Performance improvement through best practice team management: human factors in complex trauma

Extending existing recommended military casualty evacuation timelines will likely increase morbidity and mortality: a UK consensus statement

INTRODUCTION

Future conflicts may have limited use of aviation-based prehospital emergency care for evacuation. This will increase the likelihood of extended evacuation timelines and an extended hold at a forward hospital care facility following the completion of damage control surgery or acute medical interventions.

METHODS

A three-round Delphi Study was undertaken using a panel comprising 44 experts from the UK armed forces including clinicians, logisticians, medical planners and commanders. The panel was asked to consider the effect of an extended hold at Deployed Hospital Care (Forward) from the current 2-hour timeline to +4, +8, +12 and +24 hours on a broad range of clinical and logistical issues. Where 75% of respondents had the same opinion, consensus was accepted. Areas where consensus could not be achieved were used to identify future research priorities.

RESULTS

Consensus was reached that increasing timelines would increase the personnel, logistics and equipment support required to provide clinical care. There is a tipping point with a prolonged hold over 8 hours, after which the greatest number of clinical concerns emerge. Additional specialties of surgeons other than general and orthopaedic surgeons will likely be required with holds over 24 hours, and robust telemedicine would not negate this requirement.

CONCLUSIONS

Retaining acute medical emergencies at 4 hours, and head injuries was considered a particular risk. This could potentially be mitigated by an increased forward capacity of some elements of medical care and availability of a CT scanner and intracranial pressure monitoring at over 12 hours. Any efforts to mitigate the effects of prolonged timelines will come at the expense of an increased logistical burden and a reduction in mobility. Ultimately the true effect of prolonged timelines can only be answered by close audit and analysis of clinical outcomes during future operations with an extended hold.

Damage control surgery in neonates: Lessons learned from the battlefield

INTRODUCTION

Mortality for neonates requiring surgery for serious pathology such as NEC, remains high. Damage control surgery (DCS) has evolved as an operative strategy in battlefield trauma that sacrifices the completeness of the initial surgery to address the deadly triad of acidosis, hypothermia and coagulopathy. This approach is now used routinely in sick adults with nontrauma surgical emergencies. Here we describe our experience of using DCS in neonates.

METHOD

Neonates undergoing DCS at our hospital from 1/8/2010 to 30/11/17 had data collected prospectively.

RESULTS

27 neonates (median age 21 days; gestation 29 weeks; weight 1200 g; M:F 18:9) underwent DCS. Diagnosis (NEC 23, volvulus 2, meconium peritonitis 1, spontaneous perforation 1). Preoperative physiology: median temperature 35.5 °C, lactate 3.7, Activated prothrombin time 49; on a median of 1 inotrope (range 0 to 4); 19 had surgery on the intensive care unit. Surgery involved resection of dead bowel with the ends ligated and the abdomen left open. Operation took 38 min (26-80 min) and crew-resource management techniques were used to optimize efficiency. Second look occurred at 48 h (24-108 h) when the physiology had normalized. There were a total of 32 anastomoses in 18 patients with one leak; 3 patients had stomas for distal rectal disease. Overall mortality was 15% (4/27) or 18% in the NEC group (4/23).

CONCLUSION

Though techniques such as "clip and drop" exist, they have not been routinely incorporated into an operative strategy for sick neonates based on physiological derangement. The two benefits from our DCS approach were a low mortality and an avoidance of stomas. This approach deserves more investigation to see whether it is as effective in babies and children with nontrauma associated abdominal catastrophes as it is in adults.

TYPE OF STUDY

Case controlled study.

LEVEL OF EVIDENCE

Level III.

Followership in complex trauma

Recent conflicts in Iraq and Afghanistan have highlighted the importance of human factors in complex trauma management. A reorganisation of trauma services in England has led to the creation of Major Trauma Centres and Major Trauma Collaboratives, with dedicated Trauma Teams. Much attention has been devoted to the role of team leader and leadership skills, with the human factor concept of followership largely overlooked. This article examines the importance of followership in the trauma team, scrutinising several different followership styles. Followership should be highlighted during trauma team training, promoting the practice of good followership to support the team leader and improve patient care.

Training residents to lead emergency teams: A qualitative review of barriers, challenges and learning goals

OBJECTIVE

An investigation to determine any consensus in opinions and views in the literature about challenges or barriers in training leadership for emergencies.

SUMMARY OF BACKGROUND DATA

Leadership in emergencies is reported as being very important for patient outcome. A systematic review failed in 2016 to find any focused leadership training. In the literature, the research has described and focused on developing tools to evaluate leadership.

METHOD

Articles identified in the systematic review combined with other reviews and opinions were included to incorporate experiences, perceptions and emotions connected with leadership training in emergency situations. Two qualitative content analyses were conducted. The first analysis searched for opinions about leadership and leadership training in emergencies. The method was abductive - inductive qualitative content analysis. The second analysis searched, on the basis of an article written in 1986, statements about challenges regarding leadership training in all articles. This method was directed qualitative content analysis.

FINDINGS

In total 40 articles covering the years 1986-2016 were analysed. An explicit need for workable leadership training of team leaders in emergencies was identified. The importance of the teamleader in emergencies was repeatedly stressed by 31/40 articles, leadership training is needed or required was stated by 30/40 articles, 27/40 articles described the emergency situation as stressful, complex, chaotic or unpredictable, 17/40 described the importance of self-confidence by the teamleader, and 8/40 described that the situation was perceived as creating concern, anxiety or panic.

CONCLUSIONS

The literature recommends finding a solution to teach residents to gain courage and confidence in stressful surroundings. The literature recommends finding a way to work with body language, non-verbal communication, attitude and appearance in order to radiate credibility in a setting separated from medical knowledge.

Facilitators and barriers to ad hoc team performance

Most teams in hospital medicine are ad hoc, meaning that the teams vary in participants. Ad hoc teams can be found in academic teaching hospitals where team members change across shifts and rotations. Due to varying team membership, these teams face significant hurdles, because they lack an opportunity to develop a team identity, shared mental models, and trust. This article discusses facilitators and barriers to effective functioning of ad hoc teams. Communication, conflict management, power, and leadership are areas that either serve as facilitators or barriers to positive team function. In addition to discussing these aspects, solutions and recommendations from practice are shared. Solutions include data about successful teams, communication in those teams, and data about how to improve education and team training. These practical applications can be applied in practice to improve team functioning. Finally, we recommend that additional research be conducted in the area of ad hoc teams, because this type of team is a large part of medicine with a gap in evidence.

Successful Interprofessional Approach to Development of a Resuscitative Endovascular Balloon Occlusion of the Aorta Program at a Community Trauma Center

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a relatively innovative procedure designed to control critical non-compressible torso hemorrhage. In the United States, this procedure is currently in active use at only a small number of trauma centers.

OBJECTIVE

We describe how we developed our REBOA program at an independent academic-affiliated community trauma center.

DISCUSSION

Through a close interprofessional and multidisciplinary collaboration led by emergency physicians and trauma surgeons, we were able to successfully develop our program.

CONCLUSIONS

Successful implementation of a REBOA program requires close attention to multimodal training, interprofessional roles, team dynamics, financial considerations, and quality assurance processes to safely deliver this potentially life-saving procedure to our trauma patient population.

Using full immersive simulation to prepare trauma teams to work in a major trauma centre

A reconfiguration of trauma services in the UK has led to the development of trauma networks with major trauma centres. This article describes the use of fully immersive simulation to train whole trauma teams in both a traditional simulation centre setting and ‘in situ’ in the clinical environment. Carefully designed scenarios that are driven by experienced faculty allow modern trauma management concepts, such as damage control resuscitation and massive transfusion to be explored within a hospital’s own organisational structure. Human factors specific to the trauma team can also be explored as part of a video-assisted debrief.

In-situ simulation

‘In-situ’ simulation or simulation ‘in the original place’ is gaining popularity as an educational modality. This article discusses the advantages and disadvantages of performing simulation in the clinical workplace drawing on the authors’ experience, particularly for trauma teams and medical emergency teams. ‘In-situ’ simulation is a valuable tool for testing new guidelines and assessing for latent errors in the workplace.

Human factors in contingency operations

The UK Defence Medical Services are currently supporting contingency operations following a period of intensive activity in relatively mature trauma systems in Iraq and Afghanistan. Among the key lessons identified, human factors or non-technical skills played an important role in the improvement of patient care. This article describes the importance of human factors on Role 2 Afloat, one of the Royal Navy's maritime contingency capabilities, and illustrates how they are vital to ensuring that correct decisions are made for patient care in a timely manner. Teamwork and communication are particularly important to ensure that limited resources such as blood products and other consumables are best used and that patients are evacuated promptly, allowing the facility to accept further casualties and therefore maintain operational capability. These ideas may be transferred to any small specialist team given a particular role to perform.

Human factors in decision making in major trauma in Camp Bastion, Afghanistan

INTRODUCTION

The concentration of major trauma experience at Camp Bastion has allowed continuous improvements to occur in the patient pathway from the point of wounding to surgical treatment. These changes have involved clinical management as well as alterations to the physical layout of the hospital, training and decision making. Consideration of the human factors has been a major part of these improvements.

METHODS

We describe the Camp Bastion patient pathway with the communication template that focused decision making at various key moments during damage control resuscitation and damage control surgery (DCR-DCS). This system identifies four key stages: 'command huddle', 'snap brief', 'sit-reps' (situation reports) and 'sign-out/debrief'. The attitude of staff to communication and decision making is also evaluated.

RESULTS

Twenty cases admitted to Camp Bastion with battlefield injuries were studied from 6 September to 6 October 2012. Qualitative responses from 115 members of staff were collected. All patients were haemodynamically shocked with a median pH of 7.25 (range: 6.83-7.40) and a median of 18 units of mixed red cells and plasma were transfused. In 89% of instances, theatre staff were aware of what was required of them at the beginning of the case, 86% felt there were regular updates and 93% understood what was required of them as the case progressed.

CONCLUSIONS

The evolution of the hospital at Camp Bastion has been a unique learning experience in the field of major trauma. The Defence Medical Services have responded with continuous innovation to optimise DCR-DCS for seriously injured patients. Together with the improvements in clinical care, a communication and decision making matrix was developed. Staff evaluation showed a high degree of satisfaction with the quality of communication.