ANZ J. Surg. 2006; 76: 725–728
doi: 10.1111/j.1445-2197.2006.03841.x
ORIGINAL ARTICLE
TRAUMA RECEPTION AND RESUSCITATION MARK C. FITZGERALD,*† ADAM B. BYSTRZYCKI,* NATHAN C. FARROW,*† PETER A. CAMERON,*† THOMAS KOSSMANN,†‡ MICHAEL E. SUGRUE§ AND COLIN F. MACKENZIE{ *Emergency and Trauma Centre, and ‡Department of Trauma Surgery, The Alfred, and †National Trauma Research Institute, Melbourne, Victoria, and §Trauma Department, Liverpool Hospital, Sydney, New South Wales, Australia; and {National Study Center for Trauma and Emergency Medical Services, University of Maryland School of Medicine, Baltimore, Maryland, USA The hospital reception phase of major trauma management requires a great number of expedient decisions. However, despite widely taught programmes advocating a standardized, algorithmic approach to decision-making, there is an ongoing rate of human errors contributing to adverse outcomes. It is now time for a fundamental change in our approach to trauma resuscitation. Point-of-care computer technology linked to real-time decision-making and trauma team coordination may achieve error reduction through standardized decision-making and a corresponding reduction in preventable mortality and morbidity. Key words: computerized prompt, medical error, resuscitation, video audit.
Abbreviations: ARDS, adult respiratory distress syndrome; ATLS, advanced trauma life support.
INTRODUCTION Trauma reception and resuscitation have improved dramatically over the last three decades. However, even in the best centres, there is an ongoing rate of errors contributing to adverse outcomes.1,2 It is time for a fundamental change in our approach. For the seriously injured patient, trauma reception and resuscitation requires a great number of management decisions in a short span of time. The role of the trauma team is to impose organization over chaos.2 Simultaneous processes proceed at different rates in variable situations. Evaluation of the airway and circulation, correction of life-threatening abnormalities, diagnosis and treatment of primary and secondary problems, monitoring, correction of circulatory shock and the provision of pain relief require critical decisions and actions that are confounded by immediacy and urgency. Failure to act expeditiously may be due to disorganized activity, failure to recognize priorities, fixation error and an inability to appreciate the complexities of the problem(s). Errors in trauma care are non-linear and may have little immediate effect and yet may eventually compromise the patient outcome. The coordination of multiple activities may be just as critical for patient survival as making the correct diagnoses or carrying out the most appropriate procedures. Not surprisingly, most of the errors arising during the Emergency Department/Trauma Centre phase of care relate to resuscitation. Most preventable errors occur not because of ignorance or lack of resources, but because the correct therapeutic and diagM. C. Fitzgerald MB BS, FACEM; A. B. Bystrzycki MB BS, FACEM; N. C. Farrow BN (Hons) Adv Nurs (Critical Care), MPET; P. A. Cameron MB BS, MD, FACEM; T. Kossmann MD, FRACS; M. E. Sugrue MBBCh, MD, FRACS; C. F. Mackenzie MBChB, FRCA, FCCM. Correspondence: Associate Professor Mark C. Fitzgerald, Emergency and Trauma Centre, The Alfred, Prahran, Vic. 3004, Australia. Email:
[email protected] Accepted for publication 25 January 2006. Ó 2006 Royal Australasian College of Surgeons
nostic measures are ‘.not done at the right time, in the right amount or in the right order.’.3 The objectives of this brief commentary are to provide the rationale and the method for a novel approach to coordinating priorities during trauma patient reception and resuscitation and a means of assessing the clinical effect.
BACKGROUND Evidence of error in trauma management In Australia, the Victorian Consultative Committee on Road Traffic Fatalities 2001/2003 data showed that the mean number of early management problems contributing to death was at least 50% greater than in any other area of trauma care.1 In 2002– 2003, a mean of 6.09 errors were identified for all Emergency Departments, of which 3.47 contributed to death. Most of the errors were correlated to resuscitation. Even in established Major Trauma Services, 23% of deaths are considered preventable or potentially preventable. Preventable and potentially preventable death rates are a crude measure of performance4 and are a small proportion of the total trauma population.5 Errors identified only hint at factors contributing to morbidity in survivors. Factors that contribute to preventable morbidity – and these include aspiration pneumonia, sepsis, Adult Respiratory Distress Syndrome (ARDS) – also contribute to prolonged intensive care unit and hospital lengths of stay.6 These factors may also increase the likelihood of long-term disability.7 The commonest cause of preventable death in the Victorian study was the failure to diagnose and adequately manage the shock patient. Many studies have looked at a single aspect of shock recognition or resuscitation in an attempt to lower mortality. Most have ended with equivocal conclusions. These have included such factors as medical anti-shock trousers application,8 withholding i.v. fluid in penetrating truncal trauma,9,10 the value of resuscitative thoracotomy,11 transfusion limits and pathophysiological predictors,12,13 the focused assessment with sonography
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for trauma utility,14 the value of arterial blood gases,15 the influence of bedside pathology,16 the predictive value of transthoracic impedance,17 central venous pressure measurement and central venous PvO2.18,19 Not surprisingly, research findings to date have repeatedly shown that it is difficult to measure the effect of a single intervention in a complex, non-standardized environment with multiple variables. A fundamental review of the principles underpinning research into the management of shock patients is required. Evidence for potential benefit from proposed approach The major variables in resuscitation include human factors, in particular, staff experience and expertise and associated variability in resuscitation practices.20 In an attempt to establish a standardized approach and to limit the influence of these human factors, algorithms for trauma resuscitation have been introduced. Advanced Trauma Life Support (ATLS) is used internationally in civilian and military settings to deal with the complexities of the critically injured patient. The teaching effectiveness of the ATLS programme among practising physicians has been shown by improvement in Objective Structured Clinical Examination scores, adherence to trauma priorities, maintenance of an organized approach to trauma care and cognitive performance in multiple choice question examinations.21 It is generally believed that ATLS has contributed to the overall improvement in the care of the victims of trauma and has saved lives.22 Some ATLS interventions improved survival in seriously ill trauma victims initially treated at rural hospitals before transfer to Trauma Centres.23 However, adherence to ATLS protocols is variable24 and the protocols are quickly forgotten.25,26 Retention of knowledge of medical resuscitation protocols is also problematic.27 Although life-support courses may improve the knowledge or skills of the health-care provider and change their approach to a given problem, there is no rigorous scientific evidence that they decrease patient mortality and morbidity.28,29 Audit of the ‘quality’, timeliness and adequacy of the care of trauma patients has usually looked at adherence to ATLS protocols, error rates, missed diagnoses, improved outcomes (typically using historical controls) and preventable deaths.30–32 More recently, there has been an emphasis on the development of clinical guidelines or treatment algorithms, ideally evidence based.33–37 The availability of pre-printed guidelines may improve documentation but not clinical care.38 The compliance of medical staff with guidelines needs to be monitored.39
PATIENTS AND METHODS Clinical algorithms and point-of-care computer technology The deficiencies and differences in health care compared with other industries are summarized elsewhere.40 Human variables confounding a standardized environment and thereby leading to avoidable errors have been addressed by the airline industry.41 To reduce critical error rates in that industry, computerized prompts are built into flight-control systems providing immediate feedback and error avoidance. Algorithms for trauma resuscitation in emergency departments have been developed over the last two decades. This was, in part, an attempt to bring uniformity into complex environments that are often characterized by high staff turnover. Studies showed that formal algorithms encouraged consistency, reduced error rates and significantly reduced resuscitation time.37,42–45
The most rigorous application of algorithms in clinical decision-making involves rule-based computer systems. Bedside (point-of-care) computerized protocols to standardize clinical decisions for mechanical ventilation of patients with ARDS have been in use since 1992.46 Clinical algorithms using a branch tree logic approach have been used since the early 1980s to determine fluid resuscitation.3,47 These algorithms have improved the outcome in hypotensive patients in the Emergency Department and in patients with blunt or penetrating injuries of the thorax and abdomen.3,48 A more recent and relevant study showed the use of a computer-based decision aide that uses decision rules and logical deduction to generate management plans for the initial, definitive management of injured patients. Its use was confined to assess penetrating thoraco-abdominal injuries in non-pregnant adults. In a preliminary assessment, participants preferred computergenerated, patient-specific protocols for the acute management of injuries. The computer-generated protocols were also associated with improved care and potential improvement in outcome.49 In the complex environment of major trauma reception, communication remains problematic. Even when experienced clinicians are involved, communication of significant clinical decisions fails over 50% of the time.50 Linking computer-generated prompts through visual and auditory displays within the resuscitation bay may enhance clinicians’ interaction and reduce errors of omission and miscommunication.
DISCUSSION More effective measurement of trauma resuscitation: video audit The widespread availability of powerful point-of-care computers makes it possible to provide the clinician with immediate bedside information about clinical algorithms, drug doses, patient alerts, trends in monitoring data, automated physiological event detection and notification and so on.51,52 The usefulness of these additional data need to be evaluated. This can be carried out by chart review, but a more effective approach is to measure the process of care by video recording.53 Given problems with staff acceptance and storage and analysis of the data, video recording has tended to be a niche subset of quality improvement in the management of trauma.54,55 However, it has provided objective information about team leader effectiveness, adherence to performance standards and trauma resuscitation time.56,57 It identifies key processing problems in trauma management (errors of omission, commission and misprioritization).42,58 It has been used to critically analyse airway management,59 to assess the adequacy of universal precautions in resuscitation,60 to review the interaction between nurses and patients,61 to assist with the management of trauma in remote locations62 and to regularly imprint monitoring data on the video image.63 Video audit has been used to measure the effect of single interventions as well as the other multiple interventions that are occurring simultaneously. It is difficult to objectively measure process changes in the resuscitation environment without video audit. Subjective, retrospective recall following the hectic few minutes of trauma resuscitation is likely to be flawed. In 1993, Dr Ramenofsky and coworkers from Pittsburgh published ‘ATLS-based video trauma resuscitation review: education and outcome’.64 They evaluated 883 patients, including a control Ó 2006 Royal Australasian College of Surgeons
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group and concluded that trauma resuscitations can be improved with ongoing videotape reviews. The major benefits achieved were more efficient use of time, correction of conceptual and technical errors and improved survival. Furthermore studies from another level I, US trauma centre showed an initial 23% deviation from ATLS resuscitation principles detected by video audit.24 Published reports have also used video audit to examine the performance of team leaders in resuscitation, but have not linked this to an improvement in patient outcome or a reduction in management errors.55,65 Although reviews show improvements, compliance with algorithms is rarely measured in real time. Recognition of preventable error is often retrospective rather than real time.
CONCLUSION It is time for a new approach to trauma reception and resuscitation. There is evidence that a standardized algorithmic approach reduces error, real-time prompts increase compliance and video analysis improves accuracy and compliance. We need to integrate clinical algorithms and point-of-care computer technology and link them to real-time decision-making and team coordination needs. We need to refocus on the first 30 min of trauma reception and resuscitation, and establish whether putting these factors together results in improved team coordination and patient outcomes. In Australia, the Victorian Major Trauma Services are developing a scalable and exportable, computer-prompted algorithm system for real-time use on patients with major trauma.66 This project will further develop and refine best-practice algorithms for trauma resuscitation. Compliance will be guided by real-time computer-generated prompts linked to real-time data collection. A controlled, randomized trial will evaluate effectiveness with video audit verifying compliance, error rates and subsequent patient outcomes. The goal is to reduce error through standardized decision-making, leading to a reduction in both preventable mortality and morbidity for major trauma victims.
ACKNOWLEDGEMENTS The authors wish to acknowledge the administrative and financial support provided by the Victorian Trauma Foundation and Bayside Health. The authors are also grateful for the technical and research assistance provided by medical and nursing staff at the following agencies: The Alfred, Monash University Department of Epidemiology and Preventive Medicine, La Trobe University School of Nursing, The Royal Melbourne Hospital, The Royal Childrens’ Hospital, Barwon Health, The National Study Center for Trauma and Emergency Medical Services and the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, USA.
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