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BelTECC Training Manual Belfast Trauma Team Education Course LJ Mottram S. Campbell-Gray WHY TRAUMA TEAM TRAINING? ‘You can’t expect a group of strangers, albeit highly skilled individuals, to come together for the first time and perform like a Formula 1 team’ Don’t leave highly stressful time critical team performance to CHANCE. WHY? WHO? Why does the team Which team members exist and why are we are on the core Belfast training in teamwork? Trauma Team? WHEN? WHAT? Trauma Team What does the team do Activation criteria and in what timescale?WHY DO WE NEED A BELFAST TRAUMA TEAM? Trauma is the leading cause of death in the 1-44 year age group and is the fourth leading cause of death in the Western world. Dealing with severely injured trauma patients on a service-by-service basis, where each specialty performs an assessment in a vertical manner and makes single-specialty decisions on what should happen, is both lengthy and inefficient. This model serves us more than it serves the patient, resulting in delays in definitive care and worse outcomes for the most severely injured. A trauma team assesses the patient in a simultaneous ‘horizontal’ manner with the aim of formulating a damage control plan in 45 minutes. The introduction of a trauma team reduces mortality from 30.2% to 22% for those with an Injury Severity Score (ISS) of greater than 25. The requirement for a trauma team in Belfast was appreciated locally for many years and came into being in October 2015. This was in response to local data from the Northern Ireland Trauma Audit, which demonstrated time delays in the early management of severely injured patients and recommended the following: Regionally, work should be conducted to identify why the average time spent by major trauma patients in Emergency Departments is so long and to set out ways in which this may be improved. All hospitals currently receiving major trauma patients should seek to identify areas of care where protocolisation may improve standards and performance. Suggested themes include, common documentation, the management of major haemorrhage and trauma imaging. This was accompanied nationally by an NHS Clinical Advisory Group report on Regional Networks for Major Trauma (2010) and further echoed in the Kings Fund report Reconfiguration of clinical services: What is the evidence? (2014).Full implementation of these recommendations will take time. BelTACC will focus on quality care by the reception team at the door of the hospital, with the aim of getting a patient to a damage control plan at 45 minutes and definitive care within 60 minutes. Focusing on the first 60 minutes of trauma care has the potential to significantly reduce mortality from severe polytrauma, positively influencing the outcome and length of the inpatient stay as part of a whole package of care. Analysis of the Trauma Audit & research Network (TARN) database has revealed that the majority of trauma deaths occur in the first 24-48 hours of arrival in hospital and that the previously described trimodal distribution of mortality does not fully exist in the UK. We recognise that the trauma team is only one facet of a wider program of improved trauma services, including the Helicopter Emergency Service, all of which requires the infrastructure of the wider trauma network, but for us the front door of the hospital is a reasonable place to start. THE TRAUMA TEAM AND ACUTE INPATIENT CARE AS PART OF THE WIDER TRAUMA SYSTEM /NETWORK. WHY TRAIN AS A TEAM? ‘In the majority of cases the patient’s survival is dependent on the trauma team working effectively rather than the abilities of any one individual’ European Trauma Course Manual 2014 We know that many healthcare teams are comprised of highly skilled and experienced clinicians. We assume that by participating in the Belfast Trauma Team course that you are clinically competent in your field and have a sound knowledge of trauma care. With this in mind, you will not be learning how to insert a chest drain or indeed how to assist with or perform a rapid sequence induction in trauma. We assume that a member of the team has these specialist skills already. However, we recognise that a group of people coming together infrequently and applying their skills to a trauma patient, may perform sub optimally, often for simple reasons such as lack of team leadership or communication. Rather, the focus of the learning will be on how to apply your trauma skills swiftly and efficiently under the direction of the team leader. Some of these skills are regarded as the softer ‘non-technical’ aspects of teamwork. Other industries have recognised the value in this kind of learning in high stakes environments. This course will teach you a structured way to improve your team working skills, enhance your contribution to the emergency trauma team and hopefully lead to improved trauma outcomes in Belfast. WHO ARE THE CORE TEAM MEMBERS ON THE BELFAST TRAUMA TEAM? Emergency Department Consultant/ ST as TEAM LEADER Emergency Department doctor Surgical doctor (orthopaedics/ gen surgery) Two ED nurses Airway doctor Airway assistant Blood transfusion nurse/clinicians ** where major haemorrhage is ongoing Essentially the team is comprised of three smaller units consisting of clinical staff working in pairs. This is usually a nurse and doctor together, carrying out a specific set of tasks. These tasks take place simultaneously, rather than in the linear fashion taught by ATLS. All of this occurs under the direction of the Trauma Team Leader.WHAT DOES THE TEAM DO? The trauma team has four main functions, which must be understood by all: • Identify and treat life threatening injuries • Identify any other major problems • Arrange time critical treatment and investigations • Transfer the patient to definitive care and handover WHEN IS THE TRAUMA TEAM ACTIVATED? The trauma team activation criteria depend entirely on the stability of the patient and anatomical location of injuries. A graded response from red, then amber and green is initiated, with the seniority of clinicians reflecting the severity of the injuries. Communication systems have been established which allow activation of the team via switch board once a call has been received from prehospital staff with clinical information. Status can be upgraded at any time. CODE RED Shock index >0.9 Prehospital Shock index >1.1/ Lactate >3.5 in hospital Consultant (*Shock Index = HR/SBP) Enhanced UNSTABLE Trauma PATIENT Critically unstable patient Team GCS  12 Sustained systolic BP <90 Resp Rate <10 or >29 CODE Chest injury with altered physiology Traumatic amputation prox to wrist or ankle Major AMBER Penetrating trauma to neck, chest, abdomen, trauma Assess vitals & team injury back or groin Suspected open/ depressed skull fracture Suspected pelvic fracture Spinal trauma with abnormal neurology Trauma with facial and/ or circumferential burns OR Burns >20 % BSA Two or more long bone fractures Traumatic death in same passenger CODE compartment Falls > 20 feet/ 2 floors Usually GREEN managed Entrapment under vehicle by ED Evaluate Bulls eye window team Pedestrian / cyclist v motor vehicle injury Overhead view of the Trauma Team in ED Rapid Transfuser Emergency trolley 3 Monitors/Ventilator 4 1 2 5 6 9 10 7 8 1. Breathing doctor 6. Circulation Nurse 2. Breathing Nurse 7. Team Leader 3. Airway doctor 8. Scribe 4. Airway Assistant 9. Transfusion co-ordinator 5. Circulation doctor 10. NIAS/HEMS 6. Trauma Team Leader Responsibility • Co-ordinates safe and timely assessment of the patient using the team • Decides on trauma imaging, ideally achieved within 30 minutes of arrival • Directs key interventions such as intubation, thoracostomy and transfusion • Directs specialty input and determines definitive care destination The team leader coordinates the resuscitation and decides the priorities, timing and sequence of investigations and patient transfer. This will most often be the ED consultant or a senior member of the ED medical team. Pre Arrival of Patient: • Team leader is identified and he/ she will allocate team roles. • Ensure all team members appropriately identified (Team tabards) • Ensures the team dons personal protective equipment • Gives succinct Pre-Brief to assembled Team (based on Pre-Alert information) and shares mental-model of anticipated therapies etc based on this information. • Confirms level of skill available in the team • Confirms pre-alerts to CT/ theatre /blood bank and other specialty services as necessary. On Patient Arrival: • On arrival of patient performs “5 second round” (to rule out complete airway obstruction, massive external haemorrhage and traumatic cardiac arrest) • Stands back from the resuscitation area - usually NOT involved in clinical procedures • Coordinates life support and directs primary survey • Ensures that critical diagnoses are prioritised • Defines order of therapies according to clinical priority • Makes decisions about appropriate consultations, additional investigations and the need for surgical intervention • Ensures the trauma documentation is complete by liaising with the scribe • Liaises with and directs specialty services to cross the ‘red line’ as indicated • Maintains momentum to ensure the timely transfer to CT/ theatre Team Scribe Reporting Structure Responsibility To: Trauma Team Leader • Safe and timely recording of handover from NIAS/HEMS • Recording trauma team members & key interventions • Time keeping • Uses action cards to enhance team roles Pre arrival of Patient: • Identifies him/herself to team • Prepares documentation – trauma team booklet obtained. • Ensures Lab/ Radiology request forms available • Records arrival times and response of trauma team • Ensures team Action Cards are immediately available • Ensure all team members check in and out and records accordingly • Stands behind the red line and serves to keep non-team members behind this line also. On Patient arrival: • Records ATMIST handover from paramedics/HEMS • Sets the timer and provides 10 minute reminders. Enhances these to 5 minute intervals after 30 mins have passed • Ensures patient labels are in situ • Scribes all observations, fluids, blood, drugs, primary and secondary survey completion and procedures performed in a chronological fashion • Requests that consulting teams document their involvement • Communicates with entire team via team leader • Maintains an overview alongside the trauma team leader Airway Doctor Reporting Structure Responsibility To: Trauma Team Leader • Assessment and management of airway • AMPLE history in awake patients • Protection of cervical spine and assessment of D • The airway clinician is generally, but not always, the Anaesthetist • On arrival identifies him/herself to team • Assesses and manages the airway • If patient is talking, takes AMPLE history • Protects Cervical Spine (C-Spine) • Ensures a neurological examination completed before administration of paralysing agents – pupils, GCS, gross motor function, seizures. • Monitors central nervous system (CNS) status. • Assesses need for orogastric tube placement if intubated • Considers placement of an arterial line – ensures this does NOT delay definitive care/ CT scan • Ensures A & D assessment & mx is documented in the trauma booklet. • Accompanies and cares for the intubated patient during transfer /CT scan. Airway Nurse / ODP Responsibility • Works with Airway doctor to assess & manage ‘A’ • Manages drugs for intubation • Accompanies patient to CT/imaging Pre arrival of patient: • Identifies him/herself to team • Assembles necessary equipment for airway management inc suction & ETC02 • Prepares and labels appropriate medications including emergency drugs, intubation drugs, saline flushes On patient arrival: • Assists with intubation and airway management • Maintains cervical spine immobilization • Administers and announces to scribe all medications given • Assist with management of gastric aspirate, vomitus or gastric tube • In case of arrest, draws up and labels medications and flushes • Makes up sedative infusions/pressors for the intubated patient • Accompanies the intubated patient during transport Breathing Doctor (B) Reporting Structure Responsibility To: Trauma Team Leader • Works with B nurse to assess & manage ‘breathing • Requests radiology and performs interventions under B • Accompanies patient to CT/imaging • Performs the primary survey of Breathing and feeds back to team leader succinctly • Performs additional procedures (including FAST scan, if indicated) • Depending on skill level, the B doctor may be required to do a chest drain • Ensure radiology requested –primarily CT pan scan of head, neck, chest, abdomen and pelvis as indicated • Ensures maintenance of normothermia • Prescribe +/- administer Drugs such as Analgesia, Antibiotics and Tetanus • Gives medications during an arrest sequence • Works in cooperation with entire team with systematic approach B Nurse Reporting Structure Responsibility To: Trauma Team Leader • Set up of resus bay for trauma • Works with B doctor to assess & manage ‘breathing • Performs non invasive monitoring • Assists with FAST or chest drain • Assist with preparing the resus bay including monitors, chest drain trolley, pelvic binder, Bair hugger and drugs including antibiotics and tetanus • Have scissors ready and assist with removal of clothing • Apply all non invasive monitors (BP, cardiac monitors, Sp02) • Verbalise observations to the team. • Help with procedures as identified – e.g. chest drain / FAST scan • Ensures normothermia • Administers prescribed drugs • Prepare for transfer to CT as soon as possible – within first 30 minutes Surgical (C Doctor) Reporting Structure Responsibility To: Trauma Team Leader • Assess and manage circulation • IV or IO access • Lab specimens • Fluid resus, catheterisation • Identifies him/herself to the team • The C doctor should assess the circulation (pelvis, abdomen and long bones) and feeds back to team leader succinctly. • Obtains 2 x large-bore I.V. access • I.O. access should be obtained where 2 attempts to obtain venous access have failed • Obtains blood specimens (FBC, group & cross match, electrolytes, glucose & venous gas) and works with C Nurse in processing for labs • Responsible for fluid resuscitation (warmed and via rapid infuser) • Delegates replacement of blood volume to a transfusion team if Massive blood loss Protocol declared • Prompts the team to address surgical bleeding swiftly rather than spending excessive time in ED managing haemorrhage • Takes note of ECG morphology and rhythm • Considers urinary catheterisation and prescribes tranexamic acid. Circulation Nurse Reporting Structure Responsibility • Assess and manage circulation To: Trauma Team Leader • TXA administration • Lab specimens and initiation of transfusion • Fluid resus, ECG and catheterisation • Prepare the Resus bay with B Nurse before arrival of patient o Rapid infuser, syringe pump, trauma mattress, lab bottles o Prepare drugs including 1g of Tranexamic acid for infusion • Assist with obtaining IV access and blood sampling • Ensure samples sent to lab • Secure IV/IO access and administer fluids • Co-ordinates initial supply of ORh D neg blood from ED blood fridge. • Thereafter delegates the following to a Transfusion Nurse if Massive blood Loss Protocol declared o Blood bank liaison to arrange supplies of blood and blood products. o Replacement of blood volume to a transfusion team • Administration of tranexamic acid 1 g IV as bolus if not already given over 10 mins followed by 1 g over 8 hours as an infusion • Assist with the application of pelvic binder/ splints/ appropriate dressing to open wounds • Perform ECG & urinary catheterization as required • Prepare for transfer to CT as soon as possible – within first 30 minutes. Transfusion Co-ordinator Reporting Structure Responsibility To: Trauma Team Leader • Safe and timely transfusion of blood products • Liaison between trauma team and blood bank • Management of Blood products • Must have valid RPRB training Pre Alert of Major Haemorrhage Activation Required 1. If instructed by team leader, set up rapid infuser device using two litres of saline and prime line. Major Haemorrhage Activation Required 1. If instructed by Trauma Team Leader, don TC Tabard 2. Inform blood bank and Porters of MBL activation. 3. Liaise with Scribe to ensure patient has TWO correct identifying armbands. 4. When sample for Group and cross match taken, ensure there is correct labelling of form and bottle, guide MBL porter to take sample to blood bank. 5. Maintain communication with blood bank regarding blood products required, inform team leader of timeframes for products. 6. If a second sample requested by blood bank, liaise with TTL regarding the accessibility of same, inform blood bank and MBL porter if sample taken. 7. Ensure safe and timely delivery of Emergency ‘O’ Negative blood and Trauma Plasma in ED fridge – aiming for 1:1:1 ratio. ( see blood product proforma) 8. Ensure the safe management of Trauma Pack 1 and if required Trauma Pack 2. 9. Ensure 30min cold chain adhered to for Red cells; do not place yellow blood products in fridge. 10.Return unused Trauma pack products to Blood bank in timely manner. 11.Ensure correct tracking and documentation of all blood products. 12.Liaise with blood bank regarding the replenishment of Emergency products in ED fridge. Activation Stand Down 1. Stand down MBL activation when instructed by Trauma Team Leader, inform Blood Bank and Porter Dispatch manager.NIAS/HEMS It is always preferable to arrive in ED after major trauma with I.V. access and TXA administered. However valuable time at the scene can be lost if the balance between what is preferable and what is possible is not considered. • On arrival allow the TTL to check the patient status • Give a 30 -40 second CONCISE and AUDIBLE handover to the team leader following the ATMIST structure • Assist with transfer of the patient onto the ED trolley • Additional detail can be conveyed to the team leader but the trauma team need to commence assessment/resuscitation based on the key facts • Ensure the trauma whiteboard is completed legibly using ATMIST • Ensure all relevant history conveyed to team leader before leaving ED. ATMIST Handover Tool A – Age & Sex T – Time of Incident M – Mechanism of Injury I – Injuries suspected (head to toe) S – Signs / Symptoms T – Treatments givenTRAUMA TEAM RULES REMEMBER THE SHARED GOAL To manage the trauma patient safely and effectively in the golden hour of trauma To get to CT safely within 30 minutes Damage control plan formulated in 45 minutes To definitive care within 60 minutes Don’t perform unnecessary procedures in ED which will delay radiological investigations or surgery if that is what is required COMMUNICATE EVERYONE stops and listens to the ATMIST handover ECONOMY of language If everyone talks all the time, nothing can be heard Most communication will be between the nurse/doctor pairs Alert the team leader to key information but avoid data overload SUMMARISE your findings Use the ‘Assessment & Recommendation’ of the SBAR tool NO SHOUTING unless the team or patient is in immediate danger ROLES Stick to your tasks unless directed otherwise by team leader Use the action cards as cognitive aids Visiting teams cross the red line ONLY as directed by team leader Don’t work outside your own skill set Share your level of experience with the Team Leader at pre-brief. BARRIERS TO GOOD TEAM PERFORMANCE Poor communication practices Loss of situational awareness Poor task management eg task overload for one person/not setting priorities Bad decision making Loss of leadership or team structure Individual factors eg fatigueNON-TECHNICAL SKILLS in TEAMS Increasing emphasis is placed on non technical skills in team work but what are these elusive ‘soft skills’ and can we improve them? Technical skills are the knowledge and capabilities to perform specialized tasks. Examples relating to trauma include intravenous cannulation, rapid sequence induction (RSI), suturing of a wound or insertion of a chest drain Non-technical skills encompass the behaviours, attitudes and cognitive skills which complement technical ability and contribute to safe and efficient task performance. Technical skill Optimal performance Non technical skill TAXONOMY FOR NON-TECHNICAL SKILLS (NTS) The first step towards improving these cognitive and interpersonal skills is actually being able to recognise them in everyday practice. This requires a descriptive nomenclature, but many of these less tangible skills are difficult to pinpoint and categorise. Fortunately, a taxonomy has been developed both in anaesthesia and in surgery to help evaluate non technical skills. They are being developed in other specialties such as emergency medicine, and may become a summative assessment tool in the future.WHY IS THIS IMPORTANT? Patient safety and Human Factors Aside from the fact that colleagues with poor non-technical skills can be hard to work with, these behaviours can also pose a threat to patient safety. Analysis of adverse events in healthcare has revealed that errors are often caused by poor non-technical performance rather than lack of clinical skill or experience. There is evidence that improvement in NTS can be achieved by teaching and deliberate practice. SITUATIONAL AWARENESS Developing and maintaining a dynamic awareness of the trauma scenario as it unfolds, based on assembling data from the environment (patient, team, displays, equipment) understanding what they mean and thinking ahead about what may happen next There are three core elements to situational awareness: 1) SEEK: Gathering information from the environment Eg listening to handover, vital signs, reassessment of the patient, getting information from other members of the team 2) INTERPRET: Understands what the information means Increases frequency of monitoring and responds to clinical deterioration Recognises patterns to reach a diagnosis Doesn’t disregard signs that don’t fit their picture of what is happening. 3)ANTICIPATE: Predicting & preparing Eg. Prepare the resus bay before patient arrival Inform CT in a timely fashion Verbalise the next steps Has a Plan ‘B’ and communicates it. COMMUNICATION Communication is the exchange of information to enable a shared understanding of the situation by the team. Examples of good Trauma Team communication: Giving a concise handover using the ATMIST structure. Making instructions clear to team members and ensures those instructions have been heard and understood Can challenge or express concern in a constructive wayCan summon help from additional sources effectively How is this achieved in the reality of a busy resus room? STRUCTURE can be applied to all of these aspects of Trauma Team communication to improve the flow of information. 1) ATMIST Handover Tool This was described under the EMS role but essentially is a mnemonic to assist in the effective handover of trauma patients within 45 seconds. To reduce cognitive overload, the handover is deliberately kept short and covers salient points only. The A.T.M.I.S.T headings should be scribed onto the ED white board so that the whole team can refer to it. If an AMPLE history has also been obtained it can be shared with the team leader and scribed onto the board. Laminated ATMIST cards will be available in ED as a cognitive aid. 2) Ensuring clarity of instruction and comprehension This can be achieved using closed loop communication, in which the sender initiates a message, the receiver accepts it and provides feedback. The sender then confirms/double checks that it was received correctly. Message EXAMPLE sent Doc: Could you give 0.5 litre of Receiver Hartmanns as a bolus? accepts and feeds back Nurse: You want me to give 500ml Hartmanns stat? Sender Doc: Yes that’s right. confirms 3)Can challenge or express concern constructively while keeping the patient safe by using a technique known as graded assertiveness. One model for this includes ‘OBSERVE, SUGGEST, CHALLENGE, STOP’ Make an observation ‘The sats are 90% on a rebreather” Suggestion “Should we have another listen and get a Chest Xray?” Challenge “Do you think the Sats should be this low if there isn’t a problem in the chest?” STOP “ We’ve not excluded a pneumothorax. Please stop and reassess the patient ”. Another model of graded assertiveness is C.U.S.S. CONCERNED : I’m concerned that the heart rate is 140 bpm UNCOMFORTABLE/UNCERTAIN: I’m uncertain that we’ve fully addressed the reason for this SAFE : This is not safe, the patient could still be bleeding. Please STOP and listen4) Can summon help effectively The SBAR tool is the most frequently used structure for summoning help from other specialties if they do not form part of the core trauma team. • Introduce yourself SITUATION • State where you are phoning from • Dealing with a polytrauma BACKGROUND • Age, Time, Mechanism of injury • What the clincal parameter of concern is ASSESSMENT This is the I & S of ATMIST • Investigations performed/ pending RECOMMENDATION • A request to come and assess TEAMWORKING A good team is able to ensure effective and joint task completion. It has several core skill elements: Co-ordination of activities within the team In the trauma team this requires adherence to a set of specific tasks and adopting a pre-specified role. Good team co-ordination does not rely on over familiarity with team members or assumptions that someone else in the team will automatically perform the tasks. Cross checking happens within the team to ensure tasks completed. There was recognition & feedback that massive transfusion scenarios resulted in overloading the C team, so at least 2 extra transfusion nurses are allocated from ED when this occurs. How does this look on the Belfast Trauma Team? Clear role allocation and use of the Action Cards Clear protocol for Massive blood loss in traumaAssessing capability • A good team considers the skills of the collective group and allocates workload accordingly. • There is agreement that no one should work beyond his/her level of experience. • There is openness about the skills possessed by each team member. For example, a doctor who has never performed thoracostomy would be expected to declare his/her lack of experience in this area How does this look on the Belfast Trauma Team? Team leader determines the skills of each member. Task overload is avoided Develops a shared understanding - ‘shared mental model’ The team have a collective understanding of the task ahead and the clinical problems. This should be articulated and summarised by the team leader to ensure everyone is on the ‘same page’. Equally team members should voice their concerns if they don’t understand what is going on. Otherwise they will fail to anticipate the next steps and plan ahead, which is a key feature of situational awareness. How does this look on the Belfast Trauma Team? The team leader summarises progress and ensures shared goal understood LEADERSHIP Team leaders deserve a special mention because without good leadership, team structure can readily deteriorate. The team leader on the Belfast Trauma team in a senior Emergency Medicine Doctor Good leadership behaviours 1. Assertiveness - orders given to the team are clear. The leader can challenge decisions where necessary and resolve conflict swiftly. 2. Support of colleagues – the leader establishes rapport and credibility. He/she gives positive feedback to the team when it is due and debriefs the team afterwards with the aim of improving future performance. 3. Sets standards – the team leader maintains high standards by following established protocols. Doesn’t let challenging behaviour go unchecked. 4. Manages self under pressure – promotes an atmosphere of ‘calm urgency’. 5. Delegates tasks to avoid overload on one individualDECISION MAKING Good decision making involves assimilating the available information to make a judgement on the correct diagnosis or course of action. We often use mental ‘short cuts’ to make decisions in an automatic fashion. This is less taxing than thinking through every single decision we have to make in a day. However these mental short cuts (or heuristics) can make us prone to decision making errors in medicine. For example, when a patient comes in with one feature consistent with a certain diagnosis we can jump to conclusions and fail to consider alternatives. Not re- evaluating the situation can lead the whole team down the wrong path, wasting valuable time or performing unnecessary interventions. There are 3 core skills elements to good decision making: • Identifying options What are ALL the possible diagnoses or therapeutic options? • Balancing risks and selecting the options What are the risks of taking/ not taking a particular course of action? • Re-evaluating Continues to assess the patient and considers another option if intended not achieved. Widens the diagnostic field. COGNITIVE BIAS IN THE TRAUMA TEAM Confirmation bias or ‘making it fit Being so convinced by a particular diagnosis, that data which support this conclusion are overemphasised rather than data which clearly refutes it. Premature closure/ Anchoring Making a decision on what is happening too early in the scenario eg diagnosis based on the ATMIST handover information rather than performing an independent assessment Availability bias Having recently seen a case of X or having been to a training course on X, then this case is prematurely diagnosed/treated as such. Search satisfaction When one abnormality is found, there is a tendency to stop searching for other problems. Commission bias Tendency towards action rather than inaction. For some patients, conservative options and observation rather than surgical intervention will be appropriate.DEBRIEFING Debriefing forms an important part of feeding back to the trauma team on performance. Performance can be very good and should be acknowledged, but in many instances team performance may need to improve. By subjecting the team to scrutiny, and analysing what happened, overall performance can improve. The debriefing process can also examine how the team interacts with the clinical environment. A number of improvements have been made to ED trauma documentation and the process of care in massive transfusion as a direct result of observing these latent barriers by trauma team members. ‘Hot debriefing’, while still in the clinical setting, is difficult to achieve but is by no means impossible. Making a specific time - such as immediately after the patient has been dispatched to theatre or ICU - may be the most practicable. However, some of the trauma team will continue to be actively caring for the patient at this time and may not be able to participate fully. Despite these barriers, debriefing is an important tool to develop the team and should be conducted by an experienced Trauma Team Leader. Avoid only doing debriefs in scenarios when something didn’t go well, otherwise team members will dread what would otherwise be formative experiences. The essential components of debriefing include: DESRIPTION, ANALYSIS and SUMMARY phases. Other debrief tools are available e.g. the TALK clinical debriefing tool (www.talkdebrief.org) DESCRIBE Reactions and description of events. ANALYSIS – genuine enquiry about factors driving the team’s actions. This will determine how to improve any gaps in performance. Coming up with a team plan helps to reduce the focus on individual error. SUMMARY of learning points / areas for improvement and key action points. Discussion of the salient points of a clinical case can also occur more formally at Trauma Grand Rounds, local audit meetings and at a regional level.REFERENCES & RESOURCES 1. Regional networks for major trauma: NHS Clinical Advisory group report 2010. 2. Timing of Trauma deaths within UK hospitals. Leckie T et al. for the Trauma Audit and Research Network ww.tarn.ac.uk/content/downloads/68/leckie1.pdf 3. Celso B, Tepas J, Langland-Orban B, Pracht E, Papa L, Lottenberg L et al. A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma 2006; 60: 371–378. 4. Northern Ireland Trauma Audit https://www.rqia.org.uk/RQIA/files/49/494ff427-9511-4311-bcca- db5fe7bc3eca.pdf 5. Steinemann S, et al Assessing teamwork in the trauma bay: introduction of a modified “Notechs” scale for trauma. Am J Surg. 2012; 203: 69-75. 6. D. Tiel Groenestege-Kreb et al. Trauma team. Br J Anaesthesia 2014; 113: 258-265 7. R. Flin et al. Anaesthetists Non Technical skills. Br. J. Anaesth. 2010; 105: 38-44. 8. Mercer et al. Human Factors in Complex Trauma. BJA Education, Volume 15, Issue 5, October 2015, Pages 231–236. 9. TALK debrief tool www.talkdebrief.org