility. And in calculating the emergency department times, they were all significantly longer. But if you think about it, this makes sense because the facilities knew that these patients were injured, but were trying to see how injured they were in working them up. So these patients underwent a more extensive workup and were there at those facilities longer. Those greater than 30 were clearly severely injured, recognized, and they packed them up and got them out of there even quicker than the ISS of 1 to 15. But what you see with this is that when we start looking at our deaths, over 50% of our deaths had an ED length of stay at the outlying facilities of greater than two hours. So clearly we identify this as some opportunity. And if you look at that, over 25% of them had a length of stay greater than three hours at the outside facilities. So what we found is delays were more pronounced for ISS 16 to 30 with the associated need for operative or critical care intervention whenever they arrived. And half of our deaths at outside EDs had a ED length of stay greater than two hours there. And most of these delays were due to extensive workups or under recognition of injury severity. So clearly it was something that we looked at in the region as an opportunity for improvement. And so how do you get better? You've got to focus on your regional outreach. And as a level one trauma center, you can't just sit within your walls. Or the level two, whoever you are and responsible for, you need to push out and give resources and education. And then see what you can do to assist the referring facilities and adhering to established guidelines that have been put forward. And then other things that you look at is when you're sending them to me, which OR is going to be faster? Is it going to be at your facility where you happen to have a surgeon during the day and you can take that patient with a pressure of 70, take a spleen out, pack them up and get them to me? Interventional radiology, what are the resources and availability there? Hybrid ORs, which for us, we're fortunate enough to have two hybrid ORs. So if I've got a patient that needs a pelvic embolization and a splenectomy or has a mesenteric injury, we can take them and do it all at the same time without having to go to an OR and then to an IR suite. And then 24-7 critical care and say that one of these patients, the 32-year-old dad gets a transfusion related acute lung injury and goes into Florida ARDS. The resources for advanced ventilation and immediate ECMO teams. And the reality is we know our level three centers and down farther don't look like this. And this is why we transfer up the chain is because of the resources. When someone rolls into my trauma bay, this is what I have. I have a team and then some, but that's why you have the level one center and you move up that transfer. And then it was mentioned earlier, trying to simplify these handoffs, anything you can do to expedite it. And you see, this is kind of our, you know, our protocol for EMS entering the room and the team leader confirms who the team is, prompts EMS to give their report and do a timeout before you move to the stretcher. But that being said, if there's an airway issue, CPR or something immediate, you can bypass move and then take report when you're on the bed. So the entire team can start working. And as mentioned before the miss, this is great. We have these posted on our walls in the resuscitation bay so that if there's ever a question and the EMS provider starts to get a little long winded, we just kind of stop them for a second and point to the poster and say, can you give us this please? And then when we were looking at the transfer criteria, this was about as simple as we could do it, rolling this out to the entire region, every referral center and all 20 counties that we have and looking at the immediate transfer criteria, what qualifies to basically get this patient, don't do a prolonged workup because you know they're coming to the trauma center. And in doing this, this is how we decreased our times in that group, specifically ISS of 16 to 30. And you can see even the primary management, here's what we expect you to do with your resuscitation before you get them to us. And then since you're going to do it for adults, we did the same thing for pediatrics. And as you can see, even broke out the blood pressure requirements and anatomic criteria and everything, because what we have to do is make it as simple as possible for these referring centers so that they can literally look and say, if then, and I think that is the way that we really decrease the transport times, don't get a lot of extra imaging, but at the same time, hold all of our centers accountable on both ends for as the level one, we expect you to transfer this right away. But on the other end, I also expect you to not hear anybody from my team say, well, why didn't you get X, Y, and Z? And I think that's the way we get better as a system, which is what it's all about. Thank you.

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