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Barriers to implementing the World Health Organization’s Trauma Care Checklist: A Canadian single-center experience

Nolan, Brodie MD; Zakirova, Rimma MD, PhD; Bridge, Jennifer MPA, MHSc; Nathens, Avery B. MD, PhD, MPH

Journal of Trauma and Acute Care Surgery: November 2014 - Volume 77 - Issue 5 - p 679–683
doi: 10.1097/TA.0000000000000454
TAC 2014 Plenary Paper

BACKGROUND Management of trauma patients is difficult because of their complexity and acuity. In an effort to improve patient care and reduce morbidity and mortality, the World Health Organization developed a trauma care checklist. Local stakeholder input led to a modified 16-item version that was subsequently piloted. Our study highlights the barriers and challenges associated with implementing this checklist at our hospital.

METHODS The checklist was piloted over a 6-month period at St. Michael’s Hospital, a Level 1 trauma center in Toronto, Canada. At the end of the pilot phase, individual, semistructured interviews were held with trauma team leaders and nursing staff regarding their experiences with the checklist. Axial coding was used to create a typology of attitudes and barriers toward the checklist, and then, vertical coding was used to further explore each identified barrier. Checklist compliance was assessed for the first 7 months.

RESULTS Checklist compliance throughout the pilot phase was 78%. Eight key barriers to implementing the checklist were identified as follows: perceived lack of time for the use of the checklist in critically ill patients, unclear roles, no memory trigger, no one to enforce completion, not understanding its importance or purpose, difficulty finding physicians at the end of resuscitation, staff/trainee changes, and professional hierarchy.

CONCLUSION The World Health Organization Trauma Care Checklist was a well-received tool; however, consideration of barriers to the implementation and staff adoption must be done for successful integration, with special attention to its use in critically ill patients.

LEVEL OF EVIDENCE Therapeutic/care management, level V.

From the Departments of Medicine (B.N.), General Surgery Research (R.Z.), and Surgery (J.B., A.B.N.), University of Toronto; and Division of General Surgery (J.B., A.B.N.), Sunnybrook Health Science Center, Toronto, Ontario, Canada.

Submitted: June 25, 2014, Revised: August 2, 2014, Accepted: August 4, 2014.

This study was presented at the The Trauma Association of Canada Annual Scientific Meeting, April 10–11, 2014, in Montreal, Quebec, Canada.

Address for reprints: Brodie Nolan, MD, 1 Market St, Unit 2004, Toronto, Ontario, Canada M5E 0A2; email:

© 2014 Lippincott Williams & Wilkins, Inc.