title: Decision making in trauma settings: simulation to improve diagnostic skills.
abstract: BACKGROUND
  In the setting of acute injury, a wrong, missed, or delayed diagnosis can impact survival. Clinicians rely on pattern recognition and heuristics to rapidly assess injuries, but an overreliance on these approaches can result in a diagnostic error. Simulation has been advocated as a method for practitioners to learn how to recognize the limitations of heuristics and develop better diagnostic skills. The objective of this study was to determine whether simulation could be used to provide teams the experiences in managing scenarios that require the use of heuristic as well as analytic diagnostic skills to effectively recognize and treat potentially life-threatening injuries.
  
  
  METHODS
  Ten scenarios were developed to assess the ability of trauma teams to provide initial care to a severely injured patient. Seven standard scenarios simulated severe injuries that once diagnosed could be effectively treated using standard Advanced Trauma Life Support algorithms. Because diagnostic error occurs more commonly in complex clinical settings, 3 complex scenarios required teams to use more advanced diagnostic skills to uncover a coexisting condition and treat the patient. Teams composed of 3 to 5 practitioners were evaluated in the performance of 7 (of 10) randomly selected scenarios (5 standard, 2 complex). Expert rates scored teams using standardized checklists and global scores.
  
  
  RESULTS
  Eighty-three surgery, emergency medicine, and anesthesia residents constituted 21 teams. Expert raters were able to reliably score the scenarios. Teams accomplished fewer checklist actions and received lower global scores on the 3 analytic scenarios (73.8% [12.3%] and 5.9 [1.6], respectively) compared with the 7 heuristic scenarios (83.2% [11.7%] and 6.6 [1.3], respectively; P < 0.05 for both). Teams led by more junior residents received higher global scores on the analytic scenarios (6.4 [1.3]) than the more senior team leaders (5.3 [1.7]).
  
  
  CONCLUSIONS
  This preliminary study indicates that teams led by more senior residents received higher scores when managing heuristic scenarios but were less effective when managing the scenarios that require a more analytic approach. Simulation can be used to provide teams with decision-making experiences in trauma settings and could be used to improve diagnostic skills as well as study the decision-making process.
authors.affiliation: From the Howard & Joyce Wood Simulation Center (D.J.M., J.W.), Department of Anesthesiology (D.J.M., J.J.F.), Department of Surgery (B.F., M.K.), Washington University School of Medicine, St. Louis, MO; and Foundation for Advancement of International Medical Education and Research (J.R.B.), Philadelphia, PA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Murray
authors.forename: Brad D
authors.initials: BD
authors.lastname: Freeman
authors.forename: John R
authors.initials: JR
authors.lastname: Boulet
authors.forename: Julie
authors.initials: J
authors.lastname: Woodhouse
authors.forename: James J
authors.initials: JJ
authors.lastname: Fehr
authors.forename: Mary E
authors.initials: ME
authors.lastname: Klingensmith
mesh_terms: D061906:Advanced Trauma Life Support Care / Q000458:organization & administration* / Q000592:standards; D015897:Comorbidity; D003951:Diagnostic Errors / Q000517:prevention & control; D006801:Humans; D007396:Internship and Residency / Q000458:organization & administration* / Q000592:standards; D010348:Patient Care Team / Q000458:organization & administration*; D000066908:Simulation Training / Q000458:organization & administration*; D015599:Trauma Severity Indices; D014947:Wounds and Injuries / Q000628:therapy*