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Checklist implementation reduces Advanced Trauma Life Support workflow deviations during trauma resuscitations without pre-arrival notification
Vol. 217, No. 3S, September 2013
Surgical Forum Abstracts
Based on these observations, four interventions were implemented: trauma bay standardization, patient whiteboards, pre-briefings, and teamwork training. Repeat observations were conducted to measure the impact of the interventions. Cases were stratified based upon time from activation to patient arrival; 0-8 minutes, and >9 minutes. RESULTS: 64 cases from the pre-intervention phase and 108 from the post-intervention phase met criteria. During the pre-intervention phase, more FD and higher FD/min were seen in the >9 minute group. When comparing pre and post intervention phases, the interventions reduced ED case duration in both groups (0-8 min: 66 vs 41.5, p¼0.003; Group 1 (0e8 minutes)
ED duration (min) ED FD rate ED FD rate (FD/min) Group 2 (9 minutes) ED duration (min) ED FD rate ED FD rate (FD/min)
Pre-intervention Post-intervention (mean SD) (mean SD) p Value
66 49.5 7.74 6.1
41.5 27.9 6.51 4.6
0.003 0.17
0.16 0.15
0.18 0.11
0.31
61 40 11.67 8.13
46.3 23.7 5.96 4.03
0.045 <0.0001
0.25 0.17
0.15 0.09
0.001
>9 min: 61 vs 46.3 p¼0.045). There was no significant dfference between FD or FD/min in the 0-8 min group; however, the >9 min group had significant differences in both number of FD (11.7 vs 5.9 p<0.0001) and FD/min (0.25 vs 0.15 p¼0.001). CONCLUSIONS: Using the time before a patient arrives to prepare equipment, gather and share information, and utilize enhanced team skills provides system-level support for improved coordination. These interventions result in faster and more efficient care.
Checklist implementation reduces Advanced Trauma Life Support workflow deviations during trauma resuscitations without pre-arrival notification Deirdre C Kelleher, MD, RP, Jagadeesh Chandra Bose, PhD, Lauren J Waterhouse, BS, Elizabeth A Carter, PhD, MPH, Randall S Burd, MD, PhD, FACS Children’s National Medical Center, Washington, DC INTRODUCTION: Trauma resuscitations without pre-arrival notification are often chaotic, potentially compromising patient care. Checklists may standardize these events and reduce effects of prearrival notification on performance. We hypothesized that trauma resuscitations without pre-arrival notification are performed with more variable adherence to the Advanced Trauma Life Support (ATLS) protocol and that implementation of a checklist would reduce this variability.
S101
METHODS: We analyzed video-review logs of trauma resuscitations from two four-month periods before (n¼222) and after (n¼215) checklist implementation. Individual resuscitations were compared to an optimized workflow model of primary survey tasks and tested for model fitness (range 0 to 1) using process mining. Mean fitness scores and conformance frequency (fitness¼1) were compared (Pearson’s chi-square and Student’s t-test). Multivariate regression analysis controlling for patient and resuscitation characteristics was also performed to determine the effect of checklist implementation. RESULTS: Fifty-five (12.6%) resuscitations lacked pre-arrival notification (pre-implementation, n¼23, post-implementation, n¼32; p¼0.15). Before checklist implementation, resuscitations without notification had lower fitness (0.80 vs 0.90, p<0.001) and conformance (26.1% vs 50.8%, p¼0.03) than those with notification. Following checklist implementation, fitness (0.80 vs 0.91, p¼0.007) and conformance (26.1% vs 59.4%, p¼0.01) improved for resuscitations without notification, with both measurements closer to those of resuscitations with notification (Table 1). Using multivariate analysis, checklist implementation remained associated with higher fitness for resuscitations without pre-arrival notification (B¼0.13, p¼0.006).
Measurement
Notification Yes Fitness, mean (SD) No Yes Conformance, % No Total n ¼ 437
Preimplementation 0.90 (0.13) 0.80 (0.17) 50.8% 26.1%
Postimplementation p Value 0.96 (0.09) <0.001 0.91 (0.13) 0.007 77.6% <0.001 59.4% 0.01
CONCLUSIONS: Trauma resuscitations without pre-arrival notification persist and are associated with a decreased adherence to the ATLS protocol. The addition of a checklist improves protocol adherence and reduces the variability of care between resuscitations with and without notification. Massachusetts health care reform is associated with reduced disparities in the management of acute cholecystitis Andrew P Loehrer, MD, Hugh G Auchincloss, MD, Zirui Song, PhD, Matthew M Hutter, MD, MPH, FACS Massachusetts General Hospital, Boston, MA INTRODUCTION: Immediate cholecystectomy has been shown to be the optimal treatment for acute cholecystitis (AC), yet variation in care persists by insurance status and patient race. The impact of insurance expansion on disparities in surgical care is not known. We evaluated the effect of the 2006 Massachusetts coverage expansion on disparities in the management of AC. METHODS: We used Hospital Cost and Utilization Project State Inpatient Databases to conduct a cohort study comparing Massachusetts with three control states from 2001-2009. All non-elderly
Surgical Forum Abstracts
Based on these observations, four interventions were implemented: trauma bay standardization, patient whiteboards, pre-briefings, and teamwork training. Repeat observations were conducted to measure the impact of the interventions. Cases were stratified based upon time from activation to patient arrival; 0-8 minutes, and >9 minutes. RESULTS: 64 cases from the pre-intervention phase and 108 from the post-intervention phase met criteria. During the pre-intervention phase, more FD and higher FD/min were seen in the >9 minute group. When comparing pre and post intervention phases, the interventions reduced ED case duration in both groups (0-8 min: 66 vs 41.5, p¼0.003; Group 1 (0e8 minutes)
ED duration (min) ED FD rate ED FD rate (FD/min) Group 2 (9 minutes) ED duration (min) ED FD rate ED FD rate (FD/min)
Pre-intervention Post-intervention (mean SD) (mean SD) p Value
66 49.5 7.74 6.1
41.5 27.9 6.51 4.6
0.003 0.17
0.16 0.15
0.18 0.11
0.31
61 40 11.67 8.13
46.3 23.7 5.96 4.03
0.045 <0.0001
0.25 0.17
0.15 0.09
0.001
>9 min: 61 vs 46.3 p¼0.045). There was no significant dfference between FD or FD/min in the 0-8 min group; however, the >9 min group had significant differences in both number of FD (11.7 vs 5.9 p<0.0001) and FD/min (0.25 vs 0.15 p¼0.001). CONCLUSIONS: Using the time before a patient arrives to prepare equipment, gather and share information, and utilize enhanced team skills provides system-level support for improved coordination. These interventions result in faster and more efficient care.
Checklist implementation reduces Advanced Trauma Life Support workflow deviations during trauma resuscitations without pre-arrival notification Deirdre C Kelleher, MD, RP, Jagadeesh Chandra Bose, PhD, Lauren J Waterhouse, BS, Elizabeth A Carter, PhD, MPH, Randall S Burd, MD, PhD, FACS Children’s National Medical Center, Washington, DC INTRODUCTION: Trauma resuscitations without pre-arrival notification are often chaotic, potentially compromising patient care. Checklists may standardize these events and reduce effects of prearrival notification on performance. We hypothesized that trauma resuscitations without pre-arrival notification are performed with more variable adherence to the Advanced Trauma Life Support (ATLS) protocol and that implementation of a checklist would reduce this variability.
S101
METHODS: We analyzed video-review logs of trauma resuscitations from two four-month periods before (n¼222) and after (n¼215) checklist implementation. Individual resuscitations were compared to an optimized workflow model of primary survey tasks and tested for model fitness (range 0 to 1) using process mining. Mean fitness scores and conformance frequency (fitness¼1) were compared (Pearson’s chi-square and Student’s t-test). Multivariate regression analysis controlling for patient and resuscitation characteristics was also performed to determine the effect of checklist implementation. RESULTS: Fifty-five (12.6%) resuscitations lacked pre-arrival notification (pre-implementation, n¼23, post-implementation, n¼32; p¼0.15). Before checklist implementation, resuscitations without notification had lower fitness (0.80 vs 0.90, p<0.001) and conformance (26.1% vs 50.8%, p¼0.03) than those with notification. Following checklist implementation, fitness (0.80 vs 0.91, p¼0.007) and conformance (26.1% vs 59.4%, p¼0.01) improved for resuscitations without notification, with both measurements closer to those of resuscitations with notification (Table 1). Using multivariate analysis, checklist implementation remained associated with higher fitness for resuscitations without pre-arrival notification (B¼0.13, p¼0.006).
Measurement
Notification Yes Fitness, mean (SD) No Yes Conformance, % No Total n ¼ 437
Preimplementation 0.90 (0.13) 0.80 (0.17) 50.8% 26.1%
Postimplementation p Value 0.96 (0.09) <0.001 0.91 (0.13) 0.007 77.6% <0.001 59.4% 0.01
CONCLUSIONS: Trauma resuscitations without pre-arrival notification persist and are associated with a decreased adherence to the ATLS protocol. The addition of a checklist improves protocol adherence and reduces the variability of care between resuscitations with and without notification. Massachusetts health care reform is associated with reduced disparities in the management of acute cholecystitis Andrew P Loehrer, MD, Hugh G Auchincloss, MD, Zirui Song, PhD, Matthew M Hutter, MD, MPH, FACS Massachusetts General Hospital, Boston, MA INTRODUCTION: Immediate cholecystectomy has been shown to be the optimal treatment for acute cholecystitis (AC), yet variation in care persists by insurance status and patient race. The impact of insurance expansion on disparities in surgical care is not known. We evaluated the effect of the 2006 Massachusetts coverage expansion on disparities in the management of AC. METHODS: We used Hospital Cost and Utilization Project State Inpatient Databases to conduct a cohort study comparing Massachusetts with three control states from 2001-2009. All non-elderly