Date Published: April 11, 2019
Publisher: BioMed Central
Author(s): Ralph James MacKinnon, Karin Pukk-Härenstam, Ulrica Von Thiele Schwarz, Christopher Kennedy, Terese Stenfors.
Trauma is the leading cause of death in children. The lack of an accepted definition of what constitutes a high-quality stabilisation of a traumatically injured child has limited the evaluation of direct interventions in simulation-based education and service-delivery models to improve trauma care. The aim of this study was to create a framework that delineates quality by exploring the perceptions of the multi-disciplinary team providing and improving this initial care.
Interviews were conducted with 36 experienced UK trauma team members and governance administrators (clinical directors to executive board level), from three standard UK trauma units. This study used a phenomenographic approach to explore the relationships and hierarchy between the contrasting perceptions of quality and evaluation of quality in this acute context.
The findings show that defining quality is a more complex concept than simple proxy measurements, such as time to CT scanning. They also show that the concept of quality requires the consideration of a spectrum of perspectives that range from the simple to the more sophisticated.
This study has created a framework of understanding of acute paediatric trauma care quality and its measurement from the perspectives of team members and administrators. A framework and future tools to capture and disseminate the System, Team, Process, Individual, Data and Culture perspectives of the quality of trauma stabilisations could be a key advance in the care of severely injured children.
The online version of this article (10.1186/s41077-019-0091-z) contains supplementary material, which is available to authorized users.
Trauma is the leading cause of death in children . The initial stabilisation of a traumatically injured child encompasses the primary assessment, lifesaving interventions, re-evaluation and, when needed, transfer to a major trauma centre . High-quality trauma care depends on the knowledge, skills, attitudes and behaviours of the individuals that comprise a trauma team, team member interaction and health system organisation . Over the past two decades, much attention has focused on simulation-based team training and the development of both technical and non-technical skills to improve resuscitation quality . In situ trauma simulations, training trauma teams in their place of work, are becoming a normal practice in trauma centres across the globe . Conversely, very little attention has focused on understanding the parameters defining high-quality initial trauma stabilisation. The understanding of what quality means in this context may be dependent on perspective, for example the perspective of a trauma team member, a team leader, an administrator or an educator.
The results of a phenomenographic study are presented as structural categories of perspectives and a hierarchy of the variation of perspectives. Each structural category is presented with sub-categories, termed referential categories, derived from the individual meaning units from all participants (Table 2). The hierarchy described is from a basic to a more comprehensive understanding of quality and how it can be measured. At each level of the hierarchy, more categories are incorporated. At the most basic level, only three structural categories are present; at the most complex, there are six.Table 2The perspectives of the quality and measurement of acute stabilisation of a traumatically injured childStructural categories of perspective of qualityReferential categories of perspective of qualitySystem: the organisational design to facilitate optimal performance.Ready/pre-planned, critical incident reporting systems, equity of care, standards, prioritisation, value for money, feedback to team, feedback from major trauma centres, coffee room feedback, current lack of tools to measure quality, team-working tools, friends and family test during stabilisation, checklists, cognitive aids, audit.Team: the mechanics of how the team functions.Teamwork, leadership, communication, team satisfaction, supported teams, team performance monitoring, ongoing team training.Process: the direct delivery of care to the patient.Best care provision with resources available, best evidenced, following protocols (Advanced Trauma Life Support, European Trauma Course), timelines.Individual: the innate personal perspective of healthcare providers.Internal assessment by team members, personal desire, personal satisfaction, specifically trained/experienced, patient’s experience, patient-centred, safety of patient, perception of carers/parents.Data: the facts and details collectable for analysis.Patient outcomes (morbidity, mortality), adverse clinical events (sudden untoward incidents), clinical data, Trauma Audit Research Network data (timings), electronic patient record, retrospective note reviews, benchmarking against other hospitals.Culture: the social behaviour and customs of the team and organisation.Debriefings post-resuscitation, reflective practice, guardians/champions of quality, inter-professional discourse, approachability of senior clinicians.
This study has created a framework of understanding of acute paediatric trauma care quality and its measurement from the perspectives of team members and administrators. It has highlighted that defining quality is a more complex concept than simple proxy measurements, such as time to CT scanning. It has also highlighted that the concept of quality requires the consideration of a spectrum of perspectives that range from simple to more sophisticated ways of understanding. The importance of teamwork, individualised perspectives and the culture of care provision, when delineating quality, has been emphasised by both trauma team members and administrators, in addition to System, Process and Data. An understanding of the complexity of quality is the key to future simulation-based training, debriefing and performance reports of hospital readiness to receive patients. The capability to capture and disseminate the System, Team, Process, Individual, Data and Culture perspectives of the quality of trauma stabilisations could be a key advance in the care of severely injured children.