Checklist in Trauma Simulation (CheLTS), a new tool for improving trauma management

Introduction Trauma is a leading cause of death and disability in the earliest decades of life. Management of major trauma is challenging for emergency physicians due to multiple, simultaneous and potentially fatal lesions. The aim of the present study was to test the effectiveness of a checklist (CL) in improving the management of patients with major trauma. Methods We tested our hypothesis in a simulation environment. We included 25 teams, each composed by four Emergency Medicine trainees, in which the most expert was the team leader. We designed four scenarios, focused on the management of trauma. The teams performed all the scenarios in a random sequence. We created a CL with the critical actions to be performed in trauma patients. We gave the CL to the teams alternatively during the first or the last two scenarios. The primary outcomes were the adherence to critical processes of care and the time to critical actions in the scenarios with versus those without the CL. The secondary outcome was the evaluation of non-technical skills. Results & Discussion We identified 52 critical actions, which had to be performed during the simulation. In the scenarios performed with the aid of CL, the number of completed actions was significantly higher than in the scenarios without CL (27 ± 9 vs 24 ± 7, p <0.001). By restricting the analysis to critical actions relating to the primary assessment, this result was confirmed again (22 ± 5 vs 19 ± 4, p <0.001). Analyzing the individual actions, in 7 cases they were performed significantly more often in the scenarios performed with the help of the CL: evaluation and treatment of external haemorrhages, evaluation and treatment of back haemorrhages, evaluation and treatment of perineum haemorrhages, removal of all clothes, evaluation of body temperature, immobilization of the cervical spine, evaluation of the neurological status of the four limbs. As regards the timing of execution of critical actions, among the 49 evaluable actions, a significant reduction in time was observed for only 4 items, in favor of scenarios without checklist: objective examination of the chest, positioning of two venous accesses, sample collection for blood count and coagulation, evaluation of the pulses. Non-technical skills were evaluated with the Clinical Teamwork Scale. Global score was significantly higher (95 vs 90, p 0,05) in the simulation performed with the CL vs the simulation performed without. In a high-fidelity simulation environment, the use of a checklist has improved the completeness of management of the patient with major trauma and the non-technical skills of the team in the face of a slowdown in execution. These results suggest that the use of a checklist could lead to a marked improvement in patient safety but that its use, still not widespread in clinical practice, requires specific training. Moreover, further clinical studies should be designed to confirm in the clinical setting this preliminary results obtained in the simulation lab.