In this section
The linear Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to management of severely injured patients in modern, well resourced, emergency departments is increasingly being questioned. A rigid application of the ABCDE principles, where airway is assessed and managed, prior to proceeding to
breathing, which in turn is assessed and managed prior to the C, D and E components, can be inefficient for those patients with multiple complex injuries and competing clinical demands. A contemporary approach recognizes that the management of severely
injured patients often proceeds in a “horizontal” fashion – with a team of skilled individuals addressing multiple tasks at the same time. This approach is thought to be effective in reducing the total resuscitation time1
- and thereby facilitating the early delivery of definitive care. However, this adds complexity to the management of the injured patient as there are multiple processes occurring simultaneously, proceeding at different rates, and occurring in a wide variety
of situations. As a result, the coordinationof these processes may be “just as critical for patient survival as making the correct diagnoses or carrying out the most appropriate tasks”2
. This simultaneous management of tasks, personnel and the patient requires both the application of medical expertise and an understanding of human factors. The objective of this chapter is to review some of the human factors that are relevant to reception and resuscitation of a
severely injured child.
“Human factors” have been defined as “all the things that make us different from logical, completely predictable machines; how we think and relate to other people, equipment and our environment.”3
One starting point in understanding the relevance of human factors to healthcare provision, is to accept the fact that healthcare is provided by humans. Whilst healthcare providers may be highly skilled, well-motivated, and knowledgeable individuals,
they remain human, and as such are prone to error. Therefore, it is arguable that an understanding of human factors can help mitigate the chances of errors and adverse events.4 Error itself can be viewed from an individual or systems approach. A systems approach
recognizes that given human fallibility, errors will occur even in the best organisation, and therefore risk reduction requires that processes or safeguards be put in place. Reason has described this conception of error as the “Swiss cheese model of system
accidents”5. He argues that systems have multiple layers of defence whose function is to protect errors from occurring. However, each layer, like a slice of Swiss cheese, has weaknesses or holes. The presence of a hole in any single slice does not usually lead to a bad outcome – but where the holes in
multiple layers line up, bad outcomes occur. Reason suggests that holes arise in each layer due to one of two factors – an active
failure – such as a slip, lapse, mistake, or procedural violation, or due to a latent condition – that exists within the system and has arisen from decisions made by “designers, builders, procedure writers and top level management”6
Active failures such as lapses and slips are well known to occur more frequently with fatigue, stress, illness, overload, inexperience and complacency. But they are also more likely to be triggered by factors commonly found in complex trauma resuscitations - specifically7
However, the specific form of lapse or error is hard to predict, which can hinder attempts to prevent them.
In contrast, latent conditions through the study of systems, can be identified, and ideally, remedied before an adverse event occurs.
Non-technical skills commonly refer to those human factors that operate at the individual level. They include interpersonal skills – such as leadership, team work and conflict management - as well as cognitive skills such as situational awareness, planning and decision
making. Communication is a core component that runs through all of these non-technical skills. These skills are part of an understanding of how human factors affect performance during critical events.
Leadership has been described as a “multi-dimensional, complex behavior that includes effective communication, efficiency, decision-making, and resource management skills.8
” It is regarded as an essential non-technical skill, required for the optimal functioning of the trauma team.9
The clear identification of a team leader leads to increased adherence to trauma guidelines, a more complete secondary survey, and improved trauma team coordination10
. The goal of the team leader is to ensure timely appropriate care to the patient, and facilitate rapid delivery of definitive therapy. In order to do this they need to accept responsibility for the patient, provide strategic direction based on the anticipated needs of the patient and monitor the progression of
the clinical care provided. They may need to provide feedback or teaching for other team members, as well as coordinate the needs and preferences of multiple specialist teams. The attributes needed for leadership have been summarised as follows11:
Consideration and application of these attributes can help individuals refine and develop their leadership skills. And, although it is difficult to measure precisely, training has also been shown to increase leadership skills.
The trauma team that assembles and cares for the severely injured child is not simply a group of people working side by side. Rather they are bound together, as a team, by their single purpose in achieving the best outcome for their patient. As members of a team they have
specific roles or functions to perform and interact with each other “dynamically, interdependently, and adaptively.13
” This means they are not just performing task roles (jobs team members do) but they are also performing team roles (working, supporting and looking out for each other)14
. Furthermore, team members are not mere subordinates following the direction of a team leader. Rather they must demonstrate good “followership” or “teamwork” which involves them actively engaging in patient care and utilising their own expertise, knowledge, and clinical skills to help
the team achieve its goals. This may involve them challenging the team leader, in an appropriate fashion, when required based on their own assessment the patient. It may involve ensuring that the information they need to relay to the team leader is done so at the appropriate time - when
team leader is ready to receive it. Important information will not be heard or interpreted if delivered in the wrong way at the wrong time:15
team members need to gauge the optimal time at which they should relay information back to the team leader – doing so requires a degree of awareness of the overall priorities for the patient and an ability to assess the relative importance of the information they themselves wish to relay. Furthermore, followership may involve
structuring questions/requests in a way that is helpful to the team leader. For example, where nursing staff have access to a drug book or other resource, they may find the question: “Are you happy with a 0.5mg/kg dose of ketamine for this patient? It works out to be 20mg, based
on an estimated weight of 40kg,” is superior to “How much ketamine do you want?” The latter question places a greater cognitive load on the team leader – it requires them to recall an appropriate dose of a drug and then to perform mental arithmetic when this information
is typically readily available to team member who posed the question. The former question demonstrates an ability to anticipate the needs of the team leader and the patient. The relevant information is presented to the team leader and this allows them to devote a greater amount of their cognitive
resources on deciding if this is the right drug at the right dose at the right time for the patient – without also having to contend with mental arithmetic.
The attributes necessary for good followership (or teamwork) have been summarized as follows16
Conflict is inevitable in almost every team, and its successful resolution is required for optimal team performance. Conflict is likely to arise in trauma teams for a number of reasons17:
The potential for conflict is further increased by the need to make decisions in situations with incomplete or potentially conflicting data. Individuals within teams will bring with them their own set of experiences and motivations which lead to divergent
perspectives and opinions. This range of opinions can be seen as constructive, as when correctly managed, they can help a team arrive at a more comprehensive assessment of the patient than any single assessor is able to obtain.
However, conflict that spills into the territory of a power struggle, where the focus becomes “who is right” rather than “what is right” can be destructive18
. The costs of conflict within teams include the wasting of both time and resources and distraction away from the management of the patient. Conflict within the team ought to be addressed by the team leader. Whilst several models exist on how to do this, the following principles
Ultimately however, most defer final responsibility for the course of action taken to the team leader, who in extreme situations may ask disruptive team members to leave the resuscitation.
Situational Awareness is a key component of effective trauma team management. It has been described as “knowing what is going on so you can figure out what to do.”20
It requires a global overview of the patient – knowledge of what has happened to the patient, their current state and what is likely to happen to the patient. Situational awareness is informed by an understanding of how mechanism influences injuries, the patients past medical history, detection of abnormal
clinical and vital signs, an ability to discern relevant clues and set aside distracting information, and expertise in being able to predict diagnoses based on incomplete information in dynamic situations. A designated trauma team leader should remain
“hands-off” in a complex trauma in order to retain overall situational awareness. A successful team requires the trauma team leader to periodically share situational awareness with them – most commonly via a “sit-rep”, “recap” or summary of the patient’s current situation
with a recommendation for the ongoing course of action.
All healthcare professionals wish to make “good” decisions during critical situations. Such decisions are characterized by the following21:
A key attribute in good decision making is the ability to predict what might happen to a patient with a particular set of injuries were differing courses of action to be taken, and then selecting the most appropriate course of action and communicating it to the team. Many such
decisions may be reviewed and contemplated through a process of mental simulation prior to the arrival of the patient. Team leaders are encouraged to pre-brief their teams where there is time to provide this shared mental model with their team. A variety of situations may be presented to
the team with appropriate courses of action suggested for each one. In doing this the team leader is psychologically preparing his team and facilitating their own decision making process by outlining an anticipated structure for the course of the resuscitation. Clearly, an adaptive model is required should
the patient arrive in a situation that is different to that predicted, but where the prior mental model and the observed reality are well matched, the team leader will have reduced their own cognitive load during the resuscitation.
One method of making a plan and facilitating decision making is to use an explicit structure during a pre-arrival briefing to enable a shared mental model to be held by all the team members. The current model taught at the Royal Children’s Hospital is for the team leader to
include a “synthesis” within the pre-arrival briefing that augments the information provided in the pre-arrival notification. This synthesis [xxii] has five components:
Commenting on the severity at the start allows the team to begin visualising whether this will be a standard resuscitation, or whether the patient will be in extremis and require a more urgent approach. If all team members are anticipating the same degree of illness/injury they are more likely to then
enter the case in an appropriate and co-ordinated fashion.
Stating the main type of injuring force can prepare the team for certain types or patterns of injury. Blunt trauma often results in injuries to multiple body areas, internal bleeding and internal organ lacerations/contusions. Penetrating trauma may be more likely to result in external bleeding and
more direct/localised areas of injury. Extremity crush injuries or amputations may be more likely to result in external bleeding and potentially metabolic complications.
Certain mechanisms may also trigger specific concerns. For example, high risk features of motor vehicle accidents - such as high speed, rollover or ejection warrant a more thorough search for occult serious injury even if the patient does not appear seriously injured on initial assessment. A penetrating injury (such as a stabbing) to
the chest may trigger the team to consider tension pneumothorax, haemothorax and cardiac tamponade. It may also prompt the team to consider looking for additional wounds in the “hidden” areas for stab injuries (such as axillae, groins / perineum, buttocks).
These are obviously generalisations but focusing the team on the type of injury force and expected injuries can allow them start visualising what the case may entail and potential injury patterns they can expect. Furthermore, stating the problem out loud may help the team leader
identify potential management priorities to conduct on arrival of the patient.
Example: “We are
expecting a moderately unwell, blunt trauma patient, pedestrian vs car. The
ambulance service have identified a head injury and a lower limb injury. From
the mechanism we should also retain a high index of suspicion for an abdominal
or pelvic injury as these are common with this type of mechanism. Let’s make sure a pelvic binder if available
to place on the patient, if they don’t already have one on.”
It is important for the team leader to convey their level of concern to the team prior to patient arrival to ensure that everyone understands the degree of confidence the team leader has to manage the case, any assistance they may require and the urgency/efficiency
the team leader will expect of them. By giving this part of the synthesis an emotional context and eliciting concern in the team, the team leader may rapidly motivate his team into action, as well as elicit a stronger sense of followership within the team, than merely stating
facts is able to do.
It also allows the team leader to express any uncertainties or specific difficulties they themselves are expecting, which may relate to the specific predicted injuries and their experience in managing them, their confidence in managing a large team, or
other issues they may have that may impact their ability to manage the case.
level of concern for this case is high. We
know there is head injury which will require a prompt CT scan to identify the
nature of this injury. However, whilst
the vital signs are only slightly abnormal at the moment, I’m concerned about
the potential for rapid deterioration due to abdominal or pelvic bleeding. If this occurs we may need to prioritise
theatre for haemorrhage control over a CT head.
Rather than simply stating the body region that is injured (and assuming the team knows the potential specific injuries that may occur in that region), it is more useful for the team leader to specifically name the life threats they anticipate the patient may have
based on the information provided from the pre-hospital providers and the clinical signs that have been relayed.
For example, in blunt trauma:
Potential open fractures & haemorrhage
Amputation leading to massive haemorrhage
This step removes the assumption that team members know the specific injuries that may occur in different body regions and allows them to instead start preparing for specific treatments that may be needed. Using the specific life threat also helps “prime” the team members, enabling the ability to anticipate
patient requirements, and facilitate their shared mental model of the situation.
Whilst the team will perform a standard primary survey, certain issues may be more urgent and require re-sequencing of the assessment and management steps. For example, in a patient with a tension pneumothorax, the team leader may direct the procedure doctor not to perform IV
access first, but rather perform chest decompression as a priority.
In the case above, treatment priorities may be:
“When the patient arrives, the priority will
be to assess his haemodynamics and make a quick decision about whether he needs
blood, or bilateral finger thoracostomies and chest drain insertion. I’d also like rapid chest and pelvic films so
we can quickly rule out major injuries in those areas and then focus on the
head and abdomen”.
This system can also be used to synthesise and summarise a trauma case during the resuscitation, simply by substituting “suspected injuries” with “injuries found”. It has been suggested that in addition to the initial debrief a “recap” or “sit-rep” of the patients status is utilised
following a major intervention, and at 20mins into the resuscitation. Doing so realigns the shared mental model of the team, giving them an increased situational awareness, and knowledge of the patient’s current priorities.
OK team, can I please have everyone’s
attention. This patient is a severely injured having presented in haemorrhagic
shock after being struck at speed by a car. The injuries we’ve found so far are a blunt abdominal
injury with peritonism and likely intra-abdominal bleeding, possibly from liver
or splenic laceration. His pelvis is clinically
stable. His haemorrhagic shock has responded to 1 unit of packed red blood
cells. He also has a mild closed head injury with a GCS of 13. He doesn’t need intubation right now , and I think
he’s stable enough to get to CT, so the priorities now are to hang a 2nd
unit of packed cells and commence this only if the BP drops to below 100mmHg, again. I’ve notified CT that we’ll be there in 5
minutes so if the circulation nurse could ensure we are attached to the
transport monitor and the transport bag is ready as soon as possible. Finally, could the surgical registrar please contact
theatre and make sure there is an available theatre, should CT indicate he
needs immediate surgery.”
Good communication is critical to all the non-technical skills discussed above. Without it, leadership, followership, conflict resolution, planning and decision making are all severely constrained. Understanding how error can arise through dysfunction communication requires some thought about what communication
usually entails. It is a mistake to think that communication is simply limited to the specific words used to convey information from one person to another. The “square model” of communication has been used to identify how any message can have four aspects (like the four sides of a square)23
. This model postulates that any message contains information about:
Which aspect of the message is most important is open to interpretation by the recipient of the message. The speaker may have surprisingly little ability to influence or even predict how the recipient will interpret the message, so what is heard may not be what is intended.
So for example, when a circulation nurse says: “The blood pressure is 86 / 50” – in addition to stating the actual blood pressure (the content), they may also reveal their concern about a hypotensive patient who is deteriorating (a self-revelation);
a lack of confidence in the team leader who hasn’t yet noticed the downward trend of the patient’s blood pressure (the relationship component) and an implicit suggestion to give blood to a patient with haemorrhagic shock (the appeal component). The speaker may
intend to appeal for action in this case, but the listener may interpret the statement as an effort to undermine their authority by suggesting they have failed to notice the change in the patient’s condition.
Given the multitude of aspects of both giving and receiving information, teams adopt specific techniques to minimize misunderstanding. Communication should be:
Correct communication involves the message transmitted being the correct one. So for the circulation nurse in the above example who wants to convey an appeal for action through their statement: “The blood pressure is 86/50” may be better served by stating “The patient remains hypotensive, shall we administer blood?”
In order to do this, team members need to have a degree of metacognition in knowing what they are hoping to be understood.
Correct communication also includes ensuring that what is said is heard and understood. A method for minimizing error here, is the use of closed loop communication. This is a 3-step process, where the speaker:
The recipient will also confirm when the order is completed. For example,
Clear communication requires an avoidance of ambiguous or mitigating language. It is directed towards a specific person so the team knows to whom the message is directed. Examples include:
Concise communication involves being brief and to the point – stating problems as simply as possible. Examples include:
The management of severely injured patients in Emergency Departments can be thought to consist of 3 phases of care:
It is worth considering the impact of human factors at each of these stages of the patient journey
In mature trauma systems, the arrival of a severely injured patient to hospital is often heralded by a notification from the pre-hospital services. This typically allows for at least 10 minutes of time during which a team can be assembled and preparations made for the
patient about to arrive. A large number of decisions are made in this phase even though the information available to make such decisions may be incomplete and open to various forms of interpretation. At RCH there are a number of systems based measures that aim to reduce error. These include the following policies:
There are four criteria used at RCH, any one of which is sufficient to
activate the Trauma Team. Unlike many adult trauma team activation criteria, RCH does not use a mechanism criteria. The four criteria that can be used to activate the Trauma Team are:
1. Abnormal physiological parameters or a GCS
2. Specific anatomical injuries. These include:
3. Multiple patients: when 3 or more trauma patients are expected
4. At the request of the trauma Team Leader
Trauma team activation requires the attendance of ED and PICU medical and nursing staff, the paediatric surgical registrar, an anaesthetist, a radiographer, an ED social worker and Emergency PSA, to the resus area of the Emergency Department 10 minutes prior
to the estimated arrival of the patient.
Once the trauma team has been activated, and its members gathered together, the Trauma Team Leader is tasked with providing a succinct synthesis (detailed above) and then allocating roles and tasks to team members. A primary plan based on the anticipated course
of the patient is discussed with variations should specific criteria be met. Typically team members will have tasks allocated to them that reflect the anticipated needs of the patient arriving. Given the large number of people and tasks involved, errors of omission can occur at this time. Attempts are made to mitigate this risk
through the use of a checklist which lists many of tasks that need to be allocated out to the team.
The RCH Pre-arrival Trauma checklist prompts the trauma team leader to allocate tasks related to:
In-house simulation training at RCH has shown that where the Pre-arrival Trauma Checklist is not used, errors of omission are more common.
Some of the cognitive load of role associated with task allocation to a group whose capability may be somewhat unknown to the team leader is mitigated against by establishing default roles and tasks based on specialty. These are identified in the RCH Roles and
Responsibilities Policy and further discussed in the subsequent chapter.
Once the patient arrives the team leader and senior paramedic should rapidly agree if handover should take place prior to patient transfer onto the ED trolley – this involves a 5 second evaluation for the presence of a life threat.
In the absence of an immediate life threat, a rapid "I-MIST-AMBO" handover (see below) should occur with the patient on the ambulance stretcher.
Past medical history
Any advance care directives
Relevant social information
Family awareness / contact
Handover of documentation
The function of the primary survey is to simultaneously assess and manage life threats. It is a crucial data gathering phase that allows good decision making to occur. Failure to complete the primary survey can lead to life threats being missed, and an inability to make good decisions about how to care for the
Environmental factors – such as noise, overcrowding and disorganisation – need to be considered in the management of the primary survey. Noise in particular can rapidly escalate. Louder rooms can lead to louder voices trying to be heard. The risk of this is that information gets
missed and requests from the team leader go unheard and further dysfunction ensues. Exposure to loud noise may detrimentally affect short term memory and impair auditory vigilance (for example being able to detect alarms). Management of the noisy environment can be managed through preventing
overcrowding and specifically asking the team to observe the “sterile cockpit” rule – where all unnecessary conversation stops - for high risk moments (for example induction and intubation).
Disorganisation can be mitigated through ensuring team members are aware of where the equipment they require to perform tasks prior to the patient arriving. It has been suggested that allocating a role of logistics and safety to a team member would reduce disorganisation – this person would be tasks with
crowd and noise control, optimising patient positioning, layout of equipment and safe movement of clinical personnel within the resuscitation, as well as ensuring that checklists prior to high risk tasks are reviewed.25
One latent threat identified through the RCH Trauma Team Training program relates to role allocation during the primary survey. Where a surgical registrar has been allocated to the assessment role, and is then required to switch roles to perform a procedure – such as a chest drain insertion – the
primary survey may fail to be completed and other life threats fail to be detected.
Documentation of the primary survey is ideally done in a contemporaneous fashion. This role is typically allocated to the doctor in the Team Leader Support role at RCH. The expectation is that this doctor utilises the Trauma Tab in the electronic medical record to act as an aide-memoire in ensuring all important steps
of the primary survey have been carried out and documented.
At the end of the primary survey, the team leader should recap and summarise what progress the patient has made and the immediate plan. A “command huddle” may be utilised to allow senior decision makers (typically ED team leader, surgical consultant/registrar and anaesthetist) to plan the disposition
of the patient. A plan for CT imaging / OT or admission to PICU / the ward should be confirmed and communication with those departments delegated to appropriate team members. This command huddle should typically occur within 20-30minutes of patient arrival to the emergency department.
In most cases, the secondary survey should be commenced (and completed) in ED – however, there are some occasions where the primary survey identifies life threats that cannot be managed in the ED – massive intracavitational bleeding. In these cases the patient may need their ongoing resuscitation to be
managed in theatre as part of the primary survey intervention. The secondary survey will need to be completed either concurrently or following surgical intervention.