Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements.
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CRM and TeamSTEPPS are well-known principle-based trainings that aim to improve teamwork and patient safety in a hospital setting. Both types of training are based on similar principles. CRM is often referred to as a training intervention that mainly covers non-technical skills such as situational awareness, decision making, teamwork, leadership, coping with stress, and managing fatigue. A typical CRM training consists of a combination of information-based methods (e.g. lectures), demonstration-based methods (e.g. videos), and practice-based methods (e.g. simulation, role playing) [9]. However, CRM has a management concept at its core that aims to maximize the use of all available resources (i.e. equipment, time, procedures, and people) [324]. CRM aims to prevent and manage errors through avoiding errors, trapping errors before they are committed, and mitigating the consequences of errors that are not trapped [325]. Approximately a third of CRM-based trainings include the development, redesign or implementation of learned CRM techniques/tools (e.g. briefing, debriefing, checklists) and could therefore also be categorized in this review under programme [39, 40, 42, 51, 56, 58, 59, 61, 62].
Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.
The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.
Severe trauma is a major global public health issue. Traumatic injury contributes to about one in ten mortalities, resulting in the annual worldwide death of more than 5.8 million people [1, 2], a number that is predicted to increase to >8 million by 2020 [3]. According to the World Health Organization (WHO), road traffic accidents, suicides and homicides are the three leading causes of injury and violence-related deaths [4]. As a consequence, there have been numerous national and international initiatives that aim to prevent violence and traumatic injuries and to provide guidance on the treatment of trauma victims. Uncontrolled post-traumatic bleeding is the leading cause of potentially preventable death among injured patients [5, 6] and the bleeding trauma patient represents a significant financial burden for societies [7], therefore improvements in the management of the massively bleeding trauma patient via educational measures and state-of-the-art clinical practice guidelines should improve outcomes by assisting in the timely identification of bleeding sources, followed by prompt measures to minimise blood loss, restore tissue perfusion and achieve haemodynamic stability.
Although this set of recommendations outlines corridors for diagnosis and treatment, the author group believes that the greatest outcome improvement can be achieved through education and process adaptation by local clinical management guidelines or algorithms, the use of checklists and management bundles and participation in quality management programmes that contribute to national or international trauma databases. Therefore, this guideline attempts to suggest clinically relevant pathways for diagnosis and therapy in order to facilitate adaptation of the guiding principles to each local situation and implementation within each institution. We believe that adherence to local management guidelines or algorithms should be assessed on a regular basis and will lead, if communicated adequately, to greater adherence. If incorporated into local practice, these clinical guidelines have the potential to ensure a uniform standard of care across Europe and beyond, and better outcomes for the severely bleeding trauma patient.
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