Group Decision-Making during Trauma Patient Resuscitation and Anesthesia

Abstract

We examined decision-making in the real-world environment of trauma patient resuscitation and anesthesia in a Level One Trauma Center. The present paper focuses on the risk factors in the trauma treatment environment that can lead to errors or misjudgments, and strategies that may be helpful in reducing these risks. Video and audio recordings were made of a number of trauma cases involving tracheal intubation, including both emergency intubations performed during resuscitation and “elective” intubations prior to surgery. Post-treatment questionnaires completed by anesthesia personnel suggested that their perceived misjudgments were primarily procedural errors caused by lack of preparation for low probability events, inadequate monitoring of available indices, or carelessness. However, video analyses of a subset of the cases by a non-participant anesthesiologist, in conjunction with examination of patient management records, not only confirmed the occurrence of such errors but also identified instances of knowledge-based errors, which caused subsequent cascades of adverse events. Video analysis also documented the shortcuts that are characteristic of emergency intubations. The post-treatment questionnaires also suggested an association between team interactions and anesthesiologist performance. To follow up on this, we transcribed and categorized verbal communications for several minutes before, during, and after intubation in a subset of cases. This analysis indicated that during emergency intubations not only was more information communicated than during elective intubations, but that there were increases specifically in the incidence of directives, comments conveying plans or strategies, and comments both seeking and offering needed information. The discussion presents a number of strategies that emerged from the present analyses for reducing the risk factors involved in trauma treatment decision-making.

The role of non-technical skills in anaesthesia: a review of current literature

“…Data were collected using video cameras located in the admitting bays and an operating room. In the ®rst study, Mackenzie and colleagues 31 used the video data to analyse group decision-making processes. They found that, under stressful, time-pressured situations, knowledge-based errors, such as incorrect drug administration or dosage, were observed.…”

“…The authors point out that some of the problems associated with uncertainty, which was one of the stressors, could be reduced by increased monitoring and preparation. 31 One particular area of interest in relation to cognitive skills was the occurrence of ®xation errors. 5 13 Xiao and colleagues 49 observed ®xation errors arising from the anaesthetists moving too fast, such that they rushed past certain cues and used other, improper information, and from moving too slowly and failing to update old plans and courses of action when necessary.…”

The effects of stress on nuclear power plant operational decision making and training approaches to reduce stress effects

“…The Janis (1982) and Keinan (1987) studies indicate that certain task elements are processed in a shallow manner. A recent study of anesthesiologists in a trauma center setting (Mackenzie et al, 1993) suggests that some task elements may be omitted under stress. In this case, anesthesiologists performing airway management during emergency medical treatment omitted certain patient preparation and patient monitoring elements of the task.…”

Coordination patterns and clinical performance levels in the management of a simulated anesthetic crisis

“…In various complex work environments, the coordination processes high performing crews or teams have been described to exhibit different characteristics than those of low performing crews (Entin & Serfaty, 1999;Foushee & Manos, 1981;Mackenzie, Horst, Mahaffey, & LOTAS, 1993;Orasanu, 1990;Oser, Prince, Morgan, & Simpson, 1991;Serfaty, Entin, & Volpe, 1993;Xiao, Mackenzie, Patey, & LOTAS, 1998). One crucial characteristic of high performing crews is adaptive coordination, i.e.…”