Closed loop communication in the trauma bay: identifying opportunities for team performance improvement through a video review analysis

Peri-operative strategy in resuscitation of unstable injured surgical patients: a primer

BACKGROUND

Trauma remains a leading cause of death, both for individuals under 40 in North America, and globally, where it contributes to ~10% of deaths annually. Thoughtful, timely, balanced resuscitation, especially in the peri-operative period for unstable injured surgical patients, is vital for optimizing outcomes. The advanced trauma life support protocol plays a pivotal role in early evaluation and management, emphasizing hemorrhage control and resuscitation strategies.

OBJECTIVE

This narrative review provides a structured, evidence-based framework aimed at enhancing the educational experience of surgical trainees. It outlines key principles in peri-operative trauma resuscitation, emphasizing timely intervention, goal-directed fluid therapy, and damage control surgery (DCS) to improve patient outcomes.

METHODS

A comprehensive Scale for Quality Assessment of Narrative Review Articles -guideline compliant literature search was conducted using PubMed and Google Scholar for English-language articles published between January 2000 and February 2024. The search included relevant medical subject headings terms. Additional studies were identified from reference lists. Extracted data were reviewed and organized using thematic analysis, focusing on historical perspectives, evidence-based practices, and the concept of DCS.

RESULTS

Key findings from the 55 relevant studies selected underscore the importance of balanced fluid and blood product administration, the use of permissive hypotension in hemorrhagic shock, and the application of DCS principles. This review highlights educational strategies that foster a deeper understanding of trauma resuscitation practices, offering practical insights through case studies and technological innovations.

CONCLUSION

This review serves as an educational resource for surgical trainees, equipping them with a robust understanding of evidence-based trauma resuscitation. By integrating historical context, modern practices, and emerging technologies, the review aims to enhance both the theoretical knowledge and practical skills necessary for managing unstable trauma patients. Emphasis is placed on interdisciplinary teamwork, continuous education, and personalized resuscitation strategies to improve clinical outcomes.

Changes in multidisciplinary perceptions of trauma video review following implementation of a novel program: let us go to the tape

ABSTRACT

Background

Trauma video review (TVR) is an evolving technology that can be used to measure technical and non-technical aspects of trauma care leading to meaningful improvements. Only 30% of centers currently use TVR, with non-users citing medicolegal concerns, staff discomfort with recording, and resource constraints as barriers to implementation. Multiple studies have shown established TVR programs are well-perceived by staff. Little is known about perceptions prior to, and after implementation of a new program.

Objective

This study evaluated changes in TVR perceptions following implementation of a new program.

Methods

A 15-question survey was distributed to emergency department and trauma surgery providers at a level I trauma center prior to, and 1 year after, implementation of TVR. A 5-point Likert scale was used to evaluate perceptions of the value of TVR, measures of team dynamics, and staff discomfort with recording.

Results

A total of 106 pre-implementation and 82 post-implementation responses were recorded. Perceptions in several domains improved post-implementation including team leader effectiveness (3 (3-4) to 4 (3-4); p=0.002), communication (3 (3-4) to 4 (3-4); p<0.001), and self confidence in role (4 (3-4) to 4 (4-5); p=0.001). Staff discomfort with recording decreased post-implementation (3 (2-4) to 2 (2-3); p=0.002).

Conclusion

Our study shows that perceptions of TVR changed favorably after implementation, particularly perceptions of team dynamics and provider discomfort with recording. These results can be used to mitigate staff concerns about TVR and encourage the development of new programs.

Level of evidence

IV.

Less is more: Overlapping communication in trauma resuscitation

BACKGROUND

Timely management of trauma patients is crucial. Better team performance means faster care, but roles of specific communication practices remain unclear. We hypothesized that overlapping communication is associated with less efficient resuscitations.

METHODS

This single-center prospective observational study included hypotensive trauma patients from June-September 2023. Data were collected using Trauma Video Review. The association between overlapping communication and resuscitation length was assessed using multivariable linear regression adjusting for demographics, injury mechanism, Injury Severity Score (ISS), vitals, and number of procedures performed.

RESULTS

We included 87 patients with median ISS 26.0 [interquartile range IQR: 14.0-34.0] and median systolic blood pressure 84.0 [70.0-90.5]. Median resuscitation length was 19.1 [15.4-23.1] minutes. Overlapping communication occurred for median 1.22 [0.7-2.1] minutes. Overlapping communication was associated with longer resuscitations (p ​< ​0.0001).

CONCLUSIONS

Overlapping communication was associated with less efficient resuscitations in hypotensive trauma patients. Training for trauma teams should target "one voice at a time".

The use of specific coordination behaviours to manage information processing and task distribution in real and simulated trauma teamwork: an observational study

Trauma teams handle severely injured patients under high temporal demands and need to coordinate and achieve collaborative decision-making and task execution through communication. Specific coordination and communication behaviours are taught in simulation training to enhance team performance. An examination of the role and nature of communication could increase the understanding of educational possibilities and assess the validity of in situ simulation on behalf of communication. Our study aim was to describe the relative use of communication within information and task management, the use of coordinating behaviours, and the use of talking to the room and closed-loop communication in in-real-life trauma assessment and in the simulated domain. We video-recorded all verbal communicative events in four real-world trauma teams and four teams during simulation training. The analysis showed that although the teamwork was task-oriented, information management dominated task management at 64% of all the utterances in-real-life and 68% during simulation. In-real-life, information management was dominated by the codes "request information" (24%) and "confirmation" (21%), whereas "task distribution" (43%) was most frequently used for task management. The only difference between domains was that "give information after request" represented a smaller proportion of the utterances in-real-life compared to simulation (p ≤ 0.001). Talking to the room was primarily used by the teams in both domains to provide information without request and to delegate tasks. Closed-loop communication was used at a low frequency, 3.6% in-real-life, but was significantly higher, 7.7%, in simulation training. We suspect that this outcome reflects the Hawthorne effect. In the simulations, greater information delivery was provided in response to questions, probably accounting for instructor information. Our results may be valuable for research on trauma team behaviour in a simulated environment to draw conclusions about similar activities in-real-life.

Enhancing patient safety in trauma: Understanding adverse events, assessment tools, and the role of trauma video review

OBJECTIVES

This study aimed to investigate adverse events (AEs) in trauma resuscitation, evaluate contributing factors, and assess methods, such as trauma video review (TVR), to mitigate AEs.

BACKGROUND

Trauma remains a leading cause of global mortality and morbidity, necessitating effective trauma care. Despite progress, AEs during trauma resuscitation persist, impacting patient outcomes and the healthcare system. Identifying and analyzing AEs and their determinants are crucial for improving trauma care.

METHODS

This narrative review explored the definition, identification, and assessment of AEs associated with trauma resuscitation within the trauma system. It includes various studies and assessment tools such as STAT Taxonomy and T-NOTECHs. Additionally, it assessed the role of TVR in detecting AEs and strategies to enhance patient safety.

CONCLUSION

Integrated with standardized tools, TVR shows promise for identifying AEs. Challenges include ensuring reporting consistency and integrating approaches into existing protocols. Future research should prioritize linking trauma team performance to patient outcomes, and develop sustainable TVR programs to enhance patient safety.

Reliability of the safety threats and adverse events in trauma (STAT) taxonomy using trauma video review

PURPOSE

The STAT (Safety Threats and Adverse Events in Trauma) taxonomy was developed through expert consensus, and groups 65 identified trauma resuscitation adverse events (AEs) into nine distinct categories. It provides a framework for standardized analysis of trauma resuscitations and creates a foundation for targeted quality improvement and patient safety initiatives. This study aims to evaluate the reliability of the STAT taxonomy in identifying AEs during video-recorded trauma resuscitations.

METHODS

High-definition audiovisual data from 30 trauma resuscitations were reviewed. Videos were assessed and scored by four independent reviewers (two trainees and two staff). The STAT taxonomy was used to identify AEs based on binary responses: yes and no. Inter-rater reliability was calculated using Gwet's AC1. The frequencies of AEs were tallied and reported as counts and percentages.

RESULTS

The most common AEs identified in the videos were failure to measure temperature (86.7%) and inadequate personal protective equipment (86.7%), followed by inability to use closed-loop communication (76.7%). The agreement on all AEs between reviewers was 0.94 (95% CI: 0.93-0.95). The Gwet's AC1 agreement across the 9 AE categories was paramedic handover (0.82), airway and breathing (0.99), circulation (0.95), assessment of injuries (0.91), management of injuries (0.96), procedure-related (0.97), patient monitoring and IV access (0.99), disposition (0.98), team communication and dynamics (0.87).

CONCLUSION

The STAT taxonomy demonstrated excellent inter-rater reliability between reviewers and can be used to identify AEs in video-recorded trauma resuscitations. These results provide a foundation for adapting video review to objectively quantify and assess AEs in the trauma bay.

Speech Communication Interference in the Operating Room

INTRODUCTION

Operating room communication is frequently disrupted, raising safety concerns. We used a Speech Interference Instrument to measure the frequency, impact, and causes of speech communication interference (SCI) events.

METHODS

In this prospective study, we observed 40 surgeries, primarily general surgery, to measure the frequency of SCI, defined as "group discourse disrupted according to the participants, the goals, or the physical and situational context of the exchange." We performed supplemental observations, focused on conducting postsurgery interviews with SCI event participants to identify contextual factors. We thematically analyzed notes and interviews.

RESULTS

The observed 103 SCI events in 40 surgeries (mean 2.58) mostly involved the attending (50.5%), circulating nurse (44.6%), resident (44.6%), or scrub tech (42.7%). The majority (82.1%) of SCI events occurred during another patient-related task. 17.5% occurred at a critical moment. 27.2% of SCI events were not acknowledged or repeated and the message was lost. Including the supplemental observations, 97.0% of SCI events caused a delay (mean 5 s). Inter-rater reliability, calculated by Gwet's AC1 was 0.87-0.98. Postsurgery interviews confirmed miscommunication and distractions. Attention was most commonly diverted by loud noises (e.g., suction), conversations, or multitasking (e.g., using the electronic health record). Successful strategies included repetition or deferment of the request until competing tasks were complete.

CONCLUSIONS

Communication interference may have patient safety implications that arise from conflicts with other case-related tasks, machine noises, and other conversations. Reorganization of workflow, tasks, and communication behaviors could reduce miscommunication and improve surgical safety and efficiency.

Getting out of the bay faster: Assessing trauma team performance using trauma video review

BACKGROUND

Minutes matter for trauma patients in hemorrhagic shock. How trauma team function impacts time to the next phase of care has not been rigorously evaluated. We hypothesized better team performance scores to be associated with decreased time to the next phase of trauma care.

METHODS

This retrospective secondary analysis of a prospective multicenter observational study included hypotensive trauma patients at 19 centers. Using trauma video review, we analyzed team performance with the validated Non-Technical Skills for Trauma scale: leadership, cooperation and resource management, communication, assessment/decision making, and situational awareness. The primary outcome was minutes from patient arrival to next phase of care; deaths in the bay were excluded. Secondary outcomes included time to initiation and completion of first unit of blood and inpatient mortality. Associations between team dynamics and outcomes were assessed with a linear mixed-effects model adjusting for Injury Severity Score, mechanism, initial blood pressure and heart rate, number of team members, and trauma team lead training level and sex.

RESULTS

A total of 441 patients were included. The median Injury Severity Score was 22 (interquartile range, 10-34), and most (61%) sustained blunt trauma. The median time to next phase of care was 23.5 minutes (interquartile range, 17-35 minutes). Better leadership, communication, assessment/decision making, and situational awareness scores were associated with faster times to next phase of care (all p < 0.05). Each 1-point worsening in the Non-Technical Skills for Trauma scale score (scale, 5-15) was associated with 1.6 minutes more in the bay. The median resuscitation team size was 12 (interquartile range, 10-15), and larger teams were slower ( p < 0.05). Better situational awareness was associated with faster completion of first unit of blood by 4 to 5 minutes ( p < 0.05).

CONCLUSION

Better team performance is associated with faster transitions to next phase of care in hypotensive trauma patients, and larger teams are slower. Trauma team training should focus on optimizing team performance to facilitate faster hemorrhage control.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Evaluation of video review tools for assessing non-technical skills in emergency department resuscitation teams: a systematic review

BACKGROUND AND IMPORTANCE

Use of video review in medicine is established in contexts such as surgery. Although not widely used in the emergency department (ED), some centres use it to evaluate non-technical skills (NTS) to support teaching and quality improvement.

OBJECTIVE

There is no consensus on assessment of NTS using video review in the ED and the purpose of this review was to identify tools used in this context.

DESIGN, SETTING AND PARTICIPANTS

Studies were identified using Embase, Medline, CINAHL and Google Scholar. Inclusion criterion for the review was NTS of resuscitation teams working within the ED were assessed using video review. A systematic search method was used, and results were synthesised after search criteria was checked by two independent reviewers. Authors settled on the same 9 studies eligible for inclusion.

OUTCOME MEASURES AND ANALYSIS

Reliability and validity of tools identified for use in this context. Due to the heterogeneity of studies, no meta-analysis occurred.

MAIN RESULTS

There are 9 studies included in the review. The review was registered with PROSPERO (Ref No: CRD42022306129). Four unique tools were identified - 6 studies used T-NOTECHS, 1 used TTCA-24, 1 used CALM and 1 used the Communication tool. T-NOTECHS is validated in the literature for use in this context.

CONCLUSION

T-NOTECHS is the tool of choice for assessing ED teams in this context.