Victorian State Trauma System

Major Trauma Guidelines & Education – Victorian State Trauma System

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For the trauma team to be effective it is vital that all members of the team are aware of their role, communicate effectively and are able to operate within an atmosphere of mutual trust and respect. The structure of the trauma team will need to be fluid and adaptable to the resources available at each facility.

Effective Communication

Effective communication is essential in successfully assessing and resuscitating critically ill trauma patients, especially in times of high stress. It is important to maintain a common vocabulary, creating a shared mental model of the case to avoid assumptions (8, 11).

What is a shared mental model?

Shared mental models are the overlap of an individuals’ set of knowledge assumptions that underpin the basis for understanding and decision making between individuals of a team. Shared mental models can significantly improve and facilitate effective performance, teamwork and clinical decision making (17, 18).

Creating a shared model of the patient’s situation allows personnel from differing backgrounds to understand both the clinical and logistical implications of the case. It ensures that team members are familiar with the roles and responsibilities of all team members; that they are able to anticipate the needs of others and have a high level of adaptive capacity (19, 20).

This collaborative approach helps break down boundaries between individuals with varying levels of experience, whilst also helping to reduce the perception of a power gradients between outside specialists coming into the workspace (e.g., pre-hospital setting, emergency department, hospital ward). Stating common treatment goals prevents individual team members veering off on counterproductive tangents. An example of this is an orthopaedic surgeon fixating on a dislocated ankle while the patient has a life-threatening pneumothorax that requires immediate intervention. Clinicians can create a shared mental model through role modelling behaviours, briefing the team prior to the arrival of a patient and facilitating open discussion whilst working together – effective incorporation SA and of the ZPS (21).

 


Briefing the team

This is part of the pre-resuscitation process that stems from the ZPS and STEP-UP mnemonic.

Prior to the arrival of the trauma patient in the emergency, the team leader should gather and brief the team. The aim of the briefing is to:

  • Allocate individual roles (for example, airway doctor/nurse).
  • Allocate tasks to be completed before the patient arrives (for example, draw up drugs, prepare for a chest drain insertion, pre-notification of radiology/blood bank/theatre).
  • Allow the team to ask questions and clarify any issues before the patient arrives.
  • Create a shared mental model of the patient’s current status as well as the anticipated plan and final destination.
  • Create awareness of potential issues and how they might be dealt with (anticipate the ‘what if?’ scenario).

 


Tacit vs explicit communication

Tacit knowledge can be described as that which is acquired through practice and experience and may be difficult to communicate (22). The same idea can be applied when referring to communication skills in the ED. Tacit communication is communication that occurs, often without words, in which the intention is never actually stated. One example of this is an experienced anaesthetist putting their hand out and expecting to be handed the laryngoscope by their assistant without asking for it because that is the way they do things. It should be obvious that this method can lead to problems, especially in occasional teams in times of high stress.

By making communication explicit and specific such as ‘When I do … I would like you to do … ’ and allowing questions to be asked, errors and critical incidences can be avoided. In times of high stress communication often shifts from an explicit to a tacit form without the team being made aware. The shift from explicit to tacit communication can lead to miscommunication, disjointed or incomplete sharing of information and negatively impact patient outcomes (23-25).

 


Closed-loop communication

Closed-loop communication is a method of communication that promotes acknowledgment of the receipt of information and clarification with the sender that the information received is the same as the original, intended information. Practically, it is the process of confirming and cross- checking information for accuracy. This style of communication fosters the team to have shared understanding, expectations and awareness (26).

Remote tele-health conferencing

Once the team leader has either requested information or asked for a procedure to be performed by a named person, that receiver of the task / information should explicitly acknowledge the request and then inform the sender (in this example the team leader) once it is complete (27). This promotes clarification of requests (if needed) and avoids errors of omission. Closed-loop communication informs the sender that requests have been heard and understood, which is an essential part of keeping all parts of patient care moving forward.

Example:             Sender: James, I want you to insert a large bore IV, please. Once the task is complete can you please let me know.
‘ Receiver: You want me to insert a 16-gauge IV?
‘ Sender: Correct.
‘ Receiver: No worries, I will do that now and let you know when it is complete

Closed loop communication has been shown to reduce error rates by removing ambiguity from instructions, allowing questions if the instruction was not heard clearly, and it allows others in close proximity to be aware of the proposed course of action (26-28).

It is also especially important when ordering drug doses, especially if they are unfamiliar. If one asks for ‘50 of propofol’ , do you mean 50 mg or 50 mL? It would be better to state, ‘John, I’d like you to give 50 mg, which is 5 mL of propofol.’

The use of names avoids the problem of such requests being made to an empty space. When a team leader asks out loud for an IV to be inserted, unless they specify who they would like to perform the procedure then there is a risk it will not be done at all. It is important that the team leader also uses eye contact when making requests, allowing for non-verbal as well as verbal clarification. The leader doesn’t bark orders but should be concise and clear in their language to get the task done.

 


Handover

The Australian Commission on Safety and Quality in Healthcare recommends the use of a structured handover tool such as ISBAR. IMIST-AMBO is another mnemonic for facilitating health professional communication ensuring clarity and completeness of information in verbal communication (29). This has effectively replaced ISBAR in many circumstances. Both are acceptable and appropriate handover tools. By using a structured approach one can avoid missing vital information. By consistently using the same structured handover tool, such as ISBAR or IMIST-AMBO format for handover the team can anticipate what is coming next and be aware when important information is being presented (30, 31):

Identification: Who are you and what is your role? Patient identifiers – name, age, sex.
Mechanism: Presenting problem, how it happened.
Injuries: specific injuries that have been found or potential to exist.
Signs: vital signs, such as HR, RR, BP, Temp, BGL, GCS, etc.
Treatment and Trends: treatment administered and patient’s response to treatment,trends in vital signs.
Allergies: Specify known allergies.
Medications: Specify known patient medications.
Background history: Specify known medical history.
Other: Relevant other information – social, scene, relatives.

 


Remote support and communication

The formation of a trauma or deteriorating patient response team may be very different among health services with highly variable capacity. Developments in both technological hardware and communication infrastructure have allowed healthcare services to extend their information base beyond in-house capacity, utilising the advancement in telehealth. Difficult major trauma patient presentations, particularly when there is no or only off-site medical cover, require additional support to optimise patient care. The connection to a ‘remote expert’ to assist in identifying differential diagnoses and to guide ongoing assessment and intervention can be facilitated by Adult Retrieval Victoria (ARV) consultants. Where structures do not exist to allow telehealth consultations, voice-only teleconferencing with ARV allows for ongoing dialogue regarding best management of the major trauma patient.

Remote tele-health conferencing

Current structures allow for many Victorian health services to connect with critical care coordinators at ARV to provide expert guidance in managing major trauma patients. Engaging telehealth support person has been shown to improve the confidence and abilities of attendant staff in managing acutely unwell patients. Systems currently in place allow for high-quality video and voice transmission to add value to the on-site clinical assessment of major trauma patients. The capacity of telehealth support lends itself to wide-ranging consultation, including reviewing x-rays and electrocardiographs in addition to major trauma patient assessment and interventional support.

Interactions over telehealth may require a change in approach, with some additional training and exposure, and the dissolution of barriers to involving an additional and external expert. However, identified positive outcomes necessitate health services embracing the use of telehealth to build staff confidence and skills and therefore improved patient outcomes.