The TRUST study: Latent safety threats in trauma resuscitation

On paper, most of resuscitation is actually pretty easy. On paper, there are basic algorithms to follow. On paper, the steps are clear, and there are no obvious impediments to action. Unfortunately, real resuscitation rooms are nothing like textbooks. Knowing what to do is important, but far more important is knowing how to get it done. Communication, coordination, ergonomics, and planning become paramount. In looking at latent safety threats, these essential, pragmatic aspects of resuscitation are explored in the TRUST study, a paper from our FOAMed friends Andrew Petrosoniak (@petrosoniak), Chris Hicks (@HumanFact0rz), and their colleagues.

The paper

Petrosoniak A, Fan M, Hicks CM, White K, McGowan M, Campbell D, Trbovich P. Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review. BMJ Qual Saf. 2020 Oct 23:bmjqs-2020-011363. doi: 10.1136/bmjqs-2020-011363 PMID: 33097610

The Methods

This is a single center simulation based study looking at 12 simulated trauma resuscitations. They used cameras and microphones to record resuscitations, allowing for focused and repetitive review to identify latent safety threats. There were 4 scenarios. The first was a surgical airway. The second was a blunt trauma requiring massive transfusion. The third was a trauma precipitated by a medical event, and therefore complicating diagnostics. The fourth was a penetrating injury in an agitated patient. The scenarios were not scripted to make latent safety threats occur, but were based on clinical scenarios in which previous adverse events had been identified. Therefore, the results here are not representative of the average trauma resuscitation, but rather the most complex trauma scenarios.

In addition to identifying latent safety threats, they had a secondary goal of assessing the feasibility of running these in situ simulations monthly in the trauma bay of a busy level 1 trauma center. I won’t go into that part of the study, but the short answer is in situ simulation is feasible: they never had to cancel a simulation, but did delay a few because of simultaneous arrival of a trauma patient. 

The Results

Over the course of 12 simulated scenarios, they identified 843 latent safety threats! That is 70 potential safety issues for each simulated patient. 516 of these latent safety threats (61%) were classified as “critical”. (Remember, these are simulations designed around complex trauma cases. Routine cases would probably result in far fewer threats being identified. However, based on the examples they give, I find these numbers very believable for the more complex cases that they were running.)

They classified latent safety threats into 7 themes, with 38 subthemes. 23 were considered critical. The critical threats were:

• Physical workspace
  • Location of the vital signs monitor not ergonomically optimized
  • Equipment placement impeding clinical care
  • Knowledge deficits concerning equipment location
• Team co-orientation and mental model formation
  • Team members absent for paramedic handover
  • Shared mental models not established
  • Patient care handover information repeated
  • Essential team members absent during resuscitation
  • Information missing from paramedic report
• Communication: unclear responsibility and/or accountability
  • Lack of closed loop communication
  • Uncertain about status of outstanding orders or actions
  • Lack of role clarity among team members
  • Unclear authority between team leader and team member
• Communication: demands exceed individuals’ capacity
  • Patient care activities delayed or not completed due to task overload
  • Concurrent conversations prevent team leader communication
  • Disruptions in staff-to-staff information transmission
  • Staff distracted by non-trauma-related tasks
  • Competing priorities result in delay or non-response
• Task-specific issues
  • Team member knowledge gaps in clinical protocols
  • Delays in critical clinical care interventions
  • Clinically significant injuries missed during resuscitation
  • Drug calculation performed without verification
• Equipment and supplies
  • Equipment usability not optimized
  • Equipment unavailable and/or not accessible
• Infection prevention and/or provider safety (They didn’t actually see any critical events in this category. 

Discussion

Obviously this isn’t a perfect study. It takes place at a single center, so cultural and design issues at this hospital may not be representative of other hospitals. (Although, with Petro and Hicks in charge, my guess is that there are fewer latent safety threats at St. Mike’s than at many other trauma centers.) It is also a simulation study, with cases specifically designed to be complex. The point is not to go all Chicken Little, and worry that there are hundreds of safety threats in every one of our resuscitations. The numbers are less important. The key is reading their themes, thinking about how these threats may apply to your own resuscitation room, and perhaps even considering the role of in situ simulation to identify the unique latent safety threats in your own department. If anything, my biggest issue with this paper is that I would have liked to see a lot more detail about the various subthemes (which I assume was left out because of journal space limitations). If either Petro or Chris want some space on First10EM to expand on their lessons, they know they are always welcome.

One thing that you will notice from the list is that very few latent safety threats relate to knowledge deficits. This is partially because of the focus of the authors, but it is also consistent with other literature. When we make mistakes in resuscitation, it is usually process rather than knowledge that is the sticking point. You can’t become a great resuscitationist sitting at home reading a textbook any more than you can become a great basketball player practicing alone in your driveway. Resuscitation is a team sport, and we must train together.

One thing that might surprise people is that design aspects of the physical space were responsible for the highest number of latent safety threats. Even in the simulation world, we tend to be very focused on medical knowledge and teamwork, but design, ergonomics, and architecture are rather foreign concepts in medicine. I am very biased here, because like Petro and Hicks, and really think these design issues are essential. Unlike Petro and Hicks, I have not been successful solving them. I have never worked in a hospital where I could see the vital signs while intubating. It is always behind my head. There is no time when vitals signs are as critical as during intubation, and that is the one time I cannot see them at all. That is clearly insane. However, it is also potentially costly to fix (although it doesn’t have to be if simple fixes like mirrors are considered). Based on the results of this study, they added 2 extra monitors to their resuscitation room (a ceiling mount at the foot of the bed and a wall mount on patient right) which essentially guarantees that all team members will be able to see a monitor at all times.

They made numerous other improvements based on their simulations exercises. After identifying delays in blood delivery, and recognizing the circuitous route that porters had to take from the blood bank to the emergency department, they actually mapped out and practiced the most efficient path to take. (This is a great reminder to involve ALL members of your team in simulation. How often do you train with your porters?) Similarly, they identified that calling for blood required 2 separate phone calls, and they were able to adjust their system so that the massive transfusion protocol could be activated with only a single call. 

Finding equipment during resuscitation is another issue I think we have all encountered. During these resuscitations, they recognized that people often were searching the room for the multiple pieces of equipment required for a single procedure (in this case cricothrotomy). The simple fix was to bundle these all together, so you no longer have to find a scalpel, bougie, and endotracheal tube separately, but just have to find the one cricothyrotomy kit that has everything you need. 

I think the detailed discussion of the subthemes is the most important aspect of this paper, which is why I was disappointed that the discussion session is so short. Hopefully we will see more from these authors in the future expanding on these lessons. In the meantime, there is tremendous value in running in situ simulation and identifying latent safety threats that might be unique to your environment. (I know that sounds overwhelming, but we managed to accomplish it at a community hospital with no real simulation experience, so I really think that this is doable in every emergency department.)

Bottom line

It is not good enough to know what to do. You must know how to get it done.

Resuscitation rooms need to be designed around our needs. Too often in medicine, our actions are shaped by the constraints of our physical space.

Resuscitation is a team sport and we have to practice that way.

Other FOAMed

I haven’t seen anyone else cover this paper yet, but considering its value I am sure others will with time. 

In the meantime, if you want to read more about resuscitation, First10EM has you covered.

Jan 18, 2021 Update: OK, I knew I couldn’t be the first person to talk about this paper. It turns out I am just very behind on my podcast listening, and the paper was covered all the way back in November on SimulCast.

References

Petrosoniak A, Fan M, Hicks CM, White K, McGowan M, Campbell D, Trbovich P. Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review. BMJ Qual Saf. 2020 Oct 23:bmjqs-2020-011363. doi: 10.1136/bmjqs-2020-011363 PMID: 33097610