Lyndon B.
Johnson General
Hospital Trauma Services
Department
Guideline/Protocol Number: T24
Guidelines and Protocols
TITLE: TRAUMA TEAM
ACTIVATION PURPOSE:
The purpose of this policy is to provide guidelines to activate and assemble the
trauma team in order to facilitate the care of critical or seriously injured patients
who require rapid, organized trauma resuscitation, evaluation and stabilization to
promote optimal outcomes. It also serves to provide triage guidelines for adult and
pediatric patients
PROCESS:
I. TRAUMA TEAM ACTIVATION GUIDELINE
A. The criteria for activation of the trauma team is clearly defined
and posted at the Emergency Center triage desk and in the
Shock Rooms.
B. The trauma team may be activated prior to arrival of patients
in the Emergency Center based on the EMS pre-hospital
assessment.
C. The surgical attending, surgical resident, EC Attending, EC
resident, charge nurse, triage nurse, shock room nurse, or
Trauma Services staff may activate the trauma team.
D. The person initiating the trauma activation will call the page
operator to group page the trauma team and will specify the
code of activation required. This person will also activate the
trauma pagers with a pre-scripted text and detailed
information.
1. e.g. “Code 1 or 2, Adult or Pedi., Room, Mechanism
of Injury, Vital Signs”
E. Test pages will be sent at 0700 and at 1900 by the Ambulance
Triage Nurse. If a test page is not received at these times, then
the pager holder should report this to the ambulance triage
nurse and to physician services.
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1. e.g. “Test Page”
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Lyndon B. Johnson General
Hospital Trauma Services
Department
Guideline/Protocol Number: T24
Guidelines and Protocols
F. The page operator will announce the trauma activation on
the overhead paging system.
1. e.g. “Medical Alert: Adult Trauma Code 1 to Shock
Room 1”
G. Trauma team member notification and arrival times will be
documented in the EPIC “Trauma Narrator” Staff arrival section.
H. Trauma team members will badge in when they arrive at
the badging station outside of the Shock Room.
I. Trauma team members will be activated for all patients who
meet the following criteria:
1. Code 1 (moderate/major): life threatening injuries and/or
unstable vital signs. potentially life threatening injuries with
presently stable vital signs
2. Code 2 (minor): Significant mechanism of injury
with potentially life threatening injuries with presently
stable vital signs.
3. Injuries meeting activation criteria should have occurred
within the past 24 hours. There may be instances in
which a patient had an injury greater than 24 hours and
may need to be activated. A trauma consult should be
considered on all unstable trauma patients.
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Lyndon B. Johnson General
Hospital Trauma Services
Department
Guideline/Protocol Number: T24
Guidelines and Protocols
II. TRAUMA TEAM ACTIVATION CRITERIA
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Lyndon B. Johnson General
Hospital Trauma Services
Department
Guideline/Protocol Number: T24
Guidelines and Protocols
III. TRAUMA RESPONSE TEAMS PER TRAUMA CODE
LEVEL AND RESPONSE TIME REQUIREMENTS (FROM
ACTIVATION)
A. CODE 1
Attending Trauma Surgeon* ≤15 minutes
EC Attending* ≤10 minutes
Chief Surgery Resident As needed
Senior Surgery Resident As needed
Junior Surgery Resident ≤15 minutes
Shock room Nurse(s)* (at least 2 initially) On arrival
Charge Nurse* ≤10 minutes
Radiology Technician* ≤15 minutes
Trauma Program Manager/Director and/or
Trauma Coordinator As needed
Respiratory Care Therapist* 15 minutes
Specialty Consult (as requested) ≤60 minutes
Chaplain (as requested) As needed
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Lyndon B. Johnson General
Hospital Trauma Services
Department
Guideline/Protocol Number: T24
Guidelines and Protocols
B. CODE 2
EC Attending* ≤30 minutes
Shock room Nurse(s)* On arrival
Trauma Program Manager/Director and/or
Trauma Coordinator As needed
Specialty Consult (as requested) ≤60 minutes
*Denotes a required member of the activation team. Other members may respond as needed. EC Attending is
primarily responsible for the patient until Surgery team member arrives. Trauma
Surgery Consult
patients do not require activation page, but will be included in the trauma registry
for performance improvement monitoring. Consults should not replace trauma
activations.
A Trauma Code may be activated and upgraded (upon completion of primary
survey) and can be done by any member of the trauma team depending upon
patient’s condition related to Trauma Team Activation during primary or
secondary assessment .
Once a trauma code is activated, it cannot be downgraded.
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Lyndon B. Johnson General
Hospital Trauma Services
Department
Guideline/Protocol Number: T24
Guidelines and Protocols
REFERENCE / BIBLIOGRAPHY:
OFFICE OF PRIMARY RESPONSIBILITY:
LYNDON B. JOHNSON HOSPITAL TRAUMA SERVICES
REVIEW / REVISION HISTORY
Review/ Revision Date (Indicate
Version #
Effective Date Reviewed or Revised) Approved by:
(If Applicable)
03/17/20 8 03/17/20 Trauma Committee
02/21/17 7 02/21/17 Trauma Committee
10/21/14 6 10/21/14 Trauma Committee
10/16/12 5 10/16/12 Trauma Committee
06/19/12 4 06/19/12 Trauma Committee
09/23/11 3 09/23/11 Trauma Committee
09/15/08 2 09/15/08 Trauma Services
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