• Ken Catchpole, Eric Ley, Doug Wiegmann, Jennifer Blaha, Daniel Shouhed, Alexandra Gangi, Renaldo Blocker, Richard Karl, Cathy Karl, Bill Taggart, Benjamin Starnes, and Bruce Gewertz.
• JAMA Surg. 2014 Sep 1; 149 (9): 962-8.

ImportanceA physician-centered approach to systems design is fundamental to ameliorating the causes of many errors, inefficiencies, and reliability problems.ObjectiveTo use human factors engineering to redesign the trauma process based on previously identified impediments to care related to coordination problems, communication failures, and equipment issues.Design, Setting, And ParticipantsThis study used an interrupted time series design to collect historically controlled data via prospective direct observation by trained observers. We studied patients from a level I trauma center from August 1 through October 31, 2011, and August 1 through October 31, 2012.InterventionsA range of potential solutions based on previous observations, trauma team engagement, and iterative cycles identified the most promising subsystem interventions (headsets, equipment storage, medication packs, whiteboard, prebriefing, and teamwork training). Five of the 6 subsystem interventions were successfully deployed. Communication headsets were found to be unsuitable in simulation.Main Outcomes And MeasuresThe primary outcome measure was flow disruptions, with treatment time and length of stay as secondary outcome measures.ResultsA total of 86 patients were observed before the intervention and 120 after the intervention. Flow disruptions increased if the patient had undergone computed tomography (CT) (F1200 = 20.0, P < .001) and had been to the operating room (F1200 = 63.1, P < .001), with an interaction among the intervention, trauma level, and CT (F1200 = 6.50, P = .01). For total treatment time, there was an effect of the intervention (F1200 = 21.7, P < .001), whether the patient had undergone CT (F1200 = 43.0, P < .001), and whether the patient had been to the operating room (F1200 = 85.8, P < .001), with an interaction among the intervention, trauma level, and CT (F1200 = 15.1, P < .001), reflecting a 20- to 30-minute reduction in time in the emergency department. Length of stay was reduced significantly for patients with major mortality risk (P = .01) from a median of 8 to 5 days.Conclusions And RelevanceDeployment of complex subsystem interventions based on detailed human factors engineering and a systems analysis of the provision of trauma care resulted in reduced flow disruptions, treatment time, and length of stay.

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