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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5198_Библиотеки_им_академика_М_И_Перельмана.pdf
Trauma Bay Development andDesign
Designed toPerform: How Simulation
Can Inform theDesign ofElite Trauma
Resuscitation Environments
AndrewPetrosoniak, FrankPanici, andChristopherHicks
24
Introduction
Poor design in healthcare is common [1, 2]. Design aws are
more than simple nuisances but rather require constant
improvised or ad hoc work-around solutions that expose
patients and providers to risks and safety hazard [3]. During
a trauma resuscitation when the chest tube equipment is laid
out over the patient instead of a purposely design procedure
cart, situated in a room designed to facilitate trauma care, the
reex should be to recognize how the system fails to promote
the safe performance of the procedure.
In contrast, most healthcare workers, including those who
care for the critically injured, are not conditioned to respond
by asking how the system design failed the patient and the
team. We have been socialized to take pride in our ability to
overcome poor designs and just make things work. In most
modern healthcare systems, the onus for avoiding hazards
and safety threats falls almost exclusively on the provider [4,
5]—a model that is both unethical and unsustainable. Ask
any trauma systems provider: barriers to safe and effective
care consistently arise from systemic encumbrances that
impact their energy and impair their determination [6]. It is
not unusual for trauma clinicians to be searching for the
patient’s source of bleeding while searching even harder for
the life-saving equipment they need to stop it.
Trauma resuscitation exemplies the complexity that
exists within healthcare [7]. Clinicians are faced with competing priorities, diagnostic uncertainty, and dynamic clini-
A. Petrosoniak (*) · C. Hicks
Department of Medicine, University of Toronto, Toronto, ON,
Canada
Department of Emergency Medicine, St. Michael’s Hospital,
Toronto, ON, Canada
e-mail: Christopher.Hicks@unityhealth.to
F. Panici
Health Sciences, NORR Architects & Engineers Ltd.,
Toronto, ON, Canada
e-mail: Frank.Panici@norr.com
cal situations accentuated by critical illness. This culminates
in challenges linked to logistics, processes, and systems as
much as the inherently difcult diagnostic and management
decisions. A rational and sustainable way forward for the
engineering of resilient trauma systems requires up-front
investments in understanding system complexity and potential vulnerabilities. This approach places the end-user, both
patients and clinicians, at the center of the design process
[8]. At every point in the design process, the question should
be asked: “Is the choice we’re making increasing safety or
increasing risk?” [9].
In this chapter, we describe a framework for the design of
trauma resuscitation environments that emphasizes the needs
of the end-users (patients and providers) linked to a systemsthinking perspective. This process builds on our own experience in the design of a new trauma bay combined with
evidence-based design principles. In summary, this four- phased
approach (design-build-train-excel) systematically supports
the conceptualization (design), prototyping (build), orientation
and utilization of high-performance teams (train), and constant
evaluation (excel) necessary to create a highly functional space.
Design
Formalizing Clinician-Designer-Builder Partnerships
The typical process for the design and construction of trauma
resuscitation environments can be described as “fragmented”
at best [2]. It is not uncommon for an entire clinical space to
be constructed by teams working in silos with little communication between them. Siloed processes may result in clinical environments that lack usability especially when seconds
are the difference between life and death.
The success of any project is tightly linked with the quality of the team responsible for its completion. In trauma care,
the design of a trauma resuscitation space requires expertise
in clinical care, logistics, and architecture. Clinicians are not
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_24
185
186
A. Petrosoniak et al.
architects, contractors, or project managers, nor should they
pretend to be. Formalizing partnerships between builders
and end-users is absolutely critical. To be effective, trauma
bay design can’t happen in a bubble, but rather it should
bring all relevant parties to the table to co-create, prototype,
and test solutions prior to implementation. A nurse with a
design idea for a resuscitation room layout needs to be able
to interface with an architect to create a rendering, simulationists to test and generate feedback, and project managers
to cost, plan, and implement solutions.
In our experience, engagement with the architectural
design team is critical upon project conception. This provides ample opportunity for architects, project managers,
and other non-clinical personnel to deeply understand the
needs, workows, and challenges of the end-users. These
early conversations, facilitated through multiple techniques
that will be discussed below, will ensure even the earliest
plans and designs will be informed by end-user feedback.
A Human-Centered Approach
A purposefully designed trauma bay may be the difference
between life and death when a team is required to respond in
a rapid and coordinated fashion to a hemodynamically unstable patient requiring a sequence of time-sensitive interventions. The inherent challenges of trauma care are amplied
when they occur within poorly designed clinical spaces.
Providers have become accustomed to overcoming such
safety threats and inefciencies, relying on their individual
and team resilience. The link between the physical space and
care delivery cannot be overstated. As eloquently stated by
author James Clear:
The environment is the invisible hand that shapes human
behavior
Increasingly, healthcare has followed the way of other
domains by adopting a human-centered design processes
[10, 11]. This approach involves applying the human perspective throughout all steps of the problem-solving process.
This links closely with participatory ergonomics whereby
people are involved in the planning of their own work, resulting in improved productivity [12]. This deeper understanding of work as done has been achieved recently using
simulation in several case studies of assembly line and
healthcare systems design [13–16].
Participatory ergonomics and human-centered design,
well studied in several domains, have yet to be robustly
applied within the design of the trauma care environment.
We advocate for an easily implementable framework to support these principles by way of simulation-informed clinical
design. This puts the patient, clinician, and other involved
care providers front and center in the design process [17].
Within this process, we utilized design thinking methodology, a toolkit familiar to those in technology and business, to
create end-user optimized designs [18–20]. Simulationinformed clinical design places a signicant emphasis on
understanding the needs of the end-user. This upfront investment pays dividends later through design solutions that are
iteratively prototyped, achieving proven benets for patient,
provider, and system [21].
The Missing Link
Business and technology sectors have long understood the
importance of the customer experience [22]. The patient experience during healthcare delivery is the subject of increasing
interest among healthcare organizations as they integrate
patient-centered metrics in their evaluation processes [23].
Much of this focus relates to patient-provider interactions and
processes to improve pain control or wait times. There is a lack
of well-formulated mechanisms, however, to integrate the
patient perspective during the design of new healthcare infrastructure, including those for trauma care. The importance of
creating positive patient experiences cannot be discounted as it
serves to enhance trust among clinicians, reduce posttraumatic
stress disorder, and improve patient outcomes [24].
An illustrative example of the positive impact of integrating the patient experience into the design process comes
from Doug Dietz, an executive at General Electric [25, 26].
He was tasked with designing a new MRI machine for pediatric patients. When he observed the machine in use, he saw
children so scared and anxious that many required sedation.
While satised with the technical outputs of the machine, he
realized it did not meet the needs of the “end-user,” in this
case the children. Using principles of human-centered design
and design thinking methodology, he re-designed the experience to feature “adventure” environments that resonated
with children, like an MRI room to mimic a pirate ship.
Multiple iterations of child-friendly designs were created
and the experience was completely re-imagined and redesigned. These designs may sound great, but is there a clinically relevant outcome? Interestingly, this project resulted in
a substantial reduction in the need for sedation, both a safety
and patient-centered outcome [27]. An amazing result from a
seemingly simple yet elegant design.
How can we translate the patient perspective into the
trauma bay design process? Following the design thinking
methodology, the rst step is empathize, whereby the designers seek to better understand the needs of the user. There is
growing research about the emotions experienced by trauma
patients [24]. Semi-structured interviews can offer designers
a unique lens through the eyes of the patient and how the care
process can be improved without compromising efcacy.
Additionally, standardized patients can provide their insights
24 Trauma Bay Development and Design Designed to Perform: How Simulation Can Inform the Design of Elite Trauma…
187
during the debrieng phase of a simulation session. Ensuring
the architects and design team are present only further
enhances the value of the session.
We believe that each trauma program should seek to
understand the unique aspects of the patient experience at
their institution to inform future designs, and we summarize
some common themes from both the literature and our personal experiences: [24, 28, 29].
1. Trauma patients experience a range of emotions that may
impact their understanding of the steps taken during a
resuscitation.
2. Pain is nearly ubiquitous in trauma and will substantially
impact the patient experiences.
3. Exposure to strangers while necessary to provide care
creates a vulnerable environment.
4. Uncertainty and concern about the patient’s clinical con-
dition are common among family members.
It is our contention that these themes, while not allencompassing, represent a starting point to inform unique
design features to enhance the patient experience. For example, it may be possible to mitigate some of the negative emotions inherent with serious injuries with adjustments in noise
and wall color or perhaps calming images on the ceiling that
serve to reassure the patient that they will be cared for with
dignity and respect. Additional design features might serve to
support patient-oriented outcomes such as timely analgesia
delivery.
The Case forLess
In a healthcare system hungry for additional capacity, the
desire for more can drive decision-making, without considering if more translates to better. At St Michael’s Hospital in
Toronto, the design for a new trauma bay included expanding
from two to three stretchers, ostensibly to care for 50% more
critically injured patients at any given time.
Added capacity has advantages but presents challenges as
well, many of which are difcult to see. These latent hazards
are threats to patient and provider safety that aren’t easily
identied until they create a problem, which carries the
potential for adverse events and harm [30–32].
We used simulation-informed clinical design to put both
our old and new trauma bays through their paces [17, 32–35].
To do so, we brought a number of simulation modalities to
bear, selected based on the task at hand:
• Current state analysis: In situ simulation exercises based
on known difcult trauma cases, run with the full team in
the “old” trauma room
• Hazard matrix, framework analysis, and video review
with the help of human factors engineers
• Table-top talk simulations of the new space, using scale
models and design schematics
• Full-scale simulations in mock-ups of the proposed new
space, pre-construction
• In situ simulation in the constructed new space, prior to
opening for clinical care
At every step, our ndings were shared with the design
and project management teams. It turns out that the crowding of three stretchers created a series of negative tradeoffs and limited the ability to deliver safe and timely care.
What followed was a reworking of the space and design to
feature a two-stretcher steady state with the ability to ex
up to three if necessary; clear oor markings to preserve
the circle of care around the patient’s head, neck, and
torso; and clinical logistics to support bedside critical care
procedures.
Evidence-Based Design
With growing research in healthcare design, evidencebased healthcare design (EBD) has emerged as an important inuence as new facilities are built. The Center for
Health Design, an organization that supports this approach,
denes EBD as “the process of basing decision about the
built environment on credible research to achieve the best
possible outcomes” [36].
Although it seems obvious that resuscitation spaces for
critically injured patients should be designed using
research and end-user input, the use of EBD in this area is
still relatively new. The Agency for Healthcare Research
and Quality (AHRQ) partnered with the Centre for Health
Design and proposed 10 evidence-based design considerations. While these represent generic principles, each is
backed by evidence that it positively impacts healthcare
outcomes [37]. We describe how these 10 principles are
relevant to the built environment of the trauma bay
(Table 24.1). Notably, institutions may prioritize each
principle differently based on their current environment,
culture, and user perspectives. We advocate that these principles be included in the design process which may occur
in several ways including:
1. Conversation guide between designers-builders-clinicians
2. Checkpoints for clinicians to ensure appropriate elements
considered
3. Content to inform and support the design evaluation
process
188
Table 24.1 Evidence-based design principles applied to the trauma resuscitation environment
Evidence-based design principles Examples relevant to trauma bay design
Standardization Implementation of pre-arrival/pre-departure checklists to ensure key aspects of care
completed
Staff fatigue Optimize layout of the space to ensure high-use items are near the bedside and easily
accessible while less frequently used items placed further to minimize encumbrances to
movement around the patient
Enhance visibility to patients Vital sign monitors in multiple locations (e.g., head of bed, foot of bed) to enhance visibility
Reduce noise Ventilation systems that function quietly to minimize additional noise
Floor markings and crowd control designs that ensure efcient workows resulting
reductions in unnecessary noise and chatter
Reduce communication breakdown Ergonomically optimized labeling of equipment to help retrieval of necessary equipment
Personnel stickers for each team member denoting name/role/specialty to improve intra-team
communication
Control/eliminate sources infection Designs that promote the easy application of PPE
Keep space around the patient clear, promoting both free movement of team members and
minimizing splatter onto equipment
Minimize environmental hazards Optimize moveable procedure carts that can be brought to the bedside when needed
Floor markings that designate a “circle of care” or lines indicating care team and support
team
Flat workspaces for equipment during procedures
Automate where possible Integration of vital signs and laboratory results into clinical design support tools (e.g.,
triggers for massive hemorrhage protocol activation)
Motion sensors to trigger device activation (e.g., clinical timers, video recordings)
High-risk tasks (e.g., blood product checks and administration)
Support patient and family involvement in care Space for family to wait with dedicated trauma team members to liaise with family/friends
Physical designs that serve to calm and reassure patients (e.g., calming images on ceilings)
Consider adjacencies Construction trauma bay near EMS entry; planning for CT scanner adjacent to trauma bay
A. Petrosoniak et al.
Design Priorities Specic toTrauma
Based on our research studying trauma teams within their
authentic workplace, we have established more specic
design priorities that align with the broad evidence-based
design principles from AHRQ [32]. Building on the work of
other groups and based on our own observations, we identied several recurrent latent safety threat (LSTs) themes that
manifest during trauma care [5, 30, 32, 33, 38, 39]. LSTs can
be dened as “previously unrecognized system-based conditions that under certain circumstances manifest and threaten
patient safety” [30]. These LSTs include the physical workspace and interpersonal and team communication, establishing shared mental models, infection prevention/safety,
equipment, and procedural/process-based issues. By understanding the frequency of such safety threats, design teams
can look to proactively “design out” these hazards from
occurring. More simply, design features can be included that
serve to eliminate or mitigate LSTs.
Importantly, these themes, while likely generalizable may
not apply to every institution or organization. An in-depth
analysis by the design team using a multi-modal approach
including simulation within the existing space, stakeholder
and end-user interviews, morbidity and mortality reports,
and adverse event reviews will help form a comprehensive
understanding of the design priorities needed. At our institution, we applied a detailed workplace analysis using these
methods before we began construction of our new trauma
bay (Fig.24.1). Through this process, we identied several
unique design features relevant to trauma care:
1. Ensure 360° access to the patient: Critically injured
patients require a range of time-sensitive interventions,
including intubation, intravenous access, chest tubes, and
extremity splints, and optimizing access to the entire
body is essential.
2. Optimize sightlines to vital sign monitors: Conventional
resuscitation designs use a single monitor at the head of
the bed. The addition of vital sign monitors at the side and
foot of the bed increases visibility among team members
of key physiologic parameters that will dictate management interventions.
3. Use modular and moveable task-based carts: To ensure
easy access around the patient, the space should not be
cluttered with equipment. To facilitate this, modular and
moveable task-based carts can be stationed outside of the
immediate care space and brought to the bedside on an
as-needed basis.
4. Design room layout and equipment placement according
to frequency of use: There is predictable equipment that
will be needed frequently while other equipment rarely. A
prioritization strategy should balance frequency of use
with urgency (e.g., thoracotomy kit while rarely used
should be positioned relatively near the bedside, while
orthopedic supplies, which are less urgent items, can be
placed further away).
24 Trauma Bay Development and Design Designed to Perform: How Simulation Can Inform the Design of Elite Trauma…
ab
c
189
Fig. 24.1 A comparison of the original trauma bay with the newly redesigned trauma bay using a comprehensive design strategy including
simulation- informed design. (Location: St. Michael’s Hospital, Toronto, Canada; photo credit: Katie Cooper)
5. Apply an equipment labeling approach that is clinician
focused: Easily readable, color-coded, and appropriately
positioned to facilitate rapid location and acquisition of
necessary equipment while under stress.
6. Promote PPE application and personnel identication:
Position PPE at the entrance in easily accessible locations
to improve compliance and safety for team members. The
use of identication stickers can further improve team
communication and promote a shared understanding of
management plans.
urgency of use of equipment. During the build phase, prototyping of this layout may determine that assumptions and
design decisions do not function optimally once simulated
and minor design changes are required.
To accomplish much of the work during the build phase,
we apply simulation-informed clinical design in a more
detailed manner using a range of simulation techniques, following the functional requirements or objectives of the project [40]. This approach is growing in its application; however,
it remains novel within the trauma community. Several
groups have described their experience with various forms of
simulation-informed clinical design. This spans its applica-
Build
tion to guide the early design throughout the design process
and ultimately testing the clinical space prior to opening for
The transition from the design phase to the build phase is
described as discrete for the purposes of this chapter; however, it may overlap substantially as the design team will
toggle between each phase. The initial principles and features that emerged from the design phase, during the build
phase, are prototyped and more closely evaluated in a manner that establishes their utility within the local institution.
For example, the design team will apply the principle of creating a physical layout that aligns with frequency and
patient care [37, 41–46]. A common thread among each
group is the continued involvement of the design team who
are invited and participate in the simulation-informed clinical design process.
In our experience, the presence of architects and the construction team during simulations of design prototypes promotes a shared mental model of features that are and are not
functional. More specically, the design team comes to
understand how “work as imagined” may differ with “work
190
oject completion
A. Petrosoniak et al.
as done.” The net result is an increased probability that the
nal product will function optimally for the end-users, both
clinicians and patients alike.
Simulation involves the re-creation of real-world events,
using a variety of techniques and tools like high-tech patient
simulators, partial task trainers, and patient actors. This suite
of options allows the simulation to immerse the trauma team
in a realistic environment to elicit reection and promote
learning. When simulation is used to support design of new
ect. Below, we describe four common techniques used during simulation-informed clinical design projects
(Table24.2).
Each technique described in Table24.2, alone, will not
provide sufcient information to inform the entire design of
a new trauma environment, but rather we advocate that a
combination of techniques be used to provide a comprehensive understanding and evaluation of the design. Which technique is used depends on several factors, including:
clinical infrastructure, the unit of analysis is the physical
space and the systems within it. This “allows for reliable and
repeatable analysis of hazards and the design and testing of
controls to mitigate those hazards at a system level” [9].
There are multiple simulation techniques, each serving
a specic purpose, that can be applied throughout the proj-
Table 24.2 Descriptions of simulation modalities and application within the design of trauma infrastructure
Simulation modality Application in trauma care design
Tabletop simulation
Small-scale replica of the clinical space to evaluate workows,
systems, and spaces, contributing to a macro-understanding of the
physical space
Mock-up simulation
Replica of the clinical environment to evaluate personnel movement,
equipment location, and clinical care within a space similar or
identical in size to the nal product
In situ simulation
Simulation within the authentic clinical environment
Computer-based simulation
Clinical environments recreated using computer- based technology
1. Session objectives
2. Time, personnel, and equipment resources available to
the team
3. Expertise to conduct the session(s)
4. Project timeline (Fig.24.2)
A resource-efcient simulation modality that enables the design team
to observe high-level trauma workows and processes using blueprints
or plans of the new space
Adjacency considerations, including patient transport to the OR and/or
CT scan, are easily evaluated
A technique that allows trauma clinicians to immersively experience a
replica of the new design
A trauma team can practice diagnostic and management strategies
with real or replica equipment to evaluate the adequacy of the physical
space, the location of equipment, and their abilities to provide
time-sensitive care
The environmental delity may vary from tape on the oors denoting
equipment and walls to an identical recreation of the soon-to-beconstructed trauma environment
This modality can be used to understand the existing trauma space,
including current workows, deciencies, and areas for opportunity
Additionally, this technique can be used to “crash” test equipment and
workows (e.g., thoracotomy, intubation) within the newly
constructed trauma bay to ensure all elements required for trauma care
are fully functional before opening day
An effective technique to design and iteratively rene a new trauma
bay before investing in the actual construction of the space
Trauma clinicians can be provided tasks (e.g., chest tube insertion)
within the virtual environment and provide feedback on feasibility,
space optimization, and placement of equipment
Table top
Mock-up
Simulation
modalities
Computer-based
or virtual-reality
Fig. 24.2 Proposed sequence of simulation techniques applied during the design of a new trauma resuscitation environment
In situ
Pre-design Design development
Project timeline
Construction Pr
24 Trauma Bay Development and Design Designed to Perform: How Simulation Can Inform the Design of Elite Trauma…
191
How Can Simulation-Based Movement
Tracking BeIntegrated into Healthcare
Design?
As our modes of healthcare delivery become increasingly
complex, more advanced techniques to understand, study, and
optimize care are needed. Efciency is even more important
when patients are in the throes of a life-threatening condition.
The last thing that any team needs is to be searching for equipment scattered around the room while a patient is lying on the
stretcher waiting for a life-threatening intervention. One tool
to combat these inefciencies and improve the design of clinical spaces is movement tracking. That is, technology that
allows for removing extraneous information to highlight locations where clinicians move and concentrate their time.
Non-healthcare industries have long understood the value
of movement tracking. Look no further than UPS, which
studied the movement of their delivery vans [47]. At rst
glance, it would seem to make sense that vans take the most
direct route. Faster is better right? Think again. The company
extensively studied delivery routes and realized they could
make substantial gas savings by routing their vehicles to
avoid left turns. It may add extra miles on individual routes,
but overall speed increased and both total mileage and gas
consumption decreased. Why? Because left turns result in
increased accidents and longer waits at lights. The result:
1110 fewer trucks and ten million fewer gallons of fuel. This
counterintuitive initiative only resulted from focused movement tracking data.
We used in situ simulation coupled with movement tracking to study how a high-performance trauma team interacted
with the clinical environment (Fig.24.3) [34]. We conducted
the exact same simulation several times over the course of a
year within our trauma bay. What did we nd?
1. There are substantial differences in the distance traveled
between clinicians even when they’re performing the
same task. Why?
2. Small design changes can drastically alter how far people
move. Not surprisingly, packaging essential equipment to
perform a life-threatening procedure resulted in more
efcient movement than if the equipment was scattered
around the room.
3. Just studying the movement of people proved to be eyeopening, as clinicians suddenly realized how often they
found themselves walking aimlessly around the room
searching for equipment. The opportunity to observe
movement tracking maps was the light bulb that many
needed to prompt important design changes.
In addition to our work, other researchers and design
groups now use similar movement tracking techniques (also
described as link analyses) [44, 46, 48, 49]. Given the effort
and resources required for these investigations, the design
team should rightly ask whether it is worth it? Specically,
do participants move and behave in the same way during
mock-up simulations as within the actual space? If the
answer is yes, then important information can be gained to
guide the design of a new clinical space without investment
in construction costs. Researchers from Alberta, Canada,
investigated this question by evaluating newly constructed
medication rooms in a hospital space [46]. They built a high
(detailed) and low (simple) delity mock-up along with a
virtual reality version of the space and compared movement
from various tasks with video recordings within the actual
clinical after it opened to patient care (Fig.24.4). They concluded the “workow within each of the three mock-up types
accurately represents realistic workow in a medication
room.” Our own observations and research in the trauma
Fig. 24.3 Movement
tracking diagram during a
simulated trauma
resuscitation. Each line
represents the movement of a
clinical team member over the
course of the 18-min
simulation
192
Fig. 24.4 Movement
tracking data within three
mock-ups (simple, detailed,
virtual reality) of a
medication room compared to
the actual clinical space
(authentic room). (Modied
from Alberta HQCo [46])
A. Petrosoniak et al.
resuscitation environment support these ndings. It is very
likely that well-developed simulations within trauma
mock- ups will provide accurate and representative data of
actual trauma resuscitation workows.
A key aspect to any design project is understanding the
end-user. Movement tracking provides a unique look at how
the end-user interacts with their space, a perspective that
simply is not possible when the individual is questioned
directly. When we asked clinicians about how long it took to
nd equipment or how far they traveled, their estimates were
not even close. It is clear that people nd it conceptually difcult to accurately recall movement, especially under times
of stress. Tracing maps clearly illustrate points of congestion
and opportunities for design improvements.
The future of clinical space design includes a deeper
appreciation of “how” work is done. What better way to
understand the “how” than directly observing the path
required to make it happen? Objective and focused efforts to
track movement are essential design tools to optimize spatial
utilization, reduce time, and save money.
Train
A simulation-informed clinical design approach to the construction of a new trauma resuscitation environment is
closely linked to the team training plans once the space is
operational. While a detailed overview of trauma team training is published elsewhere and beyond the scope of this
chapter [50], there is no doubt that the built environment is
closely linked to team performance.
Look no further than the Formula 1 racing industry [51,
52]. The sport’s pit crews have become the archetype of team
performance. In pairs, the team can remove and replace four
tires, a remarkable feat and one that is only achieved with
intense training. While training is critical, the teams could not
perform tasks with such speed without perfectly designed
equipment and team members perfectly positioned around
the car. This link between design and function is a key to suc-
cess that many industries have long appreciated. In acute care
medicine, we are only now beginning to realize the importance of form-tting function, and once optimized, team performance and ultimately patient outcomes improve [53].
In trauma training, we focus extensively on teaching crisis resource management (CRM) strategies to support teams
during high-stress, time-sensitive situations [50, 54]. The
principles of CRM include an emphasis on team communication and effective teamwork strategies [55–59]. For example, two team members using closed-loop communication
might sound like the following:
Please get the chest tube cart
Where is the chest tube cart?
Behind the door on the other side of the room
OK, I see it, I’ll grab it. Here it is
Thank you, chest tube cart received
In this situation, the team members are using closed-loop
communication, and this is effective in obtaining the necessary equipment. This type of communication is effective, but
it requires practice. What is apparent, however, in this example and typical of many trauma resuscitations is that communication becomes the backstop for poorly designed spaces.
Teams rely on highly effective communication skills to overcome the deciencies of the clinical environment [32, 33]. If
the trauma resuscitation environment was designed more
intuitively, team training could focus on more patient- centered
elements rather than ensuring they can effectively request and
describe the location of poorly located equipment.
Imagine how the communication between team members
may take place in a space where the chest tube cart was
located in a more appropriate location. It may eliminate the
need to ask a fellow team member for the cart, and the clinician may be immediately ready to perform the procedure:
Team lead, I have the chest tube cart and I’m ready to proceed on
your call
Thank you, go ahead with the chest tube insertion now
At our institution, we have observed that when the layout
and usability of the space are intuitive, less time is required
24 Trauma Bay Development and Design Designed to Perform: How Simulation Can Inform the Design of Elite Trauma…
193
to teach people about how to use the space, and greater effort
is directed toward optimizing patient care. The downstream
impact of highly functional clinical design should be considered as a signicant return on investment (ROI) for future
training plans. The built environment cannot be separated
from the training process. By optimizing the physical space
and equipment within it, through intuitive designs, the
emphasis of team training can be shifted toward the nuanced
aspects of clinical decision-making and team performance.
Excel
The transition from construction to beginning clinical care is
exciting and ultimately represents the culmination of an
extensive project. Once the construction of the trauma resuscitation environment is, however, it is not sufcient to stop
the design process [42, 43]. While there is a higher probability that design aws have been identied and mitigated using
simulation-informed clinical design, latent safety threats
may still pose risks to patients. Additionally, changes in processes and systems may not have been considered during the
design process, thus requiring updates.
The construction of a new trauma resuscitation environment should be paired with ongoing evaluation strategies to
monitor for issues and recognize successes. The latter represents the traditional approach to safety (Safety I), whereby
the unit of analysis is the “accident” or the harm [8]. In
Safety I, safety is dened by the absence of harm, we seek to
learn from our errors, and the system is designed to avoid
errors. In contrast, Safety II, an approach popularized by
Braithwaite and colleagues, emphasizes the protective factors and decisions that support successes [8]. In Safety II,
safety is dened as the presence of “what goes right” and we
reorient our perspective to design our systems to support
these successful behaviors.
A well-designed trauma program and trauma environment
will include both Safety I and Safety II perspectives. The
physical structure of the environment can do so using built-in
technology like video and audio recording devices that allow
for periodic case review. We believe that both successful
cases and those involving adverse events be subject to review
as learnings will be found in both instances. During case
review, specic attention should be paid toward the design
features that supported specic behaviors. Video review of
trauma resuscitations is discussed further in Chap. 15.
Emerging technology, such as articial intelligence, may
enhance our ability to improve by providing unique insights
into behaviors, systems, and infrastructure that are otherwise
difcult to appreciate. For example, the Black Box, technology that is now in place in operating rooms, has the ability to
capture multiple environmental factors (conversations, decibel levels, team movement) and link them to the patient’s
clinical status, team decisions, life-saving procedures, and
ultimately patient outcomes [60, 61]. This in-depth understanding has the potential to completely alter our ability to
reect, rene, and improve our systems and clinical designs.
The learnings from these outputs can then be integrated into
the trauma system and, when possible, used to redesign the
clinical environment.
Return onInvestment
The costs associated with building elite trauma resuscitation
environments are not insignicant, and it behooves the
design team to complete at or under the budget available. At
rst glance, the methods we describe in this chapter may
seem overwhelming in terms of human, equipment, and
nancial resources. The evidence suggests these upfront
costs, however, are quickly mitigated given the benets of
simulation-informed and design thinking processes. This is
supported by the concepts described in the MacLeamy Curve
(Fig.24.5) which speaks to a very simple but important principle in architectural and project management: design
changes become more costly and less effective the farther
along they occur, underscoring the importance of getting it
right from the beginning [62].
While the MacLeamy Curve and its associated concepts
seem intuitive, it may not be obvious to clinicians, funders,
and the design team when developing and evaluating the initial project plan. We propose that an early meeting explicitly
addresses in part the following:
• Introduce this concept to clinicians, the design team, and
the funders
• Acknowledge that upfront costs will have downstream
savings (both time and economic)
• Heavy investment in understanding the needs of end-
users (patients and clinicians), the potential future of
trauma care, the potential to adapt for rare events (pan-
demic, mass casualties)
Upon acknowledging the value of front-loaded work to
yield dividends long term, the plan for simulation-informed
design can begin. In our experience, ndings from a
simulation- informed design process can be broken down into
two general categories:
The known unknowns: Data is a more powerful driver for
change than anecdote. Codifying and quantifying known
issues by way of a current state analysis can inform pro-
cess improvement to a greater extent than incident reports
and hallway conversations. Even if everyone already
knows there’s an issue: “It takes way too long to get blood
to the bedside in trauma.” The data from targeted in situ
194
C
abilit
change
TIMELINE
Cost of design
Fig. 24.5 MacLeamy curve.
The preferred design process
emphasizes upfront
investment during project
planning and design
development. This maximizes
the ability to make project
changes while minimizing the
cost of such changes.
(Modied from Overbey [63])
ost &
Ability to impact
project
y to
preferred
design
process
Planning Design development Construction
typical
design
process
PROJECT
A. Petrosoniak et al.
changes
simulations can substantiate those observations in ways
that are hard to ignore: “Our simulations demonstrated an
average delay to blood product delivery of X minutes,
which is associated with an increase in patient mortality
of Y.”
The unknown unknowns: Sometimes, you don’t know some-
thing is a problem until it’s a problem. Once you know
there’s an issue, simulation can help you get to the root of
the problem. Turns out, delays in blood product delivery
were due in part to the circuitous path our blood runners
had to take to get to the blood bank, and not knowing how
or when to announce themselves when they got back.
Data and observation inform better decisions for process
improvement. At our institution, the case of improving blood
product delivery times and revising the massive hemorrhage
protocol would have done nothing to make the process better
or faster. Instead, a human-focused solution to shorten the
distance traveled and facilitate awareness upon arrival
decreased blood product delivery times from 11.5min to
9 min, an improvement that is associated with a 12.5%
decrease in mortality for trauma patients [35, 64].
There is growing evidence that these forward-thinking
and innovative approaches to clinical design yield substantial dividends later on in the project. Several groups have
described their ndings using both simulation-informed clinical design and the design thinking process.
A Canadian group of researchers conducted a detailed
ROI analysis of using simulation-based mock-ups to mitigate the need for future renovations of medication rooms
(Fig.24.4) [46]. They concluded a return on investment (in
percentage) between 506% and 2685%, depending on the
simulation technique used. Translated into dollar savings, for
every dollar invested in mock-up simulations, between $5.06
and $26.85 can be saved after the investment is recovered.
The authors described additional intangible benets that
included design interventions that were applied following
the mock-up evaluation process, resulting in fewer interruptions, potential for fewer errors, and faster preparation time
for medications.
An independent ROI analysis of IBM’s design thinking
strategy concluded that its application reduced design time
of new products by 75%, doubled the speed to move products to market, decreased product testing times, and ultimately increased prots by >$100,000 for small projects
and>$1,000,000 for large projects [21].
In our experience and upon review of broader literature
using these methods, the return on investment (ROI) is substantial and favors the use of simulation-informed and design
thinking-based processes.
Putting It Together
This chapter describes a detailed and practical approach to the
design of trauma resuscitation environments using simulationinformed clinical design. Based on our experience, our
research, and the work of others, this represents a robust and
highly usable framework. Linked closely to our approach is
design thinking methodology which we have used to test, evaluate, and modify new clinical infrastructure [17].
This human-centered process is used in numerous nonhealthcare domains to support the design and testing of new
products [65]. A key difference to this methodology compared to others is the focus on the “end-user.” In trauma care,
the “end-user” is not a single individual but rather comprises
groups of people from patients/families to clinicians to nonclinical staff. The design thinking process consists of ve
steps that promote a human-centered focus, and simulation is
integrated throughout (Fig.24.6).