EVIDENCE-BASED PRACTICE GUIDELINES FOR

TRAUMA CARE

Author: Kathryn Moore, DNP, RN, CEN, CCRN, ACNP-BC, Lexington, KYSection Editor: Kathryn Moore, DNP, RN, CEN, CCRN, ACNP-BC

Anumber of proven evidence-based guidelines are inplace for accident and injury prevention. A coupleof well-known examples are seat belts and child

safety seats.1 Although the number of lives saved with thesepolicies continues to increase, until our society lives injuryfree, we will continue to need to provide trauma care. Evi-dence-based guidelines for trauma care encompass 3 dis-tinct venues of care: prehospital care, ED care, and ICUcare. In the ICU, protocols exist regarding the preventionand management of ventilator-associated pneumonia, cen-tral line–associated bloodstream infections, and many otherpatient-related issues.2,3 The American Association of Cri-tical Care Nurses has a library of practice alerts that addressnursing and multidisciplinary activities important to criticalcare practice. These alerts are an effort to provide guidanceand standardize critical care practice and are reviewed andupdated regularly to reflect current literature.4

ENA supports evidence-based practice throughthe Institute for Quality, Safety and Injury Prevention(IQSIP). IQSIP provides subject matter expertise on issuesrelated to practice, quality, safety, injury prevention, andwellness.5 A great deal of information is included in theIQSIP repository, but very little of it deals specifically withthe care of trauma patients in the emergency department.ENA does offer both the Trauma Nurse Core Course andthe Course in Advanced Trauma Nursing. Both of thesecourses provide didactic and skills components for the nur-sing management of trauma patients in the emergencydepartment and are based on the most recent literature.

Guidelines published by the American College of Sur-geons (ACS) address both the ICU and ED management

of trauma patients. The ACS is the agency that verifiesand credentials trauma centers in the United States andsponsors the Advanced Trauma Life Support Course.The programs sponsored by the ACS include education,professional development, standards of care, and assess-ment of outcomes.6 The ACS manages the repositoryfor the National Trauma Data Bank and the TraumaQuality Improvement Program. With the data collected,research has been conducted to assist in creating evi-dence-based protocols for care in both the ICU and theemergency department.

Another agency involved in the development of trau-ma care protocols and guidelines is the Eastern Associationfor the Surgery of Trauma (EAST). EAST publishes prac-tice management guidelines for trauma care that are sys-tematically developed statements to help practitioners andpatients make decisions about appropriate health care forspecific clinical circumstances in accordance with theInstitute of Medicine Report on Clinical Practice Guide-lines.7 EAST published guidelines in 2010 on the triage oftrauma patients that are related to the specific manage-ment of the trauma patient in the prehospital and ED set-tings. These guidelines include triage in both theprehospital and ED setting and present the conclusionthat a more comprehensive definition of the traumapatient requiring trauma center care needs to be devel-oped.8 EAST has convened a subcommittee to worktoward developing a more comprehensive definition thatwill also consider major trauma, complex care, resourceavailability, and regionalization of care.8

Another guideline published by EAST related to trau-ma care is the 2008 prehospital fluid resuscitation guide-line.9 This guideline states that few data support thepractice of prehospital venous access placement and fluidresuscitation. The practice recommendation from thisguideline is that if venous access is obtained, it should beobtained en route to the trauma center and that fluid resus-citation should be withheld in patients who are alert orhave a palpable radial pulse.9 A third guideline publishedin 2010 outlines the recommended procedure for bloodtransfusion in trauma patients.10 This work is guidingthe development of evidence-based massive transfusionprotocols in use in trauma centers.11

Kathryn Moore, Member, Bluegrass Chapter, is Assistant Professor, Universityof Kentucky College of Nursing, Lexington, KY.

For correspondence, write: KathrynMoore, DNP, RN, CEN, CCRN, ACNP-BC, 3033 Shirlee Dr, Lexington, KY 40502; E-mail: kmmo222@uky.edu.

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The area with the greatest gap in evidence-based pro-tocols and guidelines is prehospital care of trauma patients.In 2002, a National EMS Research Agenda was proposedby the National Highway Traffic Safety Administration,the Department of Transportation and the Departmentof Health and Human Services.12 In 2005, a consensuspaper was published outlining the progress to date.13

Although the stakeholders have been identified and consen-sus has been reached about the issues to be addressed,much remains to be done. Several barriers exist to boththe development and implementation of evidence-basedpractice in the prehospital setting. The initial hurdle inconducting prehospital research is the issue of obtaininginformed consent or convincing the Institutional ReviewBoard that the protocol qualifies as allowing waiver ofinformed consent.14 Once the study is done and published,the next barrier is applying the research in practice.15

After the initial efforts to develop a National EMSResearch Agenda, spurred on by the 2006 Institute ofMedicine report on the Future of Emergency Care in theUnited States, a national stakeholder meeting was con-vened in an effort to create evidence-based guidelines forprehospital emergency care.16 To date a great deal of dis-cussion and planning have taken place to implement amodel for the process, but no guidelines are in place yet.

Traumatic injury remains the fifth leading cause ofdeath in the United States and is projected to becomethe fourth leading cause of disability-adjusted life yearsby 2030 worldwide.17 It is incumbent on those providingcare in trauma to encourage and support efforts to researchtrauma care. Moreover, we must ensure that the researchthat is done is disseminated and put into practice.

REFERENCES1. Gielen AC, Frattaroli S, Yonas MA, Sattin RW, Levi J. The new emphasis

on implementing evidence-based interventions: the end of research or anew beginning for partnerships? Inj Prev. 2011;17(6):431.

2. Dodek P, Keenan S, Cook D, et al. Evidence-based clinical practiceguideline for the prevention of ventilator-associated pneumonia. AnnIntern Med. 2004;141(4):305-13.

3. Galpern D, Guerrero A, Tu A, Fahoum B, Wise L. Effectiveness of acentral line bundle campaign on line-associated infections in the inten-sive care unit. Surgery. 2008;144(4):492-5. discussion 495.

4. American Association of Critical Care Nurses. AACN practice alerts.http://www.aacn.org/WD/Practice/Content/practicealerts.content?me-nu=Practice. Accessed March 15, 2012.

5. Emergency Nurses Association. ENA IQSIP. http://www.ena.org/IQSIP/Pages/about.aspx. Accessed May 11, 2012.

6. American College of Surgeons. Committee on Trauma. http://www.facs.org/trauma/index.html#. Accessed March 15, 2012.

7. Field MJ, Lohr KN. Institute of Medicine Committee to Advise thePublic Health Service on Clinical Practice Guidelines, United StatesDepartment of Health and Human Services. Clinical Practice Guide-lines: Directions for a New Program. Washington, DC: National Acad-emy Press; 1990.

8. Barraco RD, Chiu WC, Bard MR, et al. Triage of the trauma patient.http://www.east.org/tpg/TraumaTriage.pdf. Accessed March 16, 2012.

9. Cotton BA, Jerome R, Collier BR, et al. Guidelines for prehospitalfluid resuscitation in the injured patient. J Trauma. 2009;67(2):389-402.

10. Napolitano LM, Kurek S, Luchette FA, et al. Red blood cell transfusionin adult trauma and critical care. http://www.east.org/tpg/SCCMrbc.pdf. Accessed March 16, 2012.

11. Riskin DJ, Tsai TC, Riskin L, et al. Massive transfusion protocols: therole of aggressive resuscitation versus product ratio in mortality reduc-tion. J Am Coll Surg. 2009;209(2):198-205.

12. Sayre MR, White LJ, Brown LH, McHenry SD. National EMSresearch agenda: proceedings of the implementation symposium.Acad Emerg Med. 2003;10(10):1100-8.

13. Sayre MR, White LJ, Brown LH, McHenry S.D.. The NationalEMS Research strategic plan. Prehosp Emerg Care. 2005;9(3):255-66.

14. Schmidt TA, Salo D, Hughes JA, et al. Confronting the ethical chal-lenges to informed consent in emergency medicine research. Acad EmergMed. 2004;11(10):1082-9.

15. Cone DC. Knowledge translation in the emergency medical services: aresearch agenda for advancing prehospital care. Acad Emerg Med.2007;14(11):1052-7.

16. Office of Emergency Medical Services, National Highway Traffic SafetyAdministration. Progress of evidence-based guidelines for prehospitalemergency care. http://www.ems.gov/pdf/2012/EBG_Project_Over-view_Dec2011.pdf. Accessed March 16, 2012.

17. Mathers CD, Loncar D. Projections of global mortality and burden ofdisease from 2002 to 2030. PLoS Med. 2006;3(11):e442.

Submissions to this column are encouraged and may be sent toKathryn Moore, DNP, RN, CEN, CCRN, ACNP-BCkmmo222@uky.edu

TRAUMA NOTEBOOK/Moore

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