Design and implementation of a “crisis resource management” training program for the initial assessment of polytrauma patients / Diseño e implementación de un programa de aprendizaje crisis resource management para la evaluación inicial del paciente politraumatizado

Introduction: To describe the design and implementation of a Crisis Resource Management (CRM) training program for the initial assessment of polytrauma patients. Methods: Prospectively implemented CRM training program in acute-care tertiary hospital by hospital personnel involved in the care of polytraumatisms. The program has a blended format and 23-h duration, including 11 h of online theoretical training followed by 12-h simulation modules and practical cases devoted to the roles of members of the trauma team, functioning of the polytrauma room, and key aspects of teamwork. The Human Factors Attitude Survey (HFAS) was used to assess attitudes related to non-technical skills, and the End-of-Course Critique (ECC) survey to evaluate satisfaction with training. We evaluated changes in the pre- and post-training assessments. Results: Eighty staff personnel (26% specialists, 16% residents, 29% nurses, 14% nursing assistant, 15% stretcher bearer) participated in three editions of the program. Theoretical knowledge improved from a mean (SD) of 5.95 (1.7) to 8.27 (2.1) (P < .0001). In the HFAS, statistically significant differences in 18 of 23 attitudinal markers were observed, with improvements in all items of “leadership” and “roles”, in 4 of 5 items of “situational awareness”, and in 4 of 8 items of “communication”. Mean values obtained in the ECC questionnaire were also very high. Conclusions: A CRM training model developed for the initial care of polytrauma patients improved theoretical knowledge and participants perceptions and attitudes regarding leadership, communication, roles, and situational awareness of members of the trauma team. (AU)

Introducción: Describir el diseño y la implementación de un programa de formación basado en Crisis Resource Management para la evaluación inicial de los pacientes con politraumatismos. Métodos: Implementación prospectiva de un programa CRM de formación en Hospital terciario con el personal del hospital involucrado en la asistencia de politraumatismos. El programa tenía un formato semipresencial de 23 horas de duración, incluyendo 11 horas de formación online de contenido teórico seguidas de 12 horas de módulos de simulación y casos prácticos referidos a los papeles de los miembros del equipo de trauma, funcionamiento del box de trauma y aspectos claves del trabajo en equipo. El Human Factors Attitude Survey (HFAS) se utilizó para evaluar las actitudes relacionadas con las habilidades no técnicas y el End-of-Course Critique (ECC) cuestionario para valorar la satisfacción con la formación. Se evaluaron los cambios antes y después de la formación. Resultados: Ochenta miembros del hospital (26% especialistas, 16% residentes, 29% enfermeras, 14% auxiliares de enfermería, 15% camilleros) participaron en tres ediciones del programa. El conocimiento teórico aumentó de una media (DE) de 5.95 (1.7) a 8.27 (2.1) (P < ,0001). En el HFAS, se observaron diferencias estadísticamente significativas en 18 de los 23 marcadores de actitud, con mejorías en todos los ítems de “liderazgo” y “roles”, en 4 de los 5 items de “consciencia situacional” y en 4 de los 8 ítems de “comunicación”. Los valores medios obtenidos en el cuestionario ECC tambien fueron muy altos. Conclusiones: Un modelo CRM de formación desarrollado para la atención inicial de los pacientes con politraumatismos mejoró el conocimiento teórico y las percepciones y actitudes de los participantes relacionadas con el liderazgo, la comunicación, los roles y la consciencia situacional de los miembros del equipo de trauma. (AU)

Design and implementation of a "crisis resource management" training program for the initial assessment of polytrauma patients.

INTRODUCTION: To describe the design and implementation of a Crisis Resource Management (CRM) training program for the initial assessment of polytrauma patients. METHODS: Prospectively implemented CRM training program in acute-care tertiary hospital by hospital personnel involved in the care of polytraumatisms. The program has a blended format and 23-h duration, including 11 h of online theoretical training followed by 12-h simulation modules and practical cases devoted to the roles of members of the trauma team, functioning of the polytrauma room, and key aspects of teamwork. The Human Factors Attitude Survey (HFAS) was used to assess attitudes related to non-technical skills, and the End-of-Course Critique (ECC) survey to evaluate satisfaction with training. We evaluated changes in the pre- and post-training assessments. RESULTS: Eighty staff personnel (26% specialists, 16% residents, 29% nurses, 14% nursing assistant, 15% stretcher bearer) participated in three editions of the program. Theoretical knowledge improved from a mean (SD) of 5.95 (1.7) to 8.27 (2.1) (P < .0001). In the HFAS, statistically significant differences in 18 of 23 attitudinal markers were observed, with improvements in all items of "leadership" and "roles", in 4 of 5 items of "situational awareness", and in 4 of 8 items of "communication". Mean values obtained in the ECC questionnaire were also very high. CONCLUSIONS: A CRM training model developed for the initial care of polytrauma patients improved theoretical knowledge and participants perceptions and attitudes regarding leadership, communication, roles, and situational awareness of members of the trauma team.

Degeneración del esófago de Barrett tras gastrectomía vertical / Degeneration of Barrett's Esophagus after Sleeve Gastrectomy

No disponible

Correction to: Esogastro-Pleuro-Bronchial Fistula: An Unusual Complication After Sleeve Gastrectomy.

Due to a Production error Figs. 1 and 2 were omitted from the original article.

Analysis of quality of life after major trauma: a spanish follow-up cohort study.

PURPOSE: Study objectives are to determine whether quality of life is recovered completely after major injury and to identify determinants associated with a worse quality of life. METHODS: Prospective 12-month follow-up of injured patients admitted to the intensive care unit in a Spanish level 1 trauma centre. The main outcome (quality of life) was measured using the EQ-5D-5L. The relationships between sociodemographic factors, injury severity and location, and quality of life scores were evaluated. Mean comparison analysis (95% confidence interval) was performed with the student "t" test for quantitative variables and with chi-squared for proportion comparison (qualitative variables). A multivariate logistic regression (odds ratio and 95% confidence interval) was performed to identify determinants of each dimension, and a multivariate linear regression (regression coefficient and 95% confidence interval) to identify the determinants of EQus and EQvas. RESULTS: Over a 2-year period, 304 patients who met the inclusion criteria were identified, and 200 patients (65.8%) were finally included. Most of patients suffered blunt trauma (91.5%), 72.5% were men, mean age was 47.8, mean ISS was 15.2. The overall health index (EQvas) improved slightly, but its mean value at 12 months was below the Spanish population norm (P < 0.001). In the multivariate analysis, age ≥ 55, female gender and unskilled employment were risk factors for a lower EQvas. Also in the multivariate analysis, having a severe extremity injury was associated with a lower score on the mobility dimension (OR 6.56 95% CI 2.00, 21.55) while age ≥ 55 years was associated with a lower score on the usual activities dimension (OR 3.52 95% CI 1.17, 10.57). Female gender was the most important factor associated with suffering pain (OR 4.54, 95% CI 2.01, 10.27) and depression/anxiety (OR 4.04, 95% CI 1.88, 8.65). In the univariate and multivariate analyses, female gender, age ≥ 55 years, ISS ≥ 25 and severe extremity injury were associated with a lower EQ utility score (EQus). CONCLUSIONS: The quality of life score improves during the first year after major trauma. However, it does not return to the reference levels for the normal population. Female gender and age ≥ 55 years are statistically significant determinants of poorer EQvas and EQus.

Comparación de la mortalidad evitable de un trauma center americano vs. un centro de referencia europeo / American vs. European Trauma Centers: A Comparison of Preventable Deaths

Introducción: El objetivo del estudio es comparar la calidad asistencial de un trauma center americano (USC) vs. un centro equivalente de referencia europeo (SRC) en España, a través del análisis de la mortalidad evitable. Métodos: Estudio comparativo que evalúa pacientes politraumatizados mayores de 16 años que han sido exitus durante su hospitalización. Se han identificado las muertes evitables o potencialmente evitables, analizando los errores en el manejo, clasificándolos según la taxonomía de la Joint Comission. Resultados: La incidencia de mortalidad evitable y potencialmente evitable fue del 7,7% en el USC, y del 13,8% en el SRC. Según la taxonomía de la Joint Comission, el principal tipo de error fue clínico en ambos centros, debido a errores de intervención (tratamiento). Los errores ocurren en urgencias y fueron causados por médicos. En el USC, el 73% de los errores fue de tipo terapéutico comparado con el 59% en el SRC (p = 0,06). El SRC tuvo un 41% de errores diagnósticos vs. solo el 18% en el USC (p = 0,001). En ambos centros, el principal tipo de error fue humano, siendo tipo knowledge-based el más frecuente en el USC (44%) vs. rule-based en el SRC (58%) (p < 0,001). Conclusiones: El uso de un lenguaje común para analizar los errores de manejo es una clave esencial para establecer puntos de referencia estándares y universales. Comparando la calidad asistencial de un trauma center americano con la de un centro de referencia español, hemos detectado unos errores evitables extraordinariamente parecidos. Se han hallado más errores diagnósticos y de tipo ruled-based en el centro español (AU)

Introduction: The aim is comparing the quality of care at a typical American trauma center (USC) vs. an equivalent European referral center in Spain (SRC), through the analysis of preventable and potentially preventable deaths. Methods: Comparative study that evaluated trauma patients older than 16 years old who died during their hospitalization. We cross-referenced these deaths and extracted all deaths that were classified as potentially preventable or preventable. All errors identified were then classified using the JC taxonomy. Results: The rate of preventable and potentially preventable mortality was 7.7% and 13.8% in the USC and SRC respectively. According to the JC taxonomy, the main error type was clinical in both centers, due to errors in intervention (treatment). Errors occurred mostly in the emergency department and were caused by physicians. In the USC, 73% of errors were therapeutic as compared to 59% in the SRC (P = .06). The SRC had a 41% of diagnosis errors vs just 18% in the USC (P = .001). In both centers, the main cause of error was human. At the USC, the most frequent human cause was "knowledge-based" (44%). In contrast, at the SRC center the most common errors were "rule-based" (58%) (P < .001). Conclusions: The use of a common language of errors among centers is key in establishing benchmarking standards. Comparing the quality of care of an American trauma center and a Spanish referral center, we have detected remarkably similar avoidable errors. More diagnostic and "ruled-based" errors have been found in the Spanish center (AU)

American vs. European Trauma Centers: A Comparison of Preventable Deaths. / Comparación de la mortalidad evitable de un trauma center americano vs. un centro de referencia europeo.

INTRODUCTION: The aim is comparing the quality of care at a typical American trauma center (USC) vs. an equivalent European referral center in Spain (SRC), through the analysis of preventable and potentially preventable deaths. METHODS: Comparative study that evaluated trauma patients older than 16 years old who died during their hospitalization. We cross-referenced these deaths and extracted all deaths that were classified as potentially preventable or preventable. All errors identified were then classified using the JC taxonomy. RESULTS: The rate of preventable and potentially preventable mortality was 7.7% and 13.8% in the USC and SRC respectively. According to the JC taxonomy, the main error type was clinical in both centers, due to errors in intervention (treatment). Errors occurred mostly in the emergency department and were caused by physicians. In the USC, 73% of errors were therapeutic as compared to 59% in the SRC (P=.06). The SRC had a 41% of diagnosis errors vs just 18% in the USC (P = .001). In both centers, the main cause of error was human. At the USC, the most frequent human cause was 'knowledge-based' (44%). In contrast, at the SRC center the most common errors were 'rule-based' (58%) (P<.001). CONCLUSIONS: The use of a common language of errors among centers is key in establishing benchmarking standards. Comparing the quality of care of an American trauma center and a Spanish referral center, we have detected remarkably similar avoidable errors. More diagnostic and 'ruled-based' errors have been found in the Spanish center.

Preventable deaths and potentially preventable deaths. What are our errors?

BACKGROUND: A variety of systems have been applied to identify and address errors in the management of multiple trauma patients. This lack of standardisation represents a serious problem. OBJECTIVES: Detect preventable and potentially preventable deaths, and classify all the errors with universal language. METHODS: We studied all trauma patients over 16 admitted to the critical care unit or who died before. In multidisciplinary sessions we decided which deaths were preventable, potentially preventable and non preventable. Guided by ATLS protocols, we detected errors in their management that were classified using the taxonomy of Joint Commission. RESULTS: We registered 1236 trauma patients (ISS 20.77). Of the 115 trauma deaths, 19 were preventable or potentially preventable deaths. We recorded 130 errors in all deaths, 46 of them in preventable or potentially preventable deaths. Using our own classification, the main errors were delay in starting correct treatment or performance of CT in hemodynamically unstable patients. Using the taxonomy of Joint Commission, the main type error was clinical, during the intervention: the delay in initiating correct treatment. Mistakes were made in the emergency department by medical specialists. The incidence of therapeutic and diagnostic errors was similar. The main cause of error was human failure, specifically 'rule-based' errors CONCLUSIONS: Measuring and recording the results is the first step on the way to improving the quality of care for trauma patients. A common language like the taxonomy of Joint Commission will help standardise patient safety data, thus improving the recording of incidents and their analysis and treatment.

Origen de la hemorragia en pacientes politraumatizados con fractura de pelvis e inestabilidad hemodinámica / Source of bleeding in trauma patients with pelvic fracture and haemodynamic instability

INTRODUCCIÓN: La principal causa de mortalidad en los politraumatizados con fracturas pélvicas es el shock hipovolémico. Analizamos la asociación entre el origen de la hemorragia, mecanismo de acción y tipo de fractura. MÉTODOS: Estudio descriptivo y prospectivo que incluye a pacientes politraumatizados mayores de 16 años, ingresados en el área de críticos o que han fallecido antes de su ingreso, con fractura pélvica e inestabilidad hemodinámica. Se define inestabilidad hemodinámica como PAS < 90 o FC > 100 latidos/min. La fractura pélvica se define según la clasificación de Tile. RESULTADOS: Un total de 157 de 1.088 politraumatizados tenían fractura pélvica. Se ha incluido a 63 pacientes, todos hemodinámicamente inestables. En el 85% de los pacientes precipitados la hemorragia procedía de la propia fractura pélvica, comparado con solo el 44% de las víctimas que sufrieron un (choque). El 65% de los pacientes con fractura de pelvis estable sangraban de lesiones asociadas; el 70% de los pacientes con fractura inestable sangraban de la propia fractura. Existe una interacción entre el mecanismo de acción y el tipo de fractura. La probabilidad de sangrar de la pelvis es mayor en los precipitados (>80%), independientemente del tipo de fractura. La hemorragia de las lesiones asociadas es mayor en un impacto, duplicándose cuando la fractura es estable (91%). CONCLUSIONES: El mecanismo de acción es un factor clave para determinar el origen de la hemorragia en pacientes con fractura de pelvis. Los pacientes precipitados sangran de la propia fractura, mientras que los pacientes con un impacto (choque) pueden sangrar tanto de la propia fractura como de las lesiones asociadas, dependiendo del tipo de fractura

INTRODUCTION: The main cause of mortality in trauma patients with pelvic fractures is hypovolemic shock. We analyzed the association between the source of bleeding, mechanism of action and type of fracture. METHODS: Prospective descriptive study involving trauma patients older than 16 years old, admitted to the intensive care unit or dead before admission, with pelvic fractures and hemodynamic instability. Hemodynamic instability was defined as SBP <90 and/or HR> 100 beats/min. Pelvic fracture was defined by the Tile classification. RESULTS: A total of 157 of 1088 trauma patients had pelvic fracture. We included 63 patients, all hemodynamically unstable. A total of 85% of pelvic fractures after falls from great heights bled from the fracture itself, compared to only 44% of victims of impact (hit). A total of 65% of patients with stable pelvic fracture bled from associated lesions; 70% of patients with unstable fracture bled from the fracture itself. There is an interaction between the mechanism of action and type of fracture. The probability of pelvic bleeding is higher in the precipitated patient (> 80%) regardless of the type of fracture. Bleeding from associated injuries is greater in impact victims, doubling when the fracture is stable (91%). CONCLUSIONS: Mechanism of action is a key to determine the source of bleeding in patients with pelvic fracture. After falls patients bleed from the fracture itself, while patients with an impact (hit) can bleed both from the fracture and associated injuries, depending on the type of fracture

Source of bleeding in trauma patients with pelvic fracture and haemodynamic instability.

INTRODUCTION: The main cause of mortality in trauma patients with pelvic fractures is hypovolemic shock. We analyzed the association between the source of bleeding, mechanism of action and type of fracture. METHODS: Prospective descriptive study involving trauma patients older than 16 years old, admitted to the intensive care unit or dead before admission, with pelvic fractures and hemodynamic instability. Hemodynamic instability was defined as SBP <90 and/or HR> 100 beats/min. Pelvic fracture was defined by the Tile classification. RESULTS: A total of 157 of 1088 trauma patients had pelvic fracture. We included 63 patients, all hemodynamically unstable. A total of 85% of pelvic fractures after falls from great heights bled from the fracture itself, compared to only 44% of victims of impact (hit). A total of 65% of patients with stable pelvic fracture bled from associated lesions; 70% of patients with unstable fracture bled from the fracture itself. There is an interaction between the mechanism of action and type of fracture. The probability of pelvic bleeding is higher in the precipitated patient (> 80%) regardless of the type of fracture. Bleeding from associated injuries is greater in impact victims, doubling when the fracture is stable (91%). CONCLUSIONS: Mechanism of action is a key to determine the source of bleeding in patients with pelvic fracture. After falls patients bleed from the fracture itself, while patients with an impact (hit) can bleed both from the fracture and associated injuries, depending on the type of fracture.

[Study on the improvement of trauma patient care: TRAUMACAT project]. / Estudio para la mejoría de la atención hospitalaria inicial del paciente politraumatizado: proyecto TRAUMACAT.

UNLABELLED: Multiple injuries are a major source of morbidity and mortality in young people. The aim of this study was to evaluate the effect of a collaborative strategy to improve the implementation of six clinical indicators, recognized internationally, for the treatment of trauma patient. Prospective, multicentre, pre-and post-intervention study, in ten referral hospitals, offering polytrauma care in Catalonia. 378 patients were recruited for the pre-intervention study and 501 for the post-intervention study. All patients had a history of high-energy trauma requiring admission to critical or semi-critical care unit. INTERVENTION: collaborative strategy aimed at participating professionals, involving the creation of a panel of experts, appointment of monitors to encourage improvements at each centre, training, distribution of information, material and meetings, to exchange impressions. MAIN OUTCOME MEASURES: frequency and characteristics of trauma and percentage of compliance with clinical indicators. Study of 879 trauma patients. The injury mechanism was overall blunt trauma, in both pre and post intervention phases. The medium ISS (injury severity score) was 21 ± 12,8 and the medium TRISS (trauma and injury severity score) was 26,4 ± 11,4. We didn't find differences between both study phases, in relation to the severity of injury. The mortality rate was 11.5%. We observed significant improvement in the performance of chest X-rays (45% vs. 62%) and pelvis X-rays (27% vs. 62%) in the trauma box and in the fixation of the pelvis in patients with a fracture at this site (24% vs. 49%). The use of diagnostic radiology in hemodynamically unstable patients remained low (33%). The collaborative strategy was effective in improving certain indicators of clinical management.