Head Injuries in Children

Pennington, Nicole, MSN, RNC. The Journal of School Nursing 26.1 (Feb 2010): 26-32.

Abstrak (ringkasan)

School nurses play a crucial role in injury prevention and initial treatment when injuries occur at
school. The role of school nurses includes being knowledgeable about the management of head
injuries, including assessment and initial treatment. The school nurse must be familiar with the
outcomes of a head injury and know when further evaluation is indicated. Developing a head
injury protocol in the school setting is one strategy to make sure that all involved are able to
consistently and effectively respond to a head injury and prevent a possible negative outcome.
The combination of a protocol, nursing judgment, and best practices can ensure that all means
are used to take care of children when a head injury is sustained. These strategies will help to
increase the safety of children at school. A systematic approach to the management of these
types of injuries is essential for preventing possible complications.

Teks Lengkap

Headnote

School nurses play a crucial role in injury prevention and initial treatment when injuries occur at
school. The role of school nurses includes being knowledgeable about the management of head
injuries, including assessment and initial treatment. The school nurse must be familiar with the
outcomes of a head injury and know when further evaluation is indicated. Developing a head
injury protocol in the school setting is one strategy to make sure that all involved are able to
consistently and effectively respond to a head injury and prevent a possible negative outcome.
The combination of a protocol, nursing judgment, and best practices can ensure that all means
are used to take care of children when a head injury is sustained. These strategies will help to
increase the safety of children at school. A systematic approach to the management of these
types of injuries is essential for preventing possible complications.

Keywords: injuries; physical assessment; best practices/practice guidelines; documentation;

standards of care
INTRODUCTION

Hippocrates once said, ''No head injury is too trivial to ignore'' (Aloi, Rempe, & Santamaria,
2008). His advice still holds true today for school nurses who assess head injuries that occur at
school. Whether it is a collision in the hallway, a fall from the monkey bars, or running into a
wall, all head injuries need to be assessed, treated, documented, and communicated. Being
knowledgeable about the management and treatment of head injuries is important for school
nurses. A prompt and accurate assessment has the potential to prevent potential negative
outcomes. A systematic approach to the management of these types of injuries is essential for
preventing possible complications. The use of a head injury protocol in the school setting can
help assure that these types of injuries are consistently and effectively responded to at school.
Knowing what potential outcomes can result and when further evaluation is indicated is critical
to optimizing outcomes for students with a head injury (Cobb & Battin, 2004). Using a protocol,
sound nursing judgment, and best practices are strategies that help ensure that head injuries are
properly attended to at school. These strategies will help ensure the safety of children when a
head injury occurs at school.

LITERATURE REVIEW

Injuries that occur in the school setting are a significant contributor of pediatric injury in the
United States. This has been attributed to the amount of time that children spend at school
(Josse, MacKay, Osmond, & MacPherson, 2009). In the United States, school-related injuries
account for 10-25% of pediatric injuries, resulting in nearly 3.7 million injuries in American
schools annually. Research indicates that children are more likely to sustain a head injury at
school than at other location, and there is an increased risk of this type of injury in autumn.
Most head injuries at school occur in recreational areas, such as playgrounds or athletic fields,
followed by classrooms and cafeterias. The next most common location for unintentional and
intentional head injuries is in passing areas, such as hallways and stairs (Limbos & Peek-Asa,
2003).

The American Academy of Pediatrics (AAP) Committee on School Health and the American
Heart Association have published guidelines recommending improving the training for school
nurses so that they can rapidly and accurately determine the status of ill or injured children,
provide lifesaving interventions, and evaluate the effectiveness of treatment (Olympia, Wan, &
Avner, 2005). An important barrier that has been identified in schools when dealing with
emergency response is the lack of school nurse availability when scheduled for only a portion of
the school day. Although there are usually school staff members trained in dealing with
emergencies, research has found that they lack confidence in responding to emergency
situations (Olympia et al., 2005).

Elementary schools have the highest rates of reported injuries, followed by high schools, and
then middle schools. Males have significantly higher numbers of reported injuries than females
(Singh & Stock, 2006). Previous research indicates that reported school injuries resulted in
trauma to the head, face, or neck. The leading causes of reported unintentional injuries are falls,
followed by being struck by or colliding with an object or another student. Most school
intentional injuries in elementary schools are the result of being pushed or shoved by another
student. Bernardo, Gardner, and Seibel (2001) report that among middle and high school
students, most intentional injuries are caused by physical fighting. Research indicates there is
little difference in the time of occurrence during the school day for intentional or unintentional
injuries, making it difficult to determine the best time of day for a school nurse to be present or
for school monitoring to be in place (Limbos & Peek-Asa, 2003).

In the United States, head trauma represents 80% of the injuries that lead to death in children
older than 1 year of age (Bayreuther & Maconochie, 2008; Singh & Stock, 2006). Pediatric
head trauma is common and can range from minor to severe. Most head injuries in children are
mild and not associated with brain injury or longterm problems (Da Dalt et al., 2006).
According to the National Center for Health Statistics, the mortality rate from head trauma is
29% in the pediatric population. Data reported by trauma centers show that head injuries
represent 75-97% of pediatric trauma deaths. Of the children with moderate-to-severe head
injury, 10-20% have short-term memory problems and delayed response times (Singh & Stock,
2006). Occult lesions and delayed intracranial complications have been reported in up to 17% of
children with apparently trivial head injuries, emphasizing the importance of a thorough
assessment by school nurses (O'Hebb, Clarke, & Tallon, 2007).

HEAD INJURIES

Head injuries fall into two main categories- external and internal (Singh & Stock, 2006).
External head injuries include scalp injuries, and internal injuries may involve the skull, blood
vessels within the skull, or the brain. Most childhood falls or blows to the head result in injury
to only the scalp, which is usually more frightening than threatening. The scalp is rich with
blood vessels, and so even a minor cut can lead to profuse bleeding. However, an internal head
injury could have more serious implications, because the skull serves as the protective casing
for the brain. Although the brain is cushioned by cerebrospinal fluid, a severe blow to the head
may knock the brain to the side of the skull or tear the blood vessels. Any internal injury, a
fractured skull, torn blood vessels, or damage to the brain can be serious and possibly life
threatening (Da Dalt et al., 2006).

Different levels of head injuries require different levels of concern (O'Hebb et al, 2007). A clear
indicator that a child has sustained a more serious head injury is when there is a loss of
consciousness (LOC) or sign of confusion. The National Institute for Health and Clinical
Excellence (NICE) provides guidance for triage, assessment, investigation, and early
management of head injuries in infants, children, and adults. The signs and symptoms listed in
Table 1 are indicators that further evaluation is warranted following a head injury.

CONCUSSION

A concussion is a form of head injury that occurs immediately after a blunt force strikes the
head causing the brain to move within the confines of the skull (Purcell & Carson, 2008). The
signs of brain injury may include headache, visual disturbances, gait disturbances, and LOC.
LOC occurs in approximately 10% of concussions; however, LOC does not always predict the
severity of outcomes from concussions (Cobb & Battin, 2004). Confusion and/or LOC are
common signs that have been found to be more predictive of postinjury deficits, including
cognitive deficits. These major symptoms and their duration are used in concussion grading
systems to help determine the severity of closed-head injury. A grade 1 concussion is indicated
by transient confusion with mental abnormalities lasting less than 15 min but with no LOC. A
grade 2 concussion is indicated by a transient confusion with mental abnormalities lasting 15
min or more but with no LOC. A grade 3 concussion is indicated by an LOC. Any student
presenting with signs and symptoms of a concussion should be referred to a physician for
evaluation (Purcell&Carson, 2008). Should this type of injury occur outside school, it is
important the school nurse is informed so the student can be monitored in the school setting.

ASSESSMENT OF HEAD INJURIES

A detailed assessment of any head injury is essential to identify neurological status (O'Hebb et
al., 2007). Because any head injury has the potential to be catastrophic, the initial assessment is
critical. After mild head trauma, symptoms may go unrecognized or be misinterpreted. The
criteria for assessing head injuries have been developed from various studies over the years.
Diagnostic criteria classify head injuries as mild, moderate, or severe. Specific signs and
symptoms for each category are indicated in Table 2.
The assessment should include checking for the presence of headache, nausea, vomiting,
dizziness, coordination, blood pressure, heart rate, pupil reactions, LOC, and mental confusion.
Children have a higher metabolic rate, resulting in slightly higher respiratory rates when
compared with adults. Pulse rates in children should not exceed 120. Pain and anxiety will
increase pulse and respirator rates. Their blood pressure may not drop until they have lost 45%
of their blood volume (Dunning, Daly, & Lomas, 2007).

Specific assessment of mental status should include checking mental orientation, ability to
concentrate, memory, and duration of memory loss or disorientation (Mailer, McLeod, & Bay,
2008). The orientation assessment should include knowledge of date, place, person, and
situation. Concentration can be assessed by asking the child to count backward or repeat a
common saying, and memory can be assessed by asking the child to name his or her favorite
teachers or how he or she got to school that day. To assess neurological status, check the child's
strength, coordination, agility, and sensation. Abnormal findings, such as headache, dizziness,
nausea, photophobia, blurred or double vision, emotional liability, or mental status changes,
need further assessment by a physician.

The Glascow Coma Scale (GCS) is a tool that can be used to assess pediatric head injuries
(Kirkham, Newton, & Whitehouse, 2008). This scale was developed to assess acute, global
neurologic status following a head injury. It correlates with injury severity and guides
prehospital and early resuscitation interventions. Serial GCS scores provide insight into overall
trajectory and response to treatment (Da Dalt et al, 2006). This scale assesses eye opening,
verbal response, and motor function. The scale is the most widely used measure of neurological
function in the presence of a head injury and has significant prognostic value. The pediatric
coma scale is a modified version of the original scale and can be used on younger children
(Table 3; Abelson-Mitchell, 2008). Generally, the pediatric coma scale is used as an assessment
tool for children 16 years and younger. A score of 13-15 is indicative of a minor head injury,
and a score of 3-12 is indicative of a major head injury. The GCS does not measure common
symptoms of head injury such as vomiting, irritability, or subtle changes in alertness. Therefore,
it is possible that some children with a GCS score of 13-15 could have clinical signs of head
trauma not assessed by GCS (Arbogast, Marguilies, & Christian, 2005).

Among children with a significant head injury, two thirds have no other significant trauma.
NICE updated the guidelines in 2007 (Pediatric Nursing, 2007). These updates provide
guidance on the Pediatric GCS (Bayreuther & Maconochie, 2008).
HEAD INJURY PROTOCOL

Fortunately, most head injuries at school are minor and do not require transport to the hospital
(Da Dalt et al., 2006). The scenario is usually one in which a child is brought to the school
health office because he or she ''hit his or her head''. It is what happens next in the assessment
and immediate treatment that can make an important difference in the outcome of a pediatric
head injury.

Step 1 of the head injury protocol (Table 4) should be the detailed physical assessment and
immediate care of the head injury (Bobo, Hallenbeck, & Robinson, 2003). As part of the
assessment, the child should be asked how the injury occurred; this should be verified with
witnesses in case of altered mental status. If any lifethreatening warning signs are identified,
911 should be notified immediately. If a laceration or abrasion is present, the site should be
gently cleansed with antibacterial soap and water. If appropriate, a cool compress or ice pack to
the injury site can be applied for comfort.

Step 2 of the protocol should include notification of parents and the classroom teacher. Parents
should always be notified by phone to inform them that a head injury has occurred. Should the
student exhibit any of the previously mentioned warning signs, parents should be notified to
seek medical treatment. Reporting and communicating is an important step in every head injury
situation. School nurses can use a head injury letter (Table 5) to document the events; a copy of
this letter should be given to the parent and teacher. An illness/injury report should be
completed and kept on file in the school health office (Table 6).

Step 3 of the protocol should be the procedure to follow for sending a student back to the
classroom. If the child returns to class following head injury, the teacher should be given a copy
of the letter with specific instructions on what to watch for in relation to the head injury. One
copy of the head injury letter should be sent home with the student. Stickers that say, ''Please
watch me, I hit my head today!'' can be purchased or made (Figure 1). The young student can
wear this sticker back to class and home so that everyone they come in contact with is aware
that the child had a head injury at school.

This three-step protocol provides a thorough system of assessment, care, and communication,
which will provide for the safety of children when they have a head injury at school.
IMPLICATIONS FOR SCHOOL NURSING PRACTICE

The school nurse's role in prevention can occur by increasing the awareness of playground
safety and supervision, providing education on helmet safety, and car seatbelt safety. School
nurses play a crucial role in injury prevention. By recognizing the unsafe practices, school
nurses can document and bring to attention the importance of safe playground behavior to
administrators, staff, parents, and children (Hudson, Olsen, & Thompson, 2008). Prevention
programs should be targeted largely toward elementary school students because there is an age
relationship with respect to the likelihood of being injured at school (Josse et al., 2009).
Passenger seatbelts and airbags may be useful in preventing head injuries, and children should
sit in appropriate booster seats as indicated by age and seated in the back seat if under the age of
12. Helmets should be used by children and adolescents during certain sporting events to reduce
the risk of head trauma (Singh & Stock, 2006). Reducing school-related injuries will promote a
safe and secure learning environment for students while reducing health-care expenditures for
preventable childhood trauma (Josse et al., 2009).

CONCLUSION

Whether it is a head-on collision in the hallway, a fall from the monkey bars, or running into a
wall, all head injuries need to be assessed, treated, documented, and communicated. The
processes presented have the potential to help ensure the safety of children when head injuries
occur at school. A systematic approach to the management of head injuries is essential for
preventing possible complications. School nurses play a crucial role in injury prevention and
initial treatment, when head injuries occur at school. The early identification and treatment of a
head injury can improve clinical outcomes (Bayreuther & Maconochie, 2008). The role of
school nurses includes being knowledgeable about the management of head injuries, including
assessment, initial treatment, communication, and reporting.

Sidebar

''In the United States, school-related injuries account for 10-25% of pediatric injuries, resulting
in nearly 3.7 million injuries in American schools annually.''

Sidebar

"In the United States, head trauma represents 80% of the injuries that lead to death in children
older than 1 year of age."
Sidebar

TABLE 1. Indicators that Warrant Further Evaluation

* Unconsciousness

* Abnormal breathing

* Obvious serious wound or fracture

* Bleeding or clear fluid from the nose, ear, or mouth

* Disturbance of speech or vision

* Pupils of unequal size and/or delayed reaction to light and accommodation

* Weakness or paralysis

* Dizziness

* Neck pain or stiffness

* Seizures

* Vomiting

* Loss of bladder or bowel control

* Irritability or other unusual behavior

* Stumbling or difficulty walking

* Confusion

* Unusual paleness that lasts for more than an hour

Sidebar

TABLE 4. Head Injury Protocol

Step 1: Assessment and Immediate Care

Ask child and witness how injury occurred.

Vital Signs: T-________P- _________R- _________B/P-__________

Pupillary Response: _______________________________________________

Presence of Headache: __________Yes __________No

Presence of Nausea/Vomiting: ___ Yes __________No

Loss of Consciousness: _________ Yes __________ No

Alteration in orientation: ________ Yes __________ No

Alteration of Vision: ___________ Yes __________ No

Glascow Coma Scale Score-initial assessment: ____________

Glascow Coma Scale Score-15-min follow-up assessment: ____________

Glascow Coma Scale Score-30-min follow-up assessment: ____________

Cleanse abrasions/lacerations with antibacterial soap and water.

Step 2: Notification of Parents

Notify parents by phone and inform them of the injury, the child's assessment state, and care
provided. Review warning signs to watch for following a head injury. Inform them that you will
be sending a head injury letter home.
Step 3: Notification of Classroom Teacher

Notify classroom teacher in person or by phone if child will be returning to the classroom so
that observation can continue when the child is in class for the remainder of the school day.
Provide the teacher with a copy of the head injury letter.

Provide the child with a head injury sticker to wear so that everyone is aware that a head injury
occurred as this can provide for a reminder to watch for signs and symptoms of complications.

TABLE 5. Head Injury Letter

Date/Time of Injury ____________________

Dear Parent/Guardian:

Today, ___________________________ was seen in the school office and was given emergent
treatment only. This treatment is not intended to be a substitute for complete medical care. It is
important that you use your own judgment in determining whether you contact your family
physician and/or have your child examined in the emergency room if your child's injury
warrants further care. Your child did not experience any problems at the time they reported to
the office, but you should watch for any of the following symptoms:

1. Severe headache

2. Excessive drowsiness (awake the child at least twice during the night)

3. Nausea and/or vomiting

4. Double vision, blurred vision, or pupils of different sizes

5. Loss of muscle coordination, such as falling down, walking strangely, or staggering

6. Any unusual behavior such as being confused, breathing irregularly, or dizziness

7. Convulsions

8. Bleeding or discharge from the ear

Contact your local physician or emergency room if you notice any of the above-mentioned
symptoms.

If your child plays any contact sports, please inform coaches or adult supervisors that your child
did sustain a head injury at school and explain warning signs to watch for.

An accident report has been completed.

Injury details: ________________________________________________________

Treatment given: _____________________________________________________

Suggestions: _________________________________________________________

School Principal/Nurse/Secretary _______________________________________

TABLE 6. Illness/Injury Report

ILLNESS/INJURY REPORT

Date: _________________ Time: __________ School: _________________

Student: ________________________

Witnesses/Phone Numbers: __________________________________________________

Circle One: Injury/Location __________ Illness/Other/Home Visit

_________Temp_______________________________________________

Intervention:__________________________________________________________________
___________________________________________

Comments &/or
Evaluation:____________________________________________________________________
__________________________

Parents Notified: Yes/No Time Contacted: ______________________________

Student sent back to class: Yes/No Time returned to class: _________________________

Student sent home: Yes/No Time picked up by parent: ______________________

Form Completed By: __________________________ Title _________________________

Sidebar

''The school nurse's role in prevention can occur by increasing the awareness of playground
safety and supervision, providing education on helmet safety, and car seatbelt safety. School
nurses play a crucial role in injury prevention.''
References

REFERENCES

Abelson-Mitchell, N. (2008). Epidemiology and prevention of head injuries: Literature review.

Journal of Clinical Nursing, 17, 46-57.

Aloi, M., Rempe, B., & Santamaria, J. (2008). Pediatric concussions. Emergency Medicine
Reports, 29, 1-12.

Arbogast, K., Marguilies, S., & Christian, C. (2005). Initial neurologic presentation in young
children sustaining inflicting and unintentional fatal head injuries. Pediatrics, 116, 180-184.

Bayreuther, J., & Maconochie, I. (2008). The evidenced-based care behind the early
management of head injured children. Trauma, 10, 85-92.

Bernardo, L., Gardner, M., & Seibel, K. (2001). Playground injuries in children: A review and
Pennsylvania Trauma Center experience. Journal of the Society of Pediatric Nurses, 6, 11.

Bobo, N., Hallenbeck, R., & Robinson, J. (2003). Recommended minimal emergency
equipment and resources for schools: National consensus group report. Journal of School
Nursing, 19, 150-156.

Cobb, S., & Battin, B. (2004). Second-impact syndrome. Journal of School Nursing, 20, 262-
267.

Da Dalt, L., Marchi, A., Laudizi, L., Crichiutti, G., Messi, G., & Pavanello, L, et al. (2006).
Predictors of intracranial injuries in children after blunt head trauma. European Journal of
Pediatrics, 165, 142-148.

Dunning, J., Daly, J., & Lomas, J. (2007). Clinical criteria predict serious head injury risk in
kids. Journal of Family Practice, 56, 16-17.
 TRAUMA CARE
Ericksen, Anne Baye. Healthcare Traveler 19.4 (Oct 2011): 26-29,31.

Abstrak (ringkasan)

According to CDC research, trauma-related fatalities drop by one-fourth if individuals receive

care at a Level I trauma center. The more certifications you have, the more motivated you
appear, and that sends a positive message about you as a traveler, McClintock says. Because
both staffing agencies and hospitals expect mobile professionals to prove their knowledge, both
mandate that candidates pass skills tests.

Teks Lengkap

Headnote

Not every emergency case is a trauma case, but every trauma case can be an emergency.
Regardless, these highly trained health travelers are ready to respond.

One...two...three...four...

Every four seconds, someone in the United States sustains a traumatic injury. That person's
outcome depends greatly on how quickly he or she arrives at a qualified hospital where an
experienced healthcare team can provide emergency care.

However, not every injury meets trauma criteria. Of course, not every hospital qualifies as a
trauma center, nor is every medical professional certified to handle these high-acuity, urgent
cases. Still, there's a certain allure to the specialty, especially for nurses with emergency
medicine backgrounds. Traumas are unpredictable, intense, exciting, and they test professional
knowledge.

It's also accepted that mobile clinicians who list Level I facilities on their résumés instantly
portray an elevated professionalism. But as enticing as this scenario, not all healthcare travelers
can step onto a trauma unit. Those who do, however, usually find the experience a good fit.

Patient profiles
Have you ever been seriously hurt in a car accident or third-degree burns? Chances are the
experience the emergency department was more intense than a visit. The critical nature often
necessitates mulproviders treating the various aspects of an injury Sometimes, specialists will be
called in, That complexity is what partially defines trauma care.

The trauma specialty was born out of triage delivered during the Korean and Vietnam conflicts.
Basically, battle wounds received tertiary treatment before the soldiers were transported to
military hospitals for comprehensive care. As a result, survival rates rose substantially
compared with previous wars. Back home, civilian practitioners took notice and adopted the
techniques for the emergency department (ED). Through research and technological
breakthroughs, the practice developed into its own specialty.

In today's healthcare setting, the emergency department often functions as a healthcare catchall.
On any given day, staff might treat strep throat, migraine headaches, or simple lacerations, in
addition to more serious cases.

"People are still utilizing the emergency room in lieu of walk-in clinics or family practitioners
because they no longer have insurance," says Nancy Dolan, a director for lnteliStaf Travel,
headquartered in Boca Raton, Fla. "At the same time, others show up with higher- acuity
illnesses because they are waiting longer to seek medical treatment. That is a reflection of the
unemployment rate and people losing their insurance coverage."

However, don't let the amount of general medicine dispensed in emergency departments mislead
you. The department is still the go-to resource for serious emergencies. For example, in 2006,
37 million of the more than 120 million emergency room visits met trauma criteria, according to
industry statistics.

As an emergency nurse, Kimberly McClintock, RN, has worked plenty of trauma cases. "I fell
in love with the specialty," she says. "I never have the same day twice."

For the last eight years, McClintock has traveled fulltime and accepted assignments to trauma
centers on both coasts. From those experiences, she noticed certain characteristics and
circumstances that set each emergency department apart.

"There are different types of trauma," she says. "In some areas, you receive a lot of high-speed
motor vehicle accident victims. That was the case in Westchester, N.Y., but in Manhattan, I did
not really see those kinds of injuries. In Oakland, Calif., because of the drugs and gangs in some
neighborhoods, there were more stabbings and gunshots."

She now works at New York-Presbyterian Hospital/Weill Cornell Medical Center via a contract
with MedStaff, Inc., a healthcare travel placement firm based in Newton Square, Pa.

On the surface and beyond, a sense of teamwork seems inherent to this type of practice.

"When you are working well together, you feel good about it," McClintock says. "Even though
you had nothing to do with why the patient was brought to the hospital, and no matter what the
outcome, at least you know the team did its best."

Highlighting hospitals

Every six minutes, someone dies or becomes permanently disabled as a result of a trauma. The
Centers for Disease Control and Prevention (CDC) list trauma as the number one cause of death
for individuals between the ages of one and 44 years old. Most clinicians and emergency
medical technicians concur that the "golden hour" - or the first 60 minutes after incurring the
injury - is the most critical time in the course of treatment. The faster victims receive care, the
better their chances for positive outcomes.

Another contributing factor in patient recovery is access to qualified trauma facilities.

According to CDC research, trauma-related fatalities drop by one-fourth if individuals receive
care at a Level I trauma center. However, less than 8 percent of all hospitals have a unit
designed to receive these complicated cases, and approximately 45 million nationwide don't live
within that all-important 60-minute transport to a Level I or Level II facility. Instead, patients
might be taken to a Level III or Level IV hospital initially.

Just like patients must meet defined criteria to be identified as a trauma case, hospitals also have
to reach specific objectives set out by the American College of Surgeons Committee on Trauma
to be designated a trauma center. There are four levels issued:

* Level I: Oftentimes, these hospitals are large medical centers located in metropolitan
communities. Although not a prerequisite, many are associated with universities or medical
schools. Hospitals staff specialists covering all areas of medicine and have the associated
equipment on premises or immediate access to it. Practitioners screen patients for substance
abuse - alcohol and drug use frequently contribute to or precede trauma injuries - and are ready
to intervene when deemed appropriate.

"People come in as overdoses or suicide attempts, and of course, they have to be treated
medically, but finding them adequate mental health services can be challenging at times,"
McClintock says. "In terms of trauma care, mental health becomes an issue because of the
potential for repeat incidents."

* Level II: These facilities generally receive trauma patients if they are hurt outside that 60-
minute drive time to a Level I center. Staff perform many procedures, but if the conditions
exceed their capabilities, patients will be transported to the nearest Level I hospital. Sometimes,
that might require air transport. Clinicians also screen for substance abuse and can provide
limited interventions if tasked.

* Level III: Many Level III facilities serve rural communities and lack comprehensive services
associated with Level I or II centers, including limited access to specialists. Rather, they work in
conjunction with higher-level hospitals, via telephone consults, to stabilize individuals so they
can make the journey to a high-acuity medical center.

* Level IV: Hospitals in this category offer life-saving treatments before transferring patients.

When accepting assignments, it's important to know the level in which you will be practicing.
"The needs will be different if it is a rural hospital or a New York City Level I trauma center.
The patient populations, depth of skills, and type of experience required all differ," says Michele
Kluger-Loebl, a senior healthcare recruiter for RN Network, a healthcare staffing firm in Boca
Raton, Fla.

"This information helps us align nurses' skills and determine better contract fits," adds Dolan.

Screening skills

Clinicians usually come to the mobile lifestyle with a spectrum of skills and work histories.
There are some who have been practicing for a few years in one, maybe two, hospitals. Others
might have decades' worth of professional experiences. Depending on the specifics, they both
might qualify for a trauma assignment. For example, if the young nurse spent those two or three
years on staff at a Level I trauma center, that could be enough to meet contracting facilities'
specifications over nurses who spent the majority of their careers at Level III hospitals.
"Clients want us to identify strong candidates. Nurses have to demonstrate a history of working
in a similar environment," says Dolan "We do not want to place nurses without experience
handling intense, high-acuity trauma cases into a facility ofthat caliber."

"You will be turned away if you do not have trauma experience. You have to be a clinical match
for the unit," Kluger-Loebl adds.

In addition to clinical experience, hospital administrators have raised the bar on mandatory
certifications. Specifically, travelers should possess advanced cardiac life support (ACLS), basic
life support (BLS), and, depending on facility specifics, pediatric advanced life support (PALS).
"Those are the standards," Kluger-Loebl says. "The expectation is that all certifications are
current because nurse managers will not wait for confirmation or renewal."

In recent years, the trauma nursing core curriculum (TNCC) certification has gained more
credibility. "Even if travelers want assignments at Level II facilities, they will need the TNCC
credential. Hospitals are not accepting anything less," says Kluger-Loebl.

"It is so important to keep up with what is going on with the specialty. If you can earn the
TNCC certification, then by all means, do it - I will be taking the course this month. The more
certifications you have, the more motivated you appear, and that sends a positive message about
you as a traveler," McClintock says.

Because both staffing agencies and hospitals expect mobile professionals to prove their
knowledge, both mandate that candidates pass skills tests. "For example, IV skills are very
important in the ED. Also, you have to be well-versed in medications," McClintock says.

"We test travelers on the basics. Hospitals sometimes ask them to take performance or situation-
based exams that include multidisciplinary points, communication abilities, and assessment
knowledge," Kluger-Loebl says. "Remember, it is not a terrible thing to be overqualified for a
position."

Flexible focus

A broad clinical base is proving quite valuable in today's marketplace. Historically, emergency
department contracts played out fairly straightforward in that travelers knew they would spend
an entire assignment solely in that unit. That's not a guarantee these days.
"We are seeing an evolution of the emergency nurse. Now, you have to be a utility player in the
emergency department," Dolan says.

Although the quantity of travel opportunities has rebounded in the past year, healthcare
organizations still struggle with restrictive budgets. As a result, mobile professionals may be
asked to perform a variety of duties, even in the emergency department.

"Hospitals previously employed other personnel to retrieve lab results or medications, and now,
in many cases that is the responsibility of the nurse," Dolan says. "Or you might find yourself
providing general medical or critical care. In the past, you could discharge patients to the
appropriate floors. Now, patients might be held in the ED for hours or even a few days. The
ideal ED traveler for a trauma center will be diverse and flexible, able to handle a wide array of
scenarios."

Sidebar

Head Matters

The effects of traumatic injuries do not necessarily end once people are medically stabilized and
on the way to recuperation. Depending on the severity of injuries, full recovery could be a
lengthy process, involving physical and occupational therapy.

Perhaps one of the more prolific examples of this is traumatic brain injuries (TBI). According to
Brainline.org, a reported 1.7 million Americans suffer TBI each year - experts assert many cases
go undiagnosed or untreated. Additionally, 275,000 people are hospitalized from it.

As with other traumas, TBIs can be caused by falls and motor vehicle accidents, but also by
assaults or being struck by or against objects. Blasts, such as those detonated by improvised
explosive devices (IEDs), are the leading contributor for TBI among active duty military
personnel returning from combat.

While not all patients undergo prolonged rehabilitative treatments, many will. The Centers for
Disease Control and Prevention estimate that 5.3 million people need long-term or lifelong
assistance as a result of a TBI. That's where physical therapists (PTs) and occupational
therapists (OTs) play influential roles.

In some cases, patients have had temporary or permanent paralysis. PTs address these physical
needs by devising exercises to assess, improve, or restore balance, strength, and movement,
among other issues. OTs prepare patients for everyday life by coaching them on new methods to
accomplish life skills, including instruction on how to use assistive technology or equipment.

Rarely will mobile therapists find assignments that solely concentrate on traumatic brain injury
rehab, even within the Veterans Affairs system. Rather, they encounter these types of patients
amidst others in acute care, outpatient, and skilled nursing facilities.

AuthorAffiliation

Anne Baye Ericksen is a freelance writer based in Simi Valley, Calif.

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Copyright Advanstar Communications, Inc. Oct 2011

 Health officials say local trauma care adequate
Flores, Taya. Journal & Courier [Lafayette, Ind] 22 Jan 2011: A.1.

Abstrak (ringkasan)

Clarian Arnett Health officials say they are considering pursuing trauma center status, although
Clarian Arnett's chief executive officer, Al Gatmaitan, says "patient interest is what counts, not
competing between one hospital or another." Dr. Thomas Heniff, medical director of the
emergency department at Clarian Arnett Health, says the hospital already is capable of handling
severe head trauma such as Giffords suffered.

Teks Lengkap

In the wake of the Arizona shooting rampage that left six people dead and nearly killed U.S.
Rep. Gabrielle Giffords, Indiana's top health official made a revelation this past week.

Dr. Gary Larkin, state health commissioner, said large swaths of Indiana, including the
northwest quadrant of the state where Greater Lafayette sits, lack adequate access to major
trauma centers.

But Greater Lafayette hospital officials say the state's main trauma centers in Indianapolis are
close enough that people here need not worry.

And, they add, local hospitals are geared to handle most types of trauma, including the type of
severe head injury that Giffords suffered.

Even so, St. Elizabeth East officials are working toward achieving verified Level III trauma
center status by the end of the year, says Dr. Marc Estes, chief of emergency medicine for St.
Elizabeth Regional Health.

If successful, St. Elizabeth East would be the first certified Level III trauma center in Greater
Lafayette and the first in the state.
"If we were a Level III trauma center at St. E (East) for example, then all the trauma in this
county and surrounding counties" would go there, he says. "It wouldn't go to St. E Central and it
wouldn't go to Clarian. It would come to us."

Clarian Arnett Health officials say they are considering pursuing trauma center status, although
Clarian Arnett's chief executive officer, Al Gatmaitan, says "patient interest is what counts, not
competing between one hospital or another."

Gatmaitan says Clarian already is capable of achieving Level III status. The status must be
verified through a site visit conducted by the American College of Surgeons.

Before granting trauma center status, the college verifies that a hospital meets the criteria
established in a document called the Resources for Optimal Care of the Injured Patient.

"A Level III trauma center does not have the full availability of specialists, but does have
resources for emergency resuscitation, surgery, and intensive care of most trauma patients,"
Larkin says.

Gatmaitan says achieving Level II designation would be a much bigger challenge. Currently
five hospitals have Level II trauma center designation in Indiana, and just three are designated
Level I and thus capable of handling mass injuries.

Why it matters

Trauma, or severe injury, is the leading cause of death in people ages 1 to 34 in Indiana and in
the U.S. according to the Indiana Department of Health. More than 95,000 Hoosiers are
hospitalized, and 5,000 die, because of such injuries each year.

Larkins says his push is to have more level I and II trauma centers, mainly to even out
distribution in western and northwestern Indiana.

Level I and II centers are equipped to handle patients with significant multiple injuries, or cases
where there are multiple trauma victims.

Larkin says Lafayette is not a major concern in that regard because of its proximity 60 miles
from Indianapolis, where three Level I trauma centers are located.

All of those centers are affiliates of Clarian Arnett Hospital.

Having a Level III trauma center in Lafayette would benefit the community, Larkin says, but
that would not address the need for more Level I or Level II centers in more remote or
underserved areas of the state.

"Level III is what most hospitals are or could be," he says. "Level III is the expectation of any
good emergency room. ... I suppose the benefit is it helps (St. Elizabeth East) demonstrate to the
community that they want to be verified as having good quality Level III service."

Harry Teter, executive director of the American Trauma Society, says technically a Level III
hospital means that it is more qualified to care for a trauma patient than a non-trauma center.
However, it does not mean that only a verified trauma center can treat trauma patients. "I'm sure
that there will be cases where you have multiple traumas (and) the other hospital would have to
treat them because sometimes you can be overrun."

Well-equipped

Although Greater Lafayette does not have a designated trauma center, local hospital officials
say the community has sufficient access to trauma care.

"We keep a lot of trauma here and take care of it quite properly," says Dr. Jeffrey Brown,
division director of adult inpatient medicine at Clarian Arnett Health. "But on occasion there are
patients for whom it makes sense that their care be undertaken at a Level I trauma center."

Estes agreed: "For the most part our individual trauma care in this city is completely adequate.
We have board-certified, residency-trained emergency medicine physicians working in all three
hospitals in town."

Dr. Thomas Heniff, medical director of the emergency department at Clarian Arnett Health,
says the hospital already is capable of handling severe head trauma such as Giffords suffered.

"We have two neurosurgeons who are very responsive," Heniff says. "They have taken care of
gunshot wounds ... that we have had, even gunshot wounds to the head. I have no reason to
believe that they wouldn't continue do so in the future."

However, Estes says a patient in this condition would most likely be transferred to a trauma
center, which is better equipped to handle patients requiring long-term hospitalization.

Indiana's eight trauma centers are in Indianapolis, Fort Wayne, South Bend and Evansville.
Costly to operate

Local physicians say trauma centers are regionalized for good reason. They are expensive to
run, and they specialize in treating a large volume of patients.

"The location of those trauma centers currently is where the most volume is," Heniff says. "You
need a certain minimum volume to maintain your certification."

A Level 1 trauma center is the only level that requires the hospital to treat a high volume of
patients or a certain number of severely injured patients, according to the American College of
Surgeons.

Teter says a city the size of Lafayette could support a Level III trauma center.

Local emergency physicians also agreed that most trauma can be treated locally with the
exception of severely burned patients or patients who require a pediatric intensive care unit.
These patients are usually transferred to Indianapolis.

That trip doesn't take long, either. By helicopter it takes about 20 to 25 minutes, and by
ambulance it takes 35 to 45 minutes, depending on the weather.

Estes says St. Elizabeth hospitals also have mass casualty and disaster plans in place.

"Every hospital has to assume that what happened in Tucson can happen in their city, because it
can."

-- Contributing: David Smith/dsmith@jconline.com

Levels of trauma defined

What's the different between a trauma center and the hospitals in Greater Lafayette?

All three local hospitals -- St. Elizabeth East, St. Elizabeth Central and Clarian Arnett Hospital -
- are acute care hospitals. These types of hospitals have the highest level of functioning
departments, such as operating rooms, emergency rooms and a variety of intensive care units,
including a cardiac and surgical intensive care unit, said Tracie Pettit, registered nurse and state
trauma registry manager.
A trauma center is an acute care hospital with a specific designation that meets certain criteria,
said Dr. Jeffrey Brown, division director of adult inpatient medicine at Clarian Arnett Health.
The American College of Surgeons sets this criteria, Pettit said.

Trauma centers in general range from Level I to Level V status, with a Level I providing the
highest level of specialized care for trauma patients. Level IV and Level V refers to trauma
centers located in smaller or rural hospitals, said Harry Teter, executive director of the
American Trauma Society.

Level I designation is the only level that requires the hospital to treat a high volume of patients
or a certain number of severely injured patients. Indiana trauma centers either have Level I or
Level II designation, according to the American College of Surgeons.

Level I trauma centers also require certain subspecialists such as anesthesiologists and general
surgeons to be in the hospital 24 hours at a time, said Dr. Thomas Heniff, medical director of
the emergency department at Clarian Arnett Health. Most trauma centers also are teaching
facilities, so surgical residents serve that purpose.

For Level III status, surgeons, radiologists and anesthesiologists must respond promptly to
treating patients. Also, anesthesiology services have to be available 24 hours a day and present
for all operations. The operating room also has to have essential equipment, according to ACS.

But an acute care hospital does not need trauma center status to treat most trauma patients,
Brown said.

The average trauma patient does not necessarily need the capabilities of a Level I trauma center,
Heniff said. People who benefit are patients who have multiple system injuries, such as having a
head injury, chest injury and multiple orthopedic injuries.

"The sickest of the sickest trauma patients are the people who benefit the most from a Level I
trauma center," Heniff said.

Also, those facilities have the services needed for trauma patients who require long-term
hospitalization, he said.

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