title: Flow disruptions in trauma care handoffs.
abstract: BACKGROUND
  Effective handoffs of care are critical for maintaining patient safety and avoiding communication problems. Using the flow disruption observation technique, we examined transitions of care along the trauma pathway. We hypothesized that more transitions would lead to more disruptions, and that different pathways would have different numbers of disruptions.
  
  
  METHODS
  We trained observers to identify flow disruptions, and then followed 181 patients from arrival in the emergency department (ED) to the completion of care using a specially formatted PC tablet. We mapped each patient's journey and recorded and classified flow disruptions during transition periods into seven categories.
  
  
  RESULTS
  Mapping the transitions of care shows that approximately four of five patients were assessed in the ED, transferred to imaging for further diagnostics, and then returned to the ED. There was a mean of 2.2 ± 0.09 transitions per patient, a mean of 0.66 ± 0.15 flow disruptions per patient, and 0.31 ± 0.07 flow disruptions per transition. Most of these (53%) were related to coordination problems. Although disruptions did not rise with more transitions, patients who went directly to the operating room or needed direct admission to intensive care unit were significantly more likely (P=0.0028) to experience flow disruptions than those who took other, less expedited pathways.
  
  
  CONCLUSIONS
  Transitions in trauma care are vulnerable to systems problems and human errors. Coordination problems predominate as the cause. Sicker, time-pressured, and more at-risk patients are more likely to experience problems. Safety practices used in motor racing and other industries might be applied to address these problems.
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA. ken.catchpole@safersurgery.co.uk
authors.forename: Ken R
authors.initials: KR
authors.lastname: Catchpole
authors.forename: Alexandra
authors.initials: A
authors.lastname: Gangi
authors.forename: Renaldo C
authors.initials: RC
authors.lastname: Blocker
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Ley
authors.forename: Jennifer
authors.initials: J
authors.lastname: Blaha
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Gewertz
authors.forename: Douglas A
authors.initials: DA
authors.lastname: Wiegmann
mesh_terms: D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration; D009873:Operating Rooms / Q000458:organization & administration; D010348:Patient Care Team / Q000458:organization & administration; D062209:Patient Handoff / Q000458:organization & administration*; D012189:Retrospective Studies; D012307:Risk Factors; D013647:Task Performance and Analysis; D014187:Transportation of Patients / Q000458:organization & administration; D014947:Wounds and Injuries / Q000453:epidemiology / Q000628:therapy*
keywords: Disruptions; Error; Handoff; Human factors; Safety; Transition; Trauma