Article Text

Download PDFPDF

Protocol compliance and time management in blunt trauma resuscitation
  1. W R Spanjersberg1,
  2. E A Bergs1,
  3. N Mushkudiani2,
  4. M Klimek3,
  5. I B Schipper1
  1. 1
    Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
  2. 2
    Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
  3. 3
    Department of Anaesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
  1. Dr I B Schipper, Erasmus MC, University Medical Center Rotterdam, Department of Surgery-Traumatology, PO Box 2040, 3000 CA Rotterdam, The Netherlands; i.schipper{at}


Objectives: To study advanced trauma life support (ATLS) protocol adherence prospectively in trauma resuscitation and to analyse time management of daily multidisciplinary trauma resuscitation at a level 1 trauma centre, for both moderately and severely injured patients.

Patients and methods: All victims of severe blunt trauma were consecutively included. Patients with a revised trauma score (RTS) of 12 were resuscitated by a “minor trauma” team and patients with an RTS of less than 12 were resuscitated by a “severe trauma” team. Digital video recordings were used to analyse protocol compliance and time management during initial assessment.

Results: From 1 May to 1 September 2003, 193 resuscitations were included. The “minor trauma” team assessed 119 patients, with a mean injury severity score (ISS) of 7 (range 1–45). Overall protocol compliance was 42%, ranging from 0% for thoracic percussion to 93% for thoracic auscultation. The median resuscitation time was 45.9 minutes (range 39.7–55.9). The “severe team” assessed 74 patients, with a mean ISS of 22 (range 1–59). Overall protocol compliance was 53%, ranging from 4% for thoracic percussion to 95% for thoracic auscultation. Resuscitation took 34.8 minutes median (range 21.6–44.1).

Conclusion: Results showed the current trauma resuscitation to be ATLS-like, with sometimes very low protocol compliance rates. Timing of secondary survey and radiology and thus time efficiency remains a challenge in all trauma patients. To assess the effect of trauma resuscitation protocols on outcome, protocol adherence needs to be improved.

Statistics from

Advanced trauma life support (ATLS)-based protocols provide a common language and framework for trauma resuscitation throughout the world.1 However, ATLS knowledge and skills are known to fade within months after initial training.24 Quality of care depends on teamwork, knowledge, skills and protocol compliance. Mistakes made during the initial assessment of trauma patients can cause up to 91% of all preventable trauma deaths5 and an increased intensive care unit length of stay, morbidity and mortality.6 As shown in aviation studies, deviation from protocols may lead to (fatal) errors.7

Several studies concerning protocol compliance during daily trauma care have been published.815 However, no studies in which digital recording and subsequent scoring was used have been published to date. The quality of initial assessment and thus the effects of ATLS will remain elusive until compliance to protocol is known. Although no study has shown a distinct relation between the speed of resuscitation and patient outcome,16 emphasis of quality improvement has been placed on time management as an indicator for quality of trauma care.13 15 17 18

Video analysis of resuscitation has been shown to be an effective way to observe and educate trauma teams.11 13 The purpose of this study was to analyse protocol compliance during day-to-day multidisciplinary trauma resuscitation using video observation.


Study design

A prospective observational study was initiated to examine protocol compliance and time management during multidisciplinary trauma resuscitation. Observation was performed using digital video recordings of all consecutive trauma resuscitations during the study period to obtain maximal objectivity of measurements.19

The study was conducted at the emergency department (ED) of a 1200+ bed level 1 trauma centre, serving an urban population of 2.5 million. Over 23 000 patients per year present to the ED.

In the period between 1 May and 1 September 2003, all victims requiring trauma resuscitation by a trauma team, due to significant blunt force trauma (table 1) were included. Tertiary referral patients and victims of penetrating trauma were excluded, because of differences in the resuscitation protocol used.

Table 1 Inclusion criteria for ATLS-based trauma resuscitation concerning blunt trauma patients

Methods of measurement

After approval by the institutional review board of the hospital, the main resuscitation room was equipped with a continuous recording digital video system. A camera (Ademco Video AD3VC4X, 3) was placed on the ceiling, aimed at the patient from the foot end of the bed to ensure optimal recording of professionals and their actions, while preventing the recognition of trauma patients. A second camera with a microphone (Charles Goffin AT 845-R) specifically recorded the vital parameters and sounds. Following study protocol, all personnel involved were informed about the video registration and all recordings were erased after 72 h.

Prehospital vital signs were used to calculate the initial revised trauma score (RTS).20 As the RTS was not used to make calculations concerning outcome, the unadjusted RTS was used. Following hospital protocol, patients with an RTS of 12 were primarily assessed and treated by the “minor trauma” team, consisting of a junior resident surgery, a junior resident emergency medicine, a radiology technician and two emergency nurses. The surgical resident acted as the team leader. Patients with an initial RTS of less than 12 were resuscitated by the “severe trauma” team, which consisted of the “minor trauma” team, supplemented by the senior residents surgery, anaesthesiology and neurology and radiology. The senior resident surgery acted as team leader and a trauma surgeon or an anaesthesiologist supervised the team. All physicians were ATLS certified and all nurses were trauma nursing core course trained. The “minor trauma” team could be upgraded to the “severe trauma” team at any given time, if the condition of the patient required it. Because of multidisciplinary teams, ATLS steps (ABCDE) could be performed simultaneously by different physicians.


A well-trained and ATLS certified physician (EAB) documented protocol compliance and time frames of each included trauma resuscitation from the videotapes. The first 30 resuscitations were excluded from calculations to minimise possible learning curve effects by the observer. Following the criteria of Gilbert et al21 for retrospective reviewing, these tapes were discussed in an expert panel.

Protocol compliance, the primary outcome measure, was defined as the percentage of indicated actions performed during the allocated ATLS step (ABCDE).22 Actions were only documented when performed during the matching ATLS step. For example, administering oxygen after the evaluation of a chest x ray was not considered to be according to protocol. Compliance with universal barrier precautions was considered if standard precautions were taken by all team members.8 Team present was considered when the entire team called was present at the ED before the arrival of the patient. Secondary outcome measures were overall trauma resuscitation time (TRT),18 timing of ATLS steps (ABCDE) and mortality. The TRT was defined as the time span from entering the trauma room until completion of the “primary survey” and the “secondary survey” including radiology, or by indicated early departure or death. Mortality was defined as death resulting from trauma within 30 days after admission.23


Data from both trauma teams were collected prospectively in a Microsoft Access 2000 database. Injury severity was determined using the injury severity score (ISS).24 All analyses were performed using the statistical package for social sciences, version 10.1. Parameters measured to determine time management were non-parametric, therefore these data are presented as median and quartiles. Age and ISS data had a normal distribution.

The probability of survival was calculated for all individual trauma patients using trauma score and injury severity score (TRISS) methodology.25 26 By accounting for the ISS,24 age and RTS,20 the chance of survival for individual trauma patients could be calculated. This expected mortality was compared with the actual mortality in the population studied.


During the 4-month study period, 205 patients were included. After data of 12 resuscitations were lost for evaluation as a result of video-related technical difficulties, data of the remaining 193 patients were analysed. The overall group characteristics showed a gender distribution of 73% men and a mean age of 33 years (SD 19).

The “minor trauma” team resuscitated 119 patients with a mean ISS of 7 (range 1–45). Table 2 provides a detailed overview of the protocol compliance during the assessment of trauma victims.

Table 2 Protocol compliance during trauma resuscitation

Despite a prehospital warning, the complete team was present in only 28% of resuscitations before the patient presented to the ED. Universal barrier precautions were met in the complete team in no resuscitations for the use of visors, in 23% for the advised x ray protection and in 31% for the use of gloves. The airway was checked in 77% of patients. When assessing “breathing”, auscultation of the thorax was performed in 93%. Patient temperature was checked in 3%. In addition, ultrasounds were performed in 84% of “minor trauma team” resuscitations. In the 119 patients, the minor team performed 1425 of the 3433 steps (42%) as dictated by the resuscitation protocol.

The “severe trauma” team resuscitated 74 patients with a mean ISS of 22 (range 1–59). The entire team was present before patient presentation in 41% of resuscitations. Universal barrier precautions were met in no resuscitations for the use of visors, in 27% of resuscitations for x ray protection and in 40% of resuscitations for the use of gloves. Auscultation of the thorax was performed in 95% of cases; saturation measurement was done at the appropriate time in 55% of the resuscitations. Pupils were checked in 64% of “disability” assessments. In addition, ultrasounds were performed in 87% of all severe trauma resuscitations.

The severe trauma team executed 1057 actions. For the 74 patients resuscitated, 1998 actions were dictated. This represents a protocol compliance of 53%.

The time management of resuscitations is shown in table 3 and fig 1.

Figure 1 Graphical depiction of timing of resuscitation steps during advanced trauma life support-based trauma resuscitation. A, airway; B, breathing; C, circulation; D, disability; E, environment.
Table 3 Time management during ATLS-based trauma resuscitation

The median TRT of the “minor trauma” team was 45.9 minutes, the primary survey was performed in 6.6 minutes and radiological assessment took 26.1 minutes. The median duration of the ATLS steps ranged from 0.2 minutes for the assessment of “airway” to 3.1 minutes for the total care for “exposure and environment”. The secondary survey took a median of 34.3 minutes.

The median TRT for the “severe trauma team” was 34.8 minutes, the primary survey was performed in 10.0 minutes median and the secondary survey took 15.6 minutes. The duration of the ATLS steps ranged between 0.3 minutes for “airway” assessment, to 5.2 minutes for the total care for “exposure and environment”. The median time to obtain a definitive airway (on indication) was 4.6 minutes and individual chest tubes were placed in approximately 8 minutes.

In the total population of 205 “minor” and “severe trauma” team patient resuscitations, 16 patients died. Using TRISS methodology25 26 expected mortality, accounting for ISS, age and RTS, was calculated for all individual patients. This resulted in an expected mortality in the current population of 18 patients.


It has been suggested that over half of the deaths in American ED malpractice cases could have been avoided by better teamwork27 and up to 91% of avoidable deaths occur during the primary survey of trauma resuscitation.5 Aviation studies also show the importance of protocol compliance to avert errors.7 28 In the current study, protocol compliance and time management in daily trauma resuscitation were analysed prospectively. The results clearly show significant deviation from the ATLS-based protocol in daily trauma care. Overall protocol compliance was 42% for the “minor trauma” team and 53% for the “severe trauma” team. Some vital actions such as thorax auscultation (93%) show good compliance. The administration of oxygen, airway assessment, pelvic rock and neurological assessment are omitted in too many resuscitations. However, mortality was not higher compared with the expected number of deaths as calculated with TRISS methodology, suggesting that suboptimal protocol adherence does not result in higher mortality in the current study. However, mortality in the current study was not higher compared with the expected number of deaths as calculated with TRISS methodology. Although it is tempting to speculate that this implies that suboptimal protocol adherence has not resulted in higher mortality in the current study, as described before,15 the power is lacking to make such a statement.15 The effect on morbidity was not studied. Although such an effect is very plausible, this parameter is very difficult to investigate properly.

Overall protocol compliance seemed better in the “severe trauma” team. Whether this is because of increased awareness when professionals are dealing with more severely injured patients remains unclear. Differences in results can also be caused by dissimilarities in the patient population, structure of resuscitation, team composition and the presence of supervision.29 Therefore, (statistical) comparison of both teams is not relevant. However, the presence of experienced supervisors in “severe trauma” team resuscitations did not, during this study, automatically result in very high protocol compliance. The studied resuscitation protocol included a surgeon as team leader and no real emergency medicine residency training programme existed at the time of the study, which might limit the applicability of results to other trauma systems.30 Whether or not loss of skills may account, at least partly, for the suboptimal compliance is unclear. Ali et al2 and Blumenfeld et al4 found significant deterioration of ATLS knowledge and skills within a few months after ATLS training, so this may be an explanation. The observed lacking compliance with hazard precautions is striking and worrisome, but is in concordance with Brooks et al,8 who found 48% compliance with protective garment standards before their safety conference.

Whether all ATLS steps should be weighed equally in calculating protocol compliance can be discussed. One could also question the medical relevance of the elaborate ATLS protocol in victims of significant force with an RTS of 12. However, patients with an RTS of less than 12 should evidently receive complete assessment according to ATLS guidelines to ensure a structured resuscitation. Furthermore, because these resuscitations are valuable possibilities to tune “trauma team” skills, the joint “training” of resuscitation contributes to improve the team for the future. It is therefore essential that protocol compliance is maintained during all resuscitations, both severe and minor.

Time management

Although treating more severely injured patients, the TRT was shorter in the “severe trauma” team resuscitations (34.8 versus 45.9 minutes). When professionals assume that a patient announced as having sustained only minor trauma is in fact not critically ill or injured, elaborate radiology and the secondary survey can take up a disproportionate amount of time. The median TRT of 34.8 minutes in the “severe trauma” team compares favourably with the literature, as do primary survey times of 10.0 and 6.6 minutes.13 1719 31 It should be noted, however, that shorter resuscitation times do not necessarily mean improved resuscitations, because cutting corners and skipping steps also saves time. Using video-assisted measurements, Hoyt et al13 found TRT ranging from 54 to 81 minutes. Santora et al14 found the primary survey to be performed within 10 minutes in 68% of trauma resuscitations. Other authors found TRT ranging from 76 to 104 minutes.32

Actual trauma resuscitation differs from training programmes such as the ATLS. In contrast to the training programmes, the clinical approach is a multidisciplinary one. This enables team members to assess and execute different steps simultaneously (horizontal approach).12 The graphic depiction of time management in fig 1 shows a “horizontal”-like distribution of the ABCDE steps. Because of the horizontal approach that was used for resuscitations in the current setting, time management in the primary survey was generally good. However, management of the secondary survey, radiology and thus departure from the ER can be improved. Professionals and institutions, including ATLS training, should not solely concentrate on the optimisation of resuscitation skills, but also on the optimisation of complete trauma team management, especially after primary assessment. A study is currently being conducted to assess the effect of video feedback on team performance, protocol compliance and time management.


Results show that current trauma resuscitation is ATLS-like. It also shows several important issues that need to be improved, such as barrier precautions. “Severe trauma” team resuscitations had higher protocol compliance and had better time management. Time management of secondary survey and radiology remains a challenge in both moderately and severely injured trauma patients. Optimal protocol compliance does not arise spontaneously. Trauma care should be further improved by optimising protocol compliance and time management, using, for example, video-assisted quality improvement programmes.



  • Competing interests: None.

  • Ethics approval: Ethics approval was obtained.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles

  • Primary survey
    Darren Walter