The outcome for a patient with life-threatening injuries is determined not only by the severity of the primary accident but also by secondary injuries associated with treatment. The quality of diagnostic and therapeutic procedures used during the initial resuscitation of trauma patients has a significant effect on patient outcome [1,2]. Under the conditions of emergency resuscitation, patient management can be extremely complex  with team performance playing a pivotal role in the efficiency of care during the initial period of multiple-trauma treatment . Recent investigations on the influence of human factors during stressful emergency situations demonstrate the important influence of organizational climate and team performance on results [5,6]. This is especially true for complex medical situations, for example, in the operating room (OR) or the emergency room (ER) where interactions between the different diagnostic and therapeutic specialities are the key factors influencing success [3,7,8]. Since interdisciplinary activity is vital, organization is based on discipline and understanding . Videotaped trauma event evaluations demonstrate that critical reflections on one's own performance allows for recognition of errors as well as reinforcement of acceptable behaviour . In this context, the satisfaction of involved health professionals is of major importance and may therefore be used as an additional indicator in multiple-trauma quality management .
In spite of the well-accepted importance of staff attitude in emergency situations, no study exists, to our knowledge, on how personnel, who are themselves involved in multiple-trauma management, assess these variables. The goal of the present study was to determine how interdisciplinary emergency hospital staff experience their daily work with multiply-injured patients. We used a newly developed questionnaire to both assess such experiences and to determine the satisfaction of the involved personnel.
Materials and methods
We evaluated the attitudes of hospital emergency teams working in multiple-trauma situations. For this investigation, we developed the ‘Multiple-Trauma Management Attitudes’ (MTMA) questionnaire. Following former investigations on personal attitude, organizational climate and team performance [11,12], we modified a previous questionnaire that assessed attitudes and judgments in resuscitation procedures (Emergency Room Management Attitudes Questionnaire) . That questionnaire was based on results from the first published surveys on OR organization, the ‘Operating Room Management Attitude Questionnaire’, which was adapted from an earlier field-tested questionnaire on cockpit management attitudes [13-15].
The MTMA questionnaire used in the present study consisted of 53 items (Table 1; translated from the original version in German). It combined the experiences of the above-mentioned studies with the results of an internal workshop, which was conducted and evaluated by one of the authors (F.A.), who is an independent psychologist. During this workshop, representatives of all involved specialities (experienced nurses and medical doctors from the Departments of Anaesthesiology, Emergency, Radiology, Surgery and the OR) considered important aspects of in-hospital emergency multiple-trauma management. The results were integrated into a questionnaire, which was sent for validation to experienced personnel from all involved professions. The final questionnaire was then distributed by internal mail to all potentially involved hospital staff members, who were asked to respond if they had participated in the multiple-trauma management services of our hospital within the last year. The confidentiality of the respondents was maintained, and questions were answered using the five-point Likert scale with choices from 1 (complete disagreement) to 5 (complete agreement).
Original data were analysed for all professional specialities. For statistical reasons, further analysis concentrated only on the main professional groups involved in the emergency period of multiple-trauma management.
In addition to the descriptive analysis of single items (e.g. professional speciality, function), item reduction was performed. Using factorial analysis, which was followed by scaling, 8 important dimensions were identified out of the 53 questions:
D1: work sequences between specialities;
D2: communication between specialities;
D3: satisfaction and identification;
D4: work sequences and communication within one's own speciality;
D5: quality of treatment;
D7: material and personnel;
D8: education and training.
The eight dimensions were created by using all items with a power >0.3 for the calculation of a score corresponding to the mean of an item; 43 of the 53 items fulfilled this condition. A new factorial analysis was performed on these 43 items to identify factorial power. The Cronbach Alpha test was used to determine the internal consistency of the scale (Table 1).
We performed multi-factorial analysis of variance (ANOVA) for repeated measures to compare the dimensions, to determine the influence of single dimensions or specialities and their interaction on the rating of team members. One-factorial ANOVA with post hoc testing was done to investigate the influence of:
- the five main speciality groups (surgeons, consultants, anaesthetists, radiologists and ER/OR nurses);
- professional function (nurse or technician vs. physician);
- hierarchy (leading position as nurse, technician or physician);
- completed Advanced Trauma Life Support (ATLS®) course and
- number of experienced multiple-trauma cases within the last year, on these new scales.
Two-factorial ANOVA was used to determine the influence and interaction of ATLS® courses and professional groups on the answers. Data analyses were performed with the Statistical Package for the Social Science (SPSS) for Windows software (Release 11.5). For discrimination of differences, the level of significance was considered to be P < 0.05.
For data analyses, results of single items were also evaluated, but are not shown. Data were collected from 128 respondents, all of who were regularly involved in the emergency period of multiple-trauma procedures. The median experience of respondents was 10 multiple-trauma situations within the last year. The experience was lowest in consulting specialists (median = 4) and highest in emergency care nurses (median = 20) (Table 2).
Comparison of single dimensions
The comparison of single dimensions revealed that team members rated the quality of work sequence and communication within one's own speciality (D4) highest, with a mean of 4.0 (out of 5) points. Whereas, individuals showed most dissatisfaction with education and training (D8) and work sequence between specialities (D1), the only dimensions that, with an average of 2.8 points, were rated worse than neutral (=3 points). All other dimensions were rated in between, with a majority of the respondents being just about satisfied with the performance (Fig. 1). The differences in rating between single dimensions were significant (ANOVA, F = 8.5; P < 0.001). Despite some significant differences in assessment based on professional speciality (see below), there was an overall accordance within the interdisciplinary team concerning the relative quality of single dimensions.
Effect of professional speciality and other covariates on single dimensions and on total rating of multiple-trauma treatment
Professional speciality showed a significant influence on the rating of work sequence between specialities (D1: F = 2.7; P < 0.05) and satisfaction, and identification (D3: F = 3.0; P < 0.05) (Figs 2 and 3). These differences in the assessment of the multiple-trauma management were most prominent between members of the Departments of Surgery and Anaesthesiology (work sequence between specialities (D1: 3.1 vs. 2.6 points, P = 0.004); satisfaction and identification (D3: 3.8 vs. 2.3 points, P = 0.005). Similar differences between surgeons and anaesthetists were found for the dimensions responsibility (D6: 3.7 vs. 3.0 points, P = 0.013) and material and personnel (D7: 3.8 vs. 3.2 points; P = 0.023), as well as for the entire rating of multiple-trauma treatments (3.5 vs. 3.2 points; P = 0.016).
For the dimensions satisfaction and identification (D3), responsibility (D6), and communication between specialities (D2), surgeons' ratings were significantly higher in comparison with ER nurses. The only dimension surgeons did not rate better than other specialities was ‘education and training’ (D8), which members of the Department of Radiology assessed highest (P < 0.05). All other analysed covariates (gender, hierarchy, professional function and multiple-trauma case experience) did not influence the observed single dimensions.
Effect of ATLS® course on ratings of surgeons and anaesthetists
With few exceptions, only surgeons and anaesthesiologist had passed an ATLS® course. Approximately 50% of surgeons (13/25) and anaesthetists (11/20) had completed an ATLS® course at the time of the survey. In those two groups, a significant interaction between professional speciality and a successfully completed ATLS® course on total rating of multiple-trauma treatment could be detected (Fig. 4). The ATLS® course revealed an opposite effect on surgeons in comparison with anaesthetists: Surgeons who had completed an ATLS® course assessed the quality of multiple-trauma management lower than did their surgical colleagues who had not taken ATLS® courses. In contrast, anaesthetists who had ATLS® training judged multiple-trauma performance higher than anaesthetists who had not taken an ATLS® course. However, after passing an ATLS® course, surgeons and anaesthetists assessed the quality of multiple-trauma management similarly. There were also significant interactions for satisfaction and identification (D3), material and personnel (D7) and education and training (D8) (data not shown).
This investigation has three main findings.
First, independent of speciality, hierarchy, professional function, multiple-trauma case experience or gender, team members rated the observed dimensions of multiple-trauma management in an identical order from best to worst. At the same time there were significant differences between professional groups concerning the detailed aspects of multiple-trauma management.
Second, passing the ATLS® training proved to significantly overcome the different attitudes that exist between surgeons and anaesthetists in the total rating of multiple-trauma treatments.
Third, from a methodological approach, the MTMA questionnaire that was developed for this investigation proved to have sufficient sensitivity to detect differences between various dimensions of multiple-trauma management as well as differences between professional specialities in the multiple-trauma setting.
Depending on the complexity of the injury and the condition of a multiply-traumatized patient, up to 20 people from different specialities are involved in ER management required to stabilize a trauma victim. This team has to function in the framework of a broader support system of other hospital departments (e.g. laboratories, ORs and radiology) . Clinical outcome parameters and scoring systems only provide an approximate characterization of the complexity of this teamwork . The ability to assess quality is generally difficult and examination of the process may be more sensitive than present outcome parameters reveal [16,17]. This is especially true for the complex multiple-trauma situation where each method used to evaluate quality control has its own limitation, and only relying on clinical or technical parameters may not be sufficient to judge quality . In order to evaluate the quality of medical care, it is necessary to distinguish between values, elements of structure, process or outcome . Organizational research in other fields has demonstrated the value of assessing quality of service on the basis of the perceptions of team members . Professionals in general are aware of their deficiencies. Assessing the satisfaction of staff members who interact to treat a seriously injured patient appears to be especially important in complex scenarios where the evaluation of patient satisfaction is not possible. Survey data and observations of factors influencing team performance in emergency situations support the hypothesis that interpersonal relationships and communication issues are responsible for many inefficiencies, errors and frustrations in this psychologically and organizationally complex environment [7,20]. Our aim was to disclose strength and weakness of the multiple-trauma management in our hospital from the involved personal staff's perspective, with the caveat that the subjectivity of such an approach remains a concern .
We found that team members assessed the overall quality of multiple-trauma management in a comparable order. Independent of their speciality, care providers rated the identical dimensions as either the lowest or the highest. This was especially seen for the negative criticisms of the quality of the two dimensions work sequences between specialities (D1) and education and training (D8). This finding of a major deficit in interdisciplinary relationships and specific emergency treatment training is in accordance with previous reports [20,21]. Consequently, these areas should be the major focus of future quality improvement projects in our hospital.
In addition, a significant influence of professional speciality on single dimensions and on the satisfaction of team members with emergency multiple-trauma treatment could be demonstrated. For example, surgeons perceived the quality of management handling and communication within the emergency-trauma team to be higher than other specialities, especially compared with anaesthetists. This finding corresponds with previous results on team performance in other clinical scenarios [6-8]. Finding an important difference in the assessment of multiple-trauma management between the members of the various involved disciplines can be viewed in two main contexts:
- All specialities must be integrated in the design and the practice of any hospital multiple-trauma quality assurance programme to assure the adequate consideration of detailed professional specific know-how.
- Ergonomic analysis of industry and clinical critical incidence reports demonstrated that different expectations between members of the working group lead to a higher rate of misunderstanding and result in more errors. This is even more valid for stressful emergency situations.
In this sense the differing view concerning detailed aspects of multiple-trauma management between single professional groups might be potentially dangerous for the patient under treatment [22,23]. By incorporating human factors engineering principles into team behaviour and multiple-trauma education patient safety as well as system efficiency might be substantially improved .
Our data has indicated the positive effect of a standardized training (ATLS®) on the quality assessment of multiple-trauma management within the specialities. The evidence that ATLS® courses have resulted in improved patient outcome is still debated [1,4,24]. Although our results support instituting a standardized high-quality training programme  they are based on only 45 anaesthetists and surgeons in one hospital. In addition, we cannot exclude the possible bias that individuals who decide to take an ATLS® course per se might have a different attitude towards multiple-trauma management compared to those who decided not to participate in such a course. Hospital staff who are motivated to work in trauma care might participate more often in ATLS® courses than others who are not as interested in the management of multiply-injured patients. Nevertheless, our findings suggest that joint training of individuals from all involved specialities would help participants to feel that their contribution to the team effort has an equally important value. If such a programme were obligatory for all staff members in multiple-trauma management, it could potentially minimize the initial differing expectations that result from discrepant speciality profiles that are, per se, an important cause for team conflict and errors in patient treatment [5,22]. A future evaluation of personnel obliged to participate in such courses should resolve this point.
Since no suitable research instrument for a multiple-trauma emergency scenario was available, we developed a new instrument for this study: the ‘MTMA’ questionnaire. This questionnaire was based on existing instruments from examinations in the field of aviation and ER analysis, and followed face validity control by the involved personnel. Therefore, our study used the same data to evaluate the instrument and to interpret the results. From a methodological point of view the discrimination of the within-team consistency and between-team differences, as described above, provided strong support for the accuracy and validity of our instrument. The significantly stronger statistical weight of the effect of dimensions compared with that of the professional specialities for the assessment of team performance showed that our approach, to create single dimensions by factorial analysis, was valid. The observed differences indicated different attitudes of team members, a finding that was relevant for the clinical setting of multiple-trauma management.
There are limitations to our study. The questionnaire has not yet been subjected to formal reliability and validity testing and the results therefore should be viewed with some degree of caution. The anonymous procedure gave all team members the opportunity to express their own point of view in an open and honest way. The low-average multiple-trauma experiences per year of involved personnel is typical for the case load and interdisciplinary approach, even for that of specialized trauma centres in Europe . The findings of this study are limited to the respondents and the multiple-trauma management team of our hospital at the time of the investigation and should not be generalized without further confirmation in other hospitals. Since this study did not deal with individual multiple-trauma situations, but rather investigated the assessment of multiple-trauma team performance over a year period, no conclusion can be drawn for the clinical outcome of individual patients. Further studies will be needed to explore the possible correlation between different ways of assessing multiple-trauma team performance and clinical outcome in real everyday situations.
Using the MTMA questionnaire, we found that multiple-trauma team members, regardless of their professional speciality, rated the overall quality of emergency treatment in a comparable way. However, despite this general agreement, members of the various specialities had significantly different opinions regarding some detailed aspects of multiple-trauma management. Based on our finding that passing an ATLS® training significantly changed the differing attitudes that exist between surgeons and anaesthetists regarding multiple-trauma procedures, the differences in multiple-trauma assessment between specialities and their potentially negative impact on team performance and patient outcome could possibly be overcome by the participation of all team members in a standardized training. Substantiation of our results by other trauma centres, would constitute a strong argument for testing an obligatory training programme that focuses on an interdisciplinary approach to emergency training and communication for the treatment of multiply-injured patients.
Special thanks are due to all team members of the University Hospital Basel who actively supported the multiple-trauma management programme and participated in the study. We are grateful for the editorial help of J. Etlinger. This study was financially supported by the Swiss National Fond (NCCR, CO-ME) and the ‘Voluntary Academic Society’ (FAG) Basel. There are no conflicts of interest of the authors.
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