The effect of an on-site trauma surgeon during resuscitations of severely injured patients.

BACKGROUND: Although the timely involvement of trauma surgeons is widely accepted as standard care in a trauma center, there is an ongoing debate regarding the value of an on-site attending trauma surgeon compared to an on-call trauma surgeon. The aim of this study was to evaluate the effect of introducing an on-site trauma surgeons and the effect of their presence on the adherence to Advanced Trauma Life Support (ATLS) related tasks and resuscitation pace in the trauma bay. METHODS: The resuscitations of severely injured (ISS > 15) trauma patients 1 month before and 1 month after the introduction of an on-site trauma surgeon were assessed using video analysis. The primary outcome was total resuscitation time. Second, time from trauma bay admission until tasks were performed, and ATLS adherence were assessed. RESULTS: Fifty-eight videos of resuscitations have been analyzed. After the introduction of an on-site trauma surgeon, the mean total resuscitation time was 259 seconds shorter (p = 0.03) and seven ATLS related tasks (breathing assessment, first and second IV access, EKG monitoring and abdominal, pelvic, and long bone examination; were performed significantly earlier during trauma resuscitation (p ≤ 0.05). Further, we found a significant enhancement to the adherence of six ATLS related tasks (Airway assessment, application of a rigid collar, IV access; EKG monitoring, log roll, and pronouncing results of arterial blood gas analysis; p-value ≤0.05). CONCLUSION: Having a trauma surgeon on-site during trauma resuscitations of severely injured patients resulted in improved processes in the trauma bay. This demonstrates the need of direct involvement of trauma surgeons in institutions treating severely injured patients.

Variation of in-hospital trauma team staffing: new resuscitation, new team.

BACKGROUND: Non-technical errors, such as insufficient communication or leadership, are a major cause of medical failures during trauma resuscitation. Research on staffing variation among trauma teams on teamwork is still in their infancy. In this study, the extent of variation in trauma team staffing was assessed. Our hypothesis was that there would be a high variation in trauma team staffing. METHODS: Trauma team composition of consecutive resuscitations of injured patients were evaluated using videos. All trauma team members that where part of a trauma team during a trauma resuscitation were identified and classified during a one-week period. Other outcomes were number of unique team members, number of new team members following the previous resuscitation and new team members following the previous resuscitation in the same shift (Day, Evening, Night). RESULTS: All thirty-two analyzed resuscitations had a unique trauma team composition and 101 unique members were involved. A mean of 5.71 (SD 2.57) new members in teams of consecutive trauma resuscitations was found, which was two-third of the trauma team. Mean team members present during trauma resuscitation was 8.38 (SD 1.43). Most variation in staffing was among nurses (32 unique members), radiology technicians (22 unique members) and anesthetists (19 unique members). The least variation was among trauma surgeons (3 unique members) and ER physicians (3 unique members). CONCLUSION: We found an extremely high variation in trauma team staffing during thirty-two consecutive resuscitations at our level one trauma center which is incorporated in an academic teaching hospital. Further research is required to explore and prevent potential negative effects of staffing variation in trauma teams on teamwork, processes and patient related outcomes.

Reliability of the assessment of non-technical skills by using video-recorded trauma resuscitations.

PURPOSE: Non-technical skills have gained attention, since enhancement of these skills is presumed to improve the process of trauma resuscitation. However, the reliability of assessing non-technical skills is underexposed, especially when using video analysis. Therefore, our primary aim was to assess the reliability of the Trauma Non-Technical Skills (T-NOTECHS) tool by video analysis. Secondarily, we investigated to what extent reliability increased when the T-NOTECHS was assessed by three assessors [average intra-class correlation (ICC)] instead of one (individual ICC). METHODS: As calculated by a pre-study power analysis, 18 videos were reviewed by three research assistants using the T-NOTECHS tool. Average and individual degree of agreement of the assessors was calculated using a two-way mixed model ICC. RESULTS: Average ICC was 'excellent' for the overall score and all five domains. Individual ICC was classified as 'excellent' for the overall score. Of the five domains, only one was classified as 'excellent', two as 'good' and two were even only 'fair'. CONCLUSIONS: Assessment of non-technical skills using the T-NOTECHS is reliable using video analysis and has an excellent reliability for the overall T-NOTECHS score. Assessment by three raters further improve the reliability, resulting in an excellent reliability for all individual domains.

Evaluation of validity and reliability of video analysis and live observations to assess trauma team performance.

INTRODUCTION: A trauma resuscitation is dynamic and complex process in which failures could lead to serious adverse events. In several trauma centers, evaluation of trauma resuscitation is part of a hospital's quality assessment program. While video analysis is commonly used, some hospitals use live observations, mainly due to ethical and medicolegal concerns. The aim of this study was to compare the validity and reliability of video analysis and live observations to evaluate trauma resuscitations. METHODS: In this prospective observational study, validity was assessed by comparing the observed adherence to 28 advanced trauma life support (ATLS) guideline related tasks by video analysis to life observations. Interobserver reliability was assessed by calculating the intra class coefficient of observed ATLS related tasks by live observations and video analysis. RESULTS: Eleven simulated and thirteen real-life resuscitations were assessed. Overall, the percentage of observed ATLS related tasks performed during simulated resuscitations was 10.4% (P < 0.001) higher when the same resuscitations were analysed using video compared to live observations. During real-life resuscitations, 8.7% (p < 0.001) more ATLS related tasks were observed using video review compared to live observations. In absolute terms, a mean of 2.9 (during simulated resuscitations) respectively 2.5 (during actual resuscitations) ATLS-related tasks per resuscitation were not identified using live observers, that were observed through video analysis. The interobserver variability for observed ATLS related tasks was significantly higher using video analysis compared to live observations for both simulated (video analysis: ICC 0.97; 95% CI 0.97-0.98 vs. live observation: ICC 0.69; 95% CI 0.57-0.78) and real-life witnessed resuscitations (video analyse 0.99; 95% CI 0.99-1.00 vs live observers 0.86; 95% CI 0.83-0.89). CONCLUSION: Video analysis of trauma resuscitations may be more valid and reliable compared to evaluation by live observers. These outcomes may guide the debate to justify video review instead of live observations.

Effects of the application of a checklist during trauma resuscitations on ATLS adherence, team performance, and patient-related outcomes: a systematic review.

PURPOSE: In this systematic literature review, the effects of the application of a checklist during in hospital resuscitation of trauma patients on adherence to the ATLS guidelines, trauma team performance, and patient-related outcomes were integrated. METHODS: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist. The search was performed in Pubmed, Embase, CINAHL, and Cochrane inception till January 2019. Randomized controlled- or controlled before-and-after study design were included. All other forms of observational study designs, reviews, case series or case reports, animal studies, and simulation studies were excluded. The Effective Public Health Practice Project Quality Assessment Tool was applied to assess the methodological quality of the included studies. RESULTS: Three of the 625 identified articles were included, which all used a before-and-after study design. Two studies showed that Advanced Trauma Life Support (ATLS)-related tasks are significantly more frequently performed when a checklist was applied during resuscitation. [14 of 30 tasks (p < 0.05), respectively, 18 of 19 tasks (p < 0.05)]. One study showed that time to task completion (- 9 s, 95% CI = - 13.8 to - 4.8 s) and workflow improved, which was analyzed as model fitness (0.90 vs 0.96; p < 0.001); conformance frequency (26.1% vs 77.6%; p < 0.001); and frequency of unique workflow traces (31.7% vs 19.1%; p = 0.005). One study showed that the incidence of pneumonia was higher in the group where a checklist was applied [adjusted odds ratio (aOR) 1.69, 95% Confidence Interval (CI 1.03-2.80)]. No difference was found for nine other assessed complications or missed injuries. Reduced mortality rates were found in the most severely injured patient group (Injury Severity score > 25, aOR 0.51, 95% CI 0.30-0.89). CONCLUSIONS: The application of a checklist may improve ATLS adherence and workflow during trauma resuscitation. Current literature is insufficient to truly define the effect of the application of a checklist during trauma resuscitation on patient-related outcomes, although one study showed promising results as an improved chance of survival for the most severely injured patients was found.

Severely injured patients benefit from in-house attending trauma surgeons.

INTRODUCTION: There is continuous drive to optimize healthcare for the most severely injured patients. Although still under debate, a possible measure is to provide 24/7 in-house (IH) coverage by trauma surgeons. The aim of this study was to compare process-related outcomes for severely injured patients before and after transition of attendance policy from an out-of-hospital (OH) on-call attending trauma surgeon to an in-house attending trauma surgeon. METHODS: Retrospective before-and-after study using prospectively gathered data in a Level 1 Trauma Center in the Netherlands. All trauma patients with an Injury Severity Score (ISS) >24 presenting to the emergency department for trauma before (2011-2012) and after (2014-2016) introduction of IH attendings were included. Primary outcome measures were the process-related outcomes Emergency Department length of stay (ED-LOS) and time to first intervention. RESULTS: After implementation of IH trauma surgeons, ED-LOS decreased (p = 0.009). Time from the ED to the intensive care unit (ICU) for patients directly transferred to the ICU was significantly shorter with more than doubling of the percentage of patients that reached the ICU within an hour. The percentage of patients undergoing emergency surgery within 30 min nearly doubled as well, with a larger amount of patients undergoing CT imaging before emergency surgery. CONCLUSIONS: Introduction of a 24/7 in-house attending trauma surgeon led to improved process-related outcomes for the most severely injured patients. There is clear benefit of continuous presence of physicians with sufficient experience in trauma care in hospitals treating large numbers of severely injured patients.