NTS Flashcards
Good morning!
Now, we will discuss an essential aspect of trauma management: the non-technical skills.
These skills are critical for patient safety in trauma management and other high-pressure scenarios.
2 ______________________________________________________________ We will discuss the role of teams in trauma management.
Introduce the concept of non-technical skills.
Describe different non-technical skills relevant to trauma.
Let’s start with a clinical case to illustrate the importance of these skills.
* Male, 45 years old, car accident, left rib fractures & abdominal trauma.
* Hypotensive, FAST positive —> emergency laparotomy.
* The patient arrives at the OR without warning.
* After the intubation, the patient develops a tension
pneumothorax
* The surgeon was not scrubbed in, and it took a while to perform
a thoracostomy.
* There is a lack of chest drain material in the room, and
multiple requests are needed.
* Two nurses leave the room to get materials, resulting in
inadequate support.
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What comments do you have about non-technical skills in this case?” “What potential problems could come from this?
Is it important to have a briefing?
What do you think about not notifying the OR?
What do you think about repeating the same order multiple times? Have you ever been in a similar situation?
(Possible answers/comments from participants
* Not warning the OR can lead to several issues (no preparation
of the OR, such as preheating, no medication ready, and no prepared materials for surgery. Nurses are not scrubbed in. In some hospitals, support staff are not readily available and should be warmed in time to arrive at the hospital.
* There is no mention of a team briefing on possible situations, such as a tension pneumothorax post-intubation. When the team takes a short moment to discuss the plan and possible complications, actions can be taken to tackle them (shared mental plan). The chest drain material would be in the room, and a surgeon could be scrubbed in to perform immediate action.
* “Multiple requests needed” suggests underperformance in non- technical skills. There is no closed-loop communication, multiple requests at the same time, etc.)
-Trauma management requires professionals from different groups and specialties.
-The knowledge and skills of the members do not guarantee a good outcome.
- Retrospective data prove that most errors in trauma management are not related to individual knowledge or skills but to problems in team performance.
In recent years, more attention has been given to human factors, especially non-technical skills.”
The Non-technical skills concept started in airlines and was later introduced into the medical field.
Non-technical skills are ‘the cognitive, social, and personal resource skills that complement technical skills and contribute to safe and efficient task performance.’
There are several Non-Technical Skills and different NTS rating scales.
We will discuss some of them, the most relevant to DCR.
Communication is in the center because it is considered the glue that joints all the other non-technical skills.
Task Management consists of planning, preparation, and prioritization.
A team briefing is required before the patient arrives at the hospital and the operating room. A good briefing allows the team to develop a shared mental plan for the situation.
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An essential part of good resource management is allocating resources effectively. It is crucial to avoid depleting resources on a single patient in a scenario with multiple victims.
Teamwork means “Maximizing mental, manual, and problem-solving skills so that the sum exceeds the parts.
For a team to perform well, several skills and behaviors are needed
* The team must coordinate activities and Exchange information.
* It must be ensured that the right person is allocated to perform
the right task, avoiding duplication of tasks and allowing responsibilities to be shifted to underutilized members. Team members should also be trained to Ask for help.
* Support for others, offering physical, emotional, or cognitive help, and predicting the needs of other team members.
* Cross-monitoring refers to ensuring errors or oversights are detected and corrected immediately.
* Conflict Management is not about who is right or wrong but what is best for the patient. Conflicts should be discussed and resolved after surgery.
Leadership is Essential to organize the team! Experienced trauma leaders reduce resuscitation time and improve decisions.
In the OR, leadership should be shared between the surgical team leader and the anesthesiologist. The anesthesiologist takes charge during critical moments when the surgeon is focused on surgical procedures.
Common leadership mistakes during surgery include:
* Give instructions that are too complicated or unclear or repeat them too much.
* Giving unnecessary instructions.
* Not communicating clearly with the team.
* Not following protocols or lacking a clear plan.
* Not adjusting leadership to the team’s experience.
Let’s go back to our clinical case:
* During the laparotomy, the surgeon performs aggressive hepatic packing, compressing the inferior vena cava.
* The anesthesiologist, busy placing an arterial line, does not notice the drop in blood pressure.
* The anesthesia nurse was too busy administering blood products.
* The anesthesia resident calls out the issue, but only the surgical resident hears.
* The surgical resident tries to warn the surgeon but is dismissed as the bleeding is not yet fully controlled.
What comments do you have about non-technical skills in this case?” * “What potential problems could come from this?
Possible remarks to/ from the audience include:
* Incorrect packing techniques. ( this presentation concerns
nontechnical skills, so discussions concerning clinical decisions
and techniques should be avoided.)
* Probably, the surgeon hasn’t mentioned to the whole team that
aggressive packing has been initiated. This would help the team to closely monitor the condition and pick up changes in vital signs and correctly interpret them.
* Anaesthesiologist is too focused on the arterial line (tunnel vision). When a procedure is performed in critical situations like this it is essential to brief your team ( so they can take over tasks such a closely monitoring the vital signs which you are unable to do during a procedure).
* Calling out an issue and not directing your remark to a specific person will probably not lead to a correct response and plan of action. (no closed-loop communication)
* Both the anesthesia and surgical resident are trying “to speak up.” A plan of action for speaking up is mentioned further on in this presentation.
Communication is the non-technical skill that connects all other skills and is probably the most important.
Communication is essential for:
* Exchanging Information.
* Coordinating Team & Tasks.
* Providing Immediate Feedback.
Good communication is crucial for a proper team function. Problems in communication are associated with errors and worse outcomes.
When considering verbal communication, we must think about different dimensions:
* Technique.
* Message Structure.
* Frequency.
Perioperative communication should use the principles of closed-loop communication.
First, say the person’s name, ideally with visual contact, and then transmit the message.
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The person receiving the instruction or information repeats it back to ensure the message is understood correctly.
After that, the sender confirms to “close the loop.”
Closed-loop Communication has several Advantages.
* When the receiver repeats the message, the sender knows that it has been received and understood.
* Increases the rate and speed of tasks performed
* Improves team performance
Do you always use Closed-loop Communication in your daily practice?
Another important dimension of communication is the content of the message.
Say only what is needed when needed—keep it basic and easy!
In the briefing, before the patient’s arrival, the most used strategy is the ATMIST.
During trauma surgery, the team must share information. The surgical plan depends on the patient’s condition, and the anesthesiologist knows the patient’s physiological status.
However, time is limited, so the message must be short and include all the essential details.
TBCS is a strategy developed by British military doctors; it has been used during the Afghanistan war.
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So, how should it be used?
At regular intervals, the whole team should pause to make a situation report using this mnemonic that covers the key parameters:
T Time since the start of the procedure. Temperature.
B BP, Blood volume given so far, Blood gases (patient current physiologic status).
C Clotting (i.e. ROTEM results).
S Surgical progress and plan.
The first 3 are the responsibility of the anesthetist, and the last is the surgeon’s responsibility.
There are other strategies for improving communication, many of which have been imported from aviation.
Resuscitating by voice. If you verbalize your thoughts and plans, you give your team information and time to support you.
Last, non-essential communication should be avoided during critical moments.
I can’t listen to anyone if I’m intubating a difficult airway. If the surgeon is clamping an artery, he/she will not hear me.
Another important dimension of communication is frequency and timing.
Critical information, like the patient’s condition, suspected injuries, needed resources, and possible risks, should be shared at the right time to coordinate the team.
The six-step approach is a framework for communication in trauma management.
Steps 1 and 2 refer to the communication that should occur before the patient arrives at the hospital and the operating room. The goal is to prepare everything to treat the patient without wasting time.
Step 3 is a crucial moment that should occur just before surgery and can be done in less than a minute.
Step 4 refers to communication during surgery.
Clear communication using a closed-loop communication strategy is essential during critical surgical maneuvers.
Controlling the bleeding is the main priority during surgery. Once it’s achieved, the surgeon should pause briefly to update the team and reassess the situation using the TBCS tool.
Regular intraoperative communication using TBCS helps accurately manage the patient’s status, potentially shifting from damage control to definitive surgery.
Step 5 refers to communication before the surgery ends, when the situation is summarized, and the patient’s plan is defined.
The last step refers to the debriefing, which is crucial for the team’s improvement. It is the opportunity to discuss what went wrong and what can be improved.
Speaking up means that a non-leader expresses concerns or suggestions to a leader, aiming to address issues before they occur.
Healthcare professionals must speak up to prevent serious events and keep patients safe, but this often doesn’t happen.”
Speaking up requires courage and skills; it is vital for maintaining safety in critical care settings.
There are several strategies and tools for expressing concerns or challenging a team member or leader.
Pace Tool is one of them!
P (Probe): Start by probing the situation, describing what you see, or asking a question to gather more information.
A (Alert): If the issue continues, alert the team by clearly stating your concern.
C (Challenge): Challenge the decision or action by respectfully questioning its safety or validity.
E (Emergency): If the concern remains unresolved, escalate it to an emergency, indicating immediate action is needed
There are Barriers to Speaking Up that should be eliminated: Fear of no change.
Fear of retaliation.
Fear of negative feedback.
During the decision-making process, it is important to identify all the options, after that balance the risk and benefits, and then plan. Once made, the decision must be communicated clearly to all team members.
There are two types of decision-making: Type 1 and Type 2.
Type 1 is fast, intuitive, and automatic, relying on patterns, but it carries more risk of errors, making it better for simple tasks.
Type 2 is slower, using logic and reasoning, and requires more effort.
In stressful situations, we tend to use Type 1 thinking because it’s faster. Simple actions, like a chin lift, can use Type 1 thinking, but complex procedures need Type 2 thinking.
Strategies to improve decision-making include taking intraoperative timeouts to reassess the situation.
The “10-seconds-for-10-minutes” principle, or “10 for 10,” is a strategy to improve patient safety by slowing down the decision-making process.
This technique helps manage information overload by slowing down.
1. When encountering a critical situation, take a 10-second pause instead of acting immediately.
2. During this 10-second pause, the team performs a formal time- out to:
1. Identify the main problem.
2. Gather facts and clarify opinions.
3. Develop a treatment plan with a sequence of actions.
4. Assign tasks and responsibilities.
5. Check with all team members for further concerns or
suggestions.
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This brief pause helps manage information overload and ensures the team is fully aware of the situation before proceeding.
Returning to the clinical case:
* The bleeding is managed only with Pringle maneuver. The surgeon loudly says: “The pedicle is clamped!”
* The anesthesiologist didn’t hear it because was placing the arterial line
* A few minutes later, the surgeon asks: “How long has the pedicle been clamped?”
* The anesthesiologist is surprised: “You guys clamped? What did you clamp?”
Have you ever been in a case like this?
Knowing and anticipating what is happening around you is mandatory, which brings us to the last non-technical skill!
Situational awareness can be defined as “the perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future.”
SA has three levels:
Level 1: Recognizing individual elements of information from the environment.
Level 2: Comprehending their collective meaning.
Level 3: Projecting the meaning of that comprehension into the immediate future.
Situational awareness can suffer from pitfalls, such as tunnel vision during focused tasks like managing a difficult airway or vascular control, failure to process or understand available information, and failure to anticipate issues based on that information.
Fatigue, excessive workload, and stress further impair situational awareness.
Strategies to improve SA:
1. Consider the transfer of leadership or the overview
responsibility during critical tasks that require Tunnel Vision.
2. Intra-operative time-outs.
Do you have any questions?
The Take Home Messages are:
* Non-technical skills are crucial in trauma management.
* Effective communication ensures team success.
* Situational awareness aids in anticipating issues.
* Strong teamwork leads to better outcomes.
* NTS are always relevant, but in critical situations, they are
crucial!
