Kathleen Louden

October 15, 2015

CHICAGO — Injured patients were evaluated and received medical imaging tests 30% faster after an innovative performance improvement project was enacted at one hospital.

"Being able to quickly identify patients' injuries can really increase our ability to treat them more effectively," lead investigator Andrea Long, MD, an acute care surgery fellow at the Wake Forest School of Medicine in Winston-Salem, North Carolina.

"Does assessing the patient faster decrease the chance of death? Absolutely," she told Medscape Medical News.

In fact, previous research has shown that the length of stay in the emergency department is an independent predictor of hospital mortality after trauma team activation (J Trauma. 2011;70:1317-1325).

The project, which involved multidisciplinary simulation training and feedback from actual trauma survivors, was tested at the Wake Forest Baptist Medical Center.

Dr Long presented the results here at the American College of Surgeons Clinical Congress 2015.

Trauma surgeons and emergency medicine physicians designed five training sessions to improve the efficiency of the team assessing trauma patients. They used a patient simulator (SimMan 3G, Laerdal Medical) to enact five scenarios, conducted 3 to 4 weeks apart.

The scenarios involved simulations of spleen laceration and rib fractures sustained in a motor vehicle collision; open-book pelvic fracture with bleeding in the abdomen and hypotension subsequent to a vehicular collision; penetrating chest injury due to a gunshot wound requiring a chest tube; difficult intubation necessitating a supraglottic airway device with conversion to an endotracheal tube; and subdural hematoma in an anticoagulated patient experiencing neurologic changes after a car collision.

Improved Patient–Provider Communication

Members of the Trauma Survivors Network, a national advocacy organization for trauma survivors and their families, watched the simulation exercises, without the providers' knowledge, and gave feedback to the team immediately after the sessions. Their input was valuable, said Dr Long.

"At the first simulation scenario, a trauma survivor noticed that team members did not tell the patient they were inserting an IV catheter, and suggested telling the patient what to expect to ease anxiety," she reported. "By the second scenario, the survivors commented that team members were communicating with patients better. Anecdotally, several of our trauma team members noted improved communication as we took care of actual patients."

William Bozeman, MD, also from Wake Forest, was a coinvestigator on the project. To objectively evaluate the impact of the training, the investigators compared time to completion of the assessment of actual trauma patients treated for 3 weeks before and 4 weeks after the final simulation training.

The goal was to perform the secondary survey in 10 minutes, which the trainees met, and to achieve a time to CT of less than 15 minutes, which they nearly met.

In fact, they shaved 7 minutes off the average time from arrival in the emergency department to transport to the CT suite, and cut in half the time required for the secondary trauma survey.

Table. Effect of Simulation Training on Assessment of Trauma Patients

Outcome Before Training, min After Training, min Change, %
Primary trauma survey (airway, breathing, circulation) 5 5 0
Secondary trauma survey (head-to-toe assessment) 14 6 57
Time from patient arrival to CT scan 23 16 30

 

The investigators excluded management procedures, such as intubation and insertion of a chest tube, in the time count for the survey so they could focus on the overall process in this pilot study, Dr Long reported.

This exclusion is an important study limitation, said study discussant Charity Evans, MD, a trauma surgeon from the University of Nebraska Medical Center in Omaha.

"Intubation and chest tube procedures need to be included in the survey. They are part of the 'golden hour'," said Dr Evans, referring to the term coined to encourage urgency of trauma care.

She also suggested that future research include the patient's injury severity score, which can affect the time needed for assessment.

The fact that the intervention "reduced emergency department length of stay is significant; it shows that multidisciplinary training does work." However, definitive conclusions cannot be drawn from this pilot study, she told Medscape Medical News.

 
Cross-specialty training is the key to success.
 

Most simulation exercises occur within the provider's own specialty, which made this project different, said David Hiller, MD, a general surgery chief resident at the Wake Forest School of Medicine, who participated in the simulation exercises, but was not otherwise involved in the study.

"The most helpful part of the training was to be with everyone involved in the care of a trauma patient. We came to understand each other's roles. It made the real trauma cases go much smoother," he told Medscape Medical News.

"Cross-specialty training is the key to success," he said.

Future studies will use cadavers and live volunteer patients during the training and will include management procedures, said Dr Long. The goal is to decrease the time needed to get patients to CT scanning even further.

Dr Long, Dr Bozeman, Dr Evans, Dr Hiller have disclosed no relevant financial relationships.

American College of Surgeons (ACS) Clinical Congress 2015. Presented October 6, 2015.

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