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Original Investigation | Pacific Coast Surgical Association

A Human Factors Subsystems Approach to Trauma Care ONLINE FIRST

Ken Catchpole, PhD1; Eric Ley, MD1; Doug Wiegmann, PhD2; Jennifer Blaha, MBA1; Daniel Shouhed, MD1; Alexandra Gangi, MD1; Renaldo Blocker, PhD3; Richard Karl, MD4; Cathy Karl, MBA4; Bill Taggart, BS4; Benjamin Starnes, MD5; Bruce Gewertz, MD1
[+] Author Affiliations
1Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
2Department of Industrial and Systems Engineering, University of Wisconsin, Madison
3Department of Healthcare Systems Engineering, Mayo Clinic, Rochester, Minnesota
4Surgical Safety Institute, Tampa, Florida
5Division of Vascular Surgery, University of Washington, Seattle
JAMA Surg. Published online August 06, 2014. doi:10.1001/jamasurg.2014.1208
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Importance  A physician-centered approach to systems design is fundamental to ameliorating the causes of many errors, inefficiencies, and reliability problems.

Objective  To use human factors engineering to redesign the trauma process based on previously identified impediments to care related to coordination problems, communication failures, and equipment issues.

Design, Setting, and Participants  This study used an interrupted time series design to collect historically controlled data via prospective direct observation by trained observers. We studied patients from a level I trauma center from August 1 through October 31, 2011, and August 1 through October 31, 2012.

Interventions  A range of potential solutions based on previous observations, trauma team engagement, and iterative cycles identified the most promising subsystem interventions (headsets, equipment storage, medication packs, whiteboard, prebriefing, and teamwork training). Five of the 6 subsystem interventions were successfully deployed. Communication headsets were found to be unsuitable in simulation.

Main Outcomes and Measures  The primary outcome measure was flow disruptions, with treatment time and length of stay as secondary outcome measures.

Results  A total of 86 patients were observed before the intervention and 120 after the intervention. Flow disruptions increased if the patient had undergone computed tomography (CT) (F1200 = 20.0, P < .001) and had been to the operating room (F1200 = 63.1, P < .001), with an interaction among the intervention, trauma level, and CT (F1200 = 6.50, P = .01). For total treatment time, there was an effect of the intervention (F1200 = 21.7, P < .001), whether the patient had undergone CT (F1200 = 43.0, P < .001), and whether the patient had been to the operating room (F1200 = 85.8, P < .001), with an interaction among the intervention, trauma level, and CT (F1200 = 15.1, P < .001), reflecting a 20- to 30-minute reduction in time in the emergency department. Length of stay was reduced significantly for patients with major mortality risk (P = .01) from a median of 8 to 5 days.

Conclusions and Relevance  Deployment of complex subsystem interventions based on detailed human factors engineering and a systems analysis of the provision of trauma care resulted in reduced flow disruptions, treatment time, and length of stay.

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Figure 1.
Design of the Multicomponent Intervention
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Figure 2.
Flow Disruptions in Computed Tomography (CT)

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Figure 3.
Time in the Emergency Department (ED)

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Figure 4.
Length of Stay × Risk of Mortality

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