Clinician’s capsule

What is known about the topic?

Trauma video review is an increasingly utilized method to observe and review trauma resuscitations for quality improvement.

What did this study ask?

How is trauma video review currently being used and what are the focuses and outcomes of review in the literature?

What did this study find?

Trauma video review uses included evaluating procedural performance, measuring protocol compliance, analyzing adverse events, and assessing team dynamics and communication.

Why does this study matter to clinicians?

Clinicians should consider adoption of a trauma video review program for purposes of quality improvement, patient safety and continuing education.

Background

Severely injured patients require rapid, coordinated assessments while simultaneously being resuscitated [1,2,3,4]. Trauma care is often provided by an ad hoc team of physicians and allied health providers working together to care for sick patients [5]. There are inherent challenges in assessing team performance, detection of adverse events or measuring quality improvement (QI) initiatives in such a dynamic environment.

Video review has been used in various healthcare settings, such as the operating room and emergency departments for education and QI purposes [6, 7]. It has been used to evaluate both technical skills, such as adherence to procedural steps, and non-technical skills like communication and team function [7, 8]. Trauma video review offers advantages over traditional after-event analysis (such as morbidity and mortality rounds), which are fraught with error from recall bias and often missing important information such as the timeline, incidence and nature of adverse events. Trauma video review has been utilized since the 1980s, however, given advances in technology and increased scrutiny of health privacy laws, it is unclear if this use has changed [5, 9, 10].

The objective of this scoping review was to provide an overview of the uses and applications of trauma video review. The following question was formulated; “What is known from the literature about the uses of video observation during trauma resuscitations at trauma centres?”

Methods

This review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-SCr) (Supplemental Appendix A), and has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020148058). The scoping review was conducted and reported according to PRISMA-SCr guidelines [11, 12]. There were no previous systematic or scoping reviews identified on this topic.

Technical descriptions of the study methods are presented Supplemental Appendix B.

Synthesis of results

For each article included we summarized the year, country, study design, number of enrolled patients, study population, study intervention/exposure, study control, and study outcomes. Additionally, the primary use of trauma video review and any measured outcomes were explored.

Results

Study selection

The literature search identified 463 publications for the screening process. Following screening for both title and abstract, 435 articles were excluded. Full text reviews of 28 studies were performed with 9 studies meeting the inclusion criteria. An additional 12 studies were identified from the references of included studies, resulting in a total of 21 studies included (Fig. 1).

Fig. 1
figure 1

PRISMA-ScR flow diagram. PRISMA-ScR preferred reporting items for systematic review and meta-analysis extension for scoping reviews

Full size image

Study characteristics

Table 1 summarizes the study demographics. Eleven studies examined technical skills, four studies examined non-technical skills, three studies examined both and the remaining three studies were surveys of trauma video review. The primary uses and measured outcomes are reported in Table 2.

Table 1 Studies characteristics: direct observations of trauma resuscitation (n = 21)
Full size table
Table 2 Reported outcomes and uses of direct observation of trauma resuscitations (n = 21)
Full size table

Synthesis of results

Trauma video review operational findings

Ten studies utilized continuous video recording of the resuscitation bays. Six studies required activation of a recording system prior to the resuscitation, with one converting to continuous recording during the study. Thirteen studies had ceiling mounted cameras and three studies utilized a camera from the foot of the bed. The majority of studies used a single camera (n = 8), while other studies used 2 (n = 3) and 3 (n = 5).

Assessment of technical skills

Four studies explored outcomes of critical procedures including thoracotomy, cardiopulmonary resuscitation and intubation [13,14,15,16]. Four studies analysed compliance with protocols such as advanced trauma life support (ATLS), and full personal protective equipment (PPE) usage [10, 17,18,19]. The remaining five studies analysed overall trauma resuscitation performance to identify errors and assess team performance [5, 9, 20,21,22,23].

Assessment of non-technical skills

Two studies focussed on communication through validation of communication assessment tools and identifying features of successful communication [8, 24]. The remaining two studies examined most common leadership strategies and the effect of team size and environment on the completion of ATLS components [25, 26].

Discussion

Assessment of technical skills using trauma video review

Our study demonstrates a number of examples of trauma video review in technical skills assessment and improved overall patient care. Trauma video review was used to analyse performance and benchmark timelines for time-sensitive procedures such as thoracotomy and intubation [13, 14]. Ensuring adequate adherence to protocols by trauma video review helped safeguard against errors in low volume centres and with inexperienced physician trainees. In both cases performance was tracked over time and improved in all studies when trauma video review was used as an educational tool [10, 18, 23]. Additionally, two studies demonstrated that residents who underwent trauma video review education outperformed their counterparts over time based on trauma performance [5, 8]. Trauma video review has shown to be more effective than chart review at detecting management errors [14, 19]. Trauma video review has improved morbidity and mortality rounds as it captures the environment and team dynamics to provide a superior learning experience [14, 19, 27, 28]. Compliance with PPE was shown to be improved with video review implementation and this is likely to be a prominent feature in trauma and emergency care moving forward in the COVID era and beyond [17].

Assessment of non-technical skills

Six studies examined non-technical skills in trauma resuscitation and primarily focussed on communication, team dynamics and leadership qualities. These studies focussed on optimal team size for trauma resuscitation and found that closed-loop communication was the only factor which led to orders being completed more rapidly [8, 25]. Trauma video review allowed for multiple aspects of communication and team dynamics to be assessed, which can be difficult in real time [21, 26]. Santora et al. [10], showed that resident leadership qualities including pre-briefing, clear and direct orders, and control of resuscitation were significantly improved over their study period with trauma video review. With the increasing need for effective medical education this may be a powerful tool to acquire expertise in resuscitation and team management that may be applicable to other emergency resuscitations [29].

Trauma video review and quality improvement

A trauma video review program can overcome the limitations of after-action reviews and provide reliable video data to better understand latent safety threats and adverse events. For example, in the case of delay to blood product administration, trauma video review can provide an accurate record of times compared to the current standard of nursing documentation. It can also provide specific causes such as the request for blood not being heard, a lack of staff available or blood products arriving unannounced. A more thorough understanding with video review can provide actionable information. Trauma video review can also provide a reliable method to track specific quality metrics, such as whether the trauma team was assembled prior to patient arrival or time to blood product administration. Some trauma video review programs also allow any team member to flag a resuscitation for review anonymously, allowing all team members to have a voice and promoting a culture of safety in trauma [30].

Limitations to trauma video review

Although trauma video review is a useful tool and positively perceived by centres using it, it is not without limitations and is not yet widely used in trauma care [31,32,33]. Medicolegal concerns are often cited as a barrier to implementation of a trauma video review program; however amongst centres using it there were very low rates of actual medicolegal issues [31, 34,35,36,37]. Implementation of trauma video review programs must be done in coordination with hospital legal and privacy departments to ensure compliance with local privacy regulations. Adequate staffing, processes and time required to acquire, record and review documented resuscitations are also cited as challenges [31,32,33]. Additionally, the cost of installation of cameras and audio recording devices, downtime required to install this equipment, logistical issues surrounding storage of data and ongoing resources required for review and analysis may be prohibitive to some hospitals in the implementation of a video review system [15, 32].

Study limitations

The heterogeneity of included studies limits the discussion to a broader summary and prevents focal conclusions from being synthesized. In addition, the abundance of studies observing technical skills may create significant bias versus studies that looked at non-technical skills wherein the latter may produce fewer positive results thus receiving fewer publications [38].

Conclusion

This scoping review demonstrated that trauma video review can be a useful tool in assessing technical and non-technical skills that are otherwise difficult to measure using traditional observational data. Current uses of trauma video review include improving clinical skills, developing protocols/checklists, provider education and improving team dynamics. Trauma video review has demonstrated its greatest benefit within the realms of medical education and quality improvement, and should be considered for implementation in Canadian trauma programs as well as general emergency departments.