Video assessment of trauma response: adherence to ATLS protocols

Under the Lens: Team Perception of Trauma Video Review

BACKGROUND

Video-based assessment and review are becoming increasingly common, and trauma video review (TVR) has been shown to be an effective educational, quality improvement, and research tool. Yet, trauma team perception of TVR remains incompletely understood.

OBJECTIVE

We evaluated positive and negative perceptions of TVR across multiple team member groups. We hypothesized that members of the trauma team would find TVR educational and that anxiety would be low across all groups.

METHODS

An anonymous electronic survey was provided to nurses, trainees, and faculty during weekly multidisciplinary trauma performance improvement conference following each TVR activity. Surveys assessed perception of performance improvement and anxiety or apprehension (Likert scale: 1 "strongly disagree" to 5 "strongly agree"). We report individual and normalized cumulative scores (average of responses for each positive [n = 6] and negative [n = 4] question stem).

RESULTS

We analyzed 146 surveys over 8 months, with 100% completion rate. Respondents were trainees (58%), faculty (29%), and nurses (13%). Of the trainees, 73% were postgraduate year (PGY) 1-3 and 27% were PGY 4-9. Of all respondents, 84% had participated previously in a TVR conference. Respondents reported an improved perception of resuscitation education quality and personal leadership skills development. Participants found TVR to be more educational than punitive overall. Analysis of team member types showed lower scores for faculty for all positive stemmed questions. Trainees were more likely to agree with negative stemmed questions if they were a lower PGY, and nurses were least likely to agree with negative stemmed questions.

CONCLUSIONS

TVR improves trauma resuscitation education in a conference setting, with trainees and nurses reporting the greatest benefit. Nurses were noted to be the least apprehensive about TVR.

Implementing the IMIST-AMBO tool for paramedic to trauma team handovers: a video review analysis

OBJECTIVE

Patient handover between paramedics and the trauma team is vulnerable to communication errors that may adversely affect patient care. This study assesses the feasibility of a handover tool, IMIST-AMBO (acronym of categories), implementation in the trauma bay and evaluates the degree to which it improves handover metrics.

METHODS

This is a prospective observational cohort study conducted at Canada's largest level-one trauma center. Feasibility of the tool implementation and improvement in handover metrics were assessed. Strategies for implementation included distribution of an educational video and posters, and point-of-care reminders in the trauma bay. Two reviewers independently assessed video recordings of handovers to evaluate handover metrics. Findings were compared to data obtained during a knowledge gap analysis conducted prior to the initiation of this study at the same institution.

RESULTS

Over 13 weeks (August to November 2020), 140 videos were recorded, of which 80 used the IMIST-AMBO tool (compliance of 57%). Paramedic adherence to the handover structure occurred in 70.4% of cases, with greater adherence to the IMIST (82.2%) compared to the AMBO (47.1%) section. The mean (± standard deviation) handover duration was shorter (1 min:58 s ± 0:44 s during implementation vs. 2 min:47 s ± 1:14 s pre-implementation, [p < 0.001]). Frequency of parallel conversations and informal handovers improved (61% to 30% and 65% to 13%, [p < 0.001], respectively). Interruptions during the handover decreased from 3.05 (± 1.95) to 1.5 (± 1.7), p < 0.001. The tool was received favorably among study participants.

CONCLUSION

The IMIST-AMBO tool reduced the frequency of interruptions, parallel conversations, and informal handovers during paramedic-trauma team handovers at our institution. The quality and amount of information communicated per handover improved, all with a decrease in handover duration. The IMIST-AMBO tool may be applied to other trauma centers across Canada, or more broadly on an international scale.

Structured approach with primary and secondary survey for major trauma care: an overview of reviews

BACKGROUND

A structured approach involves systematic management of trauma patients. We aim to conduct an overview of reviews about the clinical efficacy and safety of structured approach (i.e., primary and secondary survey) by guideline checklist compared to non-structured approach (i.e. clinical examination); moreover, routine screening whole-body computer tomography (WBCT) was compared to non-routine WBCT in patients with suspected major trauma.

METHODS

We systematically searched MEDLINE (PubMed), EMBASE and Cochrane Database of Systematic Reviews up to 3 May 2022. Systematic reviews (SRs) that investigated the use of a structured approach compared to a non-structured approach were eligible. Two authors independently extracted data, managed the overlapping of primary studies belonging to the included SRs and calculated the corrected covered area (CCA). The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

We included nine SRs investigating two comparisons in stable trauma patients: structured approach vs non-structured approach (n = 1) and routine WBCT vs non-routine WBCT (n = 8). The overlap of included primary studies was generally high across outcomes (CCA ranged between 20.85 and 42.86%) with some discrepancies in the directions of effects across reviews. The application of a structured approach by checklist may improve adherence to guidelines (e.g. Advanced Trauma Life Support) during resuscitation and might lead to a reduction in mortality among severely injured patients as compared to clinical examination (Adjusted OR 0.51; 95% CI 0.30-0.89; p = 0.018; low certainty of evidence). The use of routine WBCT seems to offer little to no effects in reducing mortality and time spent in emergency room or department, whereas non-routine WBCT seems to offer little to no effects in reducing radiation dose, intensive care unit length of stay (LOS) and hospital LOS (low-to-moderate certainty of evidence).

CONCLUSIONS

The application of structured approach by checklist during trauma resuscitation may improve patient- and process-related outcomes. Including non-routine WBCT seems to offer the best trade-offs between benefits and harm. Clinicians should consider these findings in the light of their clinical context, the volume of patients in their facilities, the need for time management, and costs.

The Need for Trauma Management Training and Evaluation on a Prehospital Setting

Trauma is one of the leading causes of death in the world, being the main cause of death in people under 45 years old. The epidemiology of these deaths shows an important peak during the first hour after a traumatic event. Therefore, learning how to manage traumatic injuries in a prehospital setting is of great importance. Medical students from Universidad Autónoma performed 66 different simulations to stabilize a trauma patient on a prehospital scene by using a web-based trauma simulator. Then, a panel of trauma experts evaluated the simulations performed, observing that, on average, an important number of simulations were scored below 5, being the score values provided from 0, minimum, to 10, maximum. Therefore, the first need detected is the need to further train prehospital trauma management in undergraduate education. Additionally, a deeper analysis of the scores provided by the experts was performed. It showed a great dispersion in the scores provided by the different trauma experts per simulation. Therefore, a second need is identified, the need to develop a system to objectively evaluate trauma management.

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.

Video recording emergency care and video-reflection to improve patient care; a narrative review and case-study of a neonatal intensive care unit

As the complexity of emergency care increases, current research methods to improve care are often unable to capture all aspects of everyday clinical practice. Video recordings can visualize clinical care in an objective way. They can be used as a tool to assess care and to reflect on care with the caregivers themselves. Although the use of video recordings to reflect on medical interventions (video-reflection) has increased over the years, it is still not used on a regular basis. However, video-reflection proved to be of educational value and can improve teams' management and performance. It has a positive effect on guideline adherence, documentation, clinical care and teamwork. Recordings can also be used for video-reflexivity. Here, caregivers review recordings together to reflect on their everyday practice from new perspectives with regard to context and conduct in general. Although video-reflection in emergency care has proven to be valuable, certain preconditions have to be met and obstacles need to be overcome. These include gaining trust of the caregivers, having a proper consent-procedure, maintaining confidentiality and adequate use of technical equipment. To implement the lessons learned from video-reflection in a sustainable way and to continuously improve care, it should be integrated in regular simulation training or education. This narrative review will describe the development of video recording in emergency care and how video-reflection can improve patient care and safety in new ways. On our own department, the NICU at the LUMC, video-reflection has already been implemented and we want to further expand this. We will describe the use of video-reflection in our own unit. Based on the results of this narrative review we will propose options for future research to increase the value of video-reflection.

Training Pulmonary Critical Care Medicine Fellows in Thoracentesis Using a Head-Mounted Video Camera

BACKGROUND

Determination of competence to perform procedures during pulmonary critical care medicine fellowship training has traditionally been based on subjective faculty opinion and numerical requirements.

OBJECTIVE

To describe an objective means of assessing competence of fellows to perform thoracentesis using a head-mounted video camera with offline scoring of the thoracentesis performed on an actual patient.

METHODS

To test competence in performance of thoracentesis after a multimodality training program, a total of eight first-year fellows performed a thoracentesis on an actual patient while recording the procedure with a lightweight head-mounted video camera in 2017 and 2018. The recordings were scored offline by two faculty members using a 30-point checklist. The percentage agreement between scorers was measured, as was the opinion of the fellows and the scorers on the testing process. If a fellow failed completion of all checklist items, they were provided with further training and retested to assure competence. As part of their training, fellows reviewed the video record of their procedures.

RESULTS

Eight first-year fellows were tested, of whom seven successfully completed key checklist items as determined by the video scorers. One failing fellow passed after further training and testing. The percentage agreement between the scorers was high, and fellows indicated that the video device was useful for training.

CONCLUSION

This study supports the use of video-based testing for assessment of competence and for training in performance of thoracentesis by fellows.

Assessment of temporal variations in adherence to NRP using video recording in the delivery room

Introduction

Video recording and video evaluation tools have been successfully used to evaluate neonatal resuscitation performance. The objective of our study was to evaluate differences in Neonatal Resuscitation Program (NRP) adherence at time of birth between three temporal resuscitative periods using scored video recordings.

Methods

This is a retrospective review of in-situ resuscitation video recordings from a level 3 perinatal center between 2017 and 2018. The modified Neonatal Resuscitation Assessment (mNRA) scoring tool was used as a surrogate marker to assess NRP adherence during daytime, evening, and nighttime hours.

Results

A total of 260 resuscitations, of which 258 were births via Cesarean section, were assessed. mNRA composite scores were 86.2% during daytime hours, 87% during evening hours, and 86.6% during nighttime hours. There were no significant differences in mNRA composite scores between any of the three time periods. Differences remained statistically similar after controlling for complexity of resuscitations with administration of positive pressure ventilation (PPV), intubation, or chest compressions.

Conclusion

Overall adherence to NRP, as measured by composite mNRA scores as a surrogate marker, was high across all three daily resuscitative periods without significant differences between daytime, evening, and nighttime hours.

Contemporary uses of trauma video review: a scoping review

OBJECTIVES

Trauma resuscitations are sporadic, high-acuity situations and conducting observation in the trauma bay for the purpose of quality improvement is challenging. We aim to review contemporary uses of trauma video review.

METHODS

Medline and Embase were searched from 1980 to May 2020 for studies involving trauma video review. English studies of adult and paediatric populations were included for study and analysed for uses of trauma video review, outcomes measured and any resulting quality improvement (QI) initiatives.

RESULTS

A total of 463 publications were identified with 21 studies meeting eligibility for final inclusion. A majority of studies (11) observed technical skills with analysis of critical procedures, including tracheal intubation and thoracotomy. The remaining studies observed team dynamics and communication. Overall, eight studies resulted in new policies being put in place for trauma resuscitations and six studies utilized trauma video review as an educational tool.

CONCLUSIONS

This study highlights common uses of trauma video review. The greatest benefit for this new technology is in quality improvement and education. The majority of studies focussed on critical procedures and QI initiatives, such as checklists, protocols and continued education. We recommend adoption of video review systems for ongoing improvement of team dynamics and overall trauma and emergency resuscitation.

Impact of video-recording on patient outcome and data collection in out-of-hospital cardiac arrests

BACKGROUND

Most research on out-of-hospital resuscitation relies on data collection from medical records. However, the data in medical records are often inaccurate.

OBJECTIVE

To compare the data registration of the medical record with the data from the video recorded resuscitation and study the impact of video recording during resuscitation on the outcome.

METHODS

Out-of-hospital cardiopulmonary resuscitation (CPR) was video recorded using a body-mounted camera. Video recordings were independently reviewed and compared with the data of the medical record. The presence of bystander CPR and witnessed arrest, the initial rhythm, total number of defibrillations, adrenaline dosage and the total duration of CPR were studied. Using the medical records, CPR outcomes were compared for the periods prior to, during and after video recording.

RESULTS

In total, 129 resuscitations were analysed. Of the six parameters, only the number of defibrillations was not significantly different in the medical record compared to the video recordings. The total duration of CPR (69.0%) and the total dose of adrenaline administered (63.6%) were the most incorrectly recorded, followed by the number of defibrillations (34.0%), witnessed arrest (31.0%), bystander CPR (24.0%) and initial rhythm (7%). No statistically significant difference was found comparing the outcomes (ROSC, 24 h and 1 month survival) of the periods before, during and after video recording.

CONCLUSION

We detected a high number of discrepancies between the medical record and the data from the video recorded resuscitation. No significant effect of video-recording on patient outcome was found.

Minimizing Pulse Check Duration Through Educational Video Review

Introduction

The American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) recommend pulse checks of less than 10 seconds. We assessed the effect of video review-based educational feedback on pulse check duration with and without point-of-care ultrasound (POCUS).

Methods

Cameras recorded cases of CPR in the emergency department (ED). Investigators reviewed resuscitation videos for ultrasound use during pulse check, pulse check duration, and compression-fraction ratio. Investigators reviewed health records for patient outcomes. Providers received written feedback regarding pulse check duration and compression-fraction ratio. Researchers reviewed selected videos in multidisciplinary grand round presentations, with research team members facilitating discussion. These presentations highlighted strategies that include the following: limit on pulse check duration; emphasis on compressions; and use of “record, then review” method for pulse checks with POCUS. The primary endpoint was pulse check duration with and without POCUS.

Results

Over 19 months, investigators reviewed 70 resuscitations with a total of 325 pulse checks. The mean pulse check duration was 11.5 ± 8.8 seconds (n = 224) and 13.8 ± 8.6 seconds (n = 101) without and with POCUS, respectively. POCUS pulse checks were significantly longer than those without POCUS (P = 0.001). Mean pulse check duration per three-month block decreased statistically significantly from study onset to the final study period (from 17.2 to 10 seconds [P<0.0001]) overall; decreased from 16.6 to 10.5 seconds (P<0.0001) without POCUS; and with POCUS from 19.8 to 9.88 seconds (P<0.0001) with POCUS. Pulse check times decreased significantly over the study period of educational interventions. The strongest effect size was found in POCUS pulse check duration (P = −0.3640, P = 0.002).

Conclusion

Consistent with previous studies, POCUS prolonged pulse checks. Educational interventions were associated with significantly decreased overall pulse-check duration, with an enhanced effect on pulse checks involving POCUS. Performance feedback and video review-based education can improve CPR by increasing chest compression-fraction ratio.

Simulation Training for Critical Care Airway Management: Assessing Translation to Clinical Practice Using a Small Video-Recording Device

BACKGROUND

Critical care airway management (CCAM) is a key skill for critical care physicians. Simulation-based training (SBT) may be an effective modality in training intensivists in CCAM.

RESEARCH QUESTION

Is SBT of critical care fellows an effective means of providing training in CCAM, in particular in urgent endotracheal intubation?

STUDY DESIGN AND METHODS

Thirteen first-year pulmonary critical care medicine (PCCM) fellows at an academic training program underwent SBT with a computerized patient simulator (CPS) in their first month of fellowship training. At the end of the training period, the fellows underwent video-based scoring using a 46-item checklist (of which 40 points could be scored) while performing a complete CCAM sequence on the CPS. They were then tested, using video-based scoring on their first real-life CCAM. Maintenance of skill at CCAM was assessed during the fellows' second and third year of training, using the same scoring method.

RESULTS

For the first-year fellows, the score on the CPS was 38.3 ± 0.75 SD out of a maximum score of 40. The score on their first real-life patient CCAM was 39.0 ± 0.81 SD (P = .003 for equivalence; 95% CI for difference between real-life patient CCAM and CPS scores, 0.011-1.373). Sixteen second- and third-year fellows were tested at a real-life CCAM event later in their fellowship to examine for maintenance of skill. The mean maintenance of skill score of this group was 38.7 ± 1.14 SD.

INTERPRETATION

Skill acquired through SBT of critical care fellows for CCAM transfers effectively to the real-life patient care arena. Second- and third-year fellows who had initially received SBT maintained skill at CCAM.

Team Assessment and Decision Making Is Associated With Outcomes: A Trauma Video Review Analysis

BACKGROUND

Teamwork is a critical element of trauma resuscitation. Assessment tools such as T-NOTECHS (Trauma NOn-TECHnical Skills) exist, but correlation with patient outcomes is unclear. Using emergency department thoracotomy (EDT), we sought to describe T-NOTECHS scores during resuscitations. We hypothesized that patients undergoing EDT whose resuscitations had better scores would be more likely to have return of spontaneous circulation (ROSC).

METHODS

Continuously recording video was used to review all captured EDTs over a 24-mo period. We used a modification of the validated T-NOTECHS instrument to measure five domains on a 3-point scale (1 = best, 2 = average, 3 = worst). A total T-NOTECHS score was calculated by one of three reviewers. The primary outcome was ROSC. ROSC was defined as an organized rhythm no longer requiring internal cardiac compressions. Associations between variables and ROSC were examined using univariate regression.

RESULTS

Sixty-one EDTs were captured. Nineteen patients had ROSC (31%) and 42 (69%) did not. The median T-NOTECHS score for all resuscitations was 8 [IQR 6-10]. As demographic and injury data (age, gender, mechanism, signs of life) were not associated with ROSC in univariate analysis, they were not considered for inclusion in a multivariable regression model. The association between overall T-NOTECHS score and ROSC did not reach statistical significance, but examination of the individual components of the T-NOTECHS score demonstrated that, compared to resuscitations that had "average" (2) or "worst" (3) scores on "Assessment and Decision Making," resuscitations with a "best" score were 5 times more likely to lead to ROSC.

CONCLUSIONS

Although the association between overall T-NOTECHS scores and ROSC did not reach statistical significance, better scores in the domain of assessment and decision making are associated with improved rates of ROSC in patients arriving in cardiac arrest who undergo EDT.

LEVEL OF EVIDENCE

Level IV Therapeutic/Care Management.

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.

Association Between Prearrival Notification Time and Advanced Trauma Life Support Protocol Adherence

BACKGROUND

Prearrival notification of injured patients facilitates preparation of personnel, equipment, and other resources needed for trauma evaluation and treatment. Our purpose was to determine the impact of prearrival notification time on adherence to Advanced Trauma Life Support (ATLS) protocols.

MATERIALS AND METHODS

Pediatric trauma activations of admitted patients were analyzed by video review to determine activities performed before and after patient arrival. Using an expert model based on ATLS, fitness scores were calculated that represented model adherence, ranging from "0" (noncompliant) to "100" (completely compliant). Multivariate regression was used to determine the association between fitness values of the evaluation phases and the length of prearrival notification time and injury profiles.

RESULTS

Ninety-four patients met study criteria. The average overall fitness was 89.0 ± 7.3, with similar fitness values being observed for the primary and secondary surveys (91.5 ± 13.4 and 88.6 ± 7.7, respectively). Prearrival notification time ranged from 67.3 min before to 4.8 min after patient arrival. Longer prearrival notification time was associated with improved completion of prearrival tasks, overall resuscitation performance, and secondary survey performance. The positive association of overall and secondary survey fitness with notification time was no longer observed when notification time was <5 min and <10 min, respectively. Notification time was correlated with a higher percentage of required team members when the patient arrived (Pearson correlation coefficient 0.46, P < 0.001).

CONCLUSIONS

Prearrival notification time has a significant impact on adherence to ATLS protocol. Strategies for improving notification time or improving performance when adequate notification cannot be achieved are needed.

Benchmarking emergency department thoracotomy: Using trauma video review to generate procedural norms

INTRODUCTION

Emergency department thoracotomy (EDT) must be rapid and well-executed. Currently there are no defined benchmarks for EDT procedural milestones. We hypothesized that trauma video review (TVR) can be used to define the 'normative EDT' and generate procedural benchmarks. As a secondary aim, we hypothesized that data collected by TVR would have less missingness and bias than data collected by review of the Electronic Medical Record (EMR).

METHODS

We used continuously recording video to review all EDTs performed at our centre during the study period. Using skin incision as start time, we defined four procedural milestones for EDT: 1. Decompression of the right chest (tube thoracostomy, finger thoracostomy, or clamshell thoracotomy with transverse sternotomy performed in conjunction with left anterolateral thoracotomy) 2. Retractor deployment 3. Pericardiotomy 4. Aortic Cross-clamp. EDTs with any milestone time ≥ 75^th percentile of time or during which a milestone was omitted were identified as outliers. We compared rates of missingness in data collected by TVR and EMR using McNemar's test.

RESULTS

44 EDTs were included from the study period. Patients had a median age of 30 [IQR 25-44] and were predominantly African-American (95%) males (93%) with penetrating trauma (95%). From skin incision, median times in minutes to milestones were as follows: right chest decompression: 2.11 [IQR 0.68-2.83], retractor deployment 1.35 [IQR 0.96-1.85], pericardiotomy 2.35 [IQR 1.85-3.75], aortic cross-clamp 3.71 [IQR 2.83-5.77]. In total, 28/44 (64%) of EDTs were either high outliers for one or more benchmarks or had milestones that were omitted. For all milestones, rates of missingness for TVR data were lower than EMR data (p < 0.001).

CONCLUSIONS

Video review can be used to define normative times for the procedural milestones of EDT. Steps exceeding the 75^th percentile of time were common, with over half of EDTs having at least one milestone as an outlier. Data quality is higher using TVR compared to EMR collection. Future work should seek to determine if minimizing procedural technical outliers improves patient outcomes.

Google Glass Video Capture of Cardiopulmonary Resuscitation Events: A Pilot Simulation Study

BACKGROUND

Video recording of resuscitation from fixed camera locations has been used to assess adherence to guidelines and provide feedback on performance. However, inpatient cardiac arrests often happen in unpredictable locations and crowded rooms, making video recording of these events problematic.

OBJECTIVE

We sought to understand the feasibility of Google Glass (GG) as a method for recording inpatient cardiac arrests and capturing salient resuscitation factors for post-event review.

METHODS

This observational study involved recording simulated cardiac arrest events on inpatient medical wards. Each simulation was reviewed by 3 methods: in-room physician direct observation, stationary video camera (SVC), and GG. Nurse and physician specialists analyzed the videos for global visibility and audibility, as well as recording quality of predefined resuscitation events and behaviors. Resident code leaders were surveyed regarding attitudes toward GG use in the clinical emergency setting.

RESULTS

Of 11 simulated cardiac arrest events, 9 were successfully recorded by all observation methods (1 GG failure, 1 SVC failure). GG was judged slightly better than SVC recording for average global visualization (3.95 versus 3.15, P = .0003) and average global audibility (4.77 versus 4.42, P = .002). Of the GG videos, 19% had limitations in overall interpretability compared with 35% of SVC recordings (P = .039). All 10 survey respondents agreed that GG was easy to use; however, 2 found it distracting and 3 were uncomfortable with future use during actual resuscitations.

CONCLUSIONS

GG is a feasible and acceptable method for capturing simulated resuscitation events in the inpatient setting.

Developing the Fourth Evaluation Dimension: A Protocol for Evaluation of Video From the Patient's Perspective During Major Incident Exercises

OBJECTIVE

Presently used evaluation techniques rely on 3 traditional dimensions: reports from observers, registration system data, and observational cameras. Some of these techniques are observer-dependent and are not reproducible for a second review. This proof-of-concept study aimed to test the feasibility of extending evaluation to a fourth dimension, the patient's perspective.

METHODS

Footage was obtained during a large, full-scale hospital trauma drill. Two mock victims were equipped with point-of-view cameras filming from the patient's head. Based on the Major Incident Hospital's first experience during the drill, a protocol was developed for a prospective, standardized method to evaluate a hospital's major incident response from the patient's perspective. The protocol was then tested in a second drill for its feasibility.

RESULTS

New insights were gained after review of the footage. The traditional observer missed some of the evaluation points, which were seen on the point-of-view cameras. The information gained from the patient's perspective proved to be implementable into the designed protocol.

CONCLUSION

Use of point-of-view camera recordings from a mock patient's perspective is a valuable addition to traditional evaluation of trauma drills and trauma care. Protocols should be designed to optimize and objectify judgement of such footage. (Disaster Med Public Health Preparedness. 2017;11:594-599).

Standardizing the initial resuscitation of the trauma patient with the Primary Assessment Completion Tool using video review

BACKGROUND

Major trauma resuscitations at pediatric trauma centers have an elevated risk for error because of their high acuity and relatively low frequency. The Advanced Trauma Life Support (ATLS) treatment paradigm was established to improve the management of trauma patients during the initial resuscitation phase and has been shown to improve outcomes through a standardized approach. The goal of this quality improvement project was to decrease assessment physician variability and improve the compliance with the ATLS primary assessment for major resuscitations.

METHODS

A video review tool was developed to score the assessment physician on completion of the primary survey components using ATLS format. Interrater reliability and content validity were established for the tool. Data were collected through video review of the trauma response team in the emergency department for all Level 1 trauma alert activations with general consent. Chi-square and regression analyses were used to evaluate the data at 30 days, 6 months, and 1 year from the baseline period.

RESULTS

A total of 142 patient videos were scored between July 28, 2015, and August 1, 2016. Eleven patients were reviewed during the baseline period, and only 9.1% of the total scores were ≥85. Thirty days following project implementation, 37.5% were ≥ 85. Six months following project implementation, 64.4% scored ≥85. One year following project implementation, 91.5% scored ≥85. These were statistically significant changes (p < .0001) with less variability over time.

CONCLUSION

Effective leadership using a standardized approach during the trauma resuscitation has been found to have a positive effect on task completion and the overall functioning of the trauma team. This focused quality improvement project improved compliance with ATLS format and decreased variability by the assessment physician, potentially improving patient safety and outcomes.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Video Review as a Tool to Improve Orthopedic Residents׳ Performance of Closed Manipulative Reductions

OBJECTIVE

Orthopedic residents commonly perform closed manipulative reductions as a part of their training. Traditionally, this skill is taught early in training but difficult to simulate. Proficiency is achieved through repetition and experience; faculty observation and instruction is unfortunately often limited. Direct resident teaching has been shown to increase competency, comfort, and long-term skill retention. We hypothesize that video review of closed fracture reductions will provide an inexpensive and valuable tool for resident education and improve skill performance.

DESIGN

Closed reductions performed by orthopaedic residents were recorded using a secured mobile tablet device in the emergency department (ED). Video review sessions were performed with both peer and faculty feedback/analysis of reduction technique. Anonymous resident and faculty surveys were completed following each session to evaluate the usage and perceived benefit of the program.

SETTING

University-based Level I Trauma Center.

PARTICIPANTS

Orthopedic surgery residents and faculty.

RESULTS

All junior orthopedic residents (postgraduate year [PGY] 1-3) reported that direct video observation by faculty was beneficial. Furthermore, 97% of junior resident and 100% of faculty responses reported that they would use this educational technology in the future. Residents and faculty both strongly agreed that video review was more useful than other methods, improved resident preparation for ED fracture care, and felt this technique would improve patient care and outcomes. Compared with senior residents (PGY 4-5), PGY-1s believed that this technique helped them prepare for ED fracture care (p = 0.02).

CONCLUSIONS

Video review provides a useful, innovative, and inexpensive method to improve resident competency in closed fracture reduction-a critical skill in orthopedic patient care. These procedures are uncommonly available for direct faculty observation. We have demonstrated that both residents and faculty were satisfied with the ability to review procedures, identify weaknesses, and obtain or provide direct feedback on this skill. Additionally, fracture reduction video review may help residents meet and achieve clinical milestones, an area of future investigation.

Role of Google Glass in improving patient satisfaction for otolaryngology residents: a pilot study

OBJECTIVES

To demonstrate the feasibility and efficacy of the Google Glass as a tool to improve patient satisfaction and patient-physician communication for otolaryngology residents in the outpatient clinic setting. The primary outcome of the study was to improve patient satisfaction scores based on physician communication-related questions from Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.

STUDY DESIGN

Prospective randomised trial.

SETTING

Tertiary care hospital.

SUBJECT AND METHODS

To evaluate the effect on patient satisfaction, five residents were recorded using the Google Glass in an outpatient clinic setting by 50 randomised patients. Modified surveys based on the CG-CAHPS survey were completed by patients at the conclusion of each clinic encounter. The recorded videos were evaluated by two independent faculties. Summarised data and video were distributed to each resident for review as the intervention. The residents were recorded again by 45 additional patients with evaluation by patients and faculties.

RESULTS

After intervention, the scores from faculty surveys regarding patient satisfaction including the subject of better explanations (P > 0.001), listening carefully (P > 0.001), addressing patient questions (P > 0.001), displaying respect (P > 0.001) and spending adequate time (P = 0.0005) all significantly improved, as well as overall performance (P = 0.014). The scores from patient surveys did significantly improve.

CONCLUSION

This study demonstrates the improvements in patient satisfaction and patient-physician communication can be achieved with the use of Google Glass as a first-person recording device in the outpatient otolaryngology clinic setting.

DisTeam: A decision support tool for surgical team selection

OBJECTIVE

Surgical service providers play a crucial role in the healthcare system. Amongst all the influencing factors, surgical team selection might affect the patients' outcome significantly. The performance of a surgical team not only can depend on the individual members, but it can also depend on the synergy among team members, and could possibly influence patient outcome such as surgical complications. In this paper, we propose a tool for facilitating decision making in surgical team selection based on considering history of the surgical team, as well as the specific characteristics of each patient.

METHODS

DisTeam (a decision support tool for surgical team selection) is a metaheuristic framework for objective evaluation of surgical teams and finding the optimal team for a given patient, in terms of number of complications. It identifies a ranked list of surgical teams personalized for each patient, based on prior performance of the surgical teams. DisTeam takes into account the surgical complications associated with teams and their members, their teamwork history, as well as patient's specific characteristics such as age, body mass index (BMI) and Charlson comorbidity index score.

RESULTS

We tested DisTeam using intra-operative data from 6065 unique orthopedic surgery cases. Our results suggest high effectiveness of the proposed system in a health-care setting. The proposed framework converges quickly to the optimal solution and provides two sets of answers: a) The best surgical team over all the generations, and b) The best population which consists of different teams that can be used as an alternative solution. This increases the flexibility of the system as a complementary decision support tool.

CONCLUSION

DisTeam is a decision support tool for assisting in surgical team selection. It can facilitate the job of scheduling personnel in the hospital which involves an overwhelming number of factors pertaining to patients, individual team members, and team dynamics and can be used to compose patient-personalized surgical teams with minimum (potential) surgical complications.

Optimising clinical performance during resuscitation using video evaluation

Video evaluation of resuscitation is becoming increasingly integrated into practice in a number of clinical settings. The purpose of this review article is to examine how video may enhance clinical care during resuscitation. As healthcare and available therapeutic interventions evolve, re-evaluation of accepted paradigms requires data to describe current practice and support change. Analysis of video recordings affords creation of a framework to evaluate individual and team performance and develop unique and tailored strategies to optimise care delivery. While video has been used in a number of non-clinical settings, there has been a recent increase of video systems in the prehospital and other clinical areas. This paper reviews the key opportunities in the emergency department-based resuscitation setting to enhance ergonomics, technical and non-technical skills-at both team and individual level-through video-assisted care performance analysis and feedback.

An Analysis of the Top-cited Articles in Emergency Medicine Education Literature

Introduction

Dissemination of educational research is critical to improving medical education, promotion of faculty and ultimately patient care. The objective of this study was to identify the top 25 cited education articles in the emergency medicine (EM) literature and the top 25 cited EM education articles in all journals, as well as report on the characteristics of the articles.

Methods

Two searches were conducted in the Web of Science in June 2016 using a list of education-related search terms. We searched 19 EM journals for education articles as well as all other literature for EM education-related articles. Articles identified were reviewed for citation count, article type, journal, authors, and publication year.

Results

With regards to EM journals, the greatest number of articles were classified as articles/reviews, followed by research articles on topics such as deliberate practice (cited 266 times) and cognitive errors (cited 201 times). In contrast in the non-EM journals, research articles were predominant. Both searches found several simulation and ultrasound articles to be included. The most common EM journal was Academic Emergency Medicine (n = 18), and Academic Medicine was the most common non-EM journal (n=5). A reasonable number of articles included external funding sources (6 EM articles and 13 non-EM articles.)

Conclusion

This study identified the most frequently cited medical education articles in the field of EM education, published in EM journals as well as all other journals indexed in Web of Science. The results identify impactful articles to medical education, providing a resource to educators while identifying trends that may be used to guide EM educational research and publishing efforts.

[Better apprehension of errors in the early clinical treatment of the severely injured]

BACKGROUND

Every year preventable adverse events endanger a considerable number of patients. Current guidelines of the Federal Joint Committee require clinical quality management to provide amongst others an independent clinical risk management and a critical incident reporting system (CIRS). Such guidelines increase the pressure to actively deal with errors, even in emergency medicine. Human error is considered to be the main cause of preventable adverse events in high-risk industries, such as aviation. This observation is gladly directly transferred to clinical medicine.

OBJECTIVES

This study investigated where the true causes for preventable adverse events during the resuscitation of severely injured patients can be found.

METHODS

A non-systematic literature search of the PubMed database was performed.

RESULTS

The search identified three recent studies addressing these objectives that revealed human error as the most important cause of preventable adverse events during emergency room resuscitation (88-97%). Errors during resuscitation in the emergency room occur in approximately 10 %. It is striking that such data do not differ greatly from findings described in studies undertaken 20 years ago. One possible explanation might be that the systematic evaluation of medical errors in the emergency room is a weak spot and that too few lessons can be learnt from such incidents. Therefore, this article describes models of error development and outlines methods to collect data for root cause analysis and for clinical risk management. Thus, this review aims at a better understanding of how errors originate and to allow development of strategies to prevent errors from happening again.

CONCLUSION

Human error is the most important cause of preventable adverse events during emergency room resuscitation. Presumably, errors occur unintentionally and as a result of situational misjudgment. As such errors have marked consequences on mortality and morbidity of severely injured patients, an extensive risk management is mandatory for the improvement of quality and safety. Appropriate methods to record errors in order to allow a correct root cause analysis according to well-established protocols is a basic prerequisite.

Evaluating the Cultural Validity of the Stressful Life Events Screening Questionnaire

Measures of psychological trauma are rarely evaluated for validity with disadvantaged populations. The authors used three qualitative methods to assess the cultural validity of the Stressful Life Events Screening Questionnaire (SLESQ) with low-income African American women. Focus groups ( n = 17), cognitive interviews ( n = 20), and videotape reviews of SLESQ interviews were conducted ( n = 16). Focus group participants spontaneously used similar language to the SLESQ items and tended to identify SLESQ events as traumatic. Most items were well understood in the interviews, with some criticism of wording. Tape reviews indicated little wording modification by interviewers. One item showed consistent problems. The interview was revised accordingly.

Factors influencing ambulance nurses' adherence to a national protocol ambulance care: an implementation study in the Netherlands

Objectives

Adherence to prehospital guidelines and protocols is suboptimal. Insight into influencing factors is necessary to improve adherence. The aim of this study was to identify factors that influence ambulance nurses’ adherence to a National Protocol Ambulance Care (NPAC).

Methods

A questionnaire was developed using the literature, a questionnaire and expert opinion. Ambulance nurses (n=452) from four geographically spread emergency medical services (EMSs) in the Netherlands were invited to fill out the questionnaire. The questionnaire included questions on influencing factors and self-reported adherence.

Results

Questionnaires were returned by 248 (55%) of the ambulance nurses. These ambulance nurses’ adherence to the NPAC was 83.4% (95% confidence interval 81.9–85.0). Bivariate correlations showed 23 influencing factors that could be related to the individual professional, organization, protocol characteristics and social context. Multilevel regression analysis showed that 21% of the variation in adherence (R²=0.208) was explained by protocol characteristics and social influences.

Conclusion

Ambulance nurses’ self-reported adherence to the NPAC seems high. To improve adherence, protocol characteristics (complexity, the degree of support for diagnosis and treatment, the relationship of the protocol with patient outcomes) and social influences (expectance of colleagues to work with the national protocol) should be addressed.

Mobile in Situ Simulation as a Tool for Evaluation and Improvement of Trauma Treatment in the Emergency Department

BACKGROUND

Medical simulation is an increasingly recognized tool for teaching, coaching, training, and examining practitioners in the medical field. For many years, simulation has been used to improve trauma care and teamwork. Despite technological advances in trauma simulators, including better means of mobilization and control, most reported simulation-based trauma training has been conducted inside simulation centers, and the practice of mobile simulation in hospitals' trauma rooms has not been investigated fully.

METHODS

The emergency department personnel from a second-level trauma center in Israel were evaluated. Divided into randomly formed trauma teams, they were reviewed twice using in situ mobile simulation training at the hospital's trauma bay. In all, 4 simulations were held before and 4 simulations were held after a structured learning intervention. The intervention included a 1-day simulation-based training conducted at the Israel Center for Medical Simulation (MSR), which included video-based debriefing facilitated by the hospital's 4 trauma team leaders who completed a 2-day simulation-based instructors' course before the start of the study. The instructors were also trained on performance rating and thus were responsible for the assessment of their respective teams in real time as well as through reviewing of the recorded videos; thus enabling a comparison of the performances in the mobile simulation exercise before and after the educational intervention.

RESULTS

The internal reliability of the experts' evaluation calculated in the Cronbach α model was found to be 0.786. Statistically significant improvement was observed in 4 of 10 parameters, among which were teamwork (29.64%) and communication (24.48%) (p = 0.00005).

CONCLUSION

The mobile in situ simulation-based training demonstrated efficacy both as an assessment tool for trauma teams' function and an educational intervention when coupled with in vitro simulation-based training, resulting in a significant improvement of the teams' function in various aspects of treatment.

Practitioner perceptions of trauma video review

PURPOSE

Multidisciplinary trauma team education through trauma video review (TVR) is a useful performance improvement tool, but video recording resuscitations may cause providers anxiety. We examined perceptions of educational value and anxiety associated with being reviewed in TVR.

METHODS

Trauma team members were asked to complete an anonymous online survey. Educational scores (E scores) and anxiety scores (A score) were calculated from survey responses. Respondents were divided into groups by roles: trainees (T; medical students, residents, and fellows), attending surgeons (A), and nurses (N). Kruskal-Wallis test was used for statistical testing.

FINDINGS

A total of 39 subjects completed the survey (T = 17, 43%; A = 8, 23%; N = 14, 35%). TVR scored high in educational value (median E score 90; IQR = 78-96) but provoked moderate anxiety (median A score 27; IQR = 20-36). No significant differences in E scores were seen between groups. A scores were not significantly different between groups N and T (20 vs 33; P = .11) or groups T and A (33 vs. 35; P = 1.0) but were significantly higher in group A than in group N (36 vs 20; P = .04).

CONCLUSIONS

Despite perceptions of educational value, TVR is associated with anxiety among providers, which is different between groups. Continued assessment of perceptions regarding TVR may allow for modifications to maintain educational value while decreasing anxiety.

Trauma team

The introduction of trauma teams has improved patient outcome independently. The aim of establishing a trauma team is to ensure the early mobilization and involvement of more experienced medical staff and thereby to improve patient outcome. The team approach allows for distribution of the several tasks in assessment and resuscitation of the patient in a 'horizontal approach', which may lead to a reduction in time from injury to critical interventions and thus have a direct bearing on the patient's ultimate outcome. A trauma team leader or supervisor, who coordinates the resuscitation and ensures adherence to guidelines, should lead the trauma team. There is a major national and international variety in trauma team composition, however crucial are a surgeon, an Emergency Medicine physician or both and anaesthetist. Advanced Trauma Life Support training, simulation-based training, and video review have all improved patient outcome and trauma team performance. Developments in the radiology, such as the use of computed tomography scanning in the emergency room and the endovascular treatment of bleeding foci, have changed treatment algorithms in selected patients. These developments and new insights in shock management may have a future impact on patient management and trauma team composition.

Compliance to advanced trauma life support protocols in adult trauma patients in the acute setting

INTRODUCTION

Advanced Trauma Life Support (ATLS) protocols provide a common approach for trauma resuscitations. This was a quality review assessing compliance with ATLS protocols at a Level I trauma center; specifically whether the presence or absence of a trauma team leader (TTL) influenced adherence.

METHODS

This retrospective study was conducted on adult major trauma patients with acute injuries over a one-year period in a Level I Canadian trauma center. Data were collected from the Alberta Trauma Registry, and adherence to ATLS protocols was determined by chart review.

RESULTS

The study identified 508 patients with a mean Injury Severity Score of 24.5 (SD 10.7), mean age 39.7 (SD 17.6), 73.8% were male and 91.9% were involved in blunt trauma. The overall compliance rate was 81.8% for primary survey and 75% for secondary survey. The TTL group compared to non-TTL group was more likely to complete the primary survey (90.9% vs. 81.8%, p = 0.003), and the secondary survey (100% vs. 75%, p = 0.004). The TTL group was more likely than the non-TTL group to complete the following tasks: insertion of two large bore IVs (68.2% vs. 57.7%, p = 0.014), digital rectal exam (64.6% vs. 54.7%, p = 0.023), and head to toe exam (77% vs. 67.1%, p = 0.013). Mean times from emergency department arrival to diagnostic imaging were also significantly shorter in the TTL group compared to the non-TTL group, including times to pelvis xray (mean 68min vs. 107min, p = 0.007), CT chest (mean 133min vs. 172min, p = 0.005), and CT abdomen and pelvis (mean 136min vs. 173min, p = 0.013). Readmission rates were not significantly different between the TTL and non-TTL groups (3.5% vs. 4.5%, p = 0.642).

CONCLUSIONS

While many studies have demonstrated the effectiveness of trauma systems on outcomes, few have explored the direct influence of the TTL on ATLS compliance. This study demonstrated that TTL involvement during resuscitations was associated with improved adherence to ATLS protocols, and increased efficiency (compared to non TTL involvement) to diagnostic imaging. Findings from this study will guide future quality improvement and education for early trauma management.

ATLS adherence in the transfer of rural trauma patients to a level I facility

BACKGROUND

Injury sustained in rural areas has been shown to carry higher mortality rates than trauma in urban settings. This disparity is partially attributed to increased distance from definitive care and underscores the importance of proper primary trauma management prior to transfer to a trauma facility. The purpose of this study was to assess Advanced Trauma Life Support (ATLS) guideline adherence in the management of adult trauma patients transferred from rural hospitals to a level I facility.

METHODS

We performed a retrospective analysis of all adult major trauma patients transferred ≥50km from an outlying hospital to a level I trauma centre from 2007 through 2009. Transfer practices were evaluated using ATLS guidelines.

RESULTS

646 patients were analyzed. Mean age was 40.5years and 94% sustained blunt injuries with a median Injury Severity Score (ISS) of 22. Median transport distance was 253km. Among all patients, there were notable deficiencies (<80% adherence) in 8 of 11 ATLS recommended interventions, including patient rewarming (8% adherence), chest tube insertion (53%), adequate IV access (53%), and motor/sensory exam (72%). Patients with higher ISS scores, and those transferred by air were more likely to receive ATLS recommended interventions.

CONCLUSIONS

Key aspects of ATLS resuscitation guidelines are frequently missed during transfer of trauma patients from the periphery to level I trauma centres. Comprehensive quality improvement initiatives, including targeted education, telemedicine and trauma team training programmes could improve quality of care.

Assessing patient care: summary of the breakout group on assessment of observable learner performance

There is an established expectation that physicians in training demonstrate competence in all aspects of clinical care prior to entering professional practice. Multiple methods have been used to assess competence in patient care, including direct observation, simulation-based assessments, objective structured clinical examinations (OSCEs), global faculty evaluations, 360-degree evaluations, portfolios, self-reflection, clinical performance metrics, and procedure logs. A thorough assessment of competence in patient care requires a mixture of methods, taking into account each method's costs, benefits, and current level of evidence. At the 2012 Academic Emergency Medicine (AEM) consensus conference on educational research, one breakout group reviewed and discussed the evidence supporting various methods of assessing patient care and defined a research agenda for the continued development of specific assessment methods based on current best practices. In this article, the authors review each method's supporting reliability and validity evidence and make specific recommendations for future educational research.

Adherence to ATLS primary and secondary surveys during pediatric trauma resuscitation

STUDY AIM

Adherence to Advanced Trauma Life Support (ATLS) protocol has been associated with improved management of injured patients. The objective of this study is to determine factors associated with delayed and omitted ATLS primary and secondary survey tasks at a level 1 pediatric trauma center.

METHODS

Video recorded resuscitations of 237 injured patients <18 years old obtained over a four month period at our hospital were evaluated to assess completeness and timeliness of essential tasks in the primary and secondary survey of ATLS. Multivariate analyses were performed to identify features associated with decreased ATLS performance.

RESULTS

Primary survey findings were stated less often in patients with burn injuries compared to those with blunt injuries (RR=1.72; 95% CI: 1.26-2.35) and less often during the overnight shift [11 PM-7 AM] (RR=1.22; 95% CI: 1.02-1.46). Secondary survey findings were verbalized less often in patients with penetrating injures (RR=2.30; 95% CI: 1.06-5.00). Time to statement of primary surveys findings was delayed in patients with burn injuries (HR=0.69; 95% CI: 0.48-0.98) and among those transferred from another hospital. Completeness and timeliness of ATLS task performance were not associated with age or injury severity score.

CONCLUSIONS

Mechanism of injury and hospital factors are associated with incomplete and delayed primary and secondary surveys. Interventions that address deficient ATLS adherence related to these factors may lead to a reduction in errors during this critical period of patient care.

The top five research priorities in physician-provided pre-hospital critical care: a consensus report from a European research collaboration

Background

Physician-manned emergency medical teams supplement other emergency medical services in some countries. These teams are often selectively deployed to patients who are considered likely to require critical care treatment in the pre-hospital phase. The evidence base for guidelines for pre-hospital triage and immediate medical care is often poor. We used a recognised consensus methodology to define key priority areas for research within the subfield of physician-provided pre-hospital critical care.

Methods

A European expert panel participated in a consensus process based upon a four-stage modified nominal group technique that included a consensus meeting.

Results

The expert panel concluded that the five most important areas for further research in the field of physician-based pre-hospital critical care were the following: Appropriate staffing and training in pre-hospital critical care and the effect on outcomes, advanced airway management in pre-hospital care, definition of time windows for key critical interventions which are indicated in the pre-hospital phase of care, the role of pre-hospital ultrasound and dispatch criteria for pre-hospital critical care services.

Conclusion

A modified nominal group technique was successfully used by a European expert group to reach consensus on the most important research priorities in physician-provided pre-hospital critical care.

Parental attitudes to digital recording: A paediatric hospital survey

AIM

Digital recording is ubiquitous in the community. Its objectivity, permanence and utility in medical education have led to increasing use in health-care settings. As participants in this process, the perspectives of families are important to inform practice. We surveyed family members of hospitalized children to evaluate their opinions.

METHODS

A survey was administered to adults in emergency, operating room or ICU waiting areas at a university-affiliated paediatric hospital in Toronto. Respondents rated the frequency of digital recording in the community and hospital environments, the acceptability of five clinical indications and of consent discussions.

RESULTS

Participants completed 154 surveys (response rate 83%) with median (interquartile range) of 2 (1-2) children. Community use of recording >4 times in the week prior was reported by 47 (31%); 42 (28%) reported no recording. The respondents rated the following indications for digital recording acceptable in the health care research 142 (94%), medical education 140 (93%), quality improvement 140 (92%), patient safety 147 (97%), and clinical care (96%). Within healthcare, consent discussions at different times were rated as acceptable before recording by 99%; after recording by 41%; and with no consent by 17%.

CONCLUSION

We performed the first post-privacy legislation survey of digital recording in Canadian health care. There is widespread acceptance of digital recording in public spaces and health care; however, respondents preferred to provide consent before recording. Balancing these preferences with the demonstrated advantages of video recording in health care presents challenges for optimal health policy creation. This study provides contemporary data to inform discussions.

Addressing dysfunctional relations among healthcare teams: improving team cooperation through applied organizational theories

Previous research has demonstrated that communication failure and interpersonal conflicts are significant impediments among health-care teams to assess complex information and engage in the meaningful collaboration necessary for optimizing patient care. Despite the prolific research on the role of effective teamwork in accomplishing complex tasks, such findings have been traditionally applied to business organizations and not medical contexts. This chapter, therefore, reviews and applies four theories from the fields of organizational behavior (OB) and organization development (OD) as potential means for improving team interaction in health-care contexts. This study is unique in its approach as it addresses the long-standing problems that exist in team communication and cooperation in health-care teams by applying well-established theories from the organizational literature. The utilization and application of the theoretical constructs discussed in this work offer valuable means by which the efficacy of team work can be greatly improved in health-care organizations.

The performance and assessment of hospital trauma teams

The purpose of the trauma team is to provide advanced simultaneous care from relevant specialists to the seriously injured trauma patient. When functioning well, the outcome of the trauma team performance should be greater than the sum of its parts. Trauma teams have been shown to reduce the time taken for resuscitation, as well as time to CT scan, to emergency department discharge and to the operating room. These benefits are demonstrated by improved survival rates, particularly for the most severely injured patients, both within and outside of dedicated trauma centres. In order to ensure the best possible performance of the team, the leadership skills of the trauma team leader are essential and their non-technical skills have been shown to be particularly important. Team performance can be enhanced through a process of audit and assessment of the workings of the team and the evidence currently available suggests that this is best facilitated through the process of video review of the trauma resuscitation. The use of human patient simulators to train and assess trauma teams is becoming more commonplace and this technique offers a safe environment for the future education of trauma team staff.

Trauma teams are a key component of most programmes which set out to improve trauma care. This article reviews the background of trauma teams, the evidence for benefit and potential techniques of performance assessment. The review was written after a PubMed, Ovid, Athens, Cochrane and guideline literature review of English language articles on trauma teams and their performance and hand searching of references from the relevant searched articles.

Lights, camera, action… spotlight on trauma video review: an underutilized means of quality improvement and education

BACKGROUND

Trauma video review (TVR) is an effective method of quality improvement and education. The objective of this study was to determine TVR practices in the United States and use of TVR for quality improvement and education.

METHODS

Adult and pediatric trauma centers identified by the American College of Surgeons (n = 102) and the National Association of Children's Hospitals and Related Institutions (n = 24) were surveyed by telephone. Surveys included questions regarding program demographics, residency information, and past/present TVR practices.

RESULTS

One hundred eight trauma centers (86%) were contacted, and 99% (107/108) completed surveys. Of the surveyed centers, 34% never used TVR; 37% previously used TVR and had discontinued at the time of the survey, with most reporting legal/privacy concerns; 20% were currently using TVR; and 9% were planning to use TVR in the future. Nineteen percent (14/73) of general trauma centers are using or planning to use TVR compared with 50% (17/34) of pediatric centers (P = 0.001). One hundred percent of current TVR programs report that TVR improves the trauma resuscitation process.Most pediatric emergency medicine (87%), emergency medicine (89%), and surgery (97%) trainees participate in trauma resuscitation at trauma centers. Fifty-two percent of centers using TVR report trainee attendance at TVR process/conference; 38% specifically use TVR for resident education.

CONCLUSIONS

All current TVR programs report that it improves their trauma processes. More pediatric trauma centers report planning future TVR programs, but the implication of such plans remains unclear. Opportunities exist for expanded use of TVR for resident education.

Video registration of trauma team performance in the emergency department: the results of a 2-year analysis in a Level 1 trauma center

BACKGROUND

Trauma teams responsible for the first response to patients with multiple injuries upon arrival in a hospital consist of medical specialists or resident physicians. We hypothesized that 24-hour video registration in the trauma room would allow for precise evaluation of team functioning and deviations from Advanced Trauma Life Support (ATLS) protocols.

METHODS

We analyzed all video registrations of trauma patients who visited the emergency room of a Level I trauma center in the Netherlands between September 1, 2000, and September 1, 2002. Analysis was performed with a score list based on ATLS protocols.

RESULTS

From a total of 1,256 trauma room presentations, we found a total of 387 video registrations suitable for analysis. The majority of patients had an injury severity score lower than 17 (264 patients), whereas 123 patients were classified as multiple injuries (injury severity score >or=17). Errors in team organization (omission of prehospital report, no evident leadership, unorganized resuscitation, not working according to protocol, and no continued supervision of the patient) lead to significantly more deviations in the treatment than when team organization was uncomplicated.

CONCLUSIONS

Video registration of diagnostic and therapeutic procedures by a multidisciplinary trauma team facilitates an accurate analysis of possible deviations from protocol. In addition to identifying technical errors, the role of the team leader can clearly be analyzed and related to team actions. Registration strongly depends on availability of video tapes, timely started registration, and hardware functioning. The results from this study were used to develop a training program for trauma teams in our hospital that specifically focuses on the team leader's functioning.

Medical errors and consequent adverse events in critically ill surgical patients in a tertiary care teaching hospital in Delhi

BACKGROUND

Medical errors and adverse events (AE), though common worldwide, have never been studied in India. We believe that though common these are under reported.

AIM

The aim of this study was to study medical errors and consequent AE in patients presenting with trauma and bowel perforation peritonitis.

METHODS

Five hundred and eighty-six consecutive patients with trauma or peritonitis, presenting to surgery emergency of UCMS-GTBH, were prospectively studied using review form (RF) 1 and 2. AE was defined as an outcome not expected to be part of the illness. RF 1 was filled for all and indicated if AE was present or not. RF2 was filled when RF 1 indicated presence of AE; it further confirmed the occurrence of AE and pointed to the type of medical error and resultant disability. All results were expressed as percentage.

RESULTS

There were 500 (85%) males. Mean age of the patients was 31 years. There were 332 patients with peritonitis and 254 with trauma. AE and its consequences were present in 185 (31.5%) and 183 (31.2%) patients, respectively. Consequences were as follows: disability - 157 (85%), increased hospital stay and/or increased visits in the OPD - 28 (15.3%) and both-101 (55.2%) patients. Disabilities were: death - 62 (40%), temporary disability - 90 (58%) and permanent disability - 05 (3.1%) patients. AE in 133 (71.8%) patients was definitely (level of confidence 6) due to error in healthcare management. All AE were considered preventable. Error of omission accounted for AE in 122 (65.9%) patients. System and operative errors were the commonest, 84.3% and 82.7%, respectively. One hundred and sixty-seven (90%) patients had multiple errors.

CONCLUSIONS

The study proves that medical errors and AE are a serious problem in our set-up and calls for immediate system improvement.

Trauma education and assessment

Trauma education has evolved over the past 30 years from an unstructured preceptorship to standardised courses offered worldwide. The Advanced Trauma Life Support (ATLS) course has formed the backbone of trauma management philosophy and has spawned a series of courses aimed at specific patient populations and health care groups. Trauma education and assessment for advanced trainees has taken the form of formal clinical fellowships. In addition to clinical experience, a number of tools have been validated in aiding trauma education including use of videotape review and simulation technology. Future emphasis on development and validation of teaching and assessment techniques could improve trauma education and secondarily impact trauma outcomes worldwide.

Teamwork and error in the operating room: analysis of skills and roles

OBJECTIVE

To analyze the effects of surgical, anesthetic, and nursing teamwork skills on technical outcomes.

SUMMARY BACKGROUND DATA

The value of team skills in reducing adverse events in the operating room is presently receiving considerable attention. Current work has not yet identified in detail how the teamwork and communication skills of surgeons, anesthetists, and nurses affect the course of an operation.

METHODS

Twenty-six laparoscopic cholecystectomies and 22 carotid endarterectomies were studied using direct observation methods. For each operation, teams' skills were scored for the whole team, and for nursing, surgical, and anesthetic subteams on 4 dimensions (leadership and management [LM]; teamwork and cooperation; problem solving and decision making; and situation awareness). Operating time, errors in surgical technique, and other procedural problems and errors were measured as outcome parameters for each operation. The relationships between teamwork scores and these outcome parameters within each operation were examined using analysis of variance and linear regression.

RESULTS

Surgical (F(2,42) = 3.32, P = 0.046) and anesthetic (F(2,42) = 3.26, P = 0.048) LM had significant but opposite relationships with operating time in each operation: operating time increased significantly with higher anesthetic but decreased with higher surgical LM scores. Errors in surgical technique had a strong association with surgical situation awareness (F(2,42) = 7.93, P < 0.001) in each operation. Other procedural problems and errors were related to the intraoperative LM skills of the nurses (F(5,1) = 3.96, P = 0.027).

CONCLUSIONS

Detailed analysis of team interactions and dimensions is feasible and valuable, yielding important insights into relationships between nontechnical skills, technical performance, and operative duration. These results support the concept that interventions designed to improve teamwork and communication may have beneficial effects on technical performance and patient outcome.

Physician team management affects goal achievement in the intensive care unit

OBJECTIVE

There are few investigations evaluating the impact of physician management and leadership skills on patient care. Our objective was to determine whether there were perceived differences in management and leadership performance within a group of intensivists and to correlate these differences with processes of care outcomes.

DESIGN

Prospective cohort from January 31 to June 30, 2005.

SETTING

Pediatric intensive care unit in an urban, academic children's hospital.

PARTICIPANTS

Pediatric intensive care unit staff intensivists were the primary participants.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The intensivists' management and leadership performances were assessed by residents and fellows using the Physician Management Index. The primary outcome attributable to the staff was the accomplishment of daily patient goals. A total of 827 resident and fellow assessments of the management and leadership performance of attendings (n = 8) were collected over 2077 patient days (103.4 +/- 39.0 surveys/attending). The mean Physician Management Index was 78.1 +/- 6.2 and differed significantly among the attendings (p < .001). There was excellent agreement by the raters concerning attending performance (intraclass correlation = 0.801). The attendings' Physician Management Indexes were correlated with age (r = 0.594, p < .001) and experience (r = 0.656, p < .001) but not other personal or environmental factors. An average of 3.3 +/- 0.6 goals per patient were written each day, and 86.0% +/- 7.0% were accomplished. Accomplishment of patient goals was correlated with the Physician Management Index (r = 0.306, p < .001) and length of rounds (r = -0.341, p < .001). Other variables, including midnight census, numbers of admissions and discharges, codes, and consultations, did not correlate with the Physician Management Index.

CONCLUSIONS

Management and leadership performance of attending intensivists can be measured and is associated with efficiency of care as assessed by accomplishment of daily patient goals. Attendings differ in their management and leadership performances.