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

6/20/2018 High Reliability in Trauma Resuscitation Todd Nickoles, MBA, BSN, RN Trauma Program Manager Phoenix Children’s Hospital Tucker Redfern Pediatric Trauma Symposium March 23, 2018 1 Disclosure Statement Learning Objectives • No financial conflict of interest relative to this educational • Describe a model of teamwork during trauma resuscitation activity. 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 ACS and State of Michigan Level 1 Pediatric ACS and State of Arizona Level 1 Pediatric Trauma Center Trauma Center Annual volume approx 650 Annual volume approx 2600+ ■ 50+ level 1 activations ■ 100+ level 1 activations ■ 90+ level 2 activations ■ 500+ level 2 activations Two points of entry New Emergency Department ■ Pediatric ED, adult ED Residency program Residency program trauma rotation 1

6/20/2018 Trauma page goes out… Level 1 13yo male from scene of MVC rollover, GCS 11, deformity to left leg, ETA 10min Why does this happen? Patient factors System factors Human factors 9 A chaotic environment… …which led to…  Complex patients with unknowns  Communication fails  Variable team composition  Errors  Confined space  Misses in handoffs  Multiple handoffs  Derailing of process flow, delays  Team breakdown  Large crowds and noise  Mass confusion  Brownian motion  Frustration and burnout 11 12 2

6/20/2018 Human Factors in Trauma Role of the amygdala Responsible for “fight, flight, or freeze” The Amygdala Useful for simple emergencies Optimism bias Not helpful in complex emergencies Bystander Effect Use of clear references and simulation training Authority Gradient Cooks in the Kitchen Peer Pressure Optimism bias Authority gradient Bystander Effect “We’re good!” Power distance between Demonstrated in research of lay responders perceived leaders and team In hospitals, factors include: Leads to lack of preparation members ■ Number of people around Standardize preparation with ■ Degree of responsibility felt by participant Reduce/remove the gradient checklists ■ 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 Effective leadership “Cooks in the Kitchen” Defined role “Will someone do ________?” is BAD! Cooperation and resource Identify someone by name or role for specific task Presence of multiple experts or leaders 1. management decreases the effectiveness of the team Ask for a follow-up in a specific amount of time (PALS) 2. Communication and interaction Assign someone to assign someone 3. Assessment and decision making Hildreth J, Anderson C (Feb 2016) Failure at the top: How power undermines collaborative Situational awareness performance. Journal of Personality and Social Psychology , Coping with stress 110(2), 261-286. 17 3

6/20/2018 Communication Pre-implementation Survey  197 respondents from all disciplines Fails Solutions  Role delineation Open-ended requests Direct requests  Preparation 100% 7% “Hint and Hope” Direct statements  Prioritization 90% 28% 80%  Teamwork Reluctance to speak up Make it safe & support the team 63% 70%  Safety 80% 60% No Reception/comprehension 3-way repeat back Yes 50% 93% 40% 72% Many channels of communication Coordinated communication 30% 20% 37% 20% 10% 19 20 0% Q1 Q2 Q3 Q4 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 21 22 Confirmation of Team & PTA information 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 23 24 4

6/20/2018 Crowd Control 25 26 Planning Roles and Responsibilities 27 28 Trauma Time Out EMS Handoff  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 29 30 5

6/20/2018 31 32 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 33 34 Hardwiring safety behaviors Standardizing best practices Tools and references Checklists Practice with feedback 35 36 6

6/20/2018 Standard Work for Trauma Lead Hardwiring all aspects of the process 38 Simulation  In Situ  Multidisciplinary  Surgeons  ED attendings  Residents  Nursing  Pharmacy  Lab/RT/Rad  Chap/MSW 39 40 Simulation Simulation  Objectives:  Non-Technical Skills:  Communication and interaction Non-technical skills   Leadership Technical skills   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 41 42 7

6/20/2018 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 43 44 45 46 Simulation Post-implementation Survey  Faculty teamwork evaluation  N=122 100% 90%  Role delineation  Facilitated debriefing 80%  Preparation 70%  Key learning points emphasized  Prioritization 60% 50%  Teamwork 84% 40% 93% 96% No  Safety 30% Yes 71% 77% 20% 36% 10% 21% 27% 0% Pre Post Pre Q1 Post Pre Q2 Post Pre Q3 Post 47 48 Q4 8

6/20/2018 Post-implementation Survey Auditing  N=122 Lean methodology 100%  TTO Kimishibai cards 90% •  Simulation 80% Pareto analysis •  TTO occurs 70% 60%  TTO positive Changes to the flowsheet • 50% 92% No/False 40% 85% Yes/True 89% 30% 53% 20% 10% 0% Q1 Q2 49 Q3 50 Q4 Auditing 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 • 51 52 Summary Resuscitations are very high risk Understanding team dynamics is key Team resilience can be developed ■ Effective tools ■ Hardwiring safety behaviors ■ Practice based learning 53 54 9

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