Trauma Resuscitation Process Improvement Collaborative

5/1/2019

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Marcin A. Jankowski, DO, MBA, FACS, FACOS, CHSE

Division Chief,  Trauma and Surgical Critical Care

The Charles C. Wolferth Trauma Center at Hahnemann University Hospital

Drexel University College of Medicine

Philadelphia, Pa

Trauma Resuscitation Process Improvement Collaborative (TRPIC):

Can’t We All Just Get Along?

HahnemannHOSPITALUniversity

CHARLES C. WOLFERTH TRAUMA CENTER

Disclosures

No financial disclosures

No conflicts of interest

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5/1/2019

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Who We Are

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State-designated Level 1 Trauma

Center (1st TC in Philadelphia)

Robust GS and EM residencies

Ortho, OB/Gyn, Anesthesia, Urology,

Nursing school, Rad tech school

EMS training facility

Visiting residents/fellows

Associated with DUCOM – largest

medical school class in the country

Level 2 TA – 15-20 “responders”

Level 1 TA – 25-30 “responders”

Patients #1…Teaching #2!

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We had a problem.

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A need for a change!

Trauma Resuscitation Process Improvement

Collaborative(TRPIC)

Rich Hamilton, MD (EM‐Chair)

Eric Stander, MD (EM‐Service Chief)

Gail Blinstrub (Trauma‐TPD)

Mark Weisman, MD (PGY‐2 EM)

Nicole Hartman (ED Nurse Educator)

Amanda Teichman, MD (PGY‐5 Surgery/Trauma)

Karl Henry (ED Manager)

Adam Zwislewski (Trauma Outreach Coord/Educator)

TRPIC Leadership Committee

Marcin Jankowski, DOTPMD

Trauma Resuscitation Process Improvement Collaborative

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Assemble TRPIC TEAM

Review current

protocol identify

OFIs

Develop a survey

Identify survey targets

Send outPRE

survey

Collect NOTECs

data

InterpretData &

Identify OFIs

Educatetrain staff

Send outPOST survey

Collectdata

& publish

Phase 1

Phase 2

Phase 3Phase 4

TRPIC - 4 Phases

Reinforce/ Simulate

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A 20-question online survey was sent to ALL who regularly participate in trauma resuscitations

Roles and responsibilities

Adherence to ATLS & own institutional protocols

Multidisciplinary teamwork

Supplies & procedures

Effective communication

Proper use of PPE

Crowd & noise control

Biggest obstacle to providing best trauma care…

If you could change one thing…

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Survey sent to 125 recipients

Received 111 responses within 2 weeks!

Results!

66%

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30%

43%

2%

75%

75%

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80%

71%

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95%

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Lack of PPE use

Excessive noise level

Lack of adherence to ATLS/ATCN

protocol

Lack of teamwork Lack of clearly defined trauma resuscitation

roles and responsibilities

Overcrowding

Poor communication

STRESS!

CHAOS

CONFLICT

Critically injured trauma patient

Life-saving procedures

Limited Space

Constant turnover of personnel

Residents/interns in training

A lot needs to happen in very little time

Opportunities for Improvement(based on survey results)

Change the culture

Review & revise current policy

Reeducate nursing resident,

physician staff

Identify only essential team members (6)

Change and enforce policy Change the current culture!

Personality conflicts

Duplicate orders

Repetition of 1o/2o survey

Delayed times to CT

Lack of PPE use

Overcrowding &excessive noise level

Lack of adherence to ATLS/ATCN protocol

Lack of teamwork, communication & respect

Lack of clearly defined trauma resuscitation roles

MiscommunicationInadequate documentation

High risk of exposure

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Objective

To determine if the institution of a position-based

trauma resuscitation protocol combined with in-situ

simulation improves teamwork, interdisciplinary

collaboration and efficiency.

Methods

This protocol was presented to ALL team members via three routes:

A video demonstration of “old-bad trauma resuscitation” vs “new-good trauma resuscitation” was shown to ALL team members and made available online

Reinforced with regularly-scheduled trauma in-situ simulations

A diagram outlining 6 new essential positions was distributed to every individual and displayed in trauma bay

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Specific individuals (based on their training level, skills, knowledge, & experience) were assigned to each specific role

Each team member could only have ONE role at any ONE time

Disruptive & unprofessional behavior was no longer tolerated

ATLS/ATCN concepts were constantly and repeatedly reinforced

Monthly real-time in-situ trauma simulations / videos

PPE REQUIRED for every essential team member

Non-essential personnel no longer in active zone

Everyone was empowered to tell others to keep noise levels down

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Methods

• 2 methods of data collection were used in the initial phase of the study:

• First: Online survey sent 3 months BEFORE and AFTER the roll out of TRPIC• 20 questions (5-point Likert scale) ranging from never to

always

• Questions addressed communication, leadership, comfort with protocol, overcrowding and noise level

Methods

Second: utilized a T-NOTECs scoring system

Five categories rated on a 1-5 scale

LeadershipCommunicationCooperationDecision making Situational awareness

Each trauma resuscitation required a T-NOTECHS from:EM ResidentTrauma Chief Resident Trauma Nurse

Data was collected 3 months BEFORE and AFTER rollout

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Results

Total of 125 staff eligible to participate in trauma resuscitations:111 completed the initial PRE online survey105 completed the POST online survey

Scores for ALL of the initial 18 questions demonstrated improvement and all but 1 were statistically significant

Total of 89 T-NOTECHS were collected BEFORE and 87 were collected AFTER

All areas demonstrated a significant mean improvement of at least 0.5 for overall score

T-NOTECS

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Improved Efficiency

Pre:June 2016 – Jan 2017 (N=74 level 1 traumas)

Rollout:May‐June 2017

Post:June 2017 – Jan 2018 (N=72 level 1 traumas)

Time to CT

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Identify and eliminate significant barriers to providing efficient and

effective trauma resuscitative care

Involve and engage all stakeholders in process improvement

(Trauma, ED, Nursing & all other ancillary staff)

Eliminate repetition of exam components of trauma resuscitations

and decrease total time spent in trauma bay

Promote collegial and professional multi-disciplinary & multi-

departmental team collaboration in the trauma bay

Conclusion

Establish advanced trauma education for ED and STICU nurses

(ATCN) and incorporate into resuscitation process

Incorporate regularly-scheduled mock trauma simulations for future

improvements in trauma resuscitations

Increase trauma team member accountability, improve team

morale, increase team member engagement, improve standard of

care, escalate team member expectations

Create a new culture, a new high standard of trauma care here at

Hahnemann with the ultimate goal of providing the highest-quality

trauma care possible

Conclusion

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HahnemannHOSPITALUniversity

CHARLES C. WOLFERTH TRAUMA CENTER

Thank You