- Email: [email protected]
Nontechnical skills performance and care processes in the management of the acute trauma patient
Nontechnical skills performance and care processes in the management of the acute trauma patient Philip H. Pucher, MRCS,a Rajesh Aggarwal, PhD, MA, FRCS,a,b Nicola Batrick, FRCS,c Michael Jenkins, FRCS,c,d and Ara Darzi, FACS, FRCS, PC, KBE,a London, UK, and Philadelphia, PA
Background. Acute trauma management is a complex process, with the effective cooperation among multiple clinicians critical to success. Despite this, the effect of nontechnical skills on performance on outcomes has not been investigated previously in trauma. Methods. Trauma calls in an urban, level 1 trauma center were observed directly. Nontechnical performance was measured using T-NOTECHS. Times to disposition and completion of assessment care processes were recorded, as well as any delays or errors. Statistical analysis assessed the effect of T-NOTECHS on performance and outcomes, accounting for Injury Severity Scores (ISS) and time of day as potential confounding factors. Meta-analysis was performed for incidence of delays. Results. Fifty trauma calls were observed, with an ISS of 13 (interquartile range [IQR], 5–25); duration of stay 1 (IQR, 1–8) days; T-NOTECHS, 20.5 (IQR, 18–23); time to disposition, 24 minutes (IQR, 18–42). Trauma calls with low T-NOTECHS scores had a greater time to disposition: 35 minutes (IQR, 23–53) versus 20 (IQR, 16–25; P = .046). ISS showed a significant correlation to duration of stay (r = 0.736; P <.001), but not to T-NOTECHS (r = 0.201; P = .219) or time to disposition (r = 0.113; P = .494). There was no difference between ‘‘in-hours’’ and ‘‘out-of-hours’’ trauma calls for T-NOTECHS scores (21 [IQR, 18–22] vs 20 [IQR, 20–23]; P = .361), or time to disposition (34 minutes [IQR, 24–52] vs 17 [IQR, 15–27]; P = .419). Regression analysis revealed T-NOTECHS as the only factor associated with delays (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.06–0.95). Conclusion. Better teamwork and nontechnical performance are associated with significant decreases in disposition time, an important marker of quality in acute trauma care. Addressing team and nontechnical skills has the potential to improve patient assessment, treatment, and outcomes. (Surgery 2014;155:902-9.) From the Department of Surgery and Cancer,a Imperial College London, London, UK; the Department of Gastrointestinal Surgery,b Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; St Mary’s Hospital Major Trauma Centre,c Imperial College London, London, UK; and the Regional Vascular Unit,d St Mary’s Hospital, Imperial College London, London, UK
MANAGEMENT OF THE ACUTE TRAUMA PATIENT is a complex process. Multidisciplinary teams of emergency physicians, surgeons, and allied health professionals must contend with critically ill patients, undertaking complex decision making, diagnosis, and management.1 Furthermore, these occur in the context of intense time pressure and heavy patient volume; trauma results in >2.6 million hospital admissions in the United States annually2 and is the most common cause of death in young people under the age of 45.3 As such, it is perhaps not Accepted for publication December 27, 2013. Reprint requests: Philip H. Pucher, MRCS, St Mary’s Hospital, 10th floor QEQM, Department of Surgery and Cancer, Praed Street, London, UK, W2 1NY. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2013.12.029
902 SURGERY
surprising that trauma presents an environment of appreciable risk for variability and error, as well as opportunity for the improvement of patient care.4,5 Database-based studies of performance in the acute trauma setting have in the past focused broadly on morbidity and mortality,5 rates of missed injury,6 or on more specific processes such as time to computed tomography (CT)7,8 as surrogate markers of care quality. More qualitative analyses have used morbidity and mortality meeting-derived data or that resulting from reporting of adverse events in attempts to categories error and identify patterns of causality and areas for improvement.4,9,10 Although such studies are valuable in the post hoc assessment of error and attempts to minimize future occurrences, their retrospective nature limits the nature of data from which they can draw. These types of studies suffer
Surgery Volume 155, Number 5
from the limitations of the quality of data entry, but also of the nature of recorded data.5,11 These limitations generally include patient outcomes and may include timing of important diagnostic or treatment steps (such as time to CT), but divulge little about individual clinical care processes or overall team performance, which are critical to the provision of appropriate treatment and the prevention of error.12 The development in recent years of scoring metrics for nontechnical skills underscores the burgeoning recognition of their importance.1,13-15 The effect of team-based and nontechnical skills on overall performance has been described previously in other environments. McCulloch et al16 reported a decrease in both technical and nontechnical intraoperative errors after a training program of crisis resource management for operating room staff; the growing evidence for correlation between nontechnical and technical surgical skill has also been reflected in a recent systematic review by Hull et al.17 Furthermore, in their annual analysis of root causes of sentinel events, data released by the Joint Commission name failures in nontechnical skills repeatedly, such as communication, leadership, and human factors, as the chief culprits.10 The nature of nontechnical skill, however, means that its assessment is difficult except through direct observation, with validated assessment tools only recently coming into broader use.15 Given the complex nature of team working and multidisciplinary intercommunication in trauma, the effect of failings in this area may be magnified, with negative implications for the patient. There is a need to examine the variability and quality of nontechnical performance in a modern trauma center and the consequences on patient outcomes. By employing on site observational methods, individual care processes may be documented, along with nontechnical performance utilizing a validated scoring system such as T-NOTECHS.1 Steinemann et al1 demonstrated previously the association between greater T-NOTECHS scores and a greater speed of completion of the care process1; this study, however, focused on the expert consensus-based development of the T-NOTECHS scale, with a secondary assessment of its relationship to the speed of simulated and real-life trauma calls only, and did not specify which care processes or consider other outcomes. The aim of the present study is to explore the full complexity of acute trauma, taking into account nontechnical performance, care processes, errors, and delays, and their effects on patient outcomes.
Pucher et al 903
METHODS Setting. The study took place at St Mary’s Hospital, London, UK, an academic tertiary referral and designated Major Trauma Centre (equivalent to level 1 trauma center), with dedicated trauma CT, operating room, trauma ward, and clinical team. St Mary’s Hospital covers an urban catchment population of roughly 2 million. The trauma team is at all times led by a named attending (consultant) in trauma, and includes the most senior available member of the following specialties: Anesthesia, general surgery, neurosurgery, orthopedics, and radiology, as well as emergency room nurses and physicians as required. Initial response to trauma calls is covered by residents (specialty registrars), within regular working hours (Monday–Friday, 8 am–5 pm). All specialties, including all relevant disciplines in surgery and interventional radiology, are covered additionally by attendings (consultants). ‘‘Out of hours’’ may be off-site, but are called in as required in response to ambulance pre-alerts, or clinical need after patient arrival and assessment, as is standard practice in the UK. Study design. The study was reviewed and approved by a research ethics committee, reference 12/LO/1395. Trauma calls were observed over the course of 6 months by a clinician observer trained in ethnographic notation and nontechnical skills assessment, with substantial experience in use of the T-NOTECHS scale. Owing to observer availability, a purposive sample of trauma calls was selected, with a combination of day- and night-time hours, weekdays, and weekends, to obtain a sample of patients that the investigators felt would give a representative sample of the trauma population at the study hospital. Trauma calls were observed from the time of activation of the trauma team by an ambulance prealert call, to the time of final patient disposition by the trauma team, which was defined as either a transfer of the patient to the CT if stable, to the operating room or interventional radiology for definitive management, or step-down of the trauma team after either stabilization of the patient (with decision for transfer to ward or discharge), or death in the emergency department. Data collection. The completion and timing of major prescribed patient assessment processes outlined by ATLS guidelines18 were observed. These assessment processes included obtaining vital signs, primary assessment, plain film radiography, and focused abdominal ultrasonography for trauma (FAST examination), and secondary
904 Pucher et al
assessment. Nontechnical team performance was assessed using the T-NOTECHS scale for nontechnical skills adapted for trauma. T-NOTECHS is a validated scoring system which assigns a Likert scale score of 1–5 for each of 5 behavioral domains: Leadership, communication, assessment and decision making, use of resources and cooperation, and global awareness. Based on specific exemplar behaviors, a score for each is assigned, for a total possible score of 5–25.1 Any delays, errors, or adverse events at the time of the trauma call were recorded. Delays were not defined by a specific cutoff time, but were identified where planned processes failed to take place in the intended or prescribed timeframe. A medical error was defined as an unintended act or an act that fails to achieve its aim.19 An adverse event is unintended injury to patients caused by processes other than the patient’s underlying condition.20 These adverse events were recorded from the medical record or from direct observation and agreed with experts in trauma and emergency medicine. Demographic and injury data were recorded at the time of presentation, as well as from a locally maintained database (part of the national Trauma Audit & Research Network database). Subsequent or delayed investigations, such as secondary assessment, as well as outcomes such as morbidity, adverse events, mortality, and duration of stay were recorded from the electronic and medical record after discharge. Endpoints for analysis included T-NOTECHS, time of presentation, Injury Severity Score (ISS), time to disposition, delays, and duration of stay. Statistical analysis. All data was anonymized at point of collection and entered into a database (Microsoft Excel 2011, Microsoft Corp, Redmond, WA), and statistical analysis performed in SPSS 20 (IBM Corp, Armonk, NY). To analyses the effect of nontechnical performance on outcome measures, trauma calls were divided into 2 groups based on T-NOTECHS scores above or below the median value. Time to disposition, ISS, and duration of stay (all Mann-Whitney U test), as well as proportion of patients observed in- or out-of-hours, morbidity/ mortality, and frequency of delays (all Chi-square test) were compared between the 2 groups. The effect of confounding patient and structural factors, such as injury severity and time of presentation to hospital, was considered, because these may have influenced potentially the level of nontechnical performance (eg, a team is more focused when treating a severely injured patient, or performs more
Surgery May 2014
poorly when suffering the effects of fatigue during a night shift). Pearson correlation was performed for ISS versus duration of stay, T-NOTECHS, and time to disposition. Mann-Whitney U test was performed to compare outcomes for groups of patients presenting in- and out-of-hours. Finally, logistic regression analysis, utilizing a forward stepwise model, was performed for incidence of delays, and included sex, time of presentation to hospital, injury severity, injury type, presence of complete trauma team, T-NOTECHS, premorbid state, and presence of a concurrent trauma. Continuous data are presented as median values (interquartile ranges). RESULTS A total of 50 trauma calls were recorded over a 6-month period, involving >27 hours of direct observation of the trauma team (Table I). Of these, 54% were observed ‘‘in-hours.’’ The majority of patients were male victims of blunt trauma, with a median ISS of 13; 46% of patients presented with major trauma, with ISS of >15.21 The study observation period coupled with regular staff rotation allowed observation of multiple team configurations, with not >5 trauma calls led by the same team leader, and fewer still managed by the same assessment team. Observed care processes. The completion of patient assessment processes in accordance with ATLS guidelines18 is detailed in Table II. Every patient underwent a full primary survey including measurement of vital signs and examination and protection of airway, cervical spine if appropriate, respiratory and cardiovascular system, as well abdominal, pelvic, and long bone examination. Use of radiography as part of the primary exam was variable. Although FAST examination was used in almost all cases (96%), chest and abdominal/pelvic radiographs were taken in only 54% of cases. However, focused or full-body (head, neck, chest, abdomen, and pelvis) CT was used in 66% of cases---3 patients who did not undergo CT were unstable, with penetrating thoracic injuries, and were taken directly to the operating room; the rest were patients with superficial injuries discharged subsequently home from the emergency department. A full secondary survey was performed in 64% of cases---50% of patients were assessed in the emergency department, with 14% undergoing a documented secondary examination subsequently on the ward after admission. In 36% of cases, patients had no secondary examination observed during the trauma call or documented subsequently in notes.
Pucher et al 905
Surgery Volume 155, Number 5
Table I. Demographic data for observed trauma calls Variable
Value
n In-hours:out-of-hours ratio* Age Male:female ratio Blunt:penetrating injury ratio Pre-alert time (min) ISS ISS > 15 (n)
50 27:23 44 ± 19.1 38:12 43:7 13 (7–16) 13 (5–25) 24
*In-hours denotes time where consultant (attending) on-site cover available for all specialties, Monday–Friday, 8 am–5 pm. Data reported as median values (interquartile ranges). ISS, Injury Severity Score.
Table II. Frequency of care processes for all patients (n = 50) Care process
Performed (%)
Vital signs Primary assessment Chest radiograph Abdominal/pelvic radiograph FAST examination Secondary assessment Computed tomography Full body Focused
100 100 70 54 96 64 66 32 34
FAST, Focused abdominal sonography for trauma.
Outcomes. Patient outcomes are detailed in Table III. The median duration of stay was 1 day. Morbidity was 8%: 2 patients were treated for hospital-acquired pneumonia, 1 patient was treated conservatively for postoperative bleeding, and 1 patient treated conservatively for gastrointestinal bleeding that developed on the ward. There was 1 death in an elderly, multiply comorbid patient after blunt trauma. The median disposition time was 24 minutes (interquartile range [IQR], 18–42), with a TNOTECHS score of 20.5 (IQR, 18–23). Recorded delays. Delays were noted in 16 patients, 7 (43%) of which occurred during the initial phase of trauma management. Five (31%) related to delays in procuring investigations such as radiographs or CT owing to resources being prioritized for concurrent trauma patients (delay duration, range 10–200 minutes). Five delays (31%) related to delayed secondary assessment after stabilization of the patient and completion of primary survey (range, 60–720 minutes), and 4 events related to delayed management processes
Table III. Results and observed outcomes Outcome measure Duration of stay (d) Morbidity, n (%) Mortality, n (%) Time to FAST (min) Time to CT (min) Time to disposition (min) T-NOTECHS total Leadership Cooperation Communication Assessment and decision making Global awareness
Median (IQR) 1 4 1 7 24 24 20.5 4 4 4 4 4
(0–37)* (8) (2) (5–8) (18–42) (18–42) (18–23) (3–5) (4–4) (3–5) (3–5) (4–5)
*Median (range). CT, Computed tomography; FAST, focused abdominal sonography for trauma.
such as suture closure of wounds (25%; range, 15– 180 minutes). Two delays (13%) resulted from equipment failures (range, 10–58 minutes). In 1 case, both of the emergency department’s blood gas analysis machines broke down, delaying the result and the (stable) patient’s transfer by 10 minutes. In another, a software error failed to save a CT, resulting in delays and necessitating repeat CT of a patient. No delays resulted in subsequent morbidity or mortality. Statistical analysis. Trauma calls with TNOTECHS scores below the median value were found to have a greater time to disposition (Fig) than trauma calls with higher T-NOTECH scores (35 minutes [IQR, 23–53] versus 20 [IQR, 16– 25]; P = .046). This greater time to disposition did not result in a significantly different incidence of delays (9 vs 7; P = .585) or duration of stay (1 day [IQR, 1–11] vs 1 [IQR, 0–7]; P = .967; Table IV). The effects of ISS and time of presentation as potential confounding factors were assessed. Pearson correlation analysis demonstrated a strongly positive correlation between ISS and duration of stay (correlation coefficient r = 0.736; P < .001; 1 outlier removed with ISS 16 and duration of stay 37 days for prolonged inpatient physiotherapy), but not for T-NOTECHS (r = 0.201; P = .219) or time to disposition (r = –0.245; P = .138). Greater ISS did result in a greater number of assessment processes being completed (r = 0.335; P = .032). The number of completed processes of assessment did not correlate with T-NOTECHS (r = –0.235; P = .161) or time to disposition (r = 0.113; P = .494). Similarly, Mann–Whitney U comparison for trauma calls ‘‘in-hours’’ and ‘‘out-of-hours’’ demonstrated no difference between T-NOTECHS scores (21 [IQR, 18–22] vs 20 [IQR, 20–23]; P = .361) or
906 Pucher et al
Figure. Boxplot of disposition times for high and low nontechnical skill scores (T-NOTECHS). Difference in means P = .046. Circles represent outliers. Two high outliers (175 and 229 minutes) in the below-the-median group are not shown owing to scale.
time to disposition (34 minutes [IQR, 24–52] vs 17 [IQR, 15–27]; P = .419). Patients presenting ‘‘in-hours’’ did so with a greater ISS (16 [IQR, 11–25] vs 9 [IQR, 4–17]; P = .037). Morbidity and mortality were not assessed as endpoints because their low incidence precluded meaningful statistical analysis. Logistic regression analysis of delays (Table V) found nontechnical performance as measured by T-NOTECHS score to be the only significant factor, with an odds ratio of 0.24 (95% confidence interval, 0.06–0.95). Model fit (Cox-Snell r2) was good (r2 = 0.604; P = .043). DISCUSSION This study is the first to prospectively observe and record the effects of nontechnical skills and care processes in trauma on patient outcomes. We report an inverse relationship between nontechnical skills as measured by T-NOTECHS and time to disposition (ie, definitive management) and risk of delays to patient management. Statistical analysis suggested that the decrease in treatment times with improved teamwork and nontechnical skills was independent of other potentially confounding, patient-related factors such as ISS. Regression analysis of delays, the majority of which were related to process rather than structural error, found nontechnical team performance to be the only significant independent factor. Our findings are contrary to some previously proposed theories. In 1 psychological analysis, Yun et al22 proposed that the effectiveness of leadership and team behavior in trauma was highly
Surgery May 2014
contingent upon the severity of trauma and team experience. In contrast, our study is the first to assess this in a scientific, prospective manner. Although greater ISS resulted in more through acute assessment---that is, a greater number of assessment processes performed such as radiographs, CT, logroll, and full secondary assessment---and a greater duration of stay as would be expected with recovery from severe injury, our study did not demonstrate any relationship between ISS and nontechnical performance or time to disposition. Differences in care and resource availability between normal ‘‘business hours’’ and weekends or nights have been cited as a structural factor in the variability of hospital outcomes.23,24 However, the treatment of trauma patients ‘‘out-of-hours,’’ when fatigue and disruption of the regular makeup of trauma teams might negatively affect care,23 did not, however, affect T-NOTECHS scores or time to disposition in this study. This finding is in agreement with other recent studies, which have suggested that the creation of named trauma centers with dedicated resources with around-theclock availability have acted effectively to blunt the ‘‘weekend effect’’ in trauma.25,26 Comparing the ‘‘in-hours’’ and ‘‘out-of-hours’’ patient cohorts, the 1 difference which was seen was that patients presenting at night and at weekends exhibited a significantly lesser ISS. This finding is at odds with other reports, which have found either equal25 or greater27 ISS scores among weekend or night trauma patients. One must consider the far greater proportion of penetrating and firearms-related injuries, a greater number of which present at night,25,27 which are included in these American datasets. In our patient cohort, the lesser night-time ISS can be explained by a greater number of patients at night presenting with sequelae of alcohol intoxication, such as self-incurred blunt trauma from falls or injuries suffered in physical assaults, rather than major traumas such as those resulting from road traffic accidents. The results of this study demonstrate a high compliance with recognized international guidelines (ie, ATLS) in the management of acute trauma within a designated level 1-equivalent trauma center, with 100% patients receiving rapid primary assessment and 96% undergoing FAST examination during initial assessment in the trauma bay. Although not all patients underwent plain film radiography, this was supplanted by immediate CT instead---an accepted and safe practice in clinically stable patients.28 Only 2
Pucher et al 907
Surgery Volume 155, Number 5
Table IV. Comparison of acute trauma management with lesser versus greater T-NOTECHS score (below versus above median value) Variable
Below median (T-NOTECHS < 20.5)
Above median (T-NOTECHS < 20.5)
P value
n Time to disposition Delays (n) Duration of stay (d) Injury Severity Score ‘‘In-hours’’ (%)
25 35 (23–53) 9 1 (1–11) 16 (5–21) 60
25 20 (16–25) 7 1 (0–7) 13 (5–25) 54
— .046* .585y .967* .944* .643y
*Mann-Whitney U test. yChi-square test. Values reported as medians (interquartile ranges).
Table V. Logistic regression analysis of delays Variable Male sex ‘‘In-hours’’ ISS > 15 Penetrating injury Complete trauma team T-NOTECHS > median score Preexisting comorbidity Concurrent trauma
Odds ratio (95% CI) 1.40 0.80 1.08 0.34 1.57 0.24 1.40 1.40
(0.32–6.1) (0.22–2.92) (0.30–3.92) (0.04–3.22) (0.30–8.25) (0.06–0.95) (0.32–6.10) (0.32–6.10)
P value .654 .735 .910 .346 .595 .043 .654 .654
CI, Confidence interval; ISS, Injury Severity Score.
patients (4%) had no radiologic investigation---1 unstable patient who was taken directly to the operating room and underwent both laparotomy and thoracotomy, and 1 patient with isolated superficial lacerations. Full secondary examination was either observed or subsequently documented in 64% of cases. Of the remaining 36%, 2 patients (4%) had minimal injuries with ISS of 1 and 5 and were discharged from the emergency department; the rest were admitted for $1 day and may have undergone a secondary examination (which forms part of the trauma department’s admission procedure) and was merely not documented. Delays were recorded in up to 32% of cases, with the majority of delays owing to process error. Remaining structural errors were owing to unforeseeable equipment failure or multiple traumas overwhelming routine operating resources, rather than actual structural shortage or failure. Coupled with the high rate of compliance with ATLS guidelines in primary survey completion, this observation reflects perhaps the maturity of the trauma system in which this study was conducted with appropriate standards of initial patient assessment and resource provision. Published literature places rates of error in trauma at 9–39%4,29; however, these rely on self-reporting rather than on site
observation, as such real rates might be expected to be higher. Importantly, the observed delays did not result in any negative consequences in the form of overt error or adverse events. However, they do serve as potential surrogate quality indicators. Variable observer availability and the laborintensive nature of such methodology are known limitations of on-site observational studies---however, our sample size falls within the range of sample sizes of similar studies conducted in other clinical contexts such as the operating room or intensive care unit.30,31 A purposive sample of night, day, and weekend shifts was observed to obtain as broad a sample as possible. A consecutive sample of this size would have been subject to significant bias secondary to temporal clustering, whereas randomizing a broader series of trauma calls would have necessitated 24-hour availability of observers. Observations were limited to the initial stage of patient management in the emergency room, because previous studies have demonstrated this approach to be the largest domain of complexity and observable error in trauma.4,29 With rates of major error and missed injury of <5% in published literature,4,5,29 a much larger sample would have been required for this study to show any significant differences, if present, in error, morbidity, or mortality-related outcomes; however, we believe valuable insights are to be gained from the nontechnical skills and process-based outcome data presented herein, which has not been subject to examination before. Although the trauma teams were aware they were being observed, observers are regularly present in the emergency department for purposes of education or research, such that a confounding Hawthorne effect (change in behavior owing to presence of an observer) seems unlikely, or minimal. Finally, owing to the observational nature of our study, reliant on trauma calls occurring at random at all hours, it was not feasible to have
908 Pucher et al
multiple reviewers. Observations were conducted by an experienced rater who had demonstrated excellent inter-rater reliability with use of the NOTECHS scale in previous research contexts, minimizing the risk of observer bias.32 The critical nature of timely diagnosis and treatment in acute trauma is well-recognized.33 In place of more subtle and difficult to demonstrate differences in morbidity or mortality, studies of quality improvement continue to utilize time to diagnosis or treatment as important surrogate markers for quality in trauma care.7,8,34 The influence of nontechnical skills on timely patient assessment and treatment is demonstrated conclusively by this study, with greater teamwork and improved nontechnical performance resulting in significant decreases in disposition times and decreased risk of delays. To show changes in more direct quality measures, such as morbidity, or rates of error and adverse events, larger patient cohort studies are required. Dedicated interventions for team training are beginning to take hold in many areas of medicine and surgery, with didactic interventions, augmented by simulation, improving performance and team efficiency.16,35-37 This study highlights the need for this to be further expanded within trauma, with the potential to further improve patient assessment, treatment, and outcomes. The authors thank Nick Sevdalis, PhD, for contributing his expertise in critical review and statistical analysis. REFERENCES 1. Steinemann S, Berg B, Ditullio A, Skinner A, Terada K, Anzelon K, et al. Assessing teamwork in the trauma bay: introduction of a modified ‘‘NOTECHS’’ scale for trauma. Am J Surg 2012;203:69-75. 2. Finkelstein EA, Corso PS, Miller TR. The incidence and economic burden of injuries in the United States. New York: Oxford University Press; 2006. 3. Murphy SL, Xu J, Kochanek KD, Sheery MA, Murphy L. Deaths: preliminary data for 2010. Hyattsville, MD: National Vital Statistics Reports; 2012:60. 4. Pucher PH, Aggarwal R, Twaij A, Batrick N, Jenkins M, Darzi A. Identifying and addressing preventable process errors in trauma care. World J Surg 2013;37:752-8. 5. Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV. Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg 2006;244:371-80. 6. Lawson CM, Daley BJ, Ormsby CB, Enderson B. Missed injuries in the era of the trauma scan. J Trauma 2011;70: 452-6. 7. Haas B, Jurkovich GJ, Wang J, Rivara FP, Mackenzie EJ, Nathens AB. Survival advantage in trauma centers: expeditious intervention or experience? J Am Coll Surg 2009; 208:28-36.
Surgery May 2014
8. Helling TS, Nelson PW, Shook JW, Lainhart K, Kintigh D. The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients. J Trauma 2003;55:20-5. 9. Teixeira PG, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma 2007;63:1338-46. 10. Clarke DL, Gouveia J, Thomson SR, Muckart DJ. Applying modern error theory to the problem of missed injuries in trauma. World J Surg 2008;32:1176-82. 11. Gruen RL, Gabbe BJ, Stelfox HT, Cameron PA. Indicators of the quality of trauma care and the performance of trauma systems. Br J Surg 2012;99(Suppl 1):97-104. 12. Joint Commission. Sentinel event data: root causes by event type 2004-2012 [cited 2013 Jun 1]. Available from: http:// www.jointcommission.org/assets/1/18/Root_Causes_Event_ Type_04_4Q2012.pdf. 13. Sevdalis N, Davis R, Koutantji M, Undre S, Darzi A, Vincent CA. Reliability of a revised NOTECHS scale for use in surgical teams. Am J Surg 2008;196:184-90. 14. Sharma B, Mishra A, Aggarwal R, Grantcharov TP. Nontechnical skills assessment in surgery. Surg Oncol 2011;20: 169-77. 15. Yule S, Flin R, Paterson-Brown S, Maran N. Non-technical skills for surgeons in the operating room: a review of the literature. Surgery 2006;139:140-9. 16. McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care 2009;18:109-15. 17. Hull L, Arora S, Aggarwal R, Darzi A, Vincent C, Sevdalis N. The impact of nontechnical skills on technical performance in surgery: a systematic review. J Am Coll Surg 2012;214:214-30. 18. American College of Surgeons. Trauma. In: ATLS advanced trauma life support for doctors: student course manual. 9th edition Chicago: American College of Surgeons; 2012. 19. Leape LL. Error in medicine. JAMA 1994;272:1851-7. 20. Brennan TA, Leape LL. Adverse events, negligence in hospitalized patients: results from the Harvard Medical Practice Study. Perspect Healthc Risk Manage 1991;11:2-8. 21. Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW. The Injury Severity Score revisited. J Trauma 1988;28:69-77. 22. Yun S, Faraj S, Sims HP Jr. Contingent leadership and effectiveness of trauma resuscitation teams. J Appl Psychol 2005; 90:1288-96. 23. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med 2001;345:663-8. 24. Gould JB, Qin C, Marks AR, Chavez G. Neonatal mortality in weekend vs weekday births. JAMA 2003;289:2958-62. 25. Carr BG, Jenkins P, Branas CC, Wiebe DJ, Kim P, Schwab CW, et al. Does the trauma system protect against the weekend effect? J Trauma 2010;69:1042-7. 26. Carr BG, Reilly PM, Schwab CW, Branas CC, Geiger J, Wiebe DJ. Weekend and night outcomes in a statewide trauma system. Arch Surg 2011;146:810-7. 27. Carmody IC, Romero J, Velmahos GC. Day for night: should we staff a trauma center like a nightclub? Am Surg 2002;68: 1048-51. 28. Barleben A, Jafari F, Rose J Jr, Dolich M, Malinoski D, Lekawa M, et al. Implementation of a cost-saving algorithm for pelvic radiographs in blunt trauma patients. J Trauma 2011;71:582-4.
Pucher et al 909
Surgery Volume 155, Number 5
29. Chua WC, D’Amours SK, Sugrue M, Caldwell E, Brown K. Performance and consistency of care in admitted trauma patients: our next great opportunity in trauma care? ANZ J Surg 2009;79:443-8. 30. Symons NR, Almoudaris AM, Nagpal K, Vincent CA, Moorthy K. An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery. Ann Surg 2013;257:1-5. 31. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 1995;23: 294-300. 32. Pucher PH, Darzi A, Aggarwal R. Simulation for ward processes of surgical care. Am J Surg 2013;206:96-102. 33. Tien HC, Jung V, Pinto R, Mainprize T, Scales DC, Rizoli SB. Reducing time-to-treatment decreases mortality of trauma
34.
35.
36.
37.
patients with acute subdural hematoma. Ann Surg 2011; 253:1178-83. Cornwell EE 3rd, Chang DC, Phillips J, Campbell KA. Enhanced trauma program commitment at a level I trauma center: effect on the process and outcome of care. Arch Surg 2003;138:838-43. Mishra A, Catchpole K, Dale T, McCulloch P. The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy. Surg Endosc 2008;22:68-73. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010; 304:1693-700. Capella J, Smith S, Philp A, Putnam T, Gilbert C, Fry W, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ 2010;67:439-43.
Background. Acute trauma management is a complex process, with the effective cooperation among multiple clinicians critical to success. Despite this, the effect of nontechnical skills on performance on outcomes has not been investigated previously in trauma. Methods. Trauma calls in an urban, level 1 trauma center were observed directly. Nontechnical performance was measured using T-NOTECHS. Times to disposition and completion of assessment care processes were recorded, as well as any delays or errors. Statistical analysis assessed the effect of T-NOTECHS on performance and outcomes, accounting for Injury Severity Scores (ISS) and time of day as potential confounding factors. Meta-analysis was performed for incidence of delays. Results. Fifty trauma calls were observed, with an ISS of 13 (interquartile range [IQR], 5–25); duration of stay 1 (IQR, 1–8) days; T-NOTECHS, 20.5 (IQR, 18–23); time to disposition, 24 minutes (IQR, 18–42). Trauma calls with low T-NOTECHS scores had a greater time to disposition: 35 minutes (IQR, 23–53) versus 20 (IQR, 16–25; P = .046). ISS showed a significant correlation to duration of stay (r = 0.736; P <.001), but not to T-NOTECHS (r = 0.201; P = .219) or time to disposition (r = 0.113; P = .494). There was no difference between ‘‘in-hours’’ and ‘‘out-of-hours’’ trauma calls for T-NOTECHS scores (21 [IQR, 18–22] vs 20 [IQR, 20–23]; P = .361), or time to disposition (34 minutes [IQR, 24–52] vs 17 [IQR, 15–27]; P = .419). Regression analysis revealed T-NOTECHS as the only factor associated with delays (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.06–0.95). Conclusion. Better teamwork and nontechnical performance are associated with significant decreases in disposition time, an important marker of quality in acute trauma care. Addressing team and nontechnical skills has the potential to improve patient assessment, treatment, and outcomes. (Surgery 2014;155:902-9.) From the Department of Surgery and Cancer,a Imperial College London, London, UK; the Department of Gastrointestinal Surgery,b Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; St Mary’s Hospital Major Trauma Centre,c Imperial College London, London, UK; and the Regional Vascular Unit,d St Mary’s Hospital, Imperial College London, London, UK
MANAGEMENT OF THE ACUTE TRAUMA PATIENT is a complex process. Multidisciplinary teams of emergency physicians, surgeons, and allied health professionals must contend with critically ill patients, undertaking complex decision making, diagnosis, and management.1 Furthermore, these occur in the context of intense time pressure and heavy patient volume; trauma results in >2.6 million hospital admissions in the United States annually2 and is the most common cause of death in young people under the age of 45.3 As such, it is perhaps not Accepted for publication December 27, 2013. Reprint requests: Philip H. Pucher, MRCS, St Mary’s Hospital, 10th floor QEQM, Department of Surgery and Cancer, Praed Street, London, UK, W2 1NY. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2013.12.029
902 SURGERY
surprising that trauma presents an environment of appreciable risk for variability and error, as well as opportunity for the improvement of patient care.4,5 Database-based studies of performance in the acute trauma setting have in the past focused broadly on morbidity and mortality,5 rates of missed injury,6 or on more specific processes such as time to computed tomography (CT)7,8 as surrogate markers of care quality. More qualitative analyses have used morbidity and mortality meeting-derived data or that resulting from reporting of adverse events in attempts to categories error and identify patterns of causality and areas for improvement.4,9,10 Although such studies are valuable in the post hoc assessment of error and attempts to minimize future occurrences, their retrospective nature limits the nature of data from which they can draw. These types of studies suffer
Surgery Volume 155, Number 5
from the limitations of the quality of data entry, but also of the nature of recorded data.5,11 These limitations generally include patient outcomes and may include timing of important diagnostic or treatment steps (such as time to CT), but divulge little about individual clinical care processes or overall team performance, which are critical to the provision of appropriate treatment and the prevention of error.12 The development in recent years of scoring metrics for nontechnical skills underscores the burgeoning recognition of their importance.1,13-15 The effect of team-based and nontechnical skills on overall performance has been described previously in other environments. McCulloch et al16 reported a decrease in both technical and nontechnical intraoperative errors after a training program of crisis resource management for operating room staff; the growing evidence for correlation between nontechnical and technical surgical skill has also been reflected in a recent systematic review by Hull et al.17 Furthermore, in their annual analysis of root causes of sentinel events, data released by the Joint Commission name failures in nontechnical skills repeatedly, such as communication, leadership, and human factors, as the chief culprits.10 The nature of nontechnical skill, however, means that its assessment is difficult except through direct observation, with validated assessment tools only recently coming into broader use.15 Given the complex nature of team working and multidisciplinary intercommunication in trauma, the effect of failings in this area may be magnified, with negative implications for the patient. There is a need to examine the variability and quality of nontechnical performance in a modern trauma center and the consequences on patient outcomes. By employing on site observational methods, individual care processes may be documented, along with nontechnical performance utilizing a validated scoring system such as T-NOTECHS.1 Steinemann et al1 demonstrated previously the association between greater T-NOTECHS scores and a greater speed of completion of the care process1; this study, however, focused on the expert consensus-based development of the T-NOTECHS scale, with a secondary assessment of its relationship to the speed of simulated and real-life trauma calls only, and did not specify which care processes or consider other outcomes. The aim of the present study is to explore the full complexity of acute trauma, taking into account nontechnical performance, care processes, errors, and delays, and their effects on patient outcomes.
Pucher et al 903
METHODS Setting. The study took place at St Mary’s Hospital, London, UK, an academic tertiary referral and designated Major Trauma Centre (equivalent to level 1 trauma center), with dedicated trauma CT, operating room, trauma ward, and clinical team. St Mary’s Hospital covers an urban catchment population of roughly 2 million. The trauma team is at all times led by a named attending (consultant) in trauma, and includes the most senior available member of the following specialties: Anesthesia, general surgery, neurosurgery, orthopedics, and radiology, as well as emergency room nurses and physicians as required. Initial response to trauma calls is covered by residents (specialty registrars), within regular working hours (Monday–Friday, 8 am–5 pm). All specialties, including all relevant disciplines in surgery and interventional radiology, are covered additionally by attendings (consultants). ‘‘Out of hours’’ may be off-site, but are called in as required in response to ambulance pre-alerts, or clinical need after patient arrival and assessment, as is standard practice in the UK. Study design. The study was reviewed and approved by a research ethics committee, reference 12/LO/1395. Trauma calls were observed over the course of 6 months by a clinician observer trained in ethnographic notation and nontechnical skills assessment, with substantial experience in use of the T-NOTECHS scale. Owing to observer availability, a purposive sample of trauma calls was selected, with a combination of day- and night-time hours, weekdays, and weekends, to obtain a sample of patients that the investigators felt would give a representative sample of the trauma population at the study hospital. Trauma calls were observed from the time of activation of the trauma team by an ambulance prealert call, to the time of final patient disposition by the trauma team, which was defined as either a transfer of the patient to the CT if stable, to the operating room or interventional radiology for definitive management, or step-down of the trauma team after either stabilization of the patient (with decision for transfer to ward or discharge), or death in the emergency department. Data collection. The completion and timing of major prescribed patient assessment processes outlined by ATLS guidelines18 were observed. These assessment processes included obtaining vital signs, primary assessment, plain film radiography, and focused abdominal ultrasonography for trauma (FAST examination), and secondary
904 Pucher et al
assessment. Nontechnical team performance was assessed using the T-NOTECHS scale for nontechnical skills adapted for trauma. T-NOTECHS is a validated scoring system which assigns a Likert scale score of 1–5 for each of 5 behavioral domains: Leadership, communication, assessment and decision making, use of resources and cooperation, and global awareness. Based on specific exemplar behaviors, a score for each is assigned, for a total possible score of 5–25.1 Any delays, errors, or adverse events at the time of the trauma call were recorded. Delays were not defined by a specific cutoff time, but were identified where planned processes failed to take place in the intended or prescribed timeframe. A medical error was defined as an unintended act or an act that fails to achieve its aim.19 An adverse event is unintended injury to patients caused by processes other than the patient’s underlying condition.20 These adverse events were recorded from the medical record or from direct observation and agreed with experts in trauma and emergency medicine. Demographic and injury data were recorded at the time of presentation, as well as from a locally maintained database (part of the national Trauma Audit & Research Network database). Subsequent or delayed investigations, such as secondary assessment, as well as outcomes such as morbidity, adverse events, mortality, and duration of stay were recorded from the electronic and medical record after discharge. Endpoints for analysis included T-NOTECHS, time of presentation, Injury Severity Score (ISS), time to disposition, delays, and duration of stay. Statistical analysis. All data was anonymized at point of collection and entered into a database (Microsoft Excel 2011, Microsoft Corp, Redmond, WA), and statistical analysis performed in SPSS 20 (IBM Corp, Armonk, NY). To analyses the effect of nontechnical performance on outcome measures, trauma calls were divided into 2 groups based on T-NOTECHS scores above or below the median value. Time to disposition, ISS, and duration of stay (all Mann-Whitney U test), as well as proportion of patients observed in- or out-of-hours, morbidity/ mortality, and frequency of delays (all Chi-square test) were compared between the 2 groups. The effect of confounding patient and structural factors, such as injury severity and time of presentation to hospital, was considered, because these may have influenced potentially the level of nontechnical performance (eg, a team is more focused when treating a severely injured patient, or performs more
Surgery May 2014
poorly when suffering the effects of fatigue during a night shift). Pearson correlation was performed for ISS versus duration of stay, T-NOTECHS, and time to disposition. Mann-Whitney U test was performed to compare outcomes for groups of patients presenting in- and out-of-hours. Finally, logistic regression analysis, utilizing a forward stepwise model, was performed for incidence of delays, and included sex, time of presentation to hospital, injury severity, injury type, presence of complete trauma team, T-NOTECHS, premorbid state, and presence of a concurrent trauma. Continuous data are presented as median values (interquartile ranges). RESULTS A total of 50 trauma calls were recorded over a 6-month period, involving >27 hours of direct observation of the trauma team (Table I). Of these, 54% were observed ‘‘in-hours.’’ The majority of patients were male victims of blunt trauma, with a median ISS of 13; 46% of patients presented with major trauma, with ISS of >15.21 The study observation period coupled with regular staff rotation allowed observation of multiple team configurations, with not >5 trauma calls led by the same team leader, and fewer still managed by the same assessment team. Observed care processes. The completion of patient assessment processes in accordance with ATLS guidelines18 is detailed in Table II. Every patient underwent a full primary survey including measurement of vital signs and examination and protection of airway, cervical spine if appropriate, respiratory and cardiovascular system, as well abdominal, pelvic, and long bone examination. Use of radiography as part of the primary exam was variable. Although FAST examination was used in almost all cases (96%), chest and abdominal/pelvic radiographs were taken in only 54% of cases. However, focused or full-body (head, neck, chest, abdomen, and pelvis) CT was used in 66% of cases---3 patients who did not undergo CT were unstable, with penetrating thoracic injuries, and were taken directly to the operating room; the rest were patients with superficial injuries discharged subsequently home from the emergency department. A full secondary survey was performed in 64% of cases---50% of patients were assessed in the emergency department, with 14% undergoing a documented secondary examination subsequently on the ward after admission. In 36% of cases, patients had no secondary examination observed during the trauma call or documented subsequently in notes.
Pucher et al 905
Surgery Volume 155, Number 5
Table I. Demographic data for observed trauma calls Variable
Value
n In-hours:out-of-hours ratio* Age Male:female ratio Blunt:penetrating injury ratio Pre-alert time (min) ISS ISS > 15 (n)
50 27:23 44 ± 19.1 38:12 43:7 13 (7–16) 13 (5–25) 24
*In-hours denotes time where consultant (attending) on-site cover available for all specialties, Monday–Friday, 8 am–5 pm. Data reported as median values (interquartile ranges). ISS, Injury Severity Score.
Table II. Frequency of care processes for all patients (n = 50) Care process
Performed (%)
Vital signs Primary assessment Chest radiograph Abdominal/pelvic radiograph FAST examination Secondary assessment Computed tomography Full body Focused
100 100 70 54 96 64 66 32 34
FAST, Focused abdominal sonography for trauma.
Outcomes. Patient outcomes are detailed in Table III. The median duration of stay was 1 day. Morbidity was 8%: 2 patients were treated for hospital-acquired pneumonia, 1 patient was treated conservatively for postoperative bleeding, and 1 patient treated conservatively for gastrointestinal bleeding that developed on the ward. There was 1 death in an elderly, multiply comorbid patient after blunt trauma. The median disposition time was 24 minutes (interquartile range [IQR], 18–42), with a TNOTECHS score of 20.5 (IQR, 18–23). Recorded delays. Delays were noted in 16 patients, 7 (43%) of which occurred during the initial phase of trauma management. Five (31%) related to delays in procuring investigations such as radiographs or CT owing to resources being prioritized for concurrent trauma patients (delay duration, range 10–200 minutes). Five delays (31%) related to delayed secondary assessment after stabilization of the patient and completion of primary survey (range, 60–720 minutes), and 4 events related to delayed management processes
Table III. Results and observed outcomes Outcome measure Duration of stay (d) Morbidity, n (%) Mortality, n (%) Time to FAST (min) Time to CT (min) Time to disposition (min) T-NOTECHS total Leadership Cooperation Communication Assessment and decision making Global awareness
Median (IQR) 1 4 1 7 24 24 20.5 4 4 4 4 4
(0–37)* (8) (2) (5–8) (18–42) (18–42) (18–23) (3–5) (4–4) (3–5) (3–5) (4–5)
*Median (range). CT, Computed tomography; FAST, focused abdominal sonography for trauma.
such as suture closure of wounds (25%; range, 15– 180 minutes). Two delays (13%) resulted from equipment failures (range, 10–58 minutes). In 1 case, both of the emergency department’s blood gas analysis machines broke down, delaying the result and the (stable) patient’s transfer by 10 minutes. In another, a software error failed to save a CT, resulting in delays and necessitating repeat CT of a patient. No delays resulted in subsequent morbidity or mortality. Statistical analysis. Trauma calls with TNOTECHS scores below the median value were found to have a greater time to disposition (Fig) than trauma calls with higher T-NOTECH scores (35 minutes [IQR, 23–53] versus 20 [IQR, 16– 25]; P = .046). This greater time to disposition did not result in a significantly different incidence of delays (9 vs 7; P = .585) or duration of stay (1 day [IQR, 1–11] vs 1 [IQR, 0–7]; P = .967; Table IV). The effects of ISS and time of presentation as potential confounding factors were assessed. Pearson correlation analysis demonstrated a strongly positive correlation between ISS and duration of stay (correlation coefficient r = 0.736; P < .001; 1 outlier removed with ISS 16 and duration of stay 37 days for prolonged inpatient physiotherapy), but not for T-NOTECHS (r = 0.201; P = .219) or time to disposition (r = –0.245; P = .138). Greater ISS did result in a greater number of assessment processes being completed (r = 0.335; P = .032). The number of completed processes of assessment did not correlate with T-NOTECHS (r = –0.235; P = .161) or time to disposition (r = 0.113; P = .494). Similarly, Mann–Whitney U comparison for trauma calls ‘‘in-hours’’ and ‘‘out-of-hours’’ demonstrated no difference between T-NOTECHS scores (21 [IQR, 18–22] vs 20 [IQR, 20–23]; P = .361) or
906 Pucher et al
Figure. Boxplot of disposition times for high and low nontechnical skill scores (T-NOTECHS). Difference in means P = .046. Circles represent outliers. Two high outliers (175 and 229 minutes) in the below-the-median group are not shown owing to scale.
time to disposition (34 minutes [IQR, 24–52] vs 17 [IQR, 15–27]; P = .419). Patients presenting ‘‘in-hours’’ did so with a greater ISS (16 [IQR, 11–25] vs 9 [IQR, 4–17]; P = .037). Morbidity and mortality were not assessed as endpoints because their low incidence precluded meaningful statistical analysis. Logistic regression analysis of delays (Table V) found nontechnical performance as measured by T-NOTECHS score to be the only significant factor, with an odds ratio of 0.24 (95% confidence interval, 0.06–0.95). Model fit (Cox-Snell r2) was good (r2 = 0.604; P = .043). DISCUSSION This study is the first to prospectively observe and record the effects of nontechnical skills and care processes in trauma on patient outcomes. We report an inverse relationship between nontechnical skills as measured by T-NOTECHS and time to disposition (ie, definitive management) and risk of delays to patient management. Statistical analysis suggested that the decrease in treatment times with improved teamwork and nontechnical skills was independent of other potentially confounding, patient-related factors such as ISS. Regression analysis of delays, the majority of which were related to process rather than structural error, found nontechnical team performance to be the only significant independent factor. Our findings are contrary to some previously proposed theories. In 1 psychological analysis, Yun et al22 proposed that the effectiveness of leadership and team behavior in trauma was highly
Surgery May 2014
contingent upon the severity of trauma and team experience. In contrast, our study is the first to assess this in a scientific, prospective manner. Although greater ISS resulted in more through acute assessment---that is, a greater number of assessment processes performed such as radiographs, CT, logroll, and full secondary assessment---and a greater duration of stay as would be expected with recovery from severe injury, our study did not demonstrate any relationship between ISS and nontechnical performance or time to disposition. Differences in care and resource availability between normal ‘‘business hours’’ and weekends or nights have been cited as a structural factor in the variability of hospital outcomes.23,24 However, the treatment of trauma patients ‘‘out-of-hours,’’ when fatigue and disruption of the regular makeup of trauma teams might negatively affect care,23 did not, however, affect T-NOTECHS scores or time to disposition in this study. This finding is in agreement with other recent studies, which have suggested that the creation of named trauma centers with dedicated resources with around-theclock availability have acted effectively to blunt the ‘‘weekend effect’’ in trauma.25,26 Comparing the ‘‘in-hours’’ and ‘‘out-of-hours’’ patient cohorts, the 1 difference which was seen was that patients presenting at night and at weekends exhibited a significantly lesser ISS. This finding is at odds with other reports, which have found either equal25 or greater27 ISS scores among weekend or night trauma patients. One must consider the far greater proportion of penetrating and firearms-related injuries, a greater number of which present at night,25,27 which are included in these American datasets. In our patient cohort, the lesser night-time ISS can be explained by a greater number of patients at night presenting with sequelae of alcohol intoxication, such as self-incurred blunt trauma from falls or injuries suffered in physical assaults, rather than major traumas such as those resulting from road traffic accidents. The results of this study demonstrate a high compliance with recognized international guidelines (ie, ATLS) in the management of acute trauma within a designated level 1-equivalent trauma center, with 100% patients receiving rapid primary assessment and 96% undergoing FAST examination during initial assessment in the trauma bay. Although not all patients underwent plain film radiography, this was supplanted by immediate CT instead---an accepted and safe practice in clinically stable patients.28 Only 2
Pucher et al 907
Surgery Volume 155, Number 5
Table IV. Comparison of acute trauma management with lesser versus greater T-NOTECHS score (below versus above median value) Variable
Below median (T-NOTECHS < 20.5)
Above median (T-NOTECHS < 20.5)
P value
n Time to disposition Delays (n) Duration of stay (d) Injury Severity Score ‘‘In-hours’’ (%)
25 35 (23–53) 9 1 (1–11) 16 (5–21) 60
25 20 (16–25) 7 1 (0–7) 13 (5–25) 54
— .046* .585y .967* .944* .643y
*Mann-Whitney U test. yChi-square test. Values reported as medians (interquartile ranges).
Table V. Logistic regression analysis of delays Variable Male sex ‘‘In-hours’’ ISS > 15 Penetrating injury Complete trauma team T-NOTECHS > median score Preexisting comorbidity Concurrent trauma
Odds ratio (95% CI) 1.40 0.80 1.08 0.34 1.57 0.24 1.40 1.40
(0.32–6.1) (0.22–2.92) (0.30–3.92) (0.04–3.22) (0.30–8.25) (0.06–0.95) (0.32–6.10) (0.32–6.10)
P value .654 .735 .910 .346 .595 .043 .654 .654
CI, Confidence interval; ISS, Injury Severity Score.
patients (4%) had no radiologic investigation---1 unstable patient who was taken directly to the operating room and underwent both laparotomy and thoracotomy, and 1 patient with isolated superficial lacerations. Full secondary examination was either observed or subsequently documented in 64% of cases. Of the remaining 36%, 2 patients (4%) had minimal injuries with ISS of 1 and 5 and were discharged from the emergency department; the rest were admitted for $1 day and may have undergone a secondary examination (which forms part of the trauma department’s admission procedure) and was merely not documented. Delays were recorded in up to 32% of cases, with the majority of delays owing to process error. Remaining structural errors were owing to unforeseeable equipment failure or multiple traumas overwhelming routine operating resources, rather than actual structural shortage or failure. Coupled with the high rate of compliance with ATLS guidelines in primary survey completion, this observation reflects perhaps the maturity of the trauma system in which this study was conducted with appropriate standards of initial patient assessment and resource provision. Published literature places rates of error in trauma at 9–39%4,29; however, these rely on self-reporting rather than on site
observation, as such real rates might be expected to be higher. Importantly, the observed delays did not result in any negative consequences in the form of overt error or adverse events. However, they do serve as potential surrogate quality indicators. Variable observer availability and the laborintensive nature of such methodology are known limitations of on-site observational studies---however, our sample size falls within the range of sample sizes of similar studies conducted in other clinical contexts such as the operating room or intensive care unit.30,31 A purposive sample of night, day, and weekend shifts was observed to obtain as broad a sample as possible. A consecutive sample of this size would have been subject to significant bias secondary to temporal clustering, whereas randomizing a broader series of trauma calls would have necessitated 24-hour availability of observers. Observations were limited to the initial stage of patient management in the emergency room, because previous studies have demonstrated this approach to be the largest domain of complexity and observable error in trauma.4,29 With rates of major error and missed injury of <5% in published literature,4,5,29 a much larger sample would have been required for this study to show any significant differences, if present, in error, morbidity, or mortality-related outcomes; however, we believe valuable insights are to be gained from the nontechnical skills and process-based outcome data presented herein, which has not been subject to examination before. Although the trauma teams were aware they were being observed, observers are regularly present in the emergency department for purposes of education or research, such that a confounding Hawthorne effect (change in behavior owing to presence of an observer) seems unlikely, or minimal. Finally, owing to the observational nature of our study, reliant on trauma calls occurring at random at all hours, it was not feasible to have
908 Pucher et al
multiple reviewers. Observations were conducted by an experienced rater who had demonstrated excellent inter-rater reliability with use of the NOTECHS scale in previous research contexts, minimizing the risk of observer bias.32 The critical nature of timely diagnosis and treatment in acute trauma is well-recognized.33 In place of more subtle and difficult to demonstrate differences in morbidity or mortality, studies of quality improvement continue to utilize time to diagnosis or treatment as important surrogate markers for quality in trauma care.7,8,34 The influence of nontechnical skills on timely patient assessment and treatment is demonstrated conclusively by this study, with greater teamwork and improved nontechnical performance resulting in significant decreases in disposition times and decreased risk of delays. To show changes in more direct quality measures, such as morbidity, or rates of error and adverse events, larger patient cohort studies are required. Dedicated interventions for team training are beginning to take hold in many areas of medicine and surgery, with didactic interventions, augmented by simulation, improving performance and team efficiency.16,35-37 This study highlights the need for this to be further expanded within trauma, with the potential to further improve patient assessment, treatment, and outcomes. The authors thank Nick Sevdalis, PhD, for contributing his expertise in critical review and statistical analysis. REFERENCES 1. Steinemann S, Berg B, Ditullio A, Skinner A, Terada K, Anzelon K, et al. Assessing teamwork in the trauma bay: introduction of a modified ‘‘NOTECHS’’ scale for trauma. Am J Surg 2012;203:69-75. 2. Finkelstein EA, Corso PS, Miller TR. The incidence and economic burden of injuries in the United States. New York: Oxford University Press; 2006. 3. Murphy SL, Xu J, Kochanek KD, Sheery MA, Murphy L. Deaths: preliminary data for 2010. Hyattsville, MD: National Vital Statistics Reports; 2012:60. 4. Pucher PH, Aggarwal R, Twaij A, Batrick N, Jenkins M, Darzi A. Identifying and addressing preventable process errors in trauma care. World J Surg 2013;37:752-8. 5. Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV. Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg 2006;244:371-80. 6. Lawson CM, Daley BJ, Ormsby CB, Enderson B. Missed injuries in the era of the trauma scan. J Trauma 2011;70: 452-6. 7. Haas B, Jurkovich GJ, Wang J, Rivara FP, Mackenzie EJ, Nathens AB. Survival advantage in trauma centers: expeditious intervention or experience? J Am Coll Surg 2009; 208:28-36.
Surgery May 2014
8. Helling TS, Nelson PW, Shook JW, Lainhart K, Kintigh D. The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients. J Trauma 2003;55:20-5. 9. Teixeira PG, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma 2007;63:1338-46. 10. Clarke DL, Gouveia J, Thomson SR, Muckart DJ. Applying modern error theory to the problem of missed injuries in trauma. World J Surg 2008;32:1176-82. 11. Gruen RL, Gabbe BJ, Stelfox HT, Cameron PA. Indicators of the quality of trauma care and the performance of trauma systems. Br J Surg 2012;99(Suppl 1):97-104. 12. Joint Commission. Sentinel event data: root causes by event type 2004-2012 [cited 2013 Jun 1]. Available from: http:// www.jointcommission.org/assets/1/18/Root_Causes_Event_ Type_04_4Q2012.pdf. 13. Sevdalis N, Davis R, Koutantji M, Undre S, Darzi A, Vincent CA. Reliability of a revised NOTECHS scale for use in surgical teams. Am J Surg 2008;196:184-90. 14. Sharma B, Mishra A, Aggarwal R, Grantcharov TP. Nontechnical skills assessment in surgery. Surg Oncol 2011;20: 169-77. 15. Yule S, Flin R, Paterson-Brown S, Maran N. Non-technical skills for surgeons in the operating room: a review of the literature. Surgery 2006;139:140-9. 16. McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care 2009;18:109-15. 17. Hull L, Arora S, Aggarwal R, Darzi A, Vincent C, Sevdalis N. The impact of nontechnical skills on technical performance in surgery: a systematic review. J Am Coll Surg 2012;214:214-30. 18. American College of Surgeons. Trauma. In: ATLS advanced trauma life support for doctors: student course manual. 9th edition Chicago: American College of Surgeons; 2012. 19. Leape LL. Error in medicine. JAMA 1994;272:1851-7. 20. Brennan TA, Leape LL. Adverse events, negligence in hospitalized patients: results from the Harvard Medical Practice Study. Perspect Healthc Risk Manage 1991;11:2-8. 21. Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW. The Injury Severity Score revisited. J Trauma 1988;28:69-77. 22. Yun S, Faraj S, Sims HP Jr. Contingent leadership and effectiveness of trauma resuscitation teams. J Appl Psychol 2005; 90:1288-96. 23. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med 2001;345:663-8. 24. Gould JB, Qin C, Marks AR, Chavez G. Neonatal mortality in weekend vs weekday births. JAMA 2003;289:2958-62. 25. Carr BG, Jenkins P, Branas CC, Wiebe DJ, Kim P, Schwab CW, et al. Does the trauma system protect against the weekend effect? J Trauma 2010;69:1042-7. 26. Carr BG, Reilly PM, Schwab CW, Branas CC, Geiger J, Wiebe DJ. Weekend and night outcomes in a statewide trauma system. Arch Surg 2011;146:810-7. 27. Carmody IC, Romero J, Velmahos GC. Day for night: should we staff a trauma center like a nightclub? Am Surg 2002;68: 1048-51. 28. Barleben A, Jafari F, Rose J Jr, Dolich M, Malinoski D, Lekawa M, et al. Implementation of a cost-saving algorithm for pelvic radiographs in blunt trauma patients. J Trauma 2011;71:582-4.
Pucher et al 909
Surgery Volume 155, Number 5
29. Chua WC, D’Amours SK, Sugrue M, Caldwell E, Brown K. Performance and consistency of care in admitted trauma patients: our next great opportunity in trauma care? ANZ J Surg 2009;79:443-8. 30. Symons NR, Almoudaris AM, Nagpal K, Vincent CA, Moorthy K. An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery. Ann Surg 2013;257:1-5. 31. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 1995;23: 294-300. 32. Pucher PH, Darzi A, Aggarwal R. Simulation for ward processes of surgical care. Am J Surg 2013;206:96-102. 33. Tien HC, Jung V, Pinto R, Mainprize T, Scales DC, Rizoli SB. Reducing time-to-treatment decreases mortality of trauma
34.
35.
36.
37.
patients with acute subdural hematoma. Ann Surg 2011; 253:1178-83. Cornwell EE 3rd, Chang DC, Phillips J, Campbell KA. Enhanced trauma program commitment at a level I trauma center: effect on the process and outcome of care. Arch Surg 2003;138:838-43. Mishra A, Catchpole K, Dale T, McCulloch P. The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy. Surg Endosc 2008;22:68-73. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010; 304:1693-700. Capella J, Smith S, Philp A, Putnam T, Gilbert C, Fry W, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ 2010;67:439-43.