BackgroundTrauma care represents a complex patient journey, requiring multidisciplinary coordinated care. Team members are human, and as such, how they feel about their colleagues and their work affects performance. The challenge for health service leaders is enabling culture that supports high levels of collaboration, co-operation and coordination across diverse groups. We aimed to define and improve relational aspects of trauma care at Gold Coast University Hospital.MethodsWe conducted a mixed-methods collaborative ethnography using the relational coordination survey—an established tool to analyse the relational dimensions of multidisciplinary teamwork—participant observation, interviews and narrative surveys. Findings were presented to clinicians in working groups for further interpretation and to facilitate co-creation of targeted interventions designed to improve team relationships and performance.FindingsWe engaged a complex multidisciplinary network of ~500 care providers dispersed across seven core interdependent clinical disciplines. Initial findings highlighted the importance of relationships in trauma care and opportunities to improve. Narrative survey and ethnographic findings further highlighted the centrality of a translational simulation programme in contributing positively to team culture and relational ties. A range of 16 interventions—focusing on structural, process and relational dimensions—were co-created with participants and are now being implemented and evaluated by various trauma care providers.ConclusionsThrough engagement of clinicians spanning organisational boundaries, relational aspects of care can be measured and directly targeted in a collaborative quality improvement process. We encourage healthcare leaders to consider relationship-based quality improvement strategies, including translational simulation and relational coordination processes, in their efforts to improve care for patients with complex, interdependent journeys.

Objective: To assess the feasibility of using rotational thromboelastometry (ROTEM ®)-sigma and thromboelastography (TEG ®)-6s viscoelastic pointof-care assays during rotary wing aeromedical transport, and to determine the reliability of the results obtained. Methods: A single centre, prospective, observational, non-interventional feasibility study performed at Gold Coast University Hospital intensive care unit, and in a LifeFlight Retrieval Medicine operated Leonardo AW139 helicopter. Blood was collected from eight healthy volunteers on 18 April 2019 and all testing was performed on that day. Functions measured were ROTEMsigma extrinsically activated thromboelastometry (EXTEM) clotting time (CT), EXTEM amplitude at 5 min after CT (A5) and fibrinbased extrinsically activated thromboelastometry (FIBTEM) A5, and TEG-6s Kaolin (CK) reaction time (R), functional fibrinogen (CFF) maximal amplitude (MA) and CFF amplitude at 10 min after R (A10). Differences between the results obtained in the helicopter and control results at Gold Coast University Hospital during flight and after flight, and also differences in control results over time up to 3 h were analysed. Results: During flight both the ROTEM-sigma and TEG-6s devices failed to give reliable results. Post flight, the helicopter and control samples correlated well. Repeat testing of control samples at 1 and 3 h also revealed good correlation over time. Conclusion: It is feasible to reliably run tests on both the ROTEM-sigma and TEG-6s after the devices have been flown in a rotary wing aircraft. However, testing cannot be performed while in flight conditions. It is also possible to run blood samples collected up to 3 h prior and acquire results which correlate well with initial testing.

IntroductionFirst attempt intubation success is used by many prehospital services as a marker of quality and safety. An increasing complication rate is associated with repeated intubation attempts. The aim of this study was to identify changes to intubation technique following a failed intubation attempt.MethodsLifeFlight Retrieval Medicine provides aeromedical retrieval services in Queensland, Australia. This retrospective study identified cases of failed intubation attempts from an electronic database registry over a 41-month period from March 2015 to July 2018. These data were analysed using descriptive statistics.ResultsOf the 762 patients who required intubation 758 (99.5%) were successfully intubated, with 684 intubated at the first attempt (89.8%; 95% CI: 0.87 to 0.92). There was no difference in first attempt success between direct and video laryngoscopy (511/563 (90.8%) vs 172/194 (88.6%) p=0.38), trauma or medical (374/419 (89.3%) vs 310/343 (90.4%), p=0.61), primary or interhospital missions (329/370 (88.7%) vs 355/392 (90.8%), p=0.33). 78 cases of failed first attempt intubations were identified. In 65 of these cases, intubation was successful at the second attempt. A single change was made to the intubation procedure prior to a second successful attempt in 28/78 cases (35.9%), and more than one change was made in 41/78 (52.6%). The changes included the operator, intubation device, patient position, intubating aid and external laryngeal manipulation. No change between attempts was recorded in 9/78 (11.5%). 9 cases were successfully intubated at the third attempt, and changes prior to the third attempt included operator, device and intubating aid.ConclusionAlthough a high overall intubation success was found, one in ten patients who were intubated had a failed first attempt. The majority of successful subsequent attempts were preceded by at least one change to intubating technique. Intubating clinicians need the ability to identify and correct issues leading to a failed first attempt.

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Objective: To analyse the mission profiles of helicopter emergency medical service (HEMS) winch operations involving LifeFlight Retrieval Medicine physicians in Queensland, Australia, specifically focusing on patients' clinical characteristics, extrication methods and scene times. Methods: A retrospective analysis was performed to identify all helicopter winch missions involving physicians during 2019. Demographic, clinical and non-clinical data were accessed from an electronic database used to log cases and findings presented using descriptive statistics. Results: Out of 4356 HEMS missions involving physicians, 100 (2.3%) were winch operations. Of these, 31 (31%) occurred overwater and 12 (12%) at night. In total, 106 patients were attended, and eight patient deaths occurred. Most patients were traumatically injured (66%), male (66%) and had a median (interquartile range) age of 43.5 (28-59) years. Thirteen missions (13%) involved drowning victims. This group had a higher burden of injury and comprised half of the patients treated with endotracheal intubation. Median scene time was 30 min (20-40), and the winch stretcher was the predominant patient extrication method. Physician winching occurred in 63 (63%) missions and was associated with increased scene time and increased use of the winch stretcher. Conclusions: Winch operations involving physicians occur infrequently in Queensland HEMS, although almost a third of missions occur overwater. Drowning victims are encountered more frequently than reported elsewhere in Australian HEMS and comprised half of the patients who underwent endotracheal intubation. Patients' severity of illness and injury may contribute to the associations between winching of physicians, increased scene times and increased use of the winch stretcher.