title: Flow disruptions during trauma care.
abstract: BACKGROUND
  Flow disruptions (FDs) are deviations from the progression of care that compromise safety or efficiency. The frequency and specific causes of FDs remain poorly documented in trauma care. We undertook this study to identify and quantify the rate of FDs during various phases of trauma care.
  
  
  METHODS
  Seven trained observers studied a Level I trauma center over 2 months. Observers recorded details on FDs using a validated Tablet-PC data collection tool during various phases of care-trauma bay, imaging, operating room (OR)-and recorded work-system variables including breakdowns in communication and coordination, environmental distractions, equipment issues, and patient factors.
  
  
  RESULTS
  Researchers observed 86 trauma cases including 72 low-level and 14 high-level activations. Altogether, 1,759 FDs were recorded (20.4/case). High-level trauma comprised a significantly higher number (p = 0.0003) and rate of FDs (p = 0.0158) than low-level trauma. Across the three phases of trauma care, there was a significant effect on FD number (p < 0.0001) and FD rate (p = 0.0005), with the highest in the OR, followed by computed tomography. The highest rates of FD per case and per hour were related to breakdowns in coordination.
  
  
  CONCLUSIONS
  This study is the largest direct observational study of the trauma process conducted to date. Complexities associated with the critical patient who arrives in the trauma bay lead to a high prevalence of disruptions related to breakdowns in coordination, communication, equipment issues, and environmental factors. Prospective observation allows individual hospitals to identify and analyze these systemic deficiencies. Appropriate interventions can then be evaluated to streamline the care provided to trauma patients.
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Suite 8215N, Los Angeles, CA, 90048, USA, shouhedd@cshs.org.
authors.forename: Daniel
authors.initials: D
authors.lastname: Shouhed
authors.forename: Renaldo
authors.initials: R
authors.lastname: Blocker
authors.forename: Alex
authors.initials: A
authors.lastname: Gangi
authors.forename: Eric
authors.initials: E
authors.lastname: Ley
authors.forename: Jennifer
authors.initials: J
authors.lastname: Blaha
authors.forename: Daniel
authors.initials: D
authors.lastname: Margulies
authors.forename: Douglas A
authors.initials: DA
authors.lastname: Wiegmann
authors.forename: Ben
authors.initials: B
authors.lastname: Starnes
authors.forename: Cathy
authors.initials: C
authors.lastname: Karl
authors.forename: Richard
authors.initials: R
authors.lastname: Karl
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Gewertz
authors.forename: Ken R
authors.initials: KR
authors.lastname: Catchpole
mesh_terms: D003142:Communication; D006801:Humans; D009873:Operating Rooms / Q000458:organization & administration; D017064:Process Assessment, Health Care; D011446:Prospective Studies; D014193:Trauma Centers / Q000458:organization & administration*; D014947:Wounds and Injuries / Q000601:surgery*