Elsevier

Resuscitation

Volume 84, Issue 1, January 2013, Pages 66-71
Resuscitation

Clinical paper
Adherence to ATLS primary and secondary surveys during pediatric trauma resuscitation

https://doi.org/10.1016/j.resuscitation.2011.10.032Get rights and content

Abstract

Study aim

Adherence to Advanced Trauma Life Support (ATLS) protocol has been associated with improved management of injured patients. The objective of this study is to determine factors associated with delayed and omitted ATLS primary and secondary survey tasks at a level 1 pediatric trauma center.

Methods

Video recorded resuscitations of 237 injured patients < 18 years old obtained over a four month period at our hospital were evaluated to assess completeness and timeliness of essential tasks in the primary and secondary survey of ATLS. Multivariate analyses were performed to identify features associated with decreased ATLS performance.

Results

Primary survey findings were stated less often in patients with burn injuries compared to those with blunt injuries (RR = 1.72; 95% CI: 1.26–2.35) and less often during the overnight shift [11 PM–7 AM] (RR = 1.22; 95% CI: 1.02–1.46). Secondary survey findings were verbalized less often in patients with penetrating injures (RR = 2.30; 95% CI: 1.06–5.00). Time to statement of primary surveys findings was delayed in patients with burn injuries (HR = 0.69; 95% CI: 0.48–0.98) and among those transferred from another hospital. Completeness and timeliness of ATLS task performance were not associated with age or injury severity score.

Conclusions

Mechanism of injury and hospital factors are associated with incomplete and delayed primary and secondary surveys. Interventions that address deficient ATLS adherence related to these factors may lead to a reduction in errors during this critical period of patient care.

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)

  • W.R. Spanjersberg et al.

    Protocol compliance and time management in blunt trauma resuscitation

    Emerg Med J

    (2009)
  • M. Fitzgerald et al.

    Using video audit to improve trauma resuscitation—time for a new approach

    Can J Surg

    (2006)
  • Cited by (42)

    • Pauses in compressions during pediatric CPR: Opportunities for improving CPR quality

      2019, Resuscitation
      Citation Excerpt :

      Video review methodology was performed in accordance with our site policy. Two independent researchers reviewed the study videos, with interrater reliability testing performed for 10%; published studies with similar methods of video-based data collection have reported high inter-rater reliability at our institution.6,11,12 Patient and event demographic data were collected for each case and included: patient age, date and time of arrival, location of arrest (in-hospital cardiac arrest [IHCA] or out-of-hospital cardiac arrest [OHCA]), pre-hospital interventions if applicable, ED interventions, number of CPR events, event duration, and patient outcomes according to Utstein criteria (return of spontaneous circulation lasting at least 20 min (ROSC), survival to hospital admission, and survival to hospital discharge).13

    • Association Between Prearrival Notification Time and Advanced Trauma Life Support Protocol Adherence

      2019, Journal of Surgical Research
      Citation Excerpt :

      The secondary survey is a “head to toe” evaluation that involves examination of several body regions and has more individual tasks than the primary survey. In studies of pediatric trauma resuscitation, almost 80% of patients do not have a secondary survey completed, and only 14% of patients had a complete primary and secondary survey performed before departure from the emergency department.3,23 The variability in how and in which order the secondary survey is performed may make it vulnerable to a higher number of errors when compared with the primary survey.24

    • Errors in cervical spine immobilization during pediatric trauma evaluation

      2018, Journal of Surgical Research
      Citation Excerpt :

      Comparison groups included age, gender, Injury Severity Score (classified as either <10 or ≥10), GCS motor score and the presence of a pediatric surgical fellow or attending versus a fourth-year surgical resident as the leader directing the event. We also included comparisons based on team notification (with or without pre-arrival notification of the patient), time of day (day shift [7 AM – 7 PM] versus night shift) and day of week (weekday versus weekend) because of previously identified associations of these variables with trauma team performance.14,15 We reviewed the medical record and our trauma performance improvement database to identify any cervical spine injury diagnosis or suspicion based on imaging or specialty consultation.

    View all citing articles on Scopus

    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

    View full text