Effect of a checklist on advanced trauma life support workflow deviations during trauma resuscitations without pre-arrival notification.
BACKGROUND
Trauma resuscitations without pre-arrival notification are often initially chaotic, which can potentially compromise patient care. We hypothesized that trauma resuscitations without pre-arrival notification are performed with more variable adherence to ATLS protocol and that implementation of a checklist would improve performance.


METHODS
We analyzed event logs of trauma resuscitations from two 4-month periods before (n = 222) and after (n = 215) checklist implementation. Using process mining techniques, individual resuscitations were compared with an ideal workflow model of 6 ATLS primary survey tasks performed by the bedside evaluator and given model fitness scores (range 0 to 1). Mean fitness scores and frequency of conformance (fitness = 1) were compared (using Student's t-test or chi-square test, as appropriate) for activations with and without notification both before and after checklist implementation. Multivariable linear regression, controlling for patient and resuscitation characteristics, was also performed to assess the association between pre-arrival notification and model fitness before and after checklist implementation.


RESULTS
Fifty-five (12.6%) resuscitations lacked pre-arrival notification (23 pre-implementation and 32 post-implementation; p = 0.15). Before checklist implementation, resuscitations without notification had lower fitness (0.80 vs 0.90; p < 0.001) and conformance (26.1% vs 50.8%; p = 0.03) than those with notification. After checklist implementation, the fitness (0.80 vs 0.91; p = 0.007) and conformance (26.1% vs 59.4%; p = 0.01) improved for resuscitations without notification, but still remained lower than activations with notification. In multivariable analysis, activations without notification had lower fitness both before (b = -0.11, p < 0.001) and after checklist implementation (b = -0.04, p = 0.02).


CONCLUSIONS
Trauma resuscitations without pre-arrival notification are associated with a decreased adherence to key components of the ATLS primary survey protocol. The addition of a checklist improves protocol adherence and reduces the effect of notification on task performance.
Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC.
Deirdre C
DC
Kelleher
Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, The Netherlands.
R P
RP
Jagadeesh Chandra Bose
Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC.
Lauren J
LJ
Waterhouse
Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC.
Elizabeth A
EA
Carter
Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC. Electronic address: rburd@childrensnational.org.
Randall S
RS
Burd
D061906:Advanced Trauma Life Support Care; D057189:Checklist; D004219:District of Columbia; D006801:Humans; D010348:Patient Care Team / Q000458:organization & administration; D010372:Pediatrics / Q000458:organization & administration*; D012151:Resuscitation; D013647:Task Performance and Analysis; D014193:Trauma Centers / Q000458:organization & administration*; D015599:Trauma Severity Indices; D014194:Traumatology / Q000458:organization & administration*; D057188:Workflow