The strength of this study was the use of video recordings of trauma resuscitations to analyze the pace of the resuscitation, which provides accurate documentation of the trauma resuscitation. Using video recordings allowed us to re-wind if needed, which increased the accuracy of the data collection. Our study also has some limitations. First, our study was a single-site study that enrolled a relatively small sample of 32 trauma team activations in a level one trauma center in an academic institution. The practices and policies at our institution may differ from other academic medical centers throughout and considerably vary from community-based practices. Therefore, the generalizability of our findings may be limited. Thereby, the small sample size could have introduced bias, as cofounders might be underpowered and might be overseen. There are many factors at play during trauma resuscitations, including but not limited to patient, team leader, and team member factors, not to mention interpersonal behaviors and interactions. In this explorative study, not all factors have been addressed in this study. Nevertheless, based on our results, we found that ISS could be an important cofounder when assessing the influence of the experience of the leader on resuscitation pace, as the severity of the injury of the patient seems to have an influence on resuscitation pace, as well. Furthermore, the overall severity of the injury of the resuscitated patients was medium [median 10 (IQR4-26) for Fellow trauma surgeons and 13 (IQR5-21) for Staff Trauma Surgeon; p 0.43]. The resuscitation pace is especially important for patients suffering more server injuries. The sample size of this study was too small to compare a group of the most injured patients only. However, as Fig.
1 indicates, the pace of the resuscitation led by a Fellow trauma surgeon seems, in general, to be less across all ISS scores. Therefore, it is more likely that, despite the small sample size, the results found that the experience of the trauma team leader improves resuscitation pace which is also valid for more severely injured patients. Second, patient-related outcomes were not evaluated in this explorative study. Further research is needed to investigate resuscitation pace effect on patient-related outcomes, such as length of stay, in-hospital complication, and mortality. Third, the outcome values, T1 (time to initial treatment plan), T2 (the total resuscitation time), and T3 (procedural time), might have some limitations. For the outcome time to initial treatment plan (T1) minus the procedural time (T3), bias could have potentially have been introduced, as the group who has performed most procedures (Staff trauma surgeons) may be delaying a plan to perform a procedure. However, in this study, all procedures took place after the announcement of a treatment plan and therefore have not influenced T1 minus the procedural time (T3). For the outcome total resuscitation time (T2), administrative factors might have biased the outcome. In practice, there might be some delay when the patient is leaving the trauma room when waiting for the availability of the CT scan. However, in this study only in two cases, there was a delay in transferring the patient to the CT scan. Furthermore, delays are not driven by other administrative factors (for example, bed availability, speed of transport services, etc.), while patients that do not need direct treatment are transported to another room at the ED, to prepare the shock room for new trauma resuscitations. The total resuscitation time (T1) minus procedural time might also be biased by the fact as, during procedures, plans could have been discussed and prepared for simultaneously, perhaps accounting for a seemingly quicker overall resuscitation time by the Trauma surgeon group. Fifth, the exact experience of the trauma team leader was not measured. However, the Fellows had no or only 1 year experience as trauma surgeon before the resuscitation, while staff members included in this study had at least 5 years of experience. Finally, we calculated an R-square value to assess the goodness-of-fit; however, some articles debate whether R-squared values are appropriate. [
28,
29] Nevertheless, the trendline was intended to visualize a general pattern, rather than creating a prediction model. Thereby, the sample size and the fact that this is a single site would diminish the generability of such a prediction model.
Implications for daily practice
Some considerations for daily practice, can be made. First, hospitals should consider activating a trauma team with the addition of an experienced trauma team leader in cases where it is expected that rapid resuscitation is necessary, which is typically the resuscitation of more critically injured patients. Thereby, we prefer ‘scale-down when possible’ above ‘scale-up when necessary.’ The AMC Amsterdam, a level one trauma center in the Netherlands, developed an in-hospital triage tool to downgrade the trauma team when possible to reduce over triage. The tool reduced over triage from 70% to 27%, while no undertriage was found, [
30] while under triage, proportions of 42 percent are reported for two-tiered trauma call systems. [
31] Furthermore, we suggest that the experienced trauma surgeon should be available from the beginning of the resuscitation, as already demonstrated in an earlier study [
21]. Scaling up teams could result in undesired effects. Instead of accelerating the pace of the resuscitations as desired, the addition of a new (senior) trauma leader or other team members may interfere with the existing dynamics of the team, which could be confusing and therefore work counterproductive. Tschan et al. [
32] investigated this phenomenon among cardiopulmonary resuscitations and described that the team dynamic underwent important changes each time a new team member of higher status joined the team and did not necessarily improve the performance during resuscitation. Moreover, they found that the shared responsibility of leaders leads to confusion within the team. [
32] Translated to trauma resuscitations, this could be the case when experienced trauma team leader integrates during the resuscitation. Our second suggestion is to explore opportunities to improve team members’ experience; as is shown in this study, experience is an important factor for rapid resuscitation. Previous studies have shown that simulation training and video review education of actual resuscitations improved resuscitation quality and pace. [
33‐
35]. This may imply that experience of team members, at least partly, could be based on educational and/or simulated situations and not solely on actual resuscitation-related situations. Finally, the pace of the resuscitation might be a valuable quality indicator of trauma resuscitations. For example, resuscitations could be stratified based on severity of injury and relatively slow resuscitations may be chosen for routinely evaluation during case conferences or individual educational feedback initiatives.