Training the FAST Nurse in Trauma Care

Sydney South West Area Health Service

Abstract

Trauma Surgeons and Emergency physicians have been using Focused Assessment with Sonography in Trauma (FAST) as a rapid, non-invasive and accurate tool to detect intraperitoneal free fluid in trauma patients at Liverpool Hospital since 1995. FAST is the accepted standard of practice and an integral part of the primary survey (Bhan et al, 2007; Boulanger et al, 2000). FAST assesses potential spaces for free fluid in the pericardium, morrisons pouch (between the liver and kidney), the lienorenal interface (between the spleen and the kidney) and the pouch of Douglas (behind the bladder).

This technique can indicate if the patient is bleeding internally and may require urgent surgical management in a critically injured patient. However, FAST accredited medical staff are not always present within the trauma team and many represent a transient population. FAST examination has been proved accurate for diagnosing trauma when performed by non-radiologist physicians. Recent reports have suggested that non-physicians also may be able to perform the FAST examination reliably (Sargsyan et al, 2005).Training of senior trauma and emergency nurses in the use of FAST (NFAST) was implemented in September 2006 to increase the number of available accredited FAST operators.

 Download the presentation given at the 2008 NSW Health Expo (867 KB).

Aim

• To develop a sustainable workforce in Emergency / Trauma Department by training, assessment and validation of nurse preformed FAST at Liverpool Hospital.
• To enhance emergency / trauma care provided through the use of FAST.

Nature of the Problem

In order to provide an effective twenty four hour / seven day a week service and coverage of accredited FAST trained staff for presenting trauma patient’s, senior nurses were identified as a target group to train as they are a stable workforce.  The trauma and emergency nurse are also consistently members of the trauma team with significant experience in trauma care. Liverpool Hospital is a designated and verified level one trauma centre for Sydney South West and the tertiary referral centre with a catchment population in excess of 800,000. In 2007 Liverpool managed 1310 trauma team activations.

Extent of the Problem

Data collected from 1998 tracked the use of FAST compared to other methods - diagnostic peritoneal lavage (DPL), abdominal CT and laparoscopy. The use of FAST decreased in 2004 and 2005 due to limited coverage of accredited FAST staff. Other options to ensure adequate coverage were reviewed and senior nurses within the Trauma and Emergency Departments were identified for training due to the stability of the workforce. The hospital believes this is a world-wide first for nurses to be trained in FAST.

Assessment of Abdominal Trauma 1998-2007

Strategic Importance

This service relates to NSW Health goal “providing the health care that people need” and NSW Health Strategic Direction Number 6 “Building a sustainable health workforce”. The opportunity to improve patient outcomes through rapid evaluation of trauma patients was an important consideration. There is also the potential to minimise unnecessary CT scans and expedite patient care through prioritisation and improved decision making processes.

Planning and Implementing Solutions

Education followed the same training as the medical officers; a one day emergency ultrasound course consisting of didactic lectures, live patient scanning and a multiple choice exam followed by the completion of twenty five proctored scans.  At least half of the required scans were to be indicated and an exit exam was also required by the Australasian College of Emergency medicine (ACEM) and the Australasian Trauma Society guidelines (ATS).  An Emergency Department Nurse Sonographer standing order protocol was developed to support the practice of NFAST.

Outcomes and Evaluation

All indicated, adequate NFAST scans performed were entered into an Access data registry; each result was compared with the best reference standard available for each case. Best reference standard comparisons were operation reports, contrast CT scans (reported by radiologist blinded to the NFAST result) and clinical course (the patient’s subsequent clinical progress while in hospital). The analysis of the NFAST results from the data registry has demonstrated comparative results to fellow medical colleges who historically provided this exam.

Current data shows 308 indicated  NFAST scans demonstrated a sensitivity of 75.8% (95% CI 57.4- 88-3) and specificity of 98.5% (95% CI 96.1- 99.5), a positive predictive value (PPV) of 86.2% (95% CI 67.4 – 95.5) and a negative predictive value (NPV) of 97.1% (95% CI 94.2 – 98.7). Overall accuracy of NFAST for the detection of free fluid was 96.1% (95% CI x-x). When reviewing the Liverpool trauma registry data together with the NFAST results it has shown that the accredited NFAST nurses are performing 36.5% of all indicated FAST scans on all the trauma patients meeting the major trauma category that are admitted to Liverpool Hospital since their accreditation.

Sustaining Change

The first dedicated NFAST Emergency Ultrasound training day was held at Liverpool Hospital on April 16th 2008. It was organised and run by NFAST accredited nurses from Liverpool Hospital Emergency and Trauma departments with the support of accredited medical consultants. Sixteen senior nurses from Sydney South West Area Health Service (SSWAHS) Emergency and Trauma Departments attended the course. Currently at Liverpool there are four accredited NFAST operators since February 2007 and across the SSWAHS twenty one in the process of accreditation. The next course is arranged for August 2008.

Future Scope

Emergency Ultrasound is still in its infancy, although it has recently thrived as an inexpensive, rapid, non-invasive approach to assessing patients. The NFAST nurses are developing their skills in ultrasound which include the detection of abdominal aortic aneurysms, vascular access, foetal heart traces, early pregnancy and ruptured ectopic pregnancies.  The broader goal is to continue to train and develop new skills in diagnostic emergency ultrasound and to train other senior nurse’s. Rural and remote nurses are a special target group for training in the uses of emergency ultrasound.

References

• Bhan, Chetan A; Forshaw, Matthew J B; Bew, Duncan P C; Kapadia, Yasmin K D Diagnostic peritoneal lavage and ultrasonography for blunt abdominal trauma: attitudes and training of current general surgical trainees. European Journal of Emergency Medicine. 14(4):212-215, August 2007.
• Boulanger B T, Kearney P A, Brennenman F D et al. Utilization of FAST (focused assessment with sonography for trauma) in 1999: results of a survey of North American trauma centers. Am. Surg. 2000; 66: 1049–55.
• Eppich, Walter J A; Zonfrillo, Mark R B Emergency department evaluation and management of blunt abdominal trauma in children. Current Opinion in Pediatrics. 19(3):265-269, June 2007.
• Ollerton J E, Sugrue M, Balogh Z, et al. Prospective study to evaluate the influence of FAST on trauma patient management. J Trauma 2006; 60:785–791.
• Sargsyan, Ashot E.; Hamilton, Douglas R.; Jones, Jeffrey A.; Melton, Shannon; Whitson, Peggy A.; Kirkpatrick, Andrew W.; Martin, David; Dulchavsky, Scott A. 2005. FAST at MACH 20: Clinical Ultrasound Aboard the International Space Station. Journal of Trauma-Injury Infection & Critical Care. 58(1):35-39, January 2005.

Project Team

• Sally Forest-Horder, Trauma Case Manager
• Michelle Cox, Transitional Nurse Practitioner

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