new trends / interest in human factor based ... - atls 5...

1

ATLS%Europe,Mee.ng,Berlin,,April,2012,—,From,Teaching,to,Coaching,,Markus,Rall,

From Teaching to Coaching

for Patient Safety

Marcus Rall

TüPASS Centre for Patient Safety and Simulation Tubingen

Department of Anaesthesiology and Intensive Care Medicine University of Tubingen, Germany

Modern Simulation Team Training to enhance patient safety

Man

Technique Organisation

Optimizing

the Interactions

Simulation

Focus on Team

Human Factors CRM

Debriefing with - Facilitation techniques - Self-reflection (video) - Double-loop learning

What ? How ?

New trends / interest in Human Factor based Simulation

Team Training

•  NATO SOF Medical

•  AHA Sim/CRM Italy

To err is human … … the consequences are variable…

It is risky to be a patient and: The problem remains big…

„Disappointing, but no surprise� (Landrigan): •  Patient harm is frequent and wide spread •  The incidence did not decrease in the last years! •  18% of hospitalized patients are harmed by care •  More than 60% of the cases are preventable •  1,5 to 2,4% of incidents resulted in death (1:50 bis 1:100)

(medical error was causal or contributing)

Causes of accidents in medicine

70 % due to „Human Factors� (preventable?)

•  Not a lack of medical knowledge

•  But problems with transfering theoretical knowledge into meaningful actions in the real world

•  Problems with Complexity

•  Team, Communication (Not yet appropriately reflected in medical education !)

2


Resuscitation & Reality

• Chest compressions in only 48-76% of available time

• Correct depth of compression 28-63%

Wik L: Quality of CPR, JAMA 2005; Abella BS: Quality of CPR, JAMA 2005

Crisis Resource Management (CRM is derived from Aviation)

Definition „The ability to translate the knowledge

of what needs to be done into effective team activity in the complex

and ill-structured real world of medical treatment�

David Gaba, Stanford

CRM and

Non-technical Skills (NTS) • Know the environment

• Anticipate and plan

• Call for help early

• Exercise leadership and followership

• Distribute the workload

• Mobilize all available resources

• Communicate effectively

• Use all available information

CRM Key Points

Nach Rall, Gaba

in: Miller, Anesthesia

6th Edition (2005)

• Prevent and manage

fixation errors

• Cross (double) check

• Use cognitive aids

• Re-evaluate repeatedly

• Use good teamwork

• Allocate attention wisely

• Set priorities dynamically

Communication + CRM

�  Meant

is not said

�  Said

is not heard

�  Heard

is not understood

�  Understood

is not done This is true for Sender and Receiver !

Close the loop !

© M. Rall, TüPASS

Components of CRM

Individual, cognitive Elements

•  Limitations of Human Factors (“Allocation of Attention”, cognitive aids, checklists)

•  Dynamic Decision Making •  Planing & Antizipation •  Use all available Information •  Fixation error

Team Management and Communication

•  Leadership & followership •  “Assertiveness” •  Effective Communication (!) •  Distribution of workload •  Call for help early •  Use all available resources

© M. Rall, TüPASS

3


Anatomy of Safe Medical Patient Care

Medical(Outcome(((correct,and,.mely,,

treatment,of,the,pa.ent),

Medical(Exper2se((Knowledge(&(Skills)(

Human(Factors(&(CRM((Knowledge,(Skills,(

ACtude)(

Unexpected!*

Problem!*

Error*!*

M. Rall, TuPASS

The Aircraft Carrier: The Prototypical HRO (High Reliability Organisation)

“It works !” Carriers achieve nearly failure-free record despite multiple hazards

ppt from D. Gaba, Stanford

Daily fire drills !

„Train together who work together� ! Simulator-Team-Training „Train where you work� ! mobile „in-situ� Simulator-Training

Simulation Team Training

Adult Learning

Principles

“Why should I change anything?”

The adult learner has to feel

a need to change !

(from self-reflection)

“Love your participants!”

General Assumption: All participants are highly motivated,

trained and skilled adult professionals

4


Stress, Reality, Relevance !

Simulation Control Room

Self-Reflective

© M. Rall, TüPASS

„Debriefing�

The Heart and Soul of Sim-Training, but...

Debriefing can „make or break� the sim session

ACRM-Training in OR CRM-Training on ICU

5


Simulation to Prepare for the Unexpected: Medical Response to Chemical Terrorism

Mobile Simulation Controlroom (with German Air Rescue DRF)

Mobile Simulation in Lear Jet (with German Air Rescue DRF)

Mobile Simulation Debriefing (with German Air Rescue DRF)

Live transmission

& Video-assisted

Debriefing

CRM-Training in Ambulance

TüPASS

6


Team – Team – Team

Dream Teams are made, not born!

Performance = years of „deliberate practice�

(with reflective feedback)

Shortness of breath MI? History Exams Treatment

Nitro, ASS, Betablocker, etc

???

???

???

??? harmful?

wrong w

rong

wrong w

rong

Mental Model

or Frame „The Why�

Debriefing Goal – identifying and changing mental models

„Errors� are not

the cause of accidents

E

C1

C2

C3

E

CF5

CF4

© M. Rall, TüPASS

Double-loop Learning (to achieve deep, long-lasting training effects)

Adapted from Rudolph et al 2008 & W. Eppich

Mental model

or Causes

Desired performance

Inquire Observe

Educator

Performance gap

Actual performance

Single loop

Double loop

7


Instructors: “You are not a god”

"  You have no power over your participants!

"  You can´t impose on them what to do!

"  They have cared for patients yesterday and

will do so tomorrow!

Do we critique colleagues and tell them what was wrong ?

Yes ! But:

- with exact observable behaviours - in a respectful manner - without any assumptions

- focused on finding out „Why�

Modern Simulation Team Training to enhance patient safety

Man

Technique Organisation

Optimizing

the Interactions

Simulation

Focus on Team

Human Factors CRM

Debriefing with - Facilitation techniques - Self-reflection (video) - Double-loop learning

What ? How ?

A „revolution� for healthcare and

education

Human Factors (CRM) centered facilitated Sim-Team-Training

B

A The lightbulb is

not a continuous improvement of the

candle!

© M. Rall, TüPASS

Contact-Info

Marcus Rall, M.D.

Email: [email protected]

[email protected]

Center for Patient Safety and Simulation (TuPASS) Department of Anaesthesiology and Intensive Care Medicine

University Hospital Tuebingen University of Tuebingen Medical School

Hoppe-Seyler-Str.3, D-72076 Tuebingen Tel +49 (0)7071/29 86733, Fax 29 49 43

Mobile: +49 171 388 9700

www.tupass.de

8


TüPASS Center for Patientsafety

and Simulation

Effect of initial Block-Team-Training

Avoiding „Subthreshold Training Effects�

Double-loop Learning (to achieve deep, long-lasting training effects)

Adapted from Rudolph et al 2008 & W. Eppich

Mental model

or Causes

Desired performance

Inquire Observe

Educator

Performance gap

Actual performance

Single loop

Double loop

Take-home-message: Wir passen beide aufeinander auf:

•  Nachfragen •  Bedenken äussern •  Gefahren klären •  Medikamente sicher applizieren etc.

„Es ist nett, wenn jemand nachfragt,

nachhakt, Zweifel hat, Bedenken äussert etc!�

Expertise - real existierende Tatsachen…

Anzahl

Inakzeptabel --- schlecht ----<--- Expertise --->----- sehr gut ------ Spitzenklasse

Advantages of “in-situ” simulation team training

•  Training of actual team – interdisciplinary

•  Training in the real environment

•  Optimizing of Equipment/Layout and Processes !

•  Working area = Learning area

•  Safety culture boost

•  Positive Team Intervention

•  Long lasting effects (self-sustaining from inside the team)

Instructor Courses HF, CRM, Facilitation, Video,…

Day 1 Mini-ACRM Theory and

Practice

Day 2 Mini-ACRM Reflection Simulation

for real

Day 3 Scenarios and

Debriefings with feedback patient safety

Day 4 Scenarios and

Debriefings with feedback training theory

TuPASS, EUSim-Cooperation & many others

Day 5 Coaching

© M. Rall, TüPASS

Scenario Design

Relevance not

Reality © M. Rall, TüPASS

9


© M. Rall, TuPASS, Germany

Humans do err

„Zero-Error-Strategy� is the wrong goal! (Kpt. M. Müller, 2007, Director Flight Safety German Lufthansa)

Mean Time Between Failure (Human Performance Messungen)

• Routine, used task 30 min • Complex Tasks, no Stress 5 min • Complex Tasks, + Stress 30 sec

Example: Emergency team, 4 people, working for 20 min:

a) Common team + Stress:

4 x 20 x 2 = 160 ERRORS ! b) CRM/Sim-Trained Team (no stress):

4 x 20 x 0,2 = 16 Errors ! (10-fold decrease!)

CRM Simulation Team Training

•  Know the environment

•  Anticipate and plan

•  Call for help early

•  Exercise leadership and followership

•  Distribute the workload

•  Mobilize all available resources

•  Communicate effectively

•  Use all available information

CRM Key Points – strong science behind

From Rall, Gaba

in: Miller, Anesthesia

6th Edition (2005)

•  Prevent and manage

fixation errors

•  Cross (double) check

•  Use cognitive aids

•  Re-evaluate repeatedly

•  Use good teamwork

•  Allocate attention wisely

•  Set priorities dynamically Situation

Awareness Effective (critical)

Communication Dynamic (naturalistic)

Decision Making

Fixation Error

Human error

Human limitations

Team- Work

Team cognition etc

Task Management

Why things go wrong…

Hypothesis from 10 years of simulation training:

Medical teams are too fast

Diagnosis ! Problems ?

Problem, Team, Facts,

Plan, Distribute

The „10 seconds for 10 minutes� concept

10 sec!

Rall, Glavin, Flin: BJA Bulletin 2008

Scenario Design

•  Trainiere nicht „das Schlimmste� und „Seltenste�

•  Trainiere die „common killers�: = kritische Routinesituationen

•  Verwende Daten aus IRS:

–  Aber: „Train the causes not the cases“ (Ursachen, nicht Fälle)

1 x 50% = 0,5 P

100 x 25% = 25 P

10


•  Patienten harm = Error •  Error = Guilt •  Error = stupid (stupid is - stupid does) •  Stupid action = stupid person •  Stupid = too lazy to learn •  lazy = bad attitude •  b.a. = bad character (person) •  b.c. = bad human being •  b.h. = unacceptable out !

Dilemma of Errors & Safety Culture

Tip of Iceberg Phenomenon of Behavioural vs. Mental Change From Reason 2003

Mental change

Behavioural change

1.Sim-Training

2.Sim-Training

Scenario Design

" Do not train the „worst� & „rarest�

" Do train the „common killers� Critical routine situations " Use data from IRS:

– But train the „causes� not the „cases�

100 x 25% = 25 P

1 x 50% = 0,5 P

1 ATLS%Europe,Mee.ng,Berlin,,April,2012,—,From,Teaching,to,Coaching,,Marzellus,Hofmann,

1

From%Teaching%to%Coaching%%%

2

Time%schedule%

!  9.00%–%9.20%Keynote%presentation%(M.%Rall)%!  9.20%–%9.30%Short%discussion%!  9.30%–%9.45%Short%introduction%to%the%group%

work%(Marzellus%&%Hayley)%

!  9.45%–%10.30%Group%work%!  10.30%–%11.00%WrapLup%session%

3 4

What%are%the%goals%of%this%session?%

!  Participants%can%explain%the%difference%between%teaching%and%coaching.%%

%

!  Participants%are%able%to%give%examples%of%coaching%methods%with%respect%to%ATLS%courses.%

%

!  Participants%will%take%home%coaching%tools%to%work%with%in%the%ATLSLsetting.%

5

Teaching%&%Coaching%–%what�s%the%difference?%

Provider(Courses?(

Instructor(Courses(

6

Teaching%&%Coaching%–%what�s%the%difference?%

„By(separating(teaching(from(learning,(we(have(teachers(who(do(not(listen(and(students(who(do(not(talk�.(Based%on%Palmer%P,%The%Courage%to%Teach,%1998%

„The(more(the(student(becomes(the(teacher(and(the(more(the(teacher(becomes(the(learner,(the(more(successful(are(the(outcomes�.(John%Hattie,%Visible%Learning,%2009%

2 ATLS%Europe,Mee.ng,Berlin,,April,2012,—,From,Teaching,to,Coaching,,Marzellus,Hofmann,

7

What%characterises%coaching?%

„…coaching(is(unlocking(a(person�s(potential(to(maximise(their(own(performance.(It(is(helping(them(to(learn(rather(than(teaching(them�.(Whitmore,%1992%

Coaches(play(a(part(in(learning(as:(

! %Activators…%

! %Facilitators…%

! %deliberate%change%agents…%

! %Companions%….of%the%learning%process%through%FEEDBACK( 8

What%characterises%coaches?%

Coaches(are:%%!  highly%experienced,%%

!  highly%reflective,%

!  Reevaluating%methods%and%procedures,%%%

!  Capable%of%adapting%methods%and%strategies%to%fit%the%needs%of%the%individual%learner%

!  Authentic%

!  Values%the%learners%

9

Beginning%with%the%end%in%mind…!%

Personal(development/(processJside(„Companionship�:%

! %support%&%encouragement%

! %sharing%frustration%and%success%

! %possibility%of%mutual%reflection%

Performance/outcomeJside(! %collaborative%process%

! %solutionLfocused%process%

! %resultLoriented%process%

Coaching…%

10

What%are%coaching%methods?%

! %Role%modelling/Demonstration%

! %Direct%observation%

! %Active%listening%

! %Asking%openLended%quesitions%(reflection…)%

! %Individualisation%

! %Show%relevance%

! %FEEDBACK(!!(

11

ATLS%2020%–%where%are%we%heading?%

In%your%groups%pease:%

1.  Briefly%describe%the%current%feedback/coaching%sytems%used%in%your%countries.%

2.  Review%the%„Pendleton%plus�%model%outlined%in%the%session%introduction.%

3.  Evaluate%the%feedback/coaching%practice%in%your%country%in%the%light%of%the%given%material%%L%develop%an%adapted%or%a%new%model%within%your%group.%

12

TakeLHomeLMessage%

Coaching%is%about%the%FAIRLprinciple:%

! %Feedback(

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! (Individualisation(

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��ATLS%Europe,Mee.ng,Berlin,,April,2012,—,The German Clinical Practice Guidelines,,Ber.l,Bouillon,

Evidence in Polytrauma Management - The German Clinical Practice Guidelines

Bertil Bouillon Department of Trauma and Orthopaedic Surgery Witten/ Herdecke University, Cologne Merheim Medical Center

… boaring !

Guidelines are …

… too complicated !

… too unspecific !

… unnecessary !

… far away from reality !

background

… the favourite

Anteil von Femurschaftfrakturen, die primär mit einem Fixateur versorgt wurden

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

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e Case

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Clinic

Rat

e o

f Ext

ern

al F

ixat

ion

hospitals 82%

8% ?

Rixen, J Trauma 2005

5. Grafische Klinikvergleiche

- Hospital performance: observed vs predicted outcome -

Difference between observed and predicted mortality rate

Mortality below prognosis

Mortality above prognosis

Predicted mortality calculated via RISC Score

DGU -3,7%

-20

-15

-10

-5

0

5

10

15

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Diffe

renz

(%)

-20

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hospital


TraumanetworkGermany��

www.dgu-traumanetzwerk.de

TraumanetworkGermany

structure whitebook, audit of hospitals, certification of regional traumanetwork systems

process of care courses (PHTLS, ATLS, ATCN, DSTC), clinical practice guidelines, tele consulting

outcome trauma registry quality improvement project

http://www.awmf.org/leitlinien/detail/ll/012-019.html

Published by the Committee of the Scientific Medical Societies

!  start 2004, relaunch 2009, final 2011 !  97 authors

!  11 scientific medical societies

!  445 pages (the book)

!  3 phases: pre hospital, emergency room, emergency surgery

!  264 key recommendations

!  66 pre hospital, 103 emergency room, 95 emergency surgery

clinical practice guideline … the facts

definition of a guideline (AWMF)

Guidelines are recommendations that have been

developed systematically. They contain the actual

knowledge. They should help physicians and patients

in the decision making process for adequate

treatment of a specific injury or disease.

www.awmf.org

Participating scientific medical societies


Level of guidelines (S1-S3)

S1: expert group

S2: evidence based

S3: evidence + consensus

Literaturrecherche Systematic literature review

Level of evidence

Oxford Centre of Evidence-based Medicine

Level 1: RCT

Level 2: prospective studies

Level 3: retrospective studies

Level 4: case studies

Level 5: expert opinion

Grade of recommendation (GoR)

!  GoR A: must (soll)

!  GoR B: should (sollte)

!  GoR 0: can (kann)

Consensus high consensus > 95% participants agreed

average consensus > 75% participants agreed

low consensus > 50% participants agreed

no consenus ≤ 50% participants agreed

dissemination of guideline

!  internet

!  booklet (participants of the traumanetwork system)

!  publications (journals)

!  presentations, workshops, courses


guideline: examples prehospital

airway and breathing Recommendations : !  in severely injured patients with respiratory insufficiency (RR<6) endotracheal intubation and ventilation must be performed in the pre hospital setting

! in severely injured patients with the following indications endotracheal intubation and ventilation should be performed in the pre hospital setting

!  hypoxia (sat. < 90%) despite oxygenation and exclusion of a tension pneumothorax

!  severe head trauma (GCS < 9)

!  hemodynamic instability (BPsys < 90mmHg)

!  severe chest trauma with respiratory insufficiency (RR>29)

GoR A

GoR B

ventilation and capnography

Recommendations: !  capnography must be performed in the pre- and inhospital setting for control of correct tube position in case of endotracheal intubation

!  in patients with endotracheal intubation normoventilation must be performed.

!  in hospital (emergency room and thereafter) ventilation must be monitored with control of arterial blood gases (ABGs)

GoR A

GoR A

GoR A

Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis.�DP Davis, J Peay, MJ Sise, R Coimbra; J.Trauma 69: 294-301 (2010)

- Trauma registry with 11.000 patienten with head trauma (AIS≥3)

-  groups: endotracheal intubation vs others

-  outcome: expected vs observed mortality Mortalität

-  results:

-  no difference in both groups

-  in the more severely injured patients advantages if intubated

-  patients who were treated by helicopter crews performed better


problem: wrong position of endotracheal tube

A. Timmermann. Anaest Analg 2007

literature

guideline: examples emergency room

organization Trauma teams in the ER must follow a standardized and systematic work up. They must be trained.

chest trauma: diagnostics what is the role of clinical evaluation of the chest ?

Recommendation !  a clinical examination of the chest must be performed GoR A

!  auscultation should be performed as part of the clinical examination GoR B

Comment: Even if there are only scarce scientific evaluations on the role of the clinical examination of the chest in trauma patients the experts agree that clinical examination is a prerequisite for rapid detection of relevant injuries that could be life threatening and necessitate rapid intervention. This is also true for reevaluation when arriving in teh emergency room, even if a thoracic drain had already been placed in the prehospital setting because of possible changes of the patients status.

chest trauma: radiological work up

If a chest trauma cannot be excluded a radiologic evaluation must be performed in the ER .

A CT of the chest with contrast medium should be performed in any patient with signs of a severe chest trauma.


indication for thoracotomy

Thoracotomy can be performed in case of initial blood loss of >1.500 ml or in case of blood loss of >250ml/h for more than 4 hours.

emergency room thoracotomy In patients with blunt trauma and without vital signs at the site of the accident ER thoracotomy should not be performed

posttraumatic coagulopathy Posttraumatic coagulopathy has negative influence on outcome. It must be detected and treated immediately in the ER .

Thrombelastography/-metry (ROTEM/ ROTEG) can help to monitor and monitor treatment of posttraumatic coagulopthy

treatment of coagulopathy A massive transfusion protocol should be implemented and used.

In case of coagulopathy the RBC/ FFP ratio should be 2:1 to 1:1 if FFP is used.

Fibrinogen should be given if values fall below 1.5g/l (150mg/dl)

!  … is an interdisciplinary guideline

!  ... should help in daily practice and for case review

!  … documents the available evidence

!  … experts judge this evidence and give recommendations

!  … will be published in English within the next 3 months

!  … is open for discussion

!  … must be updated regularly

… the clinical practice guideline „polytrauma�

http://www.awmf.org/leitlinien/detail/ll/012-019.html

07.05.12

1 ATLS%Europe,Mee.ng,Berlin,,April,2012,—,ATLS,and,S3,Guideline.,Does,it,fit?,,—,MaChias,Münzberg,,Ber.l,Bouillon,,

ATLS and S3 Guidline Does it fit?

BG Unfallklinik Ludwigshafen, Klinik für Unfallchirurgie und Orthopädie - Luftrettungszentrum Christoph 5

Activation of the trauma bay Airway and C Spine Protection A

A Airway and C Spine Protection


A Airway and C Spine Protection

07.05.12


Breathing B


Breathing B

S3: prehospital

Breathing


B C Breathing/Circulation C Circulation

C Circulation


C Circulation

07.05.12


C Circulation C

ATLS: STOP THE BLEEDING

Circulation


C Circulation


D Disability


D Circulation E Environment

07.05.12



ATLS is nearly conform to the S 3 guidline minor deviation:

•  CT diagnostic •  DPL •  Optimization of the intubation sequence

Summary

07.05.12'

1'ATLS,Europe'Mee4ng'Berlin,'April'2012'—'The'ATLS'Mobile'APP'—'George'Brighton''

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•  ATLS'course'to'leading'trauma'calls'in'ED'•  Debate'and'ques4ons'on'debrief.'•  I'don’t'have'the'manual'to'hand'!'•  Clinical'situa4ons'some4mes'require'an'immediate'and'reliable'reference'tool.'

''''What'beOer'reference'point'than'mobile'ATLS'content……''''

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•  On'the'go'reference'•  Excellent'teaching'and'learning'tool'and'Companion'to'the'Manual''

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'The'first'step'!'evolving'and'flexible.'

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Memorably'enjoyable'and'useful'in'both'clinical'situa4ons'and'study……..'

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•  Registra4on'and'user'specific'allowing'device'sharing.''

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Interac4ve''Visuals'

By'Chapter''Favorites'Calculators'

Just'in'Time'Videos'

Home'Menu'Op4ons'

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!!!!!Home!Page!!!4My!ATLS!!4ATLS!Learning!!4Videos!!4Calculators!!!4Favorites!!4SeCngs!!!!!!!!

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!!!ATLS!Learning!1.Assessment!and!!Management!2.Airway!3.Shock!4.Thoracic!Trauma!5.Head!Trauma!6.Spine!and!Spinal!Cord……………..!13.Transfer!to!!DefiniOve!care!!

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•  Calendars,'events'and'no4fica4ons.'•  Appropriate'links'eg.'instructor'links/resources'and'Na4onal'contacts.'

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07.05.12'


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•  ATLS'‘light’'–'interac4ve'companion'to'book.''•  Consists'of'the'13'ATLS'chapters'condensed'into'objec4ves,'key'illustra4ons'and'interac4ve'algorithms'and'calculators.'

•  Includes'links'to'appropriate'videos'and'other'graphics.'

''''

'

!!!!!Chapter!7!4Dermatomes!4Myotomes!4Muscle!strength!grading.!4C4Spine!X4rays.!4Videos!4Summary.!!

''''''

,Dermatomes'–'tap'to'view'map.',Myotomes'–'tap'to'view'affected'areas',Muscle'strength'grading'table',Skill'Sta4on'X'–'Cervical'Spine'X,rays', Skill'Sta4on'XI,E'–'Log'roll'Video.', Summary'points'–'1,5''''

x' x'

x'

'

•  To'include'all'main'procedural'videos'e.g..'Chest'Tube'inser4on,'pericardiocentesis,'Intraosseous'needle,''plus'some'extras.'

Voice'ac4vated'on'new'iphone'and'Just'in'4me'!''

'

•  The'convenience'of'a'list'of'useful'interac4ve'clinical'tools'algor4hms'and'calculators….'

'•  E.g..'GCS'tool,'Pediatric'verbal'score'and'the'Parkland'Formula.''

' '

''',App'specific'for'''''…..the'Anaesthe4c'trainee'learning'airway'maneuvers'

''''……the'surgical'trainee'using'head'injury'algorithms,'indica4ons'for'laparotomy'and'dermatomes.'

'

The'ability'to'personalise'and'define'My'ATLS'App.''

07.05.12'


'

•  Approved'sample'ques4ons..'

'

•  Many'different'ideas'and'huge'poten4al'to'develop'the'app'to'assist'with…..''',Na4onal'and'local'running'of'courses.'

',Sharing'of'course'resources'and'user'specific'log'on.'',Valuable'resource'of'ATLS'‘trainees’'

',Social'media'–'facebook'and'TwiOer'

',Complimen4ng'e,learning''''

''''

'

•  Using'GPS'to'Find'course'near'me.'•  All'registered'course'centers'pop'up'with'full'details,'contacts'etc.'

•  Upcoming'courses'and'''''availability'?'

'

•  Facebook'page'useful'to'generate'exposure,'ideas,'discussion'and'feedback.'

•  The'role'of'the'TwiOer'feed.'

•  Clinical'valida4on'of'the'App'once'developed.'''

'

'

A"randomised"control"trial"to"determine"if"use"of"iResus"applica3on"on"a"smart"phone"improves"the"performance"of"an"advanced"life"support"provider"in"a"simulated"medical"emergency."Journal"of"Anaesthesia"2011,"66"pg"255@262""

'

ATLS'Resources'

Instructors'' Coordinators'

'

•  Ini4al'ideas'and'discussion'from'the'mee4ngs'in'San'Francisco'have'now'become'a'solid'framework'for'ACS'and'programmers'to'work'from.'

•  IT'company'made'a'great'start'with'what'is'quite'a'mul4plalorm'IT'challenge'!'

•  Aiming'launch'at'the'end'of'this'year.'

•  A'fantas4c'project'that'will'enthuse'and'mo4vate'the'ATLS'students'of'the'future.''

''''''''''''''''''''''

07.05.12'


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Dr"George"Brighton,"Berlin"April"28th"2012….'

1

ATLS%Europe,Mee.ng,Berlin,,April,2012,—,The,European,Trauma,Course,—,Freddy,Lippert,

© The Course Management Committee for the European Trauma Course

European Trauma Course Learning from friends

Freddy Lippert

CEO Emergency Medical Services

The Capital Region of Denmark Copenhagen, Denmark

Ass. Professor Copenhagen University

l i p p e r t @ r e g i o n h . d k

Freddy Lippert European Resuscitation Council ERC Board / General Assembly ERC Guidelines writing Group European Trauma Course Organization

Agenda

•  History of the European Trauma Course

•  The organisation and societies behind

•  What is the European Trauma Course

•  The course concept and content

•  The future of ETC

•  ETC ATLS - future cooperation?

On behalf of •  European Trauma Course Organisation ETCO

•  Karl Thies, Guttorm Brattebø (ESA) •  Eric Voiglio, Mauro Zago (ESTES)

•  Charles Deakin, Freddy Lippert (ERC) •  Marc Sabbe, Raed Arafat (EuSEM) •  Carsten Lott (ECTO)

•  Bart Vissers (ERC management representative)

Founding persons •  Peter Driscoll •  Carl Gwinnutt •  Peter Goode •  Carsten Lott •  Mary Rose Cassar •  Ivan Esposito •  Giuseppe Nardi •  Stefano DiBartolomeo •  Rui Araujo •  Ernestina Gomes •  Mike Davis •  Freddy Lippert •  David Robinson •  Michael Hüpfl •  Markus Roessler •  Karl Thies

2


Berlin Berlin

•  A huge step forward

•  Established the structured system and common language for trauma care

•  New educational approach to teaching/learning

In the beginning…

Bologna, Italy in 2002

Letter to the Editor in Resuscitation

Do we need a European approach to trauma care? by Karl-Christian Thies.

Resuscitation 2004:60:113-114

Letter to the Editor •  “…There is obviously a demand for a reasonable,

commonly accepted approach and an enhanced programme of training in trauma care in Europe.”

•  “… it seems sensible to develop a European approach to trauma resuscitation that is more flexible, based on the best evidence available, and which is adjustable to local conditions. We suggest that an ERC Task Force be established in order to create European guidelines on trauma resuscitation.”

3


The vision of the ETG • To use state-of-the-art evidence based knowledge

• To be interdisciplinary and multi-specialty

• To teach a team approach reflecting European practice

• To address the pre-hospital and the early hospital period to enhance continuity of care

• To meet the requirements of contemporary adult learning

• To be mainly practical

• To be flexible and adaptable enough to meet the different regional needs within Europe

• To be affordable throughout Europe

Organisations behind The European Trauma Course Organisation

The role of the ERC Bene!ts from logistics and network of all the ERC courses: BLS-AED, ILS, ALS, NLS, EPLS, GIC Course Management System

ETC development •  Two years for course planning •  First pilot course in Malta in 2006 •  Two more pilot courses in 2007 - 2008

2006-2008 2 years of pilot courses, revisits & revisions

2006,MALTA,

,2007,Stavanger,

,2007,Rome,

,2008,MALTA,

The first official European Trauma Course

ERC 2008 Ghent, Belgium May 2008

4


ETC Course Structure •  2½ day scenario/simulation based,

hands-on course

•  Lectures time kept to an absolute minimum

•  Manual: electronic and printed

•  Training for individuals and teams

•  Different manikins and equipment

•  Modular to allow flexibility

ETC Course materials

•  Manual (paper)

•  Electronic version

© The Course Management Committee for the European Trauma Course

Initial assessment and resuscitation of the severely

injured patient

2.   Team leadership Command and control

•  Resources •  The Team •  The 5 second round •  Problems •  Less often “hands

on”

Coordination •  Task allocation •  Task performance •  Interventions •  “Outsiders”

Communication

•  Team members

•  Pre-hospital team •  Patient •  Other specialities •  Relatives

A B C D E

Airway with cervical spine control Breathing and ventilation Circulation & control of hemorrhage Dysfunction of the CNS Exposure & environment

Primary survey & resuscitation Assessment and test

•  Continuous assessment

•  Knowledge and skills

•  Team member competence

•  Team leader competence

•  No final written testing

•  A final scenario based examination as team leader in a team

5


Team Leader Assessment

•  Test scenario on day 3

•  Standardised scenarios

•  Candidate is Team leader

•  Instructors are the Team

•  Criteria needing to be met

From candidate to instructor

•  Candidates

•  Instructor Potential

•  Instructor Candidates

•  Generic Instructor Course and ETC-instructor day

•  Instructors

The Candidates

• Groups of four • Stay together during the course • Work together as trauma teams in workshops –  Team-leader –  Team-member or

Critiquer

Workshop Characteristics

•  Hands on

•  Scenario based

•  Small groups

Scenario training as teams

Lead instructor Second instructor

Candidates

Vertical Management: Individual Approach

Initial information

Additional information Interactions

6


Horizontal management

Planning and Discussion

Team Leader’s Brief

Examination findings on role play cards



Team Briefing



ETC comments from experts

•  “ATLS and the ETC should walk arm in arm around Europe”

•  “ATLS for basic vertical management and ETC for advanced horizontal management team training”

7


ETC comments from experts “The ETC builds on the principles of ATLS and allows

doctors to take knowledge and skills and use them as part of a team. It particularly struck me watching the team scenarios how individual components of ATLS were all running simultaneously.”

“ATLS provided a valuable springboard from which the ETC could then go on and explore more complex issues relating to trauma care in particular training in team management.”

“My hope is that the two courses will flourish along side each other in Europe and particularly in the United Kingdom.”

ETC comments from experts “Validity – pressure increases as does complexity over the

two days. Appropriate content – real cases without ridiculous injuries or unreal circumstances. Team allowed to play their own role at work rather than being forced to play the role of someone you are not – so the validity of the team trying to work out what they are capable of as a whole and who they need to supplement was very real.”

“Overall impression – I thoroughly recommend this course, it is the natural and logical progression for all StRs and consultants – and should be a mandatory course once there are enough faculty in the UK.

“Support – Yes – with no reservations.”

Thoughts for the future Trauma care with ETC and ATLS courses •  A common goal •  International guidelines on trauma care

like the ILCOR (ilcor.org) •  International consensus on science •  International treatment recommendations •  Courses with different approaches (basic,

individual, skill training, team training, team leader training)

• 

SUMMARY The European Trauma Course: •  Is interdisciplinary •  is team approach •  is practical •  is affordable •  is flexible and adaptable •  Uses modern adult learning methods

8


www.europeantraumacourse.com

07.05.12

1 ATLS%Europe,Mee.ng,Berlin,,April,2012,—,Sustainability,of,ATLS,courses,—,Bouillon,,Woelfl,,Hofmann,Muenzberg,

Sustainability of ATLS courses

Bouillon, Woelfl, Hofmann,Muenzberg

Does it work? – Question of the didactic

Does it help? – Question of the outcome

Does it work?

Meassurment of the Sustainability on two levels:

•  Knowledge

•  Skills

Does it work?

3 Meassurment points: 1.  Directly before the course

•  20 Questions of the Pre-Test •  Moulage scenario with videotaping

2. Ending of the ATLS course •  20 Question out of the Post-Test •  Videotaping of the moulage scenario • 

3. 3 month after the course •  20 Question •  Moulage scenario with videotapig

Does it help?

��ATLS%Europe,Mee.ng,Berlin,,April,2012,—,The,ATLS,classifica.on,of,shock,%,is,a,modifica.on,necessary?—,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Manuel,Mutschler,

The ATLS classification of shock- is a modification necessary?

Manuel Mutschler Department of Trauma and Orthopaedic Surgery University Witten/ Herdecke, Cologne Merheim Medical Center

Class%I, Class%II, Class%III, Class%IV,

Blood%loss%in%%% <15% 15130% 30140% >40%

Pulse%rate% <100% 1001120% 1201140% >140%

Blood%pressure% Normal% Normal% Decreased% Decreased%

Mental%status% Slightly%anxious% Mildly%anxious% Anxious,%confused% Confused,%lethargic%

Pulse,pressure,,Normal,or,increased,

Decreased, Decreased, Decreased,

Respiratory,rate, 14%20, 20%30, 30%40, >35,

Urine,output, >30, 20%30, 5%15, Negligible,

Fluid%replacement% Crystalloid% Crystalloid% Crystalloid%and%blood% Crystalloid%and%blood%

The ATLS classification of shock

Student Course Manual, 8th edition

•  Validation of the current ATLS classification of shock

•  TraumaRegister DGU

Aim of the study

®

•  > 67.000 patients included

•  357 affiliated hospitals in 6 European countries

TraumaRegister DGU ®

0

10'000

20'000

30'000

40'000

50'000

60'000

70'000

80'000

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

•  Inclusion criteria: •  2002-2010

•  Age ≥16

•  primary admission to an affiliated hospital

•  Study population: •  36.504 patients

•  Mean ISS ≥ 16 in all subgroups

•  > 90% blunt trauma

Study design


Blood%loss%in%%% <15% 15130% 30140% >40%Pulse,rate, <100, 100%120, 120%140, >140,

Blood,pressure, ≥,110, ≥,100, <,100, <,90,

Mental,status, GCS,15, GCS,15, GCS,12%14, GCS,<,12,


Definition of variables



Blood,pressure, Normal, Normal, Decreased, Decreased,

Mental,status, Slightly,anxious, Mildly,anxious, Anxious,,confused, Confused,,lethargic,



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Combination of HR, SBP, GCS

> 90% of all trauma patients are not classified adequately

Recently in our ER…

•  Pat., male, 35 years; car accident

•  HR 122/min, SBP 110 mmHg, GCS 9



Blood,pressure, Normal, Normal, Decreased, Decreased,

Mental,status, Slightly,anxious, Mildly,anxious, Anxious,,confused, Confused,,lethargic,


N = 32.458

,, ,, ,, ,,

, < 100 100-119 120-139 ≥ 140

SBP,at,ER,(mean), 126.45, 125.47, 116.36, 108.95,

GCS,at,ER,(mean), 9.27, 8.98, 7.51, 6.36,

GCS,prehospital,,(mean), 11.56, 11.38, 10.27,, 9.17,

Heart rate

ATLS < 100 100-119 120-139 ≥ 140

SBP,, Normal, Normal, Decreased, Decreased,

Mental,status, Slightly,anxious, Mildly,anxious, Anxious/confused, Confused/lethargic,

Systolic blood pressure

N,=,33.135

≥ 110 100-109 90-99 < 90

HR,at,ER,(mean),, 87.87, 89.14, 92.78, 91.01,,

GCS,at,ER,(mean), 9.92, 7.17, 6.24, 4.74,,

ATLS ≥ 110 100-109 90-99 < 90

HR, <100, 100%120, 120%140, >140,

Mental,status, Slightly,anxious, Mildly,anxious, Anxious/confused, Confused/lethargic,

Glasgow Coma Scale

•  No tachycardia in any group (88-89 bpm in all groups)

•  Moderate hypotension (SBP 117 mmHg) in patients

with a GCS < 12

Summary

•  < 10 % could be classified according to ATLS

•  Lowered SBP ≠ increased heart rate

•  GCS lower through groups I-IV


TARN registry TARN registry

Guly 2010, Resuscitation

•  Heart Rate: •  Association between reduced SBP and tachycardia: 128mmHg (HR<100) vs.114 mmHg (HR>140)

•  No relevant changes in RR and GCS (15 vs. 14)

•  Systolic Blood Pressure: •  No relevant tachycardia observed (83 vs. 88 beats/min)

•  RR unaltered

•  Respiratory rate: •  No hypotension in any group

•  Moderate tachycardia (HR >100 bpm/min) in patients with a RR > 30

Limitations of the studies

•  Retrospective analysis

•  Pulse pressure, urinary output were left out

•  Need for �translation�

What do vital signs tell us?

•  Heart Rate •  Poor correlation between hypotension and tachycardia: Victorino 2003, J Am Coll Surg

•  neither specific nor sensitive in determing the need for emergent intervention, severe injury or transfusion

of pRBC: Brasel 2007, J of Trauma

•  Relative bradycardia (SBP ≤90 mmHg; HR ≤ 90 bpm) in 44% of all patients: increased mortality, occurs

in older patients: Ley 2009, J of Trauma

What do vital signs tell us?

•  Systolic Blood Pressure •  Late marker of shock, „compensated phase of shock��

•  ≤ 110 mmHg as a cut-off point for increased mortality: Husler 2012, Resuscitation

•  Dependent on initial treatment (fluids, vasopressors)

•  Glasgow Coma Scale

•  Predictor for mortality, outcome

•  Prehospital intubation, isolated head injuries

…do we need a modified classification?

„Yes�

Based on a parameter which fulfills:

-  Fast assessment

-  Identifying patients „at risk� (transfusion, injury severity)


Base Deficit

•  BD: �a physiological marker of hypoperfusion/shock� •  In times of POCT: easy and fast assessment

•  Correlates with transfusion requirements, mortality and injury severity also in young and adult trauma

populations

•  Four classes of worsening BD •  Class 1 : ≥ -2 mmol/l „normal�

•  Class 2: < -2 to ≤-6 mmol/l „mild�

•  Class 3: < -6 to <-10 mmol/l „moderate“

•  Class 4: ≤ -10 mmol/l „severe“ Davis 1996, J of Trauma Davis 1998, J of Trauma Rixen 2001, Shock Rixen 2005, Crit Care Jung 2009, J of Trauma

Inclusion criteria

•  TraumaRegister DGU •  16.305 patients between 2002-2010

•  Age ≥ 16

•  primary admission

•  BD between +4 mmol/l to -20 mmol/l

®

Therapy

BD ≥ -2.0

BD -2.1 to ≤ -6.0

BD <-6.0 to <-10

BD < -10

pRBC transfusions/units 1.2 (3.5) 2.9 (5.6) 5.7 (8.8) 10.5 (13.9)

all blood products/units 1.5 (5.9) 4.5 (11.3) 10.3 (18.1) 20.3 (27.2)

IV fluîds at ED 1701 (1902) 2454 (2710) 2941 (2535) 3230 (2705)

Vasopressors at ED (%) 15.9 30.8 49.0 72.7

p <0.001 mean±SD

A BD-based classification

•  Worsening BD is associated with: •  Rising mortality, LOS, ICU days, sepsis, MOF

•  Increase of injury severity reflected by ISS, NISS, RISC

•  Decrease of Hb, platelets, Quick´s value

Vital signs

BD ≥ -2.0

BD -2.1 to ≤ -6.0

BD < -6.0 to <-10

BD < -10

SBP at ED 132.6 (26.3) 124.6 (28.0) 112.7 (30.7) 94.8 (40.4)

HR at ED 86.3 (17.8) 89.8 (20.3) 95.9 (22.5) 97.2 (32.4)

GCS at ED 10.3 (5.4) 7.8 (5.5) 6.1 (4.9) 4.7 (3.8)

p <0.001 mean±SD

Comparison of BD vs. ATLS

•  Mass transfusion

•  Percent of patients receiving ≥ 1 blood unit

•  Mortality

•  Definition of ATLS by the �worst category�

�ATLS%Europe,Mee.ng,Berlin,,April,2012,—,The,ATLS,classifica.on,of,shock,%,is,a,modifica.on,necessary?—,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Manuel,Mutschler,

Mass transfusion (≥10 blood units)

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(%)

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A BD-based shock classification?

�BD and/or lactate can be useful in determing the

presence and severity of shock. Serial measurement of

these parameters can be used to monitor the response

to therapy.�

Student Course Manual, 8th edition

A BD-based shock classification?


Shock,, normal, mild, moderate, severe,

BD%at%admission%,

≥12, <12to%16, <16%to%110, ≤110,

Blood,transfusion, watch, consider, act,Be,prepared,for,mass,

transfusion,

Summary

•  The ATLS classification - a good �teaching tool�,

but it seems not to reflect clinical reality appropriately

•  �Modified classification of shock� •  �teaching tool�

•  Evidence based

•  BD as a physiological marker of shock •  Dilemma: POCT in every ED or can we redefine a �new combination of vitals�?

new trends / interest in human factor based ... - atls 5...

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