Clinical paperAdherence to ATLS primary and secondary surveys during pediatric trauma resuscitation☆
Introduction
The Advanced Trauma Life Support (ATLS) protocol provides a common framework for the initial assessment of injured patients.1 Previous studies have linked patient outcome with ATLS protocol adherence,2, 3 with more compliant trauma teams making fewer higher level management errors.4 Despite this evidence, variable compliance with the primary and secondary survey components of ATLS is commonly observed.5, 6 Errors are estimated to occur in more than half of all trauma resuscitations and can be related to the omission of key tasks, delay or error in diagnosis, or error in judgment or technique, all of which can contribute to morbidity and mortality in the trauma patient.7, 8, 9
Video analysis of resuscitations has been shown to be an effective way to observe trauma team performance4, 10, 11 and has been found to be more effective than medical record review in detecting management errors and assessing adherence with ATLS.12, 13 In all studies using video review, omissions and delays in performance of key tasks have been observed. Several studies have attempted to identify features associated with poor team performance and have evaluated several factors including team expertise13, 14 and severity of patient injury.6, 14 An important limitation of these studies is the absence of rigorous statistical techniques.
At our hospital, we have been using video review for performance improvement since 2009. Although review of individual events can identify factors amenable to team feedback and change, this approach does not allow for a complete assessment of team performance. Based on previous studies showing the value of comprehensive review in identifying poor compliance with ATLS, we initiated a detailed review of sequential trauma resuscitations to identify patient, injury and environmental features associated with the omission or delay of ATLS tasks. Our overall goal of this study was to identify factors related to delayed and omitted primary and secondary survey tasks.
Section snippets
Study setting
Children's National Medical Center is a level 1 pediatric trauma center verified by the American College of Surgeons Committee on Trauma, serving injured patients from Washington, DC, MD, and VA. Children's National has a tiered activation system for the initial management of injured patients. The team required for patients brought directly from the scene of injury to our trauma bay (‘stat’ activation) includes an emergency medicine physician, surgical attending or senior surgical resident,
Results
The mean age of trauma patients was 6.7 ± 5.3 years. Most patients were male, sustained a blunt injury, and had an ISS less than 9. ‘Stat’ activations were the most frequent, while ‘transfer’ and ‘attending’ activations accounted for 25.7% and 7.2% of resuscitations, respectively. Forty-six (19.4%) patients arrived without advanced notification via pager to the trauma team. Most patients were treated on a weekday (73%) and during the evening shift (62.5%). Fifteen patients left the trauma bay
Discussion
Teams at our institution showed variable adherence to the primary and secondary survey components of the ATLS protocol. Although many key components of the primary survey such as stating an airway assessment were performed for almost all patients, other essential primary survey tasks were often omitted, such as statement of the GCS. Even when performed, many primary survey tasks were delayed and not completed within the first five minutes of the resuscitation. Variable adherence was also
Conclusions
Our findings show how video review can be used to evaluate team performance during trauma resuscitations. In our study, deficiencies in the performance of ATLS primary and secondary survey tasks were associated with several injury and environmental features. These results suggest a need for providing team training that is focused not only on general performance but on avoiding errors of omission. Because core members of our trauma teams have already completed ATLS training, this training by
References (24)
- et al.
Clinical impact of advanced trauma life support
Am J Emerg Med
(2004) - et al.
Communication during trauma resuscitation: do we know what is happening?
Injury
(2005) - et al.
Trauma resuscitation time
Injury
(2003) - et al.
Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation
J Pediatr Surg
(2008) - et al.
A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes
Ann Emerg Med
(2005) - et al.
Video assessment of trauma response: adherence to ATLS protocols
Am J Emerg Med
(1996) Advanced Trauma Life Support Course for Physicians
(1992)- et al.
Trauma outcome improves following the advanced trauma life support program in a developing country
J Trauma
(1993) - et al.
Video registration of trauma team performance in the emergency department: the results of a 2-year analysis in a Level 1 trauma center
J Trauma
(2009) - et al.
An evaluation of trauma team leader performance by video recording
Aust N Z J Surg
(1999)
Protocol compliance and time management in blunt trauma resuscitation
Emerg Med J
Using video audit to improve trauma resuscitation—time for a new approach
Can J Surg
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2011.10.032