6/20/2018 High Reliability in Trauma Resuscitation Todd Nickoles, - - PDF document

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Todd Nickoles, MBA, BSN, RN Trauma Program Manager Phoenix Children’s Hospital Tucker Redfern Pediatric Trauma Symposium March 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 ■ 90+ level 2 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+

■ 100+ level 1 activations ■ 500+ level 2 activations

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 gradient

Power 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!

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Identify someone by name or role for specific task

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

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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

20 0% 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, 2013

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Trauma Time Out

Phase 1 – Pre-Arrival

Trauma 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 problems

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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. AHRQ

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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% Pre Post Pre Post Pre Post Pre Post Q1 Q2 Q3 Q4 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% Q1 Q2 Q3 Q4 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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