El-Sherif, Nibras

AbstractBackgroundCurrent military recommendations include the use of tourniquets (TQ) in appropriate pediatric trauma patients. Although the utility of TQs has been well documented in adult patients, the efficacy of TQ application in pediatric patients is less clear. The current study attempted to identify physical constraints for TQ use in two simulated pediatric limb models.MethodsFive different TQ (Combat Application Tourniquet (CAT) Generation 6 and Generation 7, SOFTT (SOF Tactical Tourniquet), SOFTT-W (SOF Tactical Tourniquet – Wide), SWAT-T (Stretch Wrap and Tuck – Tourniquet) and a trauma dressing were evaluated in two simulated pediatric limb models. Model one employed four cardiopulmonary resuscitation (CPR) manikins simulating infant (Simulaids SaniBaby), 1 year (Gaumard HAL S3004), and 5 years (Laerdal Resusci Junior, Gaumard HAL S3005). Model two utilized polyvinyl chloride (PVC) piping with circumferences ranging from 4.25” to 16.5”. Specific end-points included tightness of the TQ and ability to secure the windlass (where applicable).ResultsIn both models, the ability to successfully apply and secure the TQ depended upon the simulated limb circumference. In the 1-year-old CPR manikin, all windlass TQs failed to tighten on the upper extremity, while all TQs successfully tightened at the high leg and mid-thigh. With the exception of the CAT7 and the SOFTT-W at the mid-thigh, no windlass TQ was successfully tightened at any extremity location on the infant. The SWAT-T was successfully tightened over all sites of all CPR manikins except the infant. No windlass TQ was able to tighten on PVC pipe 5.75” circumference or smaller (age < 24 months upper extremity). All windlass TQs were tightened and secured on the 13.25” and 15.5” circumference PVC pipes (age 7–12 years lower extremity, age >13 years upper extremity). The SWAT-T was tightened on all PVC pipes.DiscussionThe current study suggests that commercial windlass TQs can be applied to upper and lower extremities of children aged 5 years and older at the 50%th percentile for limb circumference. In younger children, windlass TQ efficacy is variable. Further study is required to better understand the limitations of TQs in the youngest children, and to determine actual hemorrhage control efficacy.

Interruptions in the emergency department (ED) have been studied across multiple clinical roles, with little investigation into how residents experience interruptions. Therefore this pilot study aimed to characterize interruptions experienced by emergency medicine (EM) residents at various post-graduate year (PGY) levels. Observers shadowed ED residents across entire shifts and logged interruptions that affected clinicians into the Workflow Interruption Tool (WIT). Interruption characteristics captured included duration, nature, location, and task priority. Chi-square analysis identified a significant association between interruption type and the interruption priority, p < 0.001. Residents at varying PGY-levels experienced significantly different amounts of interruptions, p=0.013. Observing resident interruptions across the entirety of their shifts identified that as EM residents gain more experience, they are interrupted more often while working in the ED.

Interruptions in the Emergency Department (ED) are moderately studied in regard to their impact on physicians’ workload. This study captured interruptions characteristics and measures of workload. Twenty-eight ED physicians were followed during their shifts; interruptions they faced were captured using a validated tablet PC-based tool. At the mid and end of their shift, providers completed a NASA-Task Load Index (TLX) questionnaire and a reaction time task. Descriptive statistics and ANOVA were used to identify relationships between physicians’ interruptions and workload. A total of 2355 interruptions were identified ( M =84.1, SD =14.5). The NASA-TLX results showed increase in physicians’ responses for all subscales from mid to end-shifts. Reaction time was higher at end-shift with mean difference of 33.75ms, 95% CI [20.35, 47.13], p < 0.001. At end-shift, there was a statistically significant positive correlation between reaction time and all NASA-TLX subscales. Interruption duration rather than frequency correlated positively with NASA-TLX scores. High/critical interruptions were the least frequent but had longer duration and greater impact on workload. This study provided a unique examination of interruptions over an entire provider shift and identified interruptions as potential causes of increased workload for ED physicians.

Clinicians have anecdotally indicated that interruptions increase following trauma activations in the emergency department (ED), yet it is unknown whether interruptions change following the end of a trauma case. This study aimed to examine the interruption characteristics of clinicians that participate in trauma activations before and after activations using the SEIPS model. Observers shadowed ED clinicians across entire shifts and logged interruptions that affected clinicians in a tablet PC-based tool. Interruption characteristics captured included duration, nature, location, and task priority. Trauma activations lasting more than five minutes were also recorded. Only interruptions occurring within one-hour of trauma activations were included in the analysis. Chi-square analyses identified significant associations between SEIPS-categorized interruptions and the interruption priority, p < 0.01, and between the SEIPS-categorized interruptions and the interruption location, p = 0.01, pre- and post-trauma activations. Identifying these associations revealed key opportunities to reduce unnecessary interruptions in the ED.