Poor Coordination Blamed for Flow Disruptions in Trauma Care

CHICAGO – Breakdowns in the coordination of care, rather than communication, were the most common type of flow disruption at a level I trauma center, based on an analysis of data from 86 cases.

The finding contrasts with results from previous studies showing communication breakdowns as the top flow disruptions, and the study "is one of the first and largest to objectively document that flow disruptions in trauma care occur frequently," according to Dr. Daniel Shouhed of Cedars-Sinai Medical Center in Los Angeles.

"Defective systems allow human errors to cause harm to patients," Dr. Shouhed said at the annual clinical congress of the American College of Surgeons. "We believe systems can be better designed to prevent or detect errors before a patient is harmed."

As part of an effort to improve systems, Dr. Shouhed and his colleagues conducted a prospective observational study of flow disruptions over 2 months of 24-hour coverage in a level I trauma center.

Categories of flow disruptions included communication, coordination, environment, equipment, external interruptions, patient factors, technical skills, and training.

Communication breakdowns were defined as "disruptions that involve the verbal transition of information between at least two team members," while coordination breakdowns were defined as "disruptions that involve the interaction with some piece of equipment as well as at least one other team member," Dr. Shouhed said.

Flow disruptions were defined as low or high impact, based on whether they caused a pause in the progression of patient care or significant consequences to patient care. For example, a low-impact communication disruption might be "a scribe nurse unable to hear primary survey from resident," while a high-impact disruption might be "an ED attending did not hear request for STAT blood; order not placed."

Multiple physicians reviewed and scored each disruption. Each case could include three phases of care: trauma bay, imaging, and operating room (or interventional radiology).

The researchers observed 86 cases, 6 of which required immediate surgery. The average case duration was 102 minutes. On average, patients spent 25 minutes in the trauma bay, 30 minutes in the CT scanner, and 148 minutes in the operating room.

A total of 1,757 flow disruptions were observed. Of these, 46% occurred in the trauma bay, 33% in imaging, and 21% in the operating room. The researchers examined the effect of trauma level and trauma phase on the rate of flow disruptions, excluding the six OR cases because of the small sample size.

Flow disruption rates were divided into low-level (trauma 200) or high-level (trauma 100) activations, Dr. Shouhed said.

A comparison of the rate of flow disruptions between the trauma bay and imaging phases of care based on clinical impact scores showed a significantly higher rate of low-impact flow disruptions in the imaging phase, particularly among trauma 100 cases.

In examining the relationship between high clinical impact and low clinical impact flow disruptions, the researchers found a strong correlation between the rate of low-impact and high-impact flow disruptions among all phases of care.

"Most of the flow disruptions were low impact; however, we found that as the rate of low-impact flow disruptions increased, so did the rate of high-impact flow disruptions – thus attesting to the cascade of events that typically transpire when the progression of care is even slightly disrupted," said Dr. Shouhed.

Based on type of disruption and clinical impact, the highest rate of flow disruption involved breakdowns in coordination, which were associated with approximately three low clinical impact and one high clinical impact flow disruptions per hour.

"We believe that prospective observation allows individual hospitals to accurately identify systemic deficiencies and evaluate the impact interventions may have on improving patient safety and efficiency of care," he added.

The study was funded by a Military Operating Room of the Future grant from the Department of Defense.

CHICAGO – Breakdowns in the coordination of care, rather than communication, were the most common type of flow disruption at a level I trauma center, based on an analysis of data from 86 cases.

The finding contrasts with results from previous studies showing communication breakdowns as the top flow disruptions, and the study "is one of the first and largest to objectively document that flow disruptions in trauma care occur frequently," according to Dr. Daniel Shouhed of Cedars-Sinai Medical Center in Los Angeles.

"Defective systems allow human errors to cause harm to patients," Dr. Shouhed said at the annual clinical congress of the American College of Surgeons. "We believe systems can be better designed to prevent or detect errors before a patient is harmed."

As part of an effort to improve systems, Dr. Shouhed and his colleagues conducted a prospective observational study of flow disruptions over 2 months of 24-hour coverage in a level I trauma center.

Categories of flow disruptions included communication, coordination, environment, equipment, external interruptions, patient factors, technical skills, and training.

Communication breakdowns were defined as "disruptions that involve the verbal transition of information between at least two team members," while coordination breakdowns were defined as "disruptions that involve the interaction with some piece of equipment as well as at least one other team member," Dr. Shouhed said.

Flow disruptions were defined as low or high impact, based on whether they caused a pause in the progression of patient care or significant consequences to patient care. For example, a low-impact communication disruption might be "a scribe nurse unable to hear primary survey from resident," while a high-impact disruption might be "an ED attending did not hear request for STAT blood; order not placed."

Multiple physicians reviewed and scored each disruption. Each case could include three phases of care: trauma bay, imaging, and operating room (or interventional radiology).

The researchers observed 86 cases, 6 of which required immediate surgery. The average case duration was 102 minutes. On average, patients spent 25 minutes in the trauma bay, 30 minutes in the CT scanner, and 148 minutes in the operating room.

A total of 1,757 flow disruptions were observed. Of these, 46% occurred in the trauma bay, 33% in imaging, and 21% in the operating room. The researchers examined the effect of trauma level and trauma phase on the rate of flow disruptions, excluding the six OR cases because of the small sample size.

Flow disruption rates were divided into low-level (trauma 200) or high-level (trauma 100) activations, Dr. Shouhed said.

A comparison of the rate of flow disruptions between the trauma bay and imaging phases of care based on clinical impact scores showed a significantly higher rate of low-impact flow disruptions in the imaging phase, particularly among trauma 100 cases.

In examining the relationship between high clinical impact and low clinical impact flow disruptions, the researchers found a strong correlation between the rate of low-impact and high-impact flow disruptions among all phases of care.

"Most of the flow disruptions were low impact; however, we found that as the rate of low-impact flow disruptions increased, so did the rate of high-impact flow disruptions – thus attesting to the cascade of events that typically transpire when the progression of care is even slightly disrupted," said Dr. Shouhed.

Based on type of disruption and clinical impact, the highest rate of flow disruption involved breakdowns in coordination, which were associated with approximately three low clinical impact and one high clinical impact flow disruptions per hour.

"We believe that prospective observation allows individual hospitals to accurately identify systemic deficiencies and evaluate the impact interventions may have on improving patient safety and efficiency of care," he added.

The study was funded by a Military Operating Room of the Future grant from the Department of Defense.

CHICAGO – Breakdowns in the coordination of care, rather than communication, were the most common type of flow disruption at a level I trauma center, based on an analysis of data from 86 cases.

The finding contrasts with results from previous studies showing communication breakdowns as the top flow disruptions, and the study "is one of the first and largest to objectively document that flow disruptions in trauma care occur frequently," according to Dr. Daniel Shouhed of Cedars-Sinai Medical Center in Los Angeles.

"Defective systems allow human errors to cause harm to patients," Dr. Shouhed said at the annual clinical congress of the American College of Surgeons. "We believe systems can be better designed to prevent or detect errors before a patient is harmed."

As part of an effort to improve systems, Dr. Shouhed and his colleagues conducted a prospective observational study of flow disruptions over 2 months of 24-hour coverage in a level I trauma center.

Categories of flow disruptions included communication, coordination, environment, equipment, external interruptions, patient factors, technical skills, and training.

Communication breakdowns were defined as "disruptions that involve the verbal transition of information between at least two team members," while coordination breakdowns were defined as "disruptions that involve the interaction with some piece of equipment as well as at least one other team member," Dr. Shouhed said.

Flow disruptions were defined as low or high impact, based on whether they caused a pause in the progression of patient care or significant consequences to patient care. For example, a low-impact communication disruption might be "a scribe nurse unable to hear primary survey from resident," while a high-impact disruption might be "an ED attending did not hear request for STAT blood; order not placed."

Multiple physicians reviewed and scored each disruption. Each case could include three phases of care: trauma bay, imaging, and operating room (or interventional radiology).

The researchers observed 86 cases, 6 of which required immediate surgery. The average case duration was 102 minutes. On average, patients spent 25 minutes in the trauma bay, 30 minutes in the CT scanner, and 148 minutes in the operating room.

A total of 1,757 flow disruptions were observed. Of these, 46% occurred in the trauma bay, 33% in imaging, and 21% in the operating room. The researchers examined the effect of trauma level and trauma phase on the rate of flow disruptions, excluding the six OR cases because of the small sample size.

Flow disruption rates were divided into low-level (trauma 200) or high-level (trauma 100) activations, Dr. Shouhed said.

A comparison of the rate of flow disruptions between the trauma bay and imaging phases of care based on clinical impact scores showed a significantly higher rate of low-impact flow disruptions in the imaging phase, particularly among trauma 100 cases.

In examining the relationship between high clinical impact and low clinical impact flow disruptions, the researchers found a strong correlation between the rate of low-impact and high-impact flow disruptions among all phases of care.

"Most of the flow disruptions were low impact; however, we found that as the rate of low-impact flow disruptions increased, so did the rate of high-impact flow disruptions – thus attesting to the cascade of events that typically transpire when the progression of care is even slightly disrupted," said Dr. Shouhed.

Based on type of disruption and clinical impact, the highest rate of flow disruption involved breakdowns in coordination, which were associated with approximately three low clinical impact and one high clinical impact flow disruptions per hour.

"We believe that prospective observation allows individual hospitals to accurately identify systemic deficiencies and evaluate the impact interventions may have on improving patient safety and efficiency of care," he added.

The study was funded by a Military Operating Room of the Future grant from the Department of Defense.