Usability of telepresence in a level 1 trauma center.

OBJECTIVES: Limited resources and the diminishing physician workforce in trauma require unique and innovative solutions. Our hypothesis is that telepresence by a remote physician is an appropriate application in an urban trauma setting. The purpose of this study is to assess user satisfaction and usability of a mobile telemedicine robot in trauma care. MATERIALS AND METHODS: A usability study of trauma patient assessments utilizing the Remote Presence-7 (RP-7) robot (InTouch Health, Santa Barbara, CA) with real-time, two-way communication between remote and local physicians was conducted at a Level 1 trauma center. Usability and acceptability was measured using survey questionnaires, open-ended feedback, and general observations. Comparisons were made between remote and local physician responses. RESULTS: One hundred fourteen patient encounters utilizing telepresence were performed. Remote and local physicians expressed a high level of satisfaction with the mobility (92% and 79%, respectively), communication (97% and 90%, respectively), and visual abilities (91% and 97%, respectively) of the RP-7 robot for remote consultation purposes. On average, 89% of remote and local physician participants rated their overall telemedicine experience as "excellent" or "above average." CONCLUSIONS: This study suggests that telepresence of a remote trauma surgeon may be a useful and functional adjunct in the trauma setting. Further development of these technologies could mitigate current and future concerns about gaps in rural and urban trauma care and critical care staffing shortages and during mass casualty or disaster scenarios.

Assessing the impact of teaching patient safety principles to medical students during surgical clerkships.

BACKGROUND: A critical aspect of enhancing patient safety is modifying the healthcare safety culture. We hypothesize that students who participate in safety curricula are knowledgeable regarding patient safety and likely to intervene to avoid patient errors. METHODS: A two-part patient safety curriculum was taught: introductory theories (first year) and a clinically oriented course during surgery rotations (third year). All students participated in the first year introduction and a random cohort of students (62.6%, N = 67) participated in the third year program. Multiple choice tests and web-based surveys were administered. Statistical analysis was carried out using Student's t-test for comparisons of test mean scores and z-test for comparison of the survey data. RESULTS: Students who participated in both years' curricula scored higher on didactic test than those who participated in only the first year course (82.9% versus 75.5%, P < 0.001). More students participating in both portions of the curricula intervened during at least one clinical encounter to avoid a patient error (77% versus 61%, P < 0.05). Students rated junior house-staff more receptive to patient safety suggestions than surgical fellows and faculty (84% versus 66%, P < 0.05); 75% of students rated their surgical clerkship exposure to patient safety somewhat/extremely valuable compared with 54% students who rated the first year exposure as somewhat/extremely valuable (P < 0.05). CONCLUSION: Medical students who have practical applications of patient safety education reinforced during surgery rotations are knowledgeable and willing to intervene in patient safety concerns. Teaching clinically relevant patient safety skills influences positive behavioral changes in medical students' performance on surgical teams.

Enhancing patient safety in the trauma/surgical intensive care unit.

BACKGROUND: Preventable deaths due to errors in trauma patients with otherwise survivable injuries account for up to 10% of fatalities in Level I trauma centers, 50% of these errors occur in the intensive care unit (ICU). The root cause of 67% of the Joint Commission sentinel events is communication errors. The objective is (1) to study how critical information degrades and how it is lost over 24 hours and (2) to determine whether a structured checklist for ICU handoffs prevents information loss. METHODS: Prospective cohort study of trauma and surgical ICU teams observed with and without use of the checklist. An observational period (control group) was followed by a didactic session on the science and use of a checklist (study group), which was used for patient management and handoffs. Information was tracked for a 24-hour period and all handoffs. Comparisons use chi or Fisher's exact test and a p value <0.05 was defined as significant. RESULTS: Three hundred and thirty-two patient ICU days were observed (119 control, 213 study) and 689 patient care items (303 control, 386 study) were followed. Seventy-five (10.9%) items were lost over 24 hours; 61 of 303 (20.1%) without checklist and 14 of 386 (3.6%) with checklist (p < 0.0001). Critical laboratory values and test results were the most frequent lost items (36.1% control vs. 4.5% study p < 0.0001). Six of 75 (8.1%) items were correctly ordered but not carried out by ICU nursing staff--all caught and corrected with checklist use. CONCLUSION: Critical information is degraded over 24 hours in the ICU. A structured checklist significantly reduces patient errors due to lost information and communication lapses between trauma ICU team members at handoffs of care.

Electronic medical records and mortality in trauma patients.

BACKGROUND: The Electronic Medical Record (EMR) has been proposed as a way to reduce medical errors. It can also be used to document clinician involvement, which may affect outcomes. We sought to determine whether the EMR could be used to improve attending involvement in daily care, enhance surgical revenue, and lower mortality of patients with trauma. METHODS: In 2004, the Trauma Division adopted a software program (CARE, Miami, FL) for creating an EMR and implemented a weekly report that was distributed to all members of the division and also to Departmental decision makers. Before initiation, explicit instructions were given to all surgeons that daily notes in the EMR were expected and would be followed by weekly reports. Before this, most notes were recorded in the paper chart and were difficult to track. Differences among proportions were determined with z test or chi, where appropriate with significance defined as p < 0.05. RESULTS: With implementation of the EMR, daily and weekly reports were immediately available. Both attending surgeon documented notes and divisional annual revenue increased. A reduction in mortality was also observed. CONCLUSION: The EMR can be used to change attending surgeon involvement in patient care and procedures. The increase in attending involvement was associated with an increase in revenue. Use of the EMR was associated with a significant reduction in hospital mortality.

Performance of advanced air bags based on data William Lehman Injury Research Center and new NASS PSUs.

The Ryder Trauma Center is a Level I trauma center that treats only the most severely injured occupants of vehicle crashes as well as other severe cases of trauma. The center investigates these crashes through funding provided by the Alliance of Automobile Manufacturers and the U.S. Department of Transportation-sponsored Crash Injury Research and Engineering Network (CIREN) program. MAIS 3+ nonfatal and fatal injuries comprise approximately 2 percent of the total NASS/CDS cases. Among the Ryder trauma center cases, 50 percent are MAIS 3+ and 25 percent are fatal. If the MAIS 3+ fatal and nonfatal injuries were considered as "failures" and the remaining 98 percent with MAIS 2 or less as successes, this could be equated to the 75 percent failure rate (MAIS 3+ and fatal) in the trauma center cases for analysis purposes. The total database of frontal cases with no rollover consists of 147 drivers with first-generation airbags and 58 cases with second-generation airbags.

Characteristics of crashes that increase the risk of serious injuries.

The advent of Automatic Crash Notification Systems (ACN) offers the possibility of immediately locating crashes and of determining the crash characteristics by analyzing the data transmitted from the vehicle. A challenge to EMS decision makers is to identify those crashes with serious injuries and deploy the appropriate rescue and treatment capabilities. The objective of this paper is to determine the crash characteristics that increase the risk of serious injury. Within this paper, regression models are presented which relate occupant, vehicle and impact characteristics to the probability of serious injury using the Maximum Abbreviated Injury Scale Level (MAIS). The accuracy of proposed models were evaluated using National Automotive Sampling System/ Crashworthiness Data System (NASS/CDS) and Crash Injury Research and Engineering Network (CIREN) case data. Cumulatively, the positive prediction rate of models identifying the likelihood of MAIS3 and higher injuries was 74.2%. Crash mode has a significant influence of injury risk. For crashes with 30 mph deltaV, the risk of MAIS3+ injury for each mode is 38.9%, 83.8%, 47.8% and 19.9% for frontal, near side, far side and rear impact crashes, respectively. In addition to deltaV, a number of crash variables were identified that assist in the accurate prediction of the probability of MAIS 3+ injury. These variables include occupant age, partial ejection, safety belt usage, intrusion near the occupant, and crashes with a narrow object. For frontal crashes, added crash variables include air bag deployment, steering wheel deformation, and multiple impact crashes. The quantitative relationship between each of these crash variables and injury risk has been determined and validated by regression analysis based on NASS/CDS and CIREN data.

The blue ribbon panel on depowered and advanced airbags - status report on airbag performance.

In February 2000, a group of highway safety organizations sent a letter to the Secretary of the U.S. Department of Transportation expressing concern about a possible return to the 30-mph rigid barrier test using unbelted dummies previously required by Federal Motor Vehicle Safety Standard (FMVSS) 208. The letter asked the National Highway Traffic Safety Administration (NHTSA) to expedite data collection of the real-world crash experience of airbag-equipped vehicles certified to the 30-mph sled test using unbelted dummies because of suggestions that depowered airbags may not provide the same level of protection, particularly to larger, unbelted occupants. For the same reason, the letter also recommended that the auto industry commit funding for additional data collection and to establish a panel of experts to evaluate the data. In response, the Alliance of Automobile Manufacturers (Alliance) committed to funding a 3-year program to be managed by an independent third party. A panel of experts consisting of representatives from thehighway safety research community, the National Transportation Safety Board, academia, medical institutions, and the insurance industry was established as the Blue Ribbon Panel (BRP) for Evaluation of Depowered and Advanced Airbags and met for the first time in February 2001. The BRP also includes representatives from NHTSA and the automobile industry who participate as observers. The BRP held its first public meeting in April 2003 to provide an update of its activities and to summarize the real-world evidence on the performance of depowered airbags. This AAAM session will provide a brief summary of the public meeting.

Training forward surgical teams: do military-civilian collaborations work?

UNLABELLED: The US Army and the Ryder Trauma Center (Jackson Memorial Hospital, Miami, Florida) teamed up to provide a training environment (ie, the Army Trauma Training Center) in which forward surgical teams can attend to gain critical teamwork and trauma technical skills to prepare for deployment to Iraq or Afghanistan. The purpose of this study was to gather trainee reactions to the military-civilian collaboration provided at ATTC after deployment to Iraq or Afghanistan. METHODS: Survey respondents were 135 US Army personnel (an approximately 50% response rate) who participated in the ATTC 2-week team training program between January 2005 and June 2007. The survey asked questions pertaining to their experience in the resuscitation unit and patient contact at the trauma center. RESULTS: Over 90% of participants agreed or strongly agreed that training in the resuscitation area was beneficial. A majority of participants also agreed or strongly agreed that the patient contact experience was sufficient (78.5%), was a good learning opportunity (90%), and that the experience was a good opportunity to apply what they had learned in their classroom training (over 80%). Areas of suggested improvement included the importance of clarifying roles between the ATTC trainees and the Ryder Trauma Center residents and interns. Trainees would have preferred an extension of the training as a whole, as they felt it was rushed in order to fit all training opportunities into the 2 weeks that they were in Miami. Finally, trainees noted the lack of injuries admitted to the trauma center which replicate injuries caused by blasts (ie, improvised explosive devices). CONCLUSIONS: The results of our efforts indicate that military-civilian collaborations do in fact work and are beneficial to both military and civilian medical providers. The opportunity to perform as a team in their respective roles, to respond to a variety of actual trauma patients, and access to civilian medical providers were beneficial. As mentioned, such collaborations are not without limitations. The good news is that most of the identified limitations will be corrected to ensure trainees get the best possible experience possible.

Evaluation of the field relevance of several injury risk functions.

An evaluation of the four injury risk curves proposed in the NHTSA NCAP for estimating the risk of AIS>= 3 injuries to the head, neck, chest and AIS>=2 injury to the Knee-Thigh-Hip (KTH) complex has been conducted. The predicted injury risk to the four body regions based on driver dummy responses in over 300 frontal NCAP tests were compared against those to drivers involved in real-world crashes of similar severity as represented in the NASS. The results of the study show that the predicted injury risks to the head and chest were slightly below those in NASS, and the predicted risk for the knee-thigh-hip complex was substantially below that observed in the NASS. The predicted risk for the neck by the Nij curve was greater than the observed risk in NASS by an order of magnitude due to the Nij risk curve predicting a non-zero risk when Nij = 0. An alternative and published Nte risk curve produced a risk estimate consistent with the NASS estimate of neck injury. Similarly, an alternative and published chest injury risk curve produced a risk estimate that was within the bounds of the NASS estimates. No published risk curve for femur compressive load could be found that would give risk estimates consistent with the range of the NASS estimates. Additional work on developing a femur compressive load risk curve is recommended.

The anatomy of health care team training and the state of practice: a critical review.

PURPOSE: As the U.S. health care system enters a new era, the importance of team-based care approaches grows. How is the health care community ensuring that providers and administrators are equipped with the knowledge, skills, and attitudes (KSAs) foundational for effective teamwork? Are these KSAs transferring into daily practice? This review summarizes the present state of practice for health care team training described in published literature. Drawing from empirical investigations of training effectiveness, the authors explore training design, implementation, and evaluation to provide insight into the shape, structure, and anatomy of team training in health care. METHOD: A 2009 literature search yielded 40 peer-reviewed articles detailing health care team training evaluations. Guided by 11 focal questions, two trained raters extracted details regarding training design, implementation, evaluation metrics, and outcomes. RESULTS: Findings indicate that team training is being implemented across a wide spectrum of providers and is primarily targeting communication, situational awareness, leadership, and role clarity. Relatively few details indicate how training needs were established. Most studies collected data immediately posttraining; however, less than 30% collected data six months or more posttraining. Content analyses highlight the need for enhanced detail in published training evaluation reports. CONCLUSIONS: In many respects, health care team training implementation and evaluation align with best practices suggested from the science of training, adult learning, and human performance; however, opportunities for improvement exist. The authors suggest several mechanisms for furthering the health care team training evidence base to enhance patient safety and work environment quality for clinicians.

Trauma surgeon mortality rates correlate with surgeon time at institution.

BACKGROUND: Trauma centers have been created to bring traumatized patients together with experienced surgeons. We reviewed our outcomes to determine if mortality rates for high Injury Severity Scores (>or= 35) correlate with surgeon experience at our trauma center. STUDY DESIGN: Using our prospectively collected database, we compared our results with mean mortality for high-volume American College of Surgeon-certified trauma centers reporting to the National Trauma Data Bank. Mortality rates for our 11 trauma surgeons were correlated with years of experience as faculty surgeons at our institution during a 2-year period. Statistical analysis was done with chi-square or weighted linear regression; significance was defined as p < 0.05. RESULTS: Our trauma center mortality rates were significantly below the mean rates of National Trauma Data Bank at all levels of injury (chi-square, p < 0.05). Despite this success, there was a significant correlation between years of experience as a surgeon at our institution and improved outcomes for patients with an Injury Severity Score >or= 35 (weighted linear regression, p < 0.05). It took, on average, 7.9 years of experience at our trauma center to reach benchmark mortality rates. CONCLUSIONS: Mortality rates for severely injured patients correlate significantly with surgeon experience at our institution. The training process does not end with fellowship or surgical residency, and surgeons new to an institution should be closely monitored and mentored to minimize mortality rates of severely injured patients. Even at a very high volume trauma center with overall results substantially better than mean expected survival, we can demonstrate that experience makes a difference.

Measuring team performance in simulation-based training: adopting best practices for healthcare.

Team performance measurement is a critical and frequently overlooked component of an effective simulation-based training system designed to build teamwork competencies. Quality team performance measurement is essential for systematically diagnosing team performance and subsequently making decisions concerning feedback and remediation. However, the complexities of team performance pose a challenge to effectively measuring team performance. This article synthesizes the scientific literature on this topic and provides a set of best practices for designing and implementing team performance measurement systems in simulation-based training.

Incidence and crash mechanisms of aortic injury during the past decade.

BACKGROUND: Aortic injuries were traditionally thought to be the result of severe frontal crashes. Newer data has suggested other crash types such as nearside crashes may also be important in aortic injury. We hypothesized the implementation of recent safety measures would decrease the incidence of aortic injury associated with fatal motor vehicle crashes. METHODS: The autopsy reports of all traffic fatalities for motor vehicle occupants in a large urban county for the years 1993 to 2004 were examined. The demographics, impact types, safety measures used, and the presence of any aortic injury were recorded. Trends were evaluated for significance by weighted linear regression. RESULTS: The incidence of aortic injury associated with fatal motor vehicle crashes has remained unchanged during the past 12 years (r = 0.057, p = 0.45). There is a trend toward decreased aortic injuries associated with frontal crashes (r = 0.26, p = 0.089) but no change in aortic injuries associated with nearside or farside crashes (r = 0.053, p = 0.47), when the crash resulted in a fatality. This is despite an increase in seat belt use and increased presence of airbags during the same time period. CONCLUSIONS: Despite improved safety measures designed to minimize the occurrence of aortic injuries, the incidence of blunt aortic injury in fatal motor vehicle crashes has not decreased during the past decade. Although not statistically significant, there is a trend toward decreased frontal impacts in fatal motor vehicle crashes associated with aortic injuries. The nearside crash mechanism continues to play a prominent role, and efforts at improving vehicle safety should be focused on crash mechanisms as they relate to aortic injury.

100 multivisceral transplants at a single center.

OBJECTIVE: The objective of this study was to summarize the evolution of multivisceral transplantation over a decade of experience and evaluate its current status. SUMMARY BACKGROUND DATA: Multivisceral transplantation can be valuable for the treatment of patients with massive abdominal catastrophes. Its major limitations have been technical and rejection of the intestinal graft. METHODS: This study consisted of an outcome analysis of 98 consecutive patients who received multivisceral transplantation at our institution. This represents the largest single center experience to date. RESULTS: The most common diseases in our population before transplant were intestinal gastroschisis and intestinal dysmotility syndromes in children, and mesenteric thrombosis and trauma in adults. Kaplan Meier estimated patient and graft survivals for all cases were 65% and 63% at 1 year, 49% and 47% at 3 years, and 49% and 47% at 5 years. Factors that adversely influenced patient survival included transplant before 1998 (P = 0.01), being hospitalized at the time of transplant (P = 0.05), and being a child who received Campath-1H induction (P = 0.03). Among 37 patients who had none of these 3 factors (15 adults and 22 children), estimated 1- and 3-year survivals were 89% and 71%, respectively. Patients transplanted since 2001 had significantly less moderate and severe rejections (31.6% vs 67.6%, P = 0.0005) with almost half of these patients never developing rejection. CONCLUSIONS: Multivisceral transplantation is now an effective treatment of patients with complex abdominal pathology. The incidences of serious acute rejection and patient survival have improved in the most recent experience. Our results show that the multivisceral graft seems to facilitate engraftment of transplanted organs and raises the possibility that there is a degree of immunologic protection afforded by this procedure.