high reliability in trauma resuscitation · simulation non-technical skills: communication and...

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Todd Nickoles, MBA, BSN, RNTrauma Program ManagerPhoenix Children’s Hospital

Tucker Redfern Pediatric Trauma SymposiumMarch 23, 2018

High Reliability in Trauma Resuscitation

• Describe a model of teamwork during trauma resuscitation focused on improving safety and reliability practices

• Describe the trauma time out process utilized in modeling safety behaviors

• Provide participants with actionable tools and processes to improve safety and reliability in their own facility

Learning Objectives

• No financial conflict of interest relative to this educational activity.

Disclosure Statement

ACS and State of Michigan Level 1 Pediatric Trauma Center

Annual volume approx 650

■ 50+ level 1 activations


Two points of entry

■ Pediatric ED, adult ED

Residency program trauma rotation

ACS and State of Arizona Level 1 Pediatric Trauma Center

Annual volume approx 2600+



New Emergency Department

Residency program

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Trauma page goes out…

Level 1 13yo male from scene of MVC rollover, GCS 11, deformity to left leg, ETA 10min

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Why does this happen?

Patient factors

System factors

Human factors

A chaotic environment…

Complex patients with unknowns

Variable team composition

Confined space

Multiple handoffs

Large crowds and noise

Brownian motion

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…which led to…

Communication fails

Errors

Misses in handoffs

Derailing of process flow, delays

Team breakdown

Mass confusion

Frustration and burnout

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Human Factors in Trauma

The Amygdala

Optimism bias

Bystander Effect

Authority Gradient

Cooks in the Kitchen

Peer Pressure

Role of the amygdala

Responsible for “fight, flight, or freeze”

Useful for simple emergencies

Not helpful in complex emergencies

Use of clear references and simulation training

Optimism bias“We’re good!”

Leads to lack of preparation

Standardize preparation with checklists

Authority gradientPower distance between perceived leaders and team members

Reduce/remove the gradient

Bystander Effect

Demonstrated in research of lay responders

In hospitals, factors include:

■ Number of people around

■ Degree of responsibility felt by participant

■ Whether decisions are needed vs direct action

■ Training

■ Priming a social context and cohesiveness

Latané, B; Darley, J.M. (1968). "Group inhibition of bystander intervention in emergencies". Journal of Personality and Social Psychology. 10: 308–324.

Bystander Effect

“Will someone do ________?” is BAD!

1. Identify someone by name or role for specific task

2. Ask for a follow-up in a specific amount of time (PALS)

3. Assign someone to assign someone

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Effective leadership

Defined role

Cooperation and resource management

Communication and interaction

Assessment and decision making

Situational awareness

Coping with stress

“Cooks in the Kitchen”Presence of multiple experts or leaders decreases the effectiveness of the team

Hildreth J, Anderson C (Feb 2016) Failure at the top: How power undermines collaborative performance.Journal of Personality and Social Psychology, 110(2), 261-286.

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Communication

Fails

Open-ended requests

“Hint and Hope”

Reluctance to speak up

Reception/comprehension

Many channels of communication

Solutions

Direct requests

Direct statements

Make it safe & support the team

3-way repeat back

Coordinated communication

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Pre-implementation Survey

197 respondents from all disciplines

Role delineation

Preparation

Prioritization

Teamwork

Safety

200%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1 Q2 Q3 Q4

37%

20%

93%

72%

63%

80%

7%

28%

No

Yes

High Reliability

1. Sensitivity to operations and systems

2. Reluctance to simplify

3. Preoccupation with failure

4. Deference to expertise

5. Resilience

From Becker’s Hospital Review, April 29, 201321 22

Trauma Time Out

Phase 1 – Pre-ArrivalTrauma team badges in, PPE & lead on

Trauma RN provides pre-hospital briefing of patient to team

Team Lead identifies themselves, “role” call

All present and ready, excuses extras (stickers)

Minimizes noise

Team Lead shares plan and potential problems23

Confirmation of Team & PTA information

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Crowd Control

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Roles and Responsibilities

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Planning

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Trauma Time Out

Phase 2 – Arrival

“I’m the Team Lead, I’ll take report.”

“60 seconds of silence” for EMS report

IMIST-AMBO

Q&A

Team follows ATLS protocol

Communication – 3 way repeat back

Voice concerns

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EMS Handoff

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Trauma Time Out

Phase 3 – Post resuscitation

Team leader communicates to the team

Current diagnoses

Patient disposition

Any change in status

Ready to go?

Physician and nurse handoffs

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Hardwiring safety behaviors

Standardizing best practices

Tools and references

Checklists

Practice with feedback

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Hardwiring all aspects of the process

Standard Work for Trauma Lead

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Simulation

In Situ

Multidisciplinary

Surgeons

ED attendings

Residents

Nursing

Pharmacy

Lab/RT/Rad

Chap/MSW

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Simulation

Objectives:

Non-technical skills

Technical skills

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Simulation

Non-Technical Skills:

Communication and interaction

Leadership

Cooperation and resource management

Assessment and decision making

Situational awareness and coping with stress

*Steinemann et al. Assessing teamwork in the trauma bay: Introduction of a modified “NOTECHS” scale for trauma, AJS 2012(203)69-75.

*ACS/APDS Surgical Skills Curriculum for Residents, Phase III

*TeamSTEPPS: Strategies & Tools to Enhance Performance and Patient Safety. November 2008. AHRQ42

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Simulation

Technical Skills:

Primary survey (ATLS)

Medication-assisted intubation

Diagnostic interpretation (FAST, iStat, radiographs, etc)

IO placement

Fluid resuscitation

Blood administration/ massive transfusion

Chest tube placement

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Simulation

Faculty teamwork evaluation

Facilitated debriefing

Key learning points emphasized

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Post-implementation Survey

N=122

Role delineation

Preparation

Prioritization

Teamwork

Safety

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PrePost

PrePost

PrePost

PrePost

Q1Q2

Q3Q4

36%

84%

21% 27%

93% 96%

71% 77%

No

Yes

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Post-implementation Survey

N=122

TTO

Simulation

TTO occurs

TTO positive

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1Q2

Q3Q4

92%

53%

85% 89%

No/False

Yes/True

Auditing

Lean methodology

• Kimishibai cards

• Pareto analysis

• Changes to the flowsheet

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Auditing

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Video Taping in the Trauma Bay• For PI use only

• Password protected security

• DVR overwriting (90 day limit)

• Legal/risk approved

• Analytics

• Review checklist under development

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Summary

Resuscitations are very high risk

Understanding team dynamics is key

Team resilience can be developed

■ Effective tools

■ Hardwiring safety behaviors

■ Practice based learning

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high reliability in trauma resuscitation · simulation non-technical skills: communication and...

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