A crew resource management program tailored to trauma resuscitation improves team behavior and communication.

BACKGROUND: Crew Resource Management (CRM) is a team-building communication process first implemented in the aviation industry to improve safety. It has been used in health care, particularly in surgical and intensive care settings, to improve team dynamics and reduce errors. We adapted a CRM process for implementation in the trauma resuscitation area. STUDY DESIGN: An interdisciplinary steering committee developed our CRM process to include a didactic classroom program based on a preimplementation survey of our trauma team members. Implementation with new cultural and process expectations followed. The Human Factors Attitude Survey and Communication and Teamwork Skills assessment tool were used to design, evaluate, and validate our CRM program. RESULTS: The initial trauma communication survey was completed by 160 team members (49% response). Twenty-five trauma resuscitations were observed and scored using Communication and Teamwork Skills. Areas of concern were identified and 324 staff completed our 3-hour CRM course during a 3-month period. After CRM training, 132 communication surveys and 38 Communication and Teamwork Skills observations were completed. In the post-CRM survey, respondents indicated improvement in accuracy of field to medical command information (p = 0.029); accuracy of emergency department medical command information to the resuscitation area (p = 0.002); and team leader identity, communication of plan, and role assignment (p = 0.001). After CRM training, staff were more likely to speak up when patient safety was a concern (p = 0.002). CONCLUSIONS: Crew Resource Management in the trauma resuscitation area enhances team dynamics, communication, and, ostensibly, patient safety. Philosophy and culture of CRM should be compulsory components of trauma programs and in resuscitation of injured patients.

Clinical practice guideline: red blood cell transfusion in adult trauma and critical care.

OBJECTIVE: To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care. DESIGN: Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members. METHODS: This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM. RESULTS: Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion. CONCLUSIONS: Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.

Hepatic dysfunction increases length of stay and risk of death after injury.

BACKGROUND: The relative importance of dysfunction or failure of different organ systems to recovery from critical illness is unclear. The purpose of this study was to evaluate the contribution of hepatic dysfunction to outcome after injury. METHODS: We retrospectively evaluated patients admitted to our trauma center from 1994 to 1998 for the development of hepatic dysfunction, defined as serum bilirubin > or = 2.0 mg/dL. Additional variables on patient demographics, injuries, hospital course, and development of other organ system dysfunction were collected from the trauma registry and hospital records. RESULTS: Using logistic regression analysis, hepatic dysfunction was significantly associated with increased intensive care unit length of stay (LOS) and death. The added development of hepatic dysfunction significantly increased LOS in patients with no other organ dysfunction, those with renal dysfunction, and those with respiratory dysfunction. CONCLUSION: Hepatic dysfunction influences recovery after injury independent of the dysfunction of other organ systems. The development of hepatic dysfunction prolongs LOS and increases mortality.