Trauma Team: Successful Staffing Model

Jan 07, 2019

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What better complement to the expert triage and immediate management skills of an ED nurse than a critical care nurse, whose experience lies in managing patients’ needs in their sickest moments?

Jennifer Schollenberger

As the only regional trauma center in south Orange County, California, St. Joseph Health's Mission Hospital in Mission Viejo must embrace staffing as a complex, collaborative care issue. As a result, they honed a trauma team staffing model by developing an algorithm involving dedicated primary, emergency department (ED) and critical care trauma nurses capable of adjusting to influxes of trauma patients and dedicated to the entire initial phase of trauma care.

The Problem

Mission Hospital is a 24/7 American College of Surgeons (ACS) Certified Level II Adult and Level II Pediatric trauma center, with more than 530 beds, in partnership with CHOC Children's. Around the clock, the facility ensures that they're ready for high-level traumas with appropriate staff and resources for any situation.

They must also be mindful of the individual departmental needs of their trauma, ED and surgical ICU (SICU) to ensure the optimal staffing for achieving the best possible critical care outcomes.

According to primary trauma nurse Jennifer Schollenberger, the hospital was faced with a rapidly increasing number of trauma patients. They needed an improved process to quickly identify and provide the necessary resources to resuscitate high-acuity patients, yet manage the breadth of the workload.

"We recognized the importance of determining gaps in care practice, patient safety stressors involved with staffing an influx of patients over a short timeframe and an evaluation of the impact on the staffing in both the ED and SICU departments," Schollenberger says.

The Solution

To address this issue, Mission Hospital blended ED and critical care nurses into the Trauma Team, recognizing that their skills made them ideal care providers for trauma patients during the entire resuscitation phase — from ED and diagnostics to admission, surgery and discharge.

The team consists of primary trauma nurses — all with critical care backgrounds who work full time in the Trauma Department — and ED and SICU trauma nurses who work part time. With the hospital's steady flow of trauma patients, this model also allows for trauma-trained nurses in ED/SICU to assist during mass casualty incidents.

Trauma nurses have learned to provide quality care in a fast, unpredictable environment while triaging and caring for patients. They must quickly recognize acute concerns while resolving or stabilizing life-threatening conditions. The skillset and preparation of these critical care nurses make them the optimal choice in this setting.

Additionally, trauma nurses must work independently, recognize early signs of patient clinical deterioration while acting confidently and quickly to manage emergent patient needs and prevent crises. To Schollenberger and her team, critical care nurses matched these skills.

"A critical care nurse, who cares for the most fragile of patients day in and day out, performs ideally in this role," Schollenberger says. "What better complement to the expert triage and immediate management skills of an ED nurse than a critical care nurse, whose experience lies in managing patients' needs in their sickest moments?"

Mission Hospital blended ED and critical care nurses into the Trauma Team, collaborating with trauma surgeons, medical teams and rapid response staff to provide total trauma patient care.

Measures of Success

As an ACS verified trauma center, Mission Hospital abides by a rigorous Performance Improvement Patient Safety (PIPS) review system. With detailed, real-time case reviews and physician-peer input processes, the PIPS system has earned them a quality rating of "transformational" in their most recent verification survey.

Since implementing the trauma team staffing model five years ago, Mission Hospital's optimal staffing has:

  • Improved patient outcomes in the most critical cases.
    • Patient mortality rate data below or meeting National Standard benchmark average in all risk-adjusted trauma patient groups — per Trauma Quality Improvement Program (TQIP) National Data Registry.
    • Ninety-eight percent of trauma patients with bleeding injuries (identified by CT scan and previously on anticoagulants) were reversed within one hour of CT results.
  • Experienced reduction in trauma ED diversion rates to nearly zero percent.
  • Maintained optimal outcomes while transitioning through two different physician groups.
  • Not lost any department nurses based on discontent.
  • Seen all team members strive for advanced degrees, specialty certifications and advanced clinical roles.
  • Established an annual trauma conference.

Additionally, the team provides the county's only Advanced Trauma Certified Nurse course open to the community. Meanwhile, they have earned the prestigious ACS Pediatric Trauma Level II verification and noted as a "best practice" during the most recent verification process.

True Collaboration

While developing the vision of their new Trauma Team staffing model, the group collaborated with multiple administration nursing leaders and managers, including:

  • Chief Nursing Officer
  • ED Management
  • SICU Management
  • Rapid Response Leadership
  • Pediatric Directors
  • Department staff members.

“At a time when it is difficult to prove the benefits of prevention, data helped us to best identify our needs and justify the cost variation we proposed to administration,” Schollenberger adds. “Our algorithm accommodates for an influx of trauma patients and management of those requiring ongoing critical resuscitation.”

Appropriate Nurse Staffing

Mission Hospital’s trauma nurse algorithm and plan includes:

  • A three-tiered trauma response system with multiple levels of resources and precise process flows.
  • Established call-time requirements to ensure the Trauma Department has the proper complement of staff at all times.
  • Appropriate staffing projections for an independently staffed Trauma Department.
  • A staffing forecast to manage everything from a single patient to a trauma patient surge, extending to a mass casualty incident.

In 2017, Mission Hospital’s Trauma Team had approximately 2,500 cases. For 2018, they were on pace to handle 600 additional trauma patients.

“Despite remaining well below the Trauma Verification Standards, we continued to strive to reduce our diversion time,” says Schollenberger. “A dramatic reduction in diversion can be attributed to our Trauma Team’s depth of available staffing, which reduced diversion resulting from exhausted resources.”

Lessons Learned

According to Schollenberger and her team, here are the key lessons learned while proposing their innovative staffing proposal and during transition:

  • Ensure administrative support and make sure they understand the current departmental flow and questionable care concerns.
  • Present a comprehensive business-minded outcome driven proposal: look to outcomes data (TQIP), nurse sensitive indicators, national patient safety goals (JCAHO and CMS), staffing considerations and budgetary needs.
  • Stimulate the input of all departments involved, make them key stakeholders in the process and help overcome hurdles once the model is instituted.

Advice to Nurses

Schollenberger and her team learned much during the process of bring this staffing program to fruition. Here is her advice for nurses looking to propose their own innovative staffing solution:

  • Be open-minded – the end product may not be the same vision you started with.
  • Be patient – the healthcare field is wrought with change and you need the buy-in and support of everyone involved.
  • Recognize all the specialty service lines involved in the evolution of the staffing practice. There will be frustrations and growing pains. If those involved feel valued, they will be proactive rather than divisive when reconciling dilemmas.

“We truly believe the staffing model is ideal for the care of our trauma and critical care population,” Schollenberger adds. “In an era of healthcare where the dollar dictates so much, it is imperative to have ideal approaches to optimal care.”

To learn more about Mission Hospital’s Trauma Team Staffing Model, contact us at