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BEST: BETTER & SYSTEMATIC TRAUMA CARE

Training complete trauma teams in their own trauma room with repeated video-recorded simulations and structured debriefing.
"LOW INPUT - HIGH OUTPUT"
Objective Improving trauma team performance by simulation training locally at each hospital, by focusing on leadership and communication.

Training complete trauma teams in their own trauma room with repeated video-recorded simulations and structured debriefing.
"LOW INPUT - HIGH OUTPUT"
Objective Improving trauma team performance by simulation training locally at each hospital, by focusing on leadership and communication.

Background

One-day course

Results so far

Damage control Surgery

Network

•Trauma Registry

Background The initial treatment of the trauma patient is a demanding challenge, and well recognised to be the phase with most protocol deviations and treatment mishaps. The resuscitation must be made in correct order to ensure that no valuable time is lost. In Norway, very few hospitals get enough trauma cases to enable the trauma teams to perform optimally just by doing the regular work. Training is one of the ways to make up for this gap between expected and actual experience. Aviation safety work has shown that human factors and sub-optimal team co-operation can lead to disasters, and the crew resource management (CRM) training has been developed to address this. This is even more true in medicine. Modern medicine is complicated, and the human factors tend to be forgotten in technology. For the patients it is the sum of the trauma team's performance that matters. We have developed a multi-professional course with simulated trauma patients, organised locally at each hospital called BEST (Better & Systematic Trauma Care).
One-day course The course consists of three hours of lectures, followed by four hours of practical training with a simulated patient. The course will always be based on local trauma-team composition and procedures.

Lectures All personnel involved in trauma treatment participate on the lectures. The lectures include the following themes:

• Introduction - importance of team-work

• Primary Survey - Base on ATLS®-principles

A - Airways B - Breathing C - Circulation D - Disability E - Exposure and Environment

• Principles for Damage Control Surgery

• Team work and leadership

• Communication within the team

• How to improve trauma resuscitation.

Simulations The hospital's team set-up, procedures, and equipment are used, and team members play their own professional role. A manikin is used as a patient and each team is given a case based on a real patient story, with appropriate X-rays and lab. An instructor gives physiological data after each monitoring procedure is properly performed. The simulations are video-recorded. After the simulation the team is debriefed, reviewing the video using a structured format. The team is encouraged to focus on areas for improvement in leadership, communication and co-operation during the debriefing. The team is then given case number two and simulation and debriefing follow the criteria mentioned above. The clinical problems presented in the case stories are recognisable from participants' own practice, and the instructors are aware of the limited resources available at each of the hospitals.

  Instruction

  Video recording

  Simulation

  Debriefing

Results so farBEST is now established at 44 of the 50 Norwegian trauma hospitals. More than 4380 professionals have followed the lectures and 1760 have simulated. In addition a number of subsequent training sessions, using the simulation set-up, have been arranged locally at many of the hospitals. This kind of cross-professional training has never been done before in Norway. The effects have been evaluated by self-reported change of knowledge and confidence by participants, a number of quality indicators and observation of structural changes at each hospital. The feedback is overwhelmingly positive; especially many of the health care workers find the local training with their own well-known colleagues, procedures, and equipment very useful. The focus on team performance rather than individuals is important, but there seems to be need for training the instructors, so that the debriefing is performed in a reassuring and safe way. Another important feature of BEST is that after each training session the team members can use what they have learned immediately on real trauma patients. This kind of cross-professional team training in trauma care has never been done before in Norway.
The costs have been modest, but the project needs a tight follow-up from the co-ordinators to ensure that e.g. scheduled training sessions are actually arranged. The fact that the project focuses on the team performance rather than the individual performance is rated important. The value of training locally with the trainee's own well-known colleagues, procedures and equipment is emphasised.

Damage control Surgery During the network meetings it became apparent that training of surgical teams in damage control surgery was necessary. A damage control surgery training course for surgical teams using a live animal model has now been established.

Network A voluntary network between all hospitals has also been established, as a national quality improvement collaborative. Network meetings, where procedures and experiences have been exchanged are arranged. Each hospital reports its own difficult trauma cases, with pertinent clinical information, for discussion.
Trauma Registry To enable each hospital to perform objective quality control by TRISS-methodology a combined observation chart and data collecting form has been developed and a computer program for local data registration and analysis is being distributed. This will also serve as a basis for a network based common trauma registry. The maintenance of local ownership to new developments and data is underlined.