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What Is Mindfulness, andWhat Role Can
It Play intheMental Health ofHealth
Professionals
RaePauleneSpiwak, ShaanSareen, NatalieMota,
JustinGawaziuk, andSarveshLogsetty
14
Introduction
When thinking of mindfulness, an image of a Buddhist monk
meditating on a hilltop may come to mind. In fact, this form
of mindfulness meditation has existed for nearly 3000years,
yet the popularity of mindfulness to reduce stress and help
regulate emotion has only more recently become a popular
term or buzzword. Mindfulness, or the state of being present
or aware, has been shown to reduce stress, improve attention
and memory, reduce anxiety and depression symptoms, and
help regulate emotion. This evidence goes back nearly
50years, beginning with the pioneer of meditation research,
Dr. Herbert Benson in 1975. Benson coined this technique as
the relaxation response and identied the ability for mindfulness to reduce blood pressure, heart rate, and brain activity,
including calming the body’s stress or “ght or ight”
response. This chapter will help clarify what mindfulness is,
as well as identify some of the emerging evidence-based
benets of mindfulness for patients and clinicians. We will
review the epidemiology of trauma exposure and other mental health outcomes among health professionals to highlight
the important role that mindfulness techniques can play in
improving mental health, and we will conclude with con-
R. P. Spiwak · S. Sareen · J. Gawaziuk (*)
Department of Surgery, Max Rady Faculty of Health Sciences,
University of Manitoba, Winnipeg, MB, Canada
e-mail: Rae.Spiwak@umanitoba.ca;
justin.gawaziuk@umanitoba.ca
N. Mota
Departments Clinical Health Psychology and Psychiatry, Max
Rady Faculty of Health Sciences, University of Manitoba,
Winnipeg, MB, Canada
e-mail: natalie.mota@umanitoba.ca
S. Logsetty
Departments of Surgery, Psychiatry, and Pediatrics and Child
Health, Max Rady Faculty of Health Sciences, University of
Manitoba, Winnipeg, MB, Canada
Fireghters Burn Unit, Health Sciences Centre,
Winnipeg, MB, Canada
e-mail: Sarvesh.Logsetty@umanitoba.ca
crete tools and tips for health professionals on how to use
mindfulness in their daily lives.
What Is Mindfulness andHow Can It Help
Mental Health andWell-Being?
Mindfulness has been referred to as a state of awareness
where we aim to pay attention to both internal (e.g., thoughts,
feelings, bodily sensations) and external stimuli (e.g.,
objects, sounds, activities) in a non-judgmental way, from
moment to moment, and with total acceptance (Oxford
mindfulness center NHS) [1–3]. Mindfulness techniques
allow one to be present in the moment and to fully connect
with the environment, including enabling the acknowledgment and appreciation of current thoughts and feelings. Such
a practice can be helpful in increasing awareness to times of
higher stress or anxiety. The practice of mindfulness can also
allow the brain to take a break from daily thoughts/stressors
by engaging with the world. There are several practices in
which an individual can engage to facilitate mindfulness,
including yoga, tai chi, and mindfulness meditation. These
activities focus on the practice of attending and being aware
of the current moment [4].
There are eight pillars or key concepts of mindfulness [5]
(Fig.14.1). The rst is attention, in other words, focusing
one’s attention on the present moment and redirecting the
mind away from thoughts about the present or future.
Mindfulness training with the inclusion of focusing on the
present-moment/experience has been shown to reduce anxiety and depression [5]. The second pillar of mindfulness is
automaticity the ability to do tasks and objectives automatically. Mindfulness practice includes recognizing which
thoughts and emotions are automatic (the opposite of being
mindful) and potentially harmful, then taking steps to reduce
automaticity of these thoughts. The third pillar is judgment,
which allows the individual to recognize the judgmental
nature of their mind and its problematic aspects. Recognizing
negative self-talk and transitioning to positive or motiva-
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_14
97
98
R. P. Spiwak et al.
tional self-talk has been shown to increase performance in
athletes and reduce anxiety [6]. The fourth pillar is acceptance, which enables participants to accept specic difcult
and negative experiences as inevitable (not fully within the
person’s control). Acceptance allows the individual to focus
their attention on aspects of life that are within their control.
The fth pillar is goals; participants are encouraged to balance and separate being in the present moment with planning
for the future. The sixth pillar is compassion, which discourages self-criticism. Showing oneself compassion can
decrease more severe day-to-day negative thoughts and emotions [7]. The seventh pillar is ego, allowing individuals to
experience the difference between the self as a story and an
observer. This allows the individual to practice an observational relationship with the mind instead of strictly thinking
in the rst-person. The eighth and nal pillar is integration,
which emphasizes the integration of mindfulness practice in
daily life. While identifying the eight pillars to outline important components of mindfulness is important, developing a
mindfulness practice is essential to yield the many evidencebased benets for both clinicians and non-clinicians.
Some of the empirically supported advantages of mindfulness include reduced rumination, stress, and emotional reactivity, as well as improvements to memory, ability, and focus. For
example, a study by Farb etal. (2010) found that individuals
who were part of an 8-week mindfulness-based stress reduction group experienced reduced levels of sadness and less neural reactivity (reduced emotional reactivity) as measured by
fMRI data when compared to a wait-list control group who did
not practice mindfulness [8]. Recent systematic reviews have
also supported the global benets of mindfulness related to
depression and anxiety, stress reduction, as well as promising
preliminary effects on sleep disturbance, eating disorders, and
addiction [9]. While the evidence to support mindfulness in the
treatment of post-traumatic stress disorder (PTSD) is developing, overall, it appears that meditation interventions have a
positive effect on PTSD; however, due to the vast variability in
follow-up time, study quality and overall methodological limitations, more high-quality work is needed to further understand
this relationship [9]. Taken together, mindfulness practice may
be an important prevention and mental health promotion for
both physicians and non-physicians alike.
Fig. 14.1 Eight pillars of mindfulness
What Are theBenets ofMindfulness
forPhysicians andHealth Professionals?
A growing body of literature has demonstrated the effectiveness
of mindfulness-based interventions in improving psychological
outcomes for health professionals [10]. A recent meta-analysis
14 What Is Mindfulness, andWhat Role Can It Play intheMental Health ofHealth Professionals
99
of 25 studies including both randomized and non-randomized
clinical trials found decreases in stress and burnout following
completion of mindfulness-based interventions [11]. Other systematic reviews have reached similar conclusions of reduced
burnout, improved psychological well-being, and/or decreases
in anxiety and depression in physicians participating in interventions with a mindfulness component [12–15]. Reviews have
also highlighted the benecial effects of mindfulness among
nurses, suggesting it can be helpful in reducing work-related
stress [10]. Emerging evidence in studies of physician samples
has also supported a link between mindfulness-based interventions and improvements in other outcomes relevant to wellbeing, such as loneliness and sleep [16]. One study even
identied improvements in heart rate and systolic blood pressure (e.g., biological markers of stress) during participation in a
mindfulness- based stress reduction program [17].
Mindfulness-based interventions have additionally led to
promising outcomes in some performance indicators among
physicians, including improved competencies related to
patient safety, more patient-centered communication, and
greater empathy, conscientiousness, positive tone, and emotional stability [14, 15, 17–21].
It should be noted, however, that research related to the
effectiveness of mindfulness in health professional samples
specically is still limited, the types of mindfulness-based
interventions studied in extant research have varied widely, and
the methodological rigor of studies has varied equally widely.
For example, the overall quality of the evidence in the metaanalysis of physician mindfulness by Fendel and colleagues,
for example, was determined to be low (2021). To draw more
denitive conclusions in the future for the effectiveness of
mindfulness-based interventions among physicians, more randomized clinical trials with greater standardization in length
and content of mindfulness practice are needed.
population, with female physicians having a 146% higher risk
of suicide than the general population [25]. Some work suggests that physician trainees may experience even greater
mental health consequences of trauma exposures due to being
earlier in their training and acquisition of experience, and too
often having greater responsibility for providing frontline
clinical care with a large patient volume. A recent study of
1134 medical interns found that work-related PTSD occurred
three times more often among intern physicians when compared to individuals from the general population. More than
half of this group experienced work-related trauma, and of
these individuals, almost 20% had possible PTSD [26]. A systematic review of physician and trainee mental health in
North America found that most of the existing literature
related to physician mental health focused on burnout, with
limited work on how physician mental health may impact
patients, patient satisfaction, and barriers to help seeking.
Future work in these areas is needed [27].
The COVID-19 pandemic has played a large role in the
mental health of healthcare providers, with health professionals experiencing higher levels of burnout, insomnia, and
mental disorders, including depression [28, 29]. Studies
have found that working as a frontline healthcare worker
was a risk factor for poor mental outcomes during the pandemic [30, 31]. Certain frontline workers, including those
working in emergency, respiratory, infectious disease, and
intensive care units, were found to have twice the likelihood
of anxiety and depression when compared to non-clinical
staff [31]. Whether dealing with traumatic exposures due to
death and disease, or due to the pandemic, healthcare providers may benet from better coping skills to prevent distress and poor mental outcomes. Mindfulness techniques
have been shown to reduce distress and improve coping
skills [32, 33] and may be a useful way to improve health
professional’s mental health [34, 35].
Epidemiology ofTrauma Exposure
andMental Health Outcomes
Due to the nature of their employment, healthcare providers
including attending and resident physicians are at risk for
trauma exposure, including sudden deaths, disaster exposure,
and hazard exposures such as COVID-19 [22]. These exposures place health professionals at increased risk for poorer
mental health consequences, including PTSD, all of which
not only impact well-being but have potential impact on quality of care, healthcare costs, and medical errors [23, 24]. A
systematic review of the mental health of doctors in Australia
found physician rates of depression ranged from 14% to 60%;
anxiety rates ranged between 18% and 55%; and physicians
had greater rates of prescription drug use, such as benzodiazepines when compared to other professions [25]. Physicians
had greater rates of suicide when compared to the general
Tools forClinicians: Tips forMindfulness
Limitations notwithstanding, literature to date supports the
benet of mindfulness-based interventions in improving several outcomes for healthcare providers. As such, several
helpful resources have been developed to support greater
exposure to mindfulness in this population [36]. The
Mindfulness Institute (http://www.mindfulnessinstitute.ca/
mindfulness- in- medicine) describes the different institutions
with current curricula related to mindfulness in their medical
schools, as well as mindfulness-based programs in which
physicians can register. The Institute for Physician Wellness
also hosts mindfulness-based stress reduction programs specically for healthcare professionals (https://www.institute-
forphysicianwellness.com/mindfulness- in- medicine/).
Finally, several books provide excellent starting points for
100
R. P. Spiwak et al.
embarking on mindfulness practice, including Attending:
Medicine, Mindfulness, and Humanity by Dr. Ronald Epstein
[37]. In addition, mindfulness applications are readily available on numerous handheld devices [38].
One of the reasons mindfulness is so powerful is because
it can be done anytime and anywhere. Practice begins by
attending to a chosen stimulus in the present moment,
without judgment. It is often recommended that beginners to
mindfulness start by focusing on their breath or paying attention to an object or sound in the environment or focusing on
the taste and smell of a piece of food (e.g., a mint). The idea
is to focus one’s attention on the target and really noticing all
aspects of it. For example, if it is mindfulness of breath that
is being practiced, one might notice whether their breath is
deep or shallow, its pace, and whether exhalation occurs
through their mouth or nose. It is normal and even expected
for the mind to wander during mindfulness practice, for
example, to a task that needs completing, to a feeling of
stress or anxiety, or to a thought of what is for dinner! Part of
mindfulness practice is to gently redirect one’s attention to
the target, often many times. There is no recommended
length of time for a mindfulness practice, but a few minutes
in between stressful tasks can be helpful in resetting.
Conclusions, Implications, Next Steps
While much support exists for the practice of mindfulness in
improving mental health and well-being, research studies are
needed that are of higher quality, with larger sample sizes,
appropriate and randomized comparison groups, and with the
use of consistent measurement tools and terms [9]. Second,
understanding if clinicians and/or individuals who are exposed
to trauma regularly through their employment would benet
from mindfulness practice as a form of prevention and mental
health promotion is an important future direction. Third, identifying levels of training (e.g., trainees, physicians) and how these
individuals respond to traumatic events, including the role of
meditation in this response, would be a valuable addition to the
evidence base. In conclusion, mindfulness is a powerful and
useful tool that is likely to be helpful to health professionals and
improve mental health throughout their practice.
Key Points
• Mindfulness may be a useful tool for mental health
of health professionals to reducing stress, burnout,
anxiety, and depression.
• Mindfulness is maintaining awareness of the present moment in a non-judgmental way.
• Evidence surrounding the effectiveness of mindfulness is still emerging.
• Future research is needed to understand the benets
of mindfulness.
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Trauma Video Review
MichaelA.Vella, RyanP.Dumas, ZaerA.Qasim,
AektaAndreaMiglani, andDanielN.Holena
15
Introduction/What Is Trauma Video Review?
Video review technology for use in surgical and emergency
medical education was utilized as early as the 1960s [1–3].
Trauma video review (TVR), which specically describes
the process of recording trauma resuscitations for multipurpose review, was rst described in 1988 [4]. At that time,
researchers used a camera, videocassette recorder, and television mounted on a stand to record over 2500 resuscitations.
They showed that implementation of a formal video review
conference led to improved patient care delivery.
Modern technology allows for continuous high-denition
audiovisual recording of trauma resuscitation bays, encrypted
video storage with timed auto-deletion, and the ability to
time-stamp, zoom, fast-forward, and rewind recordings [5]
(See Fig. 15.1). Integration of video laryngoscopy, ultrasound, and vital sign monitor screens is also possible, while
emerging technology allows for video-based activity recognition [6–8].
A central theme of this textbook is the concept that multidisciplinary team simulation and education lead to improved
team dynamics, which in turn lead to improved processes of
care, which ultimately lead to the common goal of improved
patient outcomes. The power of TVR lies in the fact that this
technology can be used (and is usually instrumental) in every
step of this progression.
Fig. 15.1 Typical TVR Setup as viewed from cameras (and microphones) located at the foot and head of the bed. This is the view available for
those evaluating stored videos
M. A. Vella (*) · A. A. Miglani
University of Rochester School of Medicine and Dentistry,
Rochester, NY, USA
e-mail: michael_vella@urmc.rochester.edu;
aekta_miglani@urmc.rochester.edu
R. P. Dumas
Baylor College of Medicine,
Houston, TX, USA
e-mail: ryan.dumas@bcm.edu
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_15
Z. A. Qasim
University of Pennsylvania Perelman School of Medicine,
Philadelphia, PA, USA
e-mail: zaffer.qasim@pennmedicine.upenn.edu
D. N. Holena
University of Pennsylvania Perelman School of Medicine,
Philadelphia, PA, USA
Medical College of Wisconsin, Wilwaukee, WI, USA
e-mail: dholena@mcw.edu
103
104
M. A. Vella et al.
This chapter rst describes TVR utilization and applications, focusing on the use of TVR for education, performance
improvement (PI), and research purposes. Next, the practical
considerations of starting or improving an existing TVR program are discussed. Finally, we describe the integration and
maintenance of a successful multidisciplinary program as
well as emerging opportunities for video-based review in and
out of the emergency department.
Historical Trends inTVR Utilization
Despite its potential benets, utilization of TVR has historically been low. A survey in 1999 of 221 US trauma centers
found that only 20% of centers overall and 34% of level one
centers were using TVR [9]. Subsequent surveys in 2006 and
2010, albeit with slightly different groups of institutions,
found that utilization among level one centers had decreased
to and stabilized at 18% [10, 11]. Thirty-ve percent of centers in the 2006 study reported that the recently enacted
Health Information Portability and Accountability Act
(HIPAA) had impacted their TVR programs in some capacity, presumably due to perceived patient privacy and medicolegal concerns [10]. More recently, a 2019 survey of US
trauma centers found that overall utilization and use among
level one centers had increased to 29% in both groups, and
21% of non-users reported a strong interest in starting TVR
program [12].
The most recent survey on TVR practices indicates that
the technology is used most commonly for group and individual education and is frequently used to assess trauma
team dynamics [12]. Nearly two-thirds of respondents
reported that their TVR program has generating PI initiates,
with 41% indicating that TVR has led to direct changes in
institutional practices. Overall perception of TVR programs
among active users was high, with a median score of 8 on a
10-point Likert scale on the domains of overall perception
and reliability. These recent ndings are consistent with
those of older reports, including one study where 100% of
respondents indicated that their TVR programs have led to
improvement in resuscitation practices [10, 11, 13].
video-based feedback has been shown to be more effective
than its verbal counterpart [12, 23, 24]. Trauma video review
applications can generally be categorized into three broad
yet closely related areas, including team simulation/education,
performance improvement, and research.
Team Simulation/Education
Evidence suggests that trauma team simulation and leadership training can improve team efciency, communication,
and performance [25–31]. Video equipment can be used to
record simulated resuscitations and the associated debrieng
sessions, which can be reviewed with the team immediately
after the exercise or at a later date. Simulated scenarios can
also be used at the outset of new TVR program implementation to improve familiarly with the TVR equipment and
video review process. Video-based review of simulated
trauma scenarios has also been used to identify latent safety
threats that are likely to complicate real trauma resuscitations, such as factors related to communication, physical
workspace, and equipment [32].
From an educational perspective, TVR of real trauma
resuscitations is ideal for reviewing low frequency, high
impact procedures (emergency department thoracotomy, cricothyroidotomy) as well as difcult clinical scenarios like
the management of unstable or agitated patients or multicasualty events. The technology allows these “vicarious
teachable moments” to be shared with clinicians who were
not present during the initial resuscitation and is the arguably
the next best thing to standing at the bedside [5]. Trauma
video review also allows for evaluation of team dynamics
and other “intangibles of resuscitation” that are known to be
important but difcult if not impossible to evaluate through
traditional means [5]. Various scoring system exist to grade
team dynamics during recorded trauma resuscitations, such
as the modied Trauma Non-technical Skills (NOTECHS)
score [33–35] (See Table15.1).
Performance Improvement
Current Applications andUtilization
Trauma video review has been used to evaluate a multitude
of technical and non-technical elements of trauma resuscitation, including but not limited to, airway management,
opportunities for improvement in resuscitation, compliance
with personal protective equipment, timing of emergent procedures, team dynamics and leadership, and rapid changes in
patient condition [8, 12, 14–22]. In these capacities, TVR
has been shown to be more reliable than chart review, and
Trauma resuscitation has been described as a “complex, time
critical endeavor requiring the coordinated efforts of a multidisciplinary health care team” [36]. It is imperative that
trauma teams function effectively, as 70–80% of healthcare
errors in general are related to poor teamwork and communication [37, 38]. Evidence shows that trauma team training
improves team performance. In turn, improved team performance has been associated with improved processes of care
including faster and more reliable completion of the primary
and secondary trauma surveys and patient disposition in both
simulated and actual patient scenarios [18, 25, 28, 39–46].
15 Trauma Video Review
Table 15.1 Description of a Modied Trauma-NOTECHS scoring system
Modied Trauma-NOTECHS
1 2 3
Leadership Team leader clearly recognizable at all times,
“birds’ eye” view with delegation, transitions
of leadership clear, assignment of roles,
excellent time management
Cooperation and
Resource
Management
Communication Team leader is at the head of the bed, critical
Assessment and
decision-making
Situation awareness Unforeseen ndings, distractions, or change in
Scoring systems such as this can be used to evaluate trauma team dynamics [33]
All team members clearly identied, speak up
if help needed, no team members are idle
communication through the team leader, all
orders to team leader, closed loop
communication, orders directed to specic
people
Primary and secondary survey done in order
and without omissions, ndings summarized,
goals and plan communicated to the team
patient condition did not disrupt orderly
evaluation. Team is calm, team plans ahead,
awareness of team members emotional
condition
Team leader dened but does not
fulll all functions or does
procedures meant for others or
transitions unclear
Role identity of all members not
clear, some team members idle
some of the time
Communication not always
through team leader, orders not
always acknowledged
Assessment somewhat out of
order, some elements of
secondary survey incomplete
Unforeseen ndings caused minor
delay but did not preclude task
completion
105
Team leader not clear
Role identity of most members not
clear, most team members idle
most of the time
Communication frequently
inaudible or incoherent with many
simultaneous conversations
Elements of the primary survey
incomplete, multiple team
members unclear about the next
step
Unforeseen events disrupt patient
assessment and treatment. Team
members stressed, lack of
anticipation of next steps
TVR allows for the direct evaluation of team performance
and was instrumental in many of these studies. For example,
one group found that a trauma team leader was not present in
50% of reviewed resuscitations [47]. This nding led to institutional changes in practice as well as implementation of
education sessions related to errors in resuscitation. In
another study, the implementation of a TVR program was
associated with a 17% reduction in resuscitation time as well
as improved adherence to resuscitation protocols [4].
Trauma video review is an excellent method to reliably
evaluate “known unknowns” like team dynamics and leadership. Interpersonal and qualitative factors such as these
are difcult to abstract from medical records and verbal recollections but are believed by expert clinicians to be factors
critical to processes of care and patient outcomes [5]. Using
a modied T-NOTECHS tool, Dumas etal. evaluated the
association between team dynamics and return of spontaneous circulation (ROSC) in patients presenting to a level-one
trauma center undergoing emergency department thoracotomy (EDT) [33]. Videos of 61 EDT over a two-year period
were reviewed, and the authors found that patients with a
“best” score in the domain of “assessment and decision
making” were ve times more likely to achieve ROSC compared to those with “average” or “worst” scores (See
Table 15.1). This was one of the rst studies to show an
association between team dynamics and a tangible patient
outcome. Of note, the median modied T-NOTECHS score
for resuscitations in which ROSC was achieved was seven,
indicating that even the “best” resuscitations have room for
improvement. The presence of a robust TVR program was
instrumental in this study.
Resuscitative procedures can also be evaluated with
TVR.In one recent study, researchers used TVR to evaluate
vascular access strategies in patients arriving in extremis and
requiring EDT [19]. Using time-stamped videos, they found
that intra-osseous access attempts were as fast as peripheral
intravenous access attempts but nearly twice as likely to succeed, and far faster and more successful than central venous
access attempts. Efforts such as these may lead to direct
changes in institutional resuscitation practices that would be
extremely difcult to evaluate without the presence of video
review. At another institution, a pre-intubation checklist was
evaluated using video review and was found to be associated
with fewer errors in trauma airway management [8]. The
authors discovered that poor team communication was a
major contributor to adverse outcomes, a nding that would
not have been evident from medical record review alone.
Finally, others have used video review to dene standards for
procedures such as EDT in an attempt to improve consistency and associate procedural skill with outcomes [16].
Research
The previous sections detail the important role of TVR in
research related to simulation/education and performance
improvement. The power of TVR for research purposes lies
in its ability to reliably and accurately collect data that is not
present or incompletely captured in the medical record.
Given the fast ow and density of information present in a
trauma resuscitation, even traditional gold standards of data
capture like prospective real-time in-person collection may
106
M. A. Vella et al.
fail [5]. For example, in a 2006 study of pediatric trauma
resuscitations, only 20% of errors detected on video were
found in the medical record [47]. These errors were most
commonly related to the physical exam, team dynamics, and
delays in therapy, which are ideally suited for video review.
In a more recent study utilizing TVR to time EDT, only 57%
of patients had any times recorded in the medical record,
compared to 97% with TVR [16].
Trauma video review is ideal for research that requires
accurate time stamps or the evaluation of rapid changes in
patient condition. For example, retrospective studies that
evaluate an emerging technology or location of device placement are often confounded by indication related to rapid
changes in patient physiology or other logistical factors.
While these elements are difcult to capture in a traditional
registry, TVR technology may allow for capture of more
granular data in order to answer these specic and important
research questions.
Practical Considerations When Starting
aTVR Program
Although barriers to implementation exist, the success of
established and long-standing TVR programs and the
increasing utilization of this technology suggest that TVR is
safe and feasible. The following sections describe barriers to
implementation and other practical considerations.
establishment of workows and protocols. All TVR proposals
should be vetted through hospital legal counsel, privacy ofcers, and hospital and departmental leadership. In some cases,
it may be benecial to provide evidence highlighting the
safety and feasibility of successful programs. Contacting and
establishing dialogue with similar institutions (or other
departments within the same system) that have successfully
navigated the process is helpful and prevents the need to
“reinvent the wheel.” Secure storage of videos, restricting
access to recordings, obtaining informed consent, timed autodeletion of videos, signage in resuscitation areas that indicates active recording is occurring, and separating stored
videos from the medical record are some of the strategies that
may help to mitigate legal concerns.
Consent Processes
Consent for TVR may not be required in all states, especially
because the activity is often related to performance improvement. That said, legal counsel and institutional leadership
will need to be involved to help determine both the need for
and processes surrounding informed consent. The most
recent data on consent practices show that 6% of active users
specically consent for TVR (usually in a retrospective fashion prior to video review but after the recording has occurred),
50% include video recording and review in the general hospital consent, and 30% do not consent at all [12].
Potential Barriers
Commonly cited barriers to TVR implementation include
medicolegal concerns, staff perceptions, lack of institutional
precedent, nancial implications, and potential time
constraints.
Although medicolegal concerns are often raised in surveys
on TVR practices, these reports also highlight the discrepancy between perceived concerns and actual medicolegal
cases involving the technology [9, 11, 12]. In the most recent
survey of TVR practices, only 2 of 71 (2.8%) centers with
active TVR programs reported direct knowledge of any case
involving TVR [12]. In many states, TVR is protected from
discovery as a performance improvement tool, and some have
argued that HIPAA does not apply to activities related to provider education and quality improvement. Although HIPAA
does not specically address the video recording of resuscitations, it does allow for data collection and research related to
performance and quality improvement [12, 48]. Efforts to
start a TVR program should include a detailed review of local
and state legal processes along with specic hospital policies
from the beginning. Understanding institution- specic medicolegal concerns from the outset helps direct the successful
Other Considerations
Prior to starting a program, it is important to perform a stakeholder analysis with all involved parties (included but not
limited to trauma and emergency department staff, nurses,
trainees, pre-hospital providers, and law enforcement) to discuss the benets of and reasons for starting a program as well
as to identify any potential barriers to implementation. It is
important to offer opportunities for open discussion in various formats including town halls, emails, small group meetings, and one-on-one conversations when needed. A survey
sent to all individuals who will be involved in the TVR process may help to anonymously identify individual staff concerns. While the literature suggests that TVR is well
perceived among active users, TVR has been associated with
anxiety among providers in at least one study [13]. It is the
authors’ experience that TVR is overwhelmingly a positive
experience for all involved and that initial concerns are often
assuaged once the benets of the process are realized. Those
starting a new program may nd benet in initially starting
the recording and review process using simulated scenarios.
From a practical standpoint, programs must decide who
has video access, how and what videos are chosen for review,
15 Trauma Video Review
107
what percentage of overall videos are reviewed, and who
actually partakes in the review process. The time commitment for video review can be substantial, especially if a program decides to review all trauma resuscitations. Programs
must also decide if video recording in the resuscitation bay
will be continuous or will start upon manual activation of a
button or switch. The most recent survey on TVR practices
indicates that most current users continuously record resuscitation areas, store videos less than 30 days, and review
<50% of resuscitations [12]. Institutional leadership and
staff input should be considered when making these decisions. Finally, programs must decide on when and where to
review videos, which is often done in a recurring multidisciplinary conference.
Equipment type and location, storage capacity, and existing building infrastructure should be considered when developing a TVR program. Financial investment for both initial
start-up and ongoing maintenance costs is necessary. These
factors are extremely important but beyond the scope of this
review. Those interested in starting a program should consider reaching out to existing users (including the authors of
this chapter) for advice. Potential users should also take
advantage of existing infrastructure if similar video equipment and/or vendors are utilized in another area of the institution like the operating room or intensive care unit.
Emphasizing the value of a TVR program as a patient safety
and educational tool may help to increase support from
stakeholders. Those interested in starting a TVR program are
also encouraged to pursue available grant funding.
Integrating andMaintaining aSuccessful
TVR Program
Integrating TVR into an existing PI program and maintaining enthusiasm can be challenging but are critically important. The time commitment and resource needs must not be
underestimated. In a 2006 survey on TVR practices, 70% of
programs that stopped using TVR cited scarce resources and
provider time commitment as primary reasons for abandoning a program [10]. More recently, insufcient time was a
frequently cited reason for stopping active TVR programs
[12]. Resource commitment varies based on the number of
individuals who participate in the TVR program as well as
the percentage of overall trauma resuscitations chosen for
review. These factors can be tailored to institutional needs
and constraints.
Setting realistic goals and expectations from the beginning can help prevent the outpacing of resources. The goal of
a robust TVR program should not be to review every single
case (or even every aspect of a single chosen case), but
instead to highlight elements of a trauma resuscitation that
hold educational value. We have found that selecting compo-
nents or certain elements of a resuscitation is most helpful
and often choose resuscitations involving critically unstable
patients, combative/agitated patients, simultaneous patient
arrivals, or challenging airway management. Additionally,
we have found that TVR is an ideal avenue to highlight relatively uncommon but high-risk procedures like EDT and cricothyroidotomy and to discuss the intangibles of resuscitation
like leadership and team dynamics. Reviewing high-impact
but relatively low-frequency procedures allows trainees,
nurses, and practicing physicians to discuss procedural steps
like positioning and equipment that are often underemphasized but critically important. Re-watching resuscitations on
video also allows one to identify potential barriers related to
spatial awareness, trauma bay set-up, target xation, anchor
bias, and time mismanagement that can subtly derail an otherwise effective resuscitation and are often not evident from
traditional medical record review.
Each individual TVR program must decide the most
appropriate venue to review resuscitations. We have found
that presenting a small number of resuscitations or components of resuscitations at a recurring multidisciplinary conference with the trauma surgery and emergency medicine
services is most educational. Having all members of the
trauma team, including trainees, nurses, nurse managers,
physicians, advanced practice providers, technologists, and
emergency medical services, participate in the conference
increases the educational value for all and also helps to
achieve and maintain program buy-in and enthusiasm.
Involving other specialties like neurosurgery, orthopedic surgery, obstetrics, and radiology may also be benecial
depending on the clinical scenarios presented.
While a TVR conference can be intimidating, especially
if you are the one “under the lens,” there are several important considerations that can be used to mitigate this anxiety
and improve overall buy-in. It is our opinion that team performance rather than individual clinician performance
should always be emphasized. As a general rule, all resuscitations contain opportunities for improvement as well as
aspects that may have gone exceptionally well. Rather than
focusing only on areas where a resuscitation could have been
improved, it is important to us TVR as a tool to illustrate
outstanding examples of leadership, communication, and
teamwork when they occur. Such elements can be brought to
light by asking questions such as “was there a clear team
leader?”, “did the team employ closed-loop communication?”, “did physicians and nurses or emergency medicine
and trauma surgery communicate effectively?”, and “was
crowd control managed appropriately throughout the resuscitation?”. In general, individual names should not be used,
and singling out or targeting individual providers must be
avoided. Most providers will be unrecognizable on video
when appropriate personal protective equipment is being
used. Occasionally, using a proper name to highlight an