Building capacity for ATLS trauma education: role of nurse practitioners and physician assistants.

Objectives: Advanced Trauma Life Support (ATLS) focuses on care of injured patients in the first hour of resuscitation. Expanded demand for courses has led to a concurrent need for new instructors. Nurse practitioners and physician assistants (NPs/PAs) work on trauma services and duties include patient, staff, and outreach education. The goal of this project was to assess NP/PA self-reported knowledge and skills pertinent to ATLS and identify potential barriers to becoming instructors. Materials: This was a voluntary 91-question survey emailed to NP/PA lists obtained from professional societies and online social media channels. NPs/PAs completed a survey reflecting self-reported knowledge, experience, comfort level, and barriers to teaching ATLS interactive discussions and skills. Responses were recorded using a Likert scale and results were documented as percentages. Number of years of experience versus perceived knowledge and comfort teaching were compared using a χ2 test of independence. Results: There were 1696 completed surveys. Most NPs/PAs thought they had adequate knowledge and experience to teach interactive discussions and skills. Those with more years of experience and those who completed more ATLS courses had higher percentages. The number 1 barrier to teaching was lack of formal teaching experience followed by perceived hierarchy concerns. Experience and comfort with skills that fell below 50% were pediatric airway (49.5%), needle and surgical cricothyrotomy (49.8% and 44.8%), diagnostic peritoneal lavage (21.6%), and venous cutdown (20.8%). Conclusion: NPs/PAs with experience in trauma reported having the knowledge and skill to teach ATLS. A majority are comfortable teaching interactive discussions and skills for which they are knowledgeable. The primary barrier to teaching was lack of formal teaching experience, which is covered in the ATLS Instructor course. Training NPs/PAs to become instructors would increase the instructor base and allow for increased promulgation of ATLS and trauma education. Level of evidence: IV.

The impact of brief team communication, leadership and team behavior training on ad hoc team performance in trauma care settings.

BACKGROUND: Communication breakdowns and care coordination problems often cause preventable adverse patient care events, which can be especially acute in the trauma setting, in which ad hoc teams have little time for advanced planning. Existing teamwork curricula do not address the particular issues associated with ad hoc emergency teams providing trauma care. METHODS: Ad hoc trauma teams completed a preinstruction simulated trauma encounter and were provided with instruction on appropriate team behaviors and team communication. Teams completed a postinstruction simulated trauma encounter immediately afterward and 3 weeks later, then completed a questionnaire. Blinded raters rated videotapes of the simulations. RESULTS: Participants expressed high levels of satisfaction and intent to change practice after the intervention. Participants changed teamwork and communication behavior on the posttest, and changes were sustained after a 3-week interval, though there was some loss of retention. CONCLUSIONS: Brief training exercises can change teamwork and communication behaviors on ad hoc trauma teams.

Pulmonary contusions and critical care management in thoracic trauma.

Many victims of thoracic trauma require ICU care and mechanical ventilatory support. Pressure and volume-limited modes assist in the prevention of ventilator-associated lung injury. Ventilator-associated pneumonia is a significant cause of posttraumatic morbidity and mortality. Minimizing ventilator days, secretion control, early nutritional support, and patient positioning are methods to reduce the risk of pneumonia.

Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care.

OBJECTIVE: To determine the nature of surgeon information transfer and communication (ITC) errors that lead to adverse events and near misses. To recommend strategies for minimizing or preventing these errors. SUMMARY BACKGROUND DATA: Surgical hospital practice is changing from a single provider to a team-based approach. This has put a premium on effective ITC. The Information Transfer and Communication Practices (ITCP) Project is a multi-institutional effort to: 1) better understand surgeon ITCP and their patient care consequences, 2) determine what has been done to improve ITCP in other professions, and 3) recommend ways to improve these practices among surgeons. METHODS: Separate, semi-structured focus group sessions were conducted with surgical residents (n = 59), general surgery attending physicians (n = 36), and surgical nurses (n = 42) at 5 medical centers. Case descriptions and general comments were classified by the nature of ITC lapses and their effects on patients and medical care. Information learned was combined with a review of ITC strategies in other professions to develop principles and guidelines for re-engineering surgeon ITCP. RESULTS: : A total of 328 case descriptions and general comments were obtained and classified. Incidents fell into 4 areas: blurred boundaries of responsibility (87 reports), decreased surgeon familiarity with patients (123 reports), diversion of surgeon attention (31 reports), and distorted or inhibited communication (67 reports). Results were subdivided into 30 contributing factors (eg, shift change, location change, number of providers). Consequences of ITC lapses included delays in patient care (77% of cases), wasted surgeon/staff time (48%), and serious adverse patient consequences (31%). Twelve principles and 5 institutional habit changes are recommended to guide ITCP re-engineering. CONCLUSIONS: Surgeon communication lapses are significant contributors to adverse patient consequences, and provider inefficiency. Re-engineering ITCP will require significant cultural changes.

Maximizing reimbursement from trauma response fees (UB-92: 68X) - lessons learned from a hospital comparison.

BACKGROUND: The trauma response fee (UB-92:68x) recently has been approved, to be used by hospitals to cover expenses resulting from continuous trauma team availability. These charges may be made by designated trauma centers for all defined trauma patients when notification has been received before arrival (eligible pt). This study compares two trauma centers' performance in collecting this fee help define methodologies that can enhance reimbursement. METHODS: Our trauma system uses two hospitals (A and B) that are designated as the Level I trauma center for the region on alternate years. This allows hospital performance comparisons with relatively consistent patient demographics, injury severity, and payer mix. Data were collected for a one-year period beginning on January 1, 2003 and included charges, collections, and payer source for the trauma response fee. This time frame allowed the comparison of two six-month sequential periods at each trauma center. RESULTS: Out of a total of 871 trauma patients, 625 were eligible for the trauma response fee (72%): hospital A = 65% and hospital B = 77%. Total trauma response fee charges for both centers were 1,111,882 dollars with collections of 319,684 dollars (28.8%). The following payer sources contributed to the collections: Indemnity insurance (77.4%), Managed Care (22.1%), Medicare (0.3%), and Medicaid (0.2%). No collections were obtained from any self-pay patient. Eligible patients were charged a trauma response fee much less frequently in Hospital A than B (29.35% versus 95.2%) but revenue / charge ratios were equivalent at both hospitals (0.32 versus 0.28). These differences resulted in markedly enhanced revenue for each eligible patient in Hospital B compared with A (735 dollars versus 174 dollars) CONCLUSIONS: Enhanced collection by hospital B was a result of a higher charge, compulsive billing of all eligible patients, and emphasis on pre-admission designation of trauma patients. Effective billing and collection process related to trauma response fees results in substantial additional revenue for the trauma center without additional expense.

Predictors of educational outcome: factors impacting performance on a standardized clinical evaluation.

BACKGROUND: To improve student skills specific to the evaluation of radiology studies during a required clerkship in surgery for 4th-year medical students, we initiated a self-study CD-ROM educational module midway through 2000-2001. We hypothesized that student performance would improve after implementation of this module and identified factors that predicted student performance. MATERIALS AND METHODS: Students (n = 98) chose one of two hospital sites for a clerkship that focuses on the care of acutely ill surgical patients. A standardized clinical final evaluation (Objective Structured Clinical Evaluation) contained two components: radiology (R score) and ICU clinical "flow sheet" interpretation (C score). We evaluated the effect of the CD-ROM educational module and other factors on student exam performance using univariate and multivariate analysis. RESULTS: The site of the clerkship and use of the CD-ROM educational module were significant factors affecting the C score identified by ANOVA; P < 0.05. With the R scores from both sites combined, performance improved by 22% from a mean of 29.2 +/- 1.1 to 35.7 +/- 1.1 with use of the module. A stepwise multiple regression analysis testing the effect of site, time of year, educational module, and a prior radiology clerkship on the R score identified that the site and CD-ROM educational module modeled performance; R(2) = 0.30, P < 0.01. The C score was affected by site (A: 72.5 +/- 1.6 vs B: 67.3 +/- 1.9, P < 0.05 by ANOVA). Regression analysis identified that time of year (later associated with increased score) and prior performance on the 3rd-year standardized exams (OSCE and NBME) modeled 4th-year C score; R(2) = 0.20, P < 0.01. CONCLUSIONS: In a clerkship that already emphasized faculty-facilitated case-based learning, including evaluation of radiological studies, the addition of a self-study CD-ROM radiology module significantly improved test score. This study supports the efficacy of directed self-study to improve student skills.