ATLS provide a common framework and organized approach to trauma resuscitations, and has been shown to improve outcomes [4, 5]. Studies have demonstrated the effectiveness of ATLS training on improving the quality of diagnostic and therapeutic procedures and decreasing mortality rate [4, 5]. ATLS training and implementation, as a part of a well-organized trauma system, can improve outcomes of trauma patients [12–19].
As with any quality assessment, the results from this study demonstrated a need to improve overall ATLS compliance at our institution. However, the compliance rates for primary and secondary surveys at our institution were similar or slightly higher compared to other studies [9–11]. Santora et al. found an overall deviation rate of 23% from ATLS protocols in their study using video assessment of trauma resuscitations, while the overall compliance rate for ATLS was only 53% in the study by Spanjersberg et al.. In our study, the presence of a TTL during trauma resuscitation led to a significantly higher compliance rate for primary and secondary surveys, and also increased efficiency of resuscitation as demonstrated by the decrease in time to diagnostic imaging compared to the absence of a TTL. Time for CT acquisition for trauma patients range widely in the literature, from 17 to 197 minutes [20–24], and there is no definition for acceptable time to completion of diagnostic imaging in trauma patients. The mean times from patient arrival to completion of CT scans in our center were within the time frame reported by other studies; however, times to completion of xrays were often delayed. Although CT acquisition time has not been directly linked to affect major outcomes such as mortality or LOS, faster CT acquisition may be associated with time reduction to live-saving interventions .
There were certain areas in the primary and secondary surveys where the non-TTL group seemingly out-performed the TTL group, such as the utilization of basic radiography. Although plain C spine and pelvic xrays are part of the ATLS algorithm, with the availability of CT scanners, they have a diminishing role for hemodynamically stable blunt trauma patients with a severe mechanism of injury [26–28]. Several studies have found that pelvic xray has low sensitivity compared to CT of the pelvis, and may be omitted in hemodynamically stable blunt trauma patients who will have CT of the abdomen and pelvis [26–28]. Similarly, CT C spine is superior to C spine xray (due to frequent inadequate views) [29–31], and is replacing C spine xrays in many trauma centers [32, 33]. On the basis of the current evidence, a TTL may have chosen to omit C spine and pelvic xrays on patients who were receiving CT C spine, abdomen and pelvis. This may have potentially reduced redundant imaging and unnecessary delays in the trauma resuscitation area. Overall, the times to imaging, however, were longer than expected, and could be improved upon as a quality initiative.
Our study showed a significantly longer ICU stay and a trend for longer hospital stay for the TTL group compared to the non-TTL group. This may be accounted for by the lower RTS and higher ISS in the TTL group compared the non-TTL group, indicating a higher severity of injuries in the TTL group. Although we have not been able to demonstrate a direct link between ATLS compliance and mortality, the efficiency of trauma resuscitations was improved by the presence of a TTL as demonstrated by the decreased time from patient arrival to performance of various diagnostic imaging.
Studies on medical and surgical patients have shown that the rate of early readmission is associated with quality of inpatient care . In addition, the American College of Surgeons’ Committee on Trauma has recommended that readmissions due to complications should be an audit filter in the quality of care monitors . We have therefore used readmission rate as a surrogate marker for quality of care delivered to trauma patients. Previous studies on early readmission for trauma patients showed a readmission rate ranging from 1.2 to 10.9% [36–38], which is comparable to this study. Several factors are associated with readmissions after trauma, in particular, severity of injuries [36, 38]. One would expect the TTL group to have a higher readmission rate compared to the non-TTL group due to a higher severity of injuries. The fact that the readmission rates were similar between the two groups may indicate a positive effect on patient care with the presence of a TTL, since other aspects of inpatient care were standardized for both groups of patients. Further studies are required to determine the exact impact of TTL on process of care and readmission rates.
Given the findings of this study and evidence in the literature, the consistent presence of a TTL during resuscitations of major trauma patients is important for maintaining compliance with ATLS protocols. Although one can postulate that better compliance rates for performing the primary and secondary surveys in the TTL group compared to the non-TTL group were based on increased leadership abilities, it is possible that the non-TTL group had less resources and manpower available leading to lower compliance.
At the time of the study, TTLs were composed of a multidisciplinary group of ED physicians, general surgeons, and one neurosurgeon. All of the TTLs have ATLS certification, and are involved in ATLS education, quality assurance, and research. As a whole, this group is more likely to be familiar with up to date ATLS protocols and evidence-based trauma studies, and see a higher volume of major trauma patients. The TTL serves an important role in trauma resuscitations by promoting leadership, team cohesiveness, and communication within the multidisciplinary team, to ensure efficiency and efficacy of the resuscitation . TTLs can also reinforce protocol-driven approaches to trauma care that improve patient care . Gerardo et al. demonstrated a reduction in mortality rate, most notably in the most severely injured patients, when a dedicated trauma team was implemented in a Level I trauma center.
During the time period examined in our institution, a TTL was present in only half of the trauma resuscitations. Reports from UK and Australia found similar rates of involvement by the trauma team and TTL [40, 41]. We believe there are two contributing factors: gaps in the TTL call scheduling, and lack of TTL notification as a part of activation of the trauma team. Reviewing the TTL call schedule at the study period, an average of 31% of shifts were not covered by a TTL (data not shown). At times when a TTL was not scheduled, the leadership role fell onto the attending ED physician, the attending surgeon, or senior general surgery resident. At our institution, TTL coverage can be improved by recruitment and retention of qualified physicians interested in trauma, and by including non-surgeons such as anesthetists, emergency physicians and intensivists. Although this study was not designed to measure the appropriateness of TTL or trauma team activation, there appears to be an element of under triage regarding trauma team activation and involvement of the TTL on call. Some of the current barriers include the lack of understanding surrounding the role of a TTL, interruptions in trauma resuscitations especially when a TTL arrives late, as well as the impression of chaos and “too many people” when the trauma team is activated. Various studies have demonstrated that appropriate activation of the trauma team can improve outcomes [42, 43], and under-triaged trauma patients are associated with a high risk of mortality . In order to promote a culture of safety, there needs to be ongoing education on TTL activation criteria for all staff involved in trauma resuscitations. Secondly, education should also focus on the benefits of TTL activation versus harm of “under-call”. Lastly, ongoing audits should target TTL activation rate and timely feedback should be provided to all players in trauma resuscitations to ensure proper and consistent TTL activation.
Attrition of ATLS knowledge may also have contributed to poor compliance. In a study by Ali et al. , significant attrition rates of cognitive knowledge and skills was evident as early as 6 months after participants completed an ATLS course. The same group showed the attrition rate was higher for participants from low-volume centers compared to high-volume centers . To address this issue, continued trauma education for all members of the trauma team should be actively encouraged and supported. This can take the form of multidisciplinary trauma simulations, maintenance of ATLS certification, other advanced courses in trauma, and attendance at trauma conferences. Additional training in trauma team crisis resource management may improve team cohesiveness, and the requirement of all physicians involved in trauma resuscitations to maintain active ATLS certification should also be established.
This study has a number of limitations. Trauma resuscitations are highly dynamic and as such not all actions performed were adequately documented with certainty. The chart review revealed a lack of time entries in many areas and this has made time-dependent outcome measures hard to gather. In particular, the rate of completion of FAST exams and time to FAST exam could not be reliably obtained from the chart review due to inconsistent record keeping. The study only reviewed data from a one-year period and as a result may not have the necessary power to show differences in major outcomes between the TTL compared to the non-TTL groups. However, we have obtained important data on the performance outcomes in the form of ATLS compliance rate, readmission rate, and indirect measure of efficiency of trauma resuscitations via times to diagnostic imaging. Additionally, we have also identified areas of future improvement with this quality assessment, and hope that other institutions will use our study as a model to promote their own quality reviews.