Can residents be effective trauma team leaders in a major trauma centre?

State of the art of trauma teams in Italy: A nationwide study

Trauma teams play a vital role in providing prompt and specialized care to trauma patients. This study aims to provide a comprehensive description of the presence and organization of trauma teams in Italy. A nationwide cross-sectional epidemiological study was conducted between July and October 2022, involving interviews with 137 designated trauma centers. Centers were stratified based on level: higher specialized trauma centers (CTS), intermediate level trauma centers (CTZ + N) and district general hospital with trauma capacity (CTZ). A standardized structured interview questionnaire was used to gather information on hospital characteristics, trauma team prevalence, activation pathways, structure, components, leadership, education, and governance. Descriptive statistics were used for analysis. Results showed that 53 % of the centers had a formally defined trauma team, with higher percentages in CTS (73 %) compared to CTZ + N (49 %) and CTZ (39 %). The trauma team activation pathway varied among centers, with pre-alerts predominantly received from emergency medical services. The study also highlighted the lack of formally defined massive transfusion protocols in many centers. The composition of trauma teams typically included airway and procedure doctors, nurses, and healthcare assistants. Trauma team leadership was predetermined in 59 % of the centers, with anesthesiologists/intensive care physicians often assuming this role. The study revealed gaps in trauma team education and governance, with a lack of specific training for trauma team leaders and low utilization of simulation-based training. These findings emphasize the need for improvements in trauma management education, governance, and the formalization of trauma teams. This study provides valuable insights that can guide discussions and interventions aimed at enhancing trauma care at both local and national levels in Italy.

[Indicators to measure the performance of emergency trauma care]

The objective of this paper was to identify the main indicators used to measure the performance in emergency trauma care. A literature review was carried out in the electronic databases: PubMEd, LILACS and Epistemónikos, including publications between January 2011 and December 31, 2021, in Spanish, English and Portuguese. A total of 962 publications were identified. When reviewing the full text, 48 articles were included. The indicators were classified in the dimensions of process and results. 100 different indicators were identified to analyze the performance of emergency trauma care. 71% were process indicators, including service time and triage. In the results dimension 29 indicators were identified; mortality was the indicator most analyzed as well as length of stay. Six indicators on the disability of injured people and 14 indicators related to satisfaction were identified, the most frequent being complaints. Various indicators have been used to assess the performance of emergency trauma care. In the results dimension, the indicators related to satisfaction and disability after injuries have been little explored. Decision-makers and those responsible for emergency care must promote performance evaluation exercises to learn about their current situation using appropriate and sensitive indicators with the available data.

Do patient outcomes differ when the trauma team leader is a surgeon or non-surgeon? A multicentre cohort study

PURPOSE

Trauma team leaders (TTLs) have traditionally been general surgeons; however, some trauma centres use a mixed model of care where both surgeons and non-surgeons (primarily emergency physicians) perform this role. The objective of this multicentre study was to provide a well-powered study to determine if TTL specialty is associated with mortality among major trauma patients.

METHODS

Data were collected from provincial trauma registries at six level 1 trauma centres across Canada over a 10-year period. We included adult trauma patients (age ≥ 18 yrs) who triggered the highest-level trauma activation. The primary outcome was the difference in risk-adjusted in-hospital mortality for trauma patients receiving initial care from a surgeon versus a non-surgeon TTL.

RESULTS

Overall, 12,961 major trauma patients were included in the analysis. Initial treatment was provided by a surgeon TTL in 57.8% (n = 7513) of cases, while 42.2% (n = 5448) of patients were treated by a non-surgeon TTL. Unadjusted mortality occurred in 11.6% of patients in the surgeon TTL group and 12.7% of patients in the non-surgeon TTL group (OR 0.87, 95% CI 0.78-0.98, p = 0.02). Risk-adjusted mortality was not significantly different between patients cared for by surgeon and non-surgeon TTLs (OR 0.92, 95% CI 0.80-1.06, p = 0.23). Furthermore, we did not observe differences in risk-adjusted mortality for any of the subgroups evaluated.

CONCLUSIONS

After risk adjustment, there was no difference in mortality between trauma patients treated by surgeon or non-surgeon TTLs. Our study supports emergency physicians performing the role of TTL at level 1 trauma centres.

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.

The pace of a trauma resuscitation: experience matters

Purpose

Resuscitation quality and pace depend on effective team coordination, which can be facilitated by adequate leadership. Our primary aim was to assess the influence of trauma team leader experience on resuscitation pace. Second, we investigated the influence of injury severity on resuscitation pace.

Methods

The trauma team leaders were identified (Staff trauma surgeon vs Fellow trauma surgeon) and classified from video analysis during a 1-week period. Resuscitations were assessed for time to the treatment plan, total resuscitation time, and procedure time. Furthermore, patient and resuscitation characteristics were assessed and compared: age, gender, Injury Severity Score, Glasgow Coma Scale < 9, and the number (and duration) of surgical procedures during initial resuscitation. Correlations between total resuscitation time, Injury Severity Score, and time to treatment plan were calculated.

Results

After adjustment for the time needed for procedures, the time to treatment plan and total resuscitation time was significantly shorter in resuscitations led by a Staff trauma surgeon compared to a Fellow trauma surgeon (median 648 s (IQR 472–813) vs 852 s (IQR 694–1256); p 0.01 resp. median 1280 s (IQR 979–1494) vs 1535 s (IQR 1247–1864), p 0.04). Surgical procedures were only performed during resuscitations led by Staff trauma surgeons (4 thorax drains, 1 endotracheal intubation, 1 closed fracture reduction). Moreover, a significant negative correlation (r:  – 0.698, p < 0.01) between Injury Severity Score and resuscitation time was found.

Conclusion

Experienced trauma team leaders may positively influence the pace of the resuscitation. Moreover, we found that the resuscitation pace increases when the patient is more severely injured.

Review article: Systematic literature review of leadership in emergency departments

Emergency medicine (EM) is a discipline with complex leadership demands. However, studies of EM physician leadership and ED leadership are in their infancy. As such, there is a lack of clarity about the forms, antecedents, enablers, barriers and consequences of EM physician leadership. A systematic review of the scientific literature was conducted to reveal the different conceptualisations of EM physician leadership, the activities involved in the practice of leadership, and the knowledge and skills of effective ED leaders. Seven databases were systematically searched for peer-reviewed empirical studies on the topic of EM physicians carrying out a manager or leadership role in an ED setting. Finally, 26 articles were included, and their findings were synthesised and analysed narratively. Two conceptualisations of EM physician leadership were found, reflecting clinical leadership and medical leadership, respectively. Clinical leadership is performed by all EM physicians, often informally, within their daily clinical practice, whereas medical leadership is performed by EM physicians who work at the management level within a hospital, in addition to or instead of their clinical practice. The focus of EM physician leadership and ED leadership research is team leadership, with much less attention given to wider organisation leadership. Consistent with the focus on team leadership, clinical knowledge and skill in orchestrating teams, especially trauma and resuscitation teams, emerged as the most important factors underpinning leadership effectiveness. Future research and training should make better use of existing leadership theory and research designs to illuminate the forms, dynamics, antecedents, moderators and consequences of EM physician leadership.

Auswirkung der Implementierung eines Schockraumkoordinators auf Prozessparameter der Polytraumaversorgung im Schockraum eines Maximalversorgers

Hintergrund

In der Altersgruppe bis 40 Jahre stellt das schwere Trauma die häufigste Todesursache in Deutschland dar. Entsprechend der S3-Leitlinie „Polytrauma/Schwerverletztenbehandlung“ ist seit 2011 die Anwesenheit eines Schockraumkoordinators in Erwägung zu ziehen, der durch optimierte Versorgungs- und Behandlungsabläufe das Überleben der Patienten verbessern kann. Ziel der vorliegenden Untersuchung war die Analyse unterschiedlicher Prozessparameter zur Schockraumversorgung polytraumatisierter Patienten vor und nach Implementierung eines Schockraumkoordinators für die Polytraumaversorgung.

Material und Methoden

Um einen ausreichenden zeitlichen Abstand zum Zeitpunkt der Neueinführungen (2011) einzuhalten, wurden die Jahre 2009 und 2012 zum Vergleich herangezogen: Alle eingescannten Schockraumprotokolle der Jahre 2009 (01.01.2009–31.12.2009) und 2012 (01.01.2012–31.12.2012) wurden gesichtet und ausgewertet.

Ergebnisse

Aus dem Jahr 2009 wurden 213 und aus dem Jahr 2012 wurden 420 Schockraumeinsätze in die Auswertung einbezogen. Die durchschnittliche Schockraumanzahl lag im Jahr 2009 bei 17,8/Monat und im Jahr 2012 bei 35/Monat. Die mittlere Anzahl der Schockraumeinsätze hat sich nahezu verdoppelt (p < 0,001). Die mittlere Schockraumdauer lag im Jahr 2012 im Durchschnitt 5,8 min unter der im Jahr 2009 (p = 0,56).

Schlussfolgerungen

Die Patientenversorgung war in Anwesenheit eines Schockraumkoordinators bzw. nach Implementierung der SOP weder statistisch signifikant noch klinisch relevant verkürzt.

Experienced trauma team leaders save the lives of multiple-trauma patients with severe head injuries

The trauma team leader is a professional who receives and treats trauma patients. We aimed to evaluate whether or not the seniority of a qualified trauma team leader was a prognostic factor for multiple-trauma patients managed by a trauma team. This was a retrospective cohort study conducted at a Level I Trauma Center in North Taiwan. From January 2009 to December 2013, 284 patients were randomly assigned to one of two trauma team leaders (junior and senior leaders) on duty, irrespective of the seniority of the qualified trauma team leader. All parameters were collected and compared between these two groups. In the subgroup of multiple-trauma patients with Glasgow Coma Scale (GCS) ≤ 8, there were significant differences in the injury severity score, revised trauma score, and seniority of the leader between the alive and dead groups. A multivariate logistic regression analysis showed that the seniority of the trauma team leader was an important mortality risk factor [odds ratio (OR): 14.529, 95% confidence interval (CI) 1.683-125.429, p = 0.015] in patients with GCS ≤ 8. However, in patients with GCS > 8, age was the only independent risk factor [OR: 1.055, 95% CI 1.023-1.087, p = 0.001]. The seniority of the qualified trauma leader is important for teamwork, organization, and efficiency, all of which play an important role in improving the survival outcome of patients with GCS ≤ 8.

Effect of an Emergency Medicine Resident as Team Leader on Outcomes of Trauma Team Activations

OBJECTIVES

Traditionally, a surgeon has served as trauma team leader (TTL). However, this role is increasingly being performed by emergency medicine (EM) physicians. At the Halifax Infirmary, we utilize a resident TTL (rTTL) under supervision of a staff traumatologist, a duty shared between EM and surgical residents. Our objective was to compare outcomes between cases led by EM and surgical rTTLs.

METHODS

This was a retrospective case-control study of data collected from the Nova Scotia Trauma Registry. Eligible cases were attended to by the trauma team from April 4, 2014, to March 31, 2015. Primary outcome of interest was in-hospital mortality. Secondary outcomes included hospital admission, hospital length of stay (LOS), intensive care unit (ICU) admission, ICU LOS, ventilator requirement, operating room use, and time to operating room. Univariate comparisons were made using t-tests and Fisher's test. We used logistic and linear regression to adjust for confounding.

RESULTS

A total of 571 patients were included in the analysis. A total of 179 (31.3%) were managed by an EM resident and the remainder were managed by a surgical resident. There was no statistical difference in mortality or secondary outcomes on the crude or adjusted estimates. Eighteen patients (10.1%) in the EM group died compared to 37 (9.4%) in the surgical group.

CONCLUSIONS

There was no difference in any patient outcome between cases managed by EM and surgical rTTLs. These findings support the philosophy that both groups are effective as rTTLs and should be trained in trauma leadership. Further research is warranted in introducing the rTTL into other systems.

Regionalisation of trauma care in England

AIMS

We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England.

PATIENTS AND METHODS

An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital.

RESULTS AND CONCLUSION

A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of "good recovery". In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253-61.

The initial management of severe trauma patients at hospital admission

The initial management of trauma patient is a critical period aiming at: stabilizing the vital functions; following a rigorous injury assessment; defining a therapeutic strategy. This management has to be organized to minimize loss of time that would be deleterious for the patients outcome. Thus, before patient arrival, the trauma team alert should lead to the initiation of care procedures adapted to the announced severity of the patient. Moreover, each individual should know its role in advance and the team should be managed by only one individual (the trauma leader) to avoid conflicts of decision. A rapid trauma injury assessment aims not only at guiding resuscitation (chest drainage, pelvic contention, to define the mean arterial pressure goal) but also to decide a critical intervention in case of hemodynamic instability (laparotomy, thoracotomy, arterial embolisation). This initial assessment includes a chest and a pelvic X-ray, abdominal ultrasound (extended to the lung) and transcranial Doppler (TCD). The whole body scanner with administration of intravenous contrast material is the cornerstone of the injury assessment but can be done for patients stabilized after the initial resuscitation.