District of Columbia — Targeted Issue

Author(s)/Presenter(s)

Deirdre C Kelleher, Elizabeth A Carter, Lauren J Waterhouse, Samantha E Parsons, Jennifer L Fritzeen, Randall S Burd

Abstract/Description

Objectives: Advanced Trauma Life Support (ATLS) has been shown to improve outcomes related to trauma resuscitation; however, omissions from this protocol persist. The objective of this study was to evaluate the effect of a trauma resuscitation checklist on performance of ATLS tasks.

Methods: Video recordings of resuscitations of children sustaining blunt or penetrating injuries at a Level I pediatric trauma center were reviewed for completion and timeliness of ATLS primary and secondary survey tasks, with and without checklist use. Patient and resuscitation characteristics were obtained from the trauma registry. Data were collected during two 4-month periods before (n = 222) and after (n = 213) checklist implementation. The checklist contained 50 items and included four sections: prearrival, primary survey, secondary survey, and departure plan.

Results: Five primary survey ATLS tasks (cervical spine immobilization, oxygen administration, palpating pulses, assessing neurologic status, and exposing the patient) and nine secondary survey ATLS tasks were performed more frequently (p ≤ 0.01 for all) and vital sign measurements were obtained faster (p ≤ 0.01 for all) after the checklist was implemented. When controlling for patient and event-specific characteristics, primary and secondary survey tasks overall were more likely to be completed (odds ratio [OR] = 2.66, primary survey; OR = 2.47, secondary survey; p < 0.001 for both) and primary survey tasks were performed faster (p < 0.001) after the checklist was implemented.

Conclusions: Implementation of a trauma checklist was associated with greater ATLS task performance and with increased frequency and speed of primary and secondary survey task completion.

Author(s)/Presenter(s)

Samantha E Parsons, Elizabeth A Carter, Lauren J Waterhouse, Jennifer Fritzeen, Deirdre C Kelleher, Karen J Oʼconnell, Aleksandra Sarcevic, Kelley M Baker, Erik Nelson, Nicole E Werner, Deborah A Boehm-Davis, Randall S Burd

Abstract/Description

Objective: To develop a checklist for use during pediatric trauma resuscitation and test its effectiveness during simulated resuscitations.

Background: Checklists have been used to support a wide range of complex medical activities and have effectively reduced errors and improved outcomes in different medical settings. Checklists have not been evaluated in the domain of trauma resuscitation.

Methods: A focus group of trauma specialists was organized to develop a checklist for pediatric trauma resuscitation. This checklist was then tested in simulated trauma resuscitations to evaluate its impact on team performance. Resuscitations conducted with and without the checklist were compared using the Advanced Trauma Life Support (ATLS) performance score, designed to measure adherence to ATLS protocol, and surveys of team members' subjective workload.

Results: The focus group generated a checklist with 56 items divided into 5 sections corresponding to different phases of trauma resuscitation. In simulation testing, the total ATLS performance score was 4.9 points higher with a checklist than without (P < 0.001), with most of this difference related to improvement in performance of the secondary survey (+3.3 points, P < 0.001). Overall, workload scores were not affected by the addition of the checklist.

Conclusions: Implementing a checklist during simulated pediatric trauma resuscitation improves adherence to the ATLS protocol without increasing the workload of trauma team members.

Author(s)/Presenter(s)

Kelleher DC, Carter EA, Waterhouse LJ, Burd RS

Abstract/Description

Purpose: Barrier precautions protect patients and providers from blood-borne pathogens. Although barrier precaution compliance has been shown to be low among adult trauma teams, it has not been evaluated during paediatric resuscitations in which perceived risk of disease transmission may be low. The purpose of this study was to identify factors associated with compliance with barrier precautions during paediatric trauma resuscitations.

Methods: Video recordings of resuscitations performed on injured children (<18 years old) were reviewed to determine compliance with an established policy requiring gowns and gloves. Depending on activation level, trauma team members included up to six physicians, four nurses, and a respiratory therapist. Multivariate logistic regression was used to determine the effect of team role, resuscitation factors, and injury mechanism on barrier precaution compliance.

Results: Over twelve weeks, 1138 trauma team members participated in 128 resuscitations (4.7% penetrating injuries, 9.4% highest level activations). Compliance with barrier precautions was 81.3%, with higher compliance seen among roles primarily at the bedside compared to positions not primarily at the bedside (90.7% vs. 65.1%, p<0.001). Bedside residents (98.4%) and surgical fellows (97.6%) had the highest compliance, while surgical attendings (20.8%) had the lowest (p<0.001). Controlling for role, increased compliance was observed during resuscitations of patients with penetrating injuries (OR=3.97 [95% CI: 1.35-11.70], p=0.01), during resuscitations triaged to the highest activation level (OR=2.61 [95% CI: 1.34-5.10], p=0.005), and among team members present before patient arrival (OR=4.14 [95% CI: 2.29-7.39], p<0.001).

Conclusions: Compliance with barrier precautions varies by trauma team role. Team members have higher compliance when treating children with penetrating and high acuity injuries and when arriving before the patient. Interventions integrating barrier precautions into the workflow of team members are needed to reduce this variability and improve compliance with universal precautions during paediatric trauma resuscitations.

Author(s)/Presenter(s)

Carter EA, Waterhouse LJ, Kovler ML, Fritzeen J, Burd RS

Abstract/Description

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.

Author(s)/Presenter(s)

Parsons, Carter, Waterhouse, Sarcevic, OConnell, Burd

Abstract/Description

Background: Trauma resuscitations are high-pressure, time-critical events during which health care providers form ad hoc teams to rapidly assess and treat injured patients. Trauma team members experience varying levels of workload during resuscitations resulting from the objective demands of their role-specific tasks, the circumstances surrounding the event, and their individual previous experiences. The goal of this study was to determine factors influencing workload experienced by trauma team members during pediatric trauma resuscitations.

Methods: Workload was measured using the National Aeronautics and Space Administration Task Load Index (TLX). TLX surveys were administered to four trauma team roles: charge nurse, senior surgical resident (surgical coordinator), emergency medicine physician, and junior surgical resident or nurse practitioner (bedside clinician). A total of 217 surveys were completed. Univariate and multivariate statistical techniques were used to examine the relationship between workload and patient and clinical factors.

Results: Bedside clinicians reported the highest total workload score (208.7), followed by emergency medicine physicians (156.3), surgical coordinators (144.1), and charge nurses (129.1). Workload was higher during higher-level activations (235.3), for events involving intubated patients (249.0), and for patients with an Injury Severity Score greater than 15 (230.4) (p, 0.001 for all). When controlling for potential confounders using multiple linear regression, workload was increased during higher level activations (79.0 points higher, p = 0.01) and events without previous notification (38.9 points higher, p = 0.03). Workload also remained significantly higher for the bedside clinician compared with the other three roles (p ≤ 0.005 for all).

Conclusion: Workload during pediatric trauma resuscitations differed by team role and was increased for higher-level activations and events without previous notification. This study demonstrates the validity of the TLX as a tool to measure workload in trauma resuscitation.

Level of evidence: Prognostic study, level II.