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38 Trauma Resuscitation intheHealth Information Technology Age
325
Fig. 38.1 Advances in HIT enable the integration of time-stamped, high-resolution data from numerous sources (i.e., multidimensional data) and
the ow of that data to several tiers of analysis
Rapid andComplete Documentation
Similarly, the Craig Joint Theater Hospital in Afghanistan
utilized the T6 Health Systems mobile application to improve
The major trauma patient medical record often requires input
from multiple specialties and care providers along a complex
and prolonged clinical pathway. Historically, this has led to
inaccuracies in data entry and missing or lost data, even with
the use of traditional electronic medical records [6, 7].
However, advances in HIT user interface design and mobility
have enabled trauma teams to document right at the point of
trauma resuscitation, and to create accurate, complete, and
holistic patient electronic health records (EHRs). Numerous
studies have validated the effectiveness of novel digital tools
in improving documentation practices.
A pilot study at the Trauma Unit at Groote Schuur
Hospital, University of Cape Town, demonstrated the
successful implementation of an electronic trauma health
record (eTHR) using mobile, iPad-based technology [8]. The
transition from paper-based documentation to the eTHR
resulted in higher documentation completion rates of trauma
admission records, operative notes, and discharge summa-
their trauma documentation [9]. In a comparative study, the
completeness and accuracy of data capture were evaluated
by comparing T6 electronic records with handwritten documentation from the same trauma resuscitations. The study
revealed an overall 13% increase in data capture compared to
the gold standard paper resuscitation records, and a high
accuracy rate of 96% with the electronic application [9]. This
evidence supported the hypothesis that trauma-tailored electronic documentation applications, such as T6 Health
Systems, can signicantly enhance the completeness and
accuracy of trauma documentation.
HIT, encompassing mobile applications and electronic
records, enables the development of accurate, complete, and
holistic patient EHRs in trauma care. The validation of these
digital tools in real-world trauma settings underscores their
potential to improve usable data capture, accessibility, and
interoperability, with the potential to inform improved quality of patient care.
ries, along with increased provider satisfaction [8].
326
J. Kroeker et al.
Situational Awareness: Overhead
Dashboards inTrauma Resuscitation
Optimal patient outcomes in trauma resuscitation rely on
seamless integration of multiple healthcare specialists and
disciplines, all dependent on real-time data in a fast-paced
and dynamic environment. Digital transformation brings
forth the capability for multidisciplinary team members to
share and access multidimensional data, contribute to shared
mental models, and smooth the ow of resuscitation as data
ows between user interfaces, monitors, labs and diagnostics, and overhead dashboards.
Studies in the eld of cognitive science have revealed that
the human brain possesses the highest capacity for processing visual information compared to other senses. In fact, it is
estimated to be 10 times more efcient than touch and 100
times more efcient than hearing or smell [10]. Moreover,
visual data is processed at such a remarkable speed and volume that a signicant portion of this processing occurs subconsciously. This phenomenon, known as preattentive
processing, plays a crucial role in reducing cognitive load,
enabling us to effortlessly comprehend complex images by
subconsciously organizing their components into a cohesive
system. Consequently, through collaboration with cognitive
psychologists and engineers, the application of visual cognition science has shown great promise in enhancing situational awareness within the healthcare domain.
To illustrate the potential benets, Calder etal. conducted
a study involving the implementation of an overhead visual
dashboard that provided real-time updates on patient status
during resuscitation simulations [11]. The participants in
this study reported an increase in condence levels and a
reduction in stress during simulations. Furthermore, participants felt that the visual dashboard improved provider performance and facilitated smoother transitions in patient
care. Similarly, Parush etal. (2017) showed how a visual
dashboard improved teamwork (as measured by the Clinical
Teamwork Scale), increased multidisciplinary discussion,
and enhanced situational awareness (as measured by the
Situational Awareness Global Assessment Technique tool)
in resuscitation simulations [12]. Both studies suggest data
visualization tools have the capacity to signicantly improve
team dynamics in real-life scenarios in the trauma bay.
T6 Health Systems, a mobile application specically
designed for the iPad to synchronize real-time data collection with trauma resuscitation workows (as depicted in
Fig.38.2), offers options to display data on overhead dashboards, enhancing information accessibility and situational
awareness (Fig.38.3). This visual aid is designed to present
real-time data in a way that reduces each practitioner’s cognitive load, thereby allowing the trauma team to work
together from a shared mental model. Ultimately, this technology enables a more synchronized and efcient approach
to trauma resuscitation.
Fig. 38.2 Mobile, digital
user interface congured to
trauma workows to support
near real-time collection of
resuscitation data. (Source:
T6 Health Systems (used with
permission))
38 Trauma Resuscitation intheHealth Information Technology Age
Fig. 38.3 T6 mobile
application connected to
overhead dashboard to
enhance team situational
awareness. (Source: Apple
News (https://www.apple.
com/newsroom/2021/11/
veterans- use- appletechnology- to- revolutionizetrauma- medicine/))
327
Clinical Decision Support
The digital transformation of medical records enables
context- based clinical decision support (CDS). CDS, including timely alerts, relevant clinical practice guidelines (CPGs),
checklists, and risk scores, are triggered by incoming clinical
assessments and offer tailored responses based on data
inputs.
Integration of this digital technology in the trauma bay is
already underway. For instance, a pilot study evaluating a
digital decision support tool, called BloodNavigator, for
massive transfusion during trauma resuscitation was found
to be useful based on user feedback [13]. This tool featured a
color display that changed based on the administered ratio of
blood products, providing immediate visual feedback on
adherence to evidence-based guidelines for blood product
resuscitation.
Additionally, applications such as T6 offer customizable
features that enable instant linkage to local clinical practice
guidelines, checklists, and relevant risk scores when specic
injury mechanisms are entered. For example, if a major blunt
mechanism of injury is entered, the system will generate a
suspected cervical spine injury clinical pathway with appropriate action items, such as ordering necessary imaging
(Fig.38.4). Whether CPGs or checklists are consulted or not,
they bring tailored, evidence-based best practices to the
bedside as a reference standard for teams working in stressful conditions under heavy time constraints.
Articial intelligence and machine learning (AI/ML) have
immense potential in enhancing clinical decision support in
trauma care; however, they require high-resolution, timestamped data that may not be readily available or accessible
through conventional electronic health records (EHR) or registries to realize their full potential. A comprehensive review
of AI/ML applications along the continuum of trauma care
[14] showcased the promising capabilities of AI/ML in prog-
nosticating critical care interventions and patient outcomes
and informing patient trajectory. For instance, the Epic
Deterioration Index (EDI), a machine learning tool, has been
validated as effective in predicting mortality and unplanned
ICU admission in trauma patients, achieving an impressive
AUC of 0.98 [15]. Similarly, an algorithm utilizing vital signs,
demographics, and Glasgow Coma Scale (GCS) achieved an
AUC of 0.99in determining the need for life-saving interventions upon emergency department (ED) presentation [16].
Moreover, utilization of AI/ML during the PROPPR trial,
which collected rich data during the study period, revealed
novel associations between hemostasis and time that were not
discovered via conventional statistical analysis methods [17].
By integrating AI/ML into a comprehensive digital framework, as depicted in Fig.38.5, its utility is amplied through
unrestricted access to high-resolution data.
This integration allows for a more comprehensive assessment of all available clinical clues, accounting for variations
in their importance over time, and revolutionizing decisionmaking. HIT capable of capturing and analyzing incoming
high-resolution data at the point of care may make it possible
to equip trauma teams with increasingly sophisticated AI/
ML predictive analytics to support more effective clinical
decision-making in rapidly evolving situations.
328
Fig. 38.4 T6 Dashboard
displaying clinical practice
guidelines in response to
real-time data input. Here,
input of a major blunt
mechanism of injury triggered
an institution-specic cervical
spine injury pathway. (Source:
T6 Health Systems (used with
permission))
J. Kroeker et al.
Fig. 38.5 Schematic of
dashboard view
demonstrating ongoing,
real-time renement of risk
prediction (i.e., probability of
massive transfusion) as new
data accumulates over time,
and data elements in the
predictive AI/ML model
undergo time-dependent
changes in their clinical
signicance. (Source: T6
Health Systems (used with
permission))
Quality Improvement
Utilizing digital tools, the collection and accessibility of
high-resolution digital data along the continuum of trauma
care enables tracking of specic actions performed during
the care process and the instantaneous creation of process
maps (Fig.38.6).
Process mapping is a valuable tool in quality improvement efforts as it helps identify inefciencies, bottlenecks,
and variations in the care process. By visualizing the care
pathway, healthcare teams can streamline workows, reduce
delays, and enhance overall efciency. It also facilitates the
identication of areas for standardization and the development of standardized protocols, ensuring consistent and
high-quality care delivery, promoting patient safety, and
reducing errors. For example, implementation of a hip fracture care pathway in response to patient process mapping
improved patient throughput to operative intervention and
complication identication [18].
38 Trauma Resuscitation intheHealth Information Technology Age
Fig. 38.6 Visualization of
patient data along the
space-time continuum
facilitates tracking of specic
actions during the care
process and enables creation
of process maps for quality
improvement initiatives.
(Source: T6 Health Systems
(used with permission))
329
Moreover, process mapping serves as a foundation for
value-based healthcare (VBHC) agendas. VBHC is a strategic healthcare delivery model that incorporates evidencebased medicine with patient-perceived value conferred by
healthcare interventions [19]. Successful VBHC relies on
high-resolution data for constant quality assessment, implementation of targeted interventions, monitoring of changes,
and outcome measurement. This iterative approach allows
for ongoing evaluation and renement of care processes to
continually improve patient outcomes and satisfaction.
Developing HIT innovations has tapped potential in driving
the adoption of VBHC initiatives in trauma centers. For
example, the T6 application offers an automated framework
that calculates personnel, equipment, supplies, and space
costs, enabling time-driven activity-based costing (TDABC).
This feature can measure the economic value of value-based
healthcare initiatives by providing accurate cost assessments.
However, additional research is required to validate the
effectiveness of these types of digital tools in delivering
these benets.
Research
Digital transformation of the medical health record is revolutionizing trauma research by overcoming traditional barriers
associated with data collection and analysis. Unlike conventional trauma registries built from traditional EHRs or paper
charts, which lack congurability for efcient data retrieval
and require substantial time and resources for creation and
maintenance, digital data capture applications and advancements in data storage and exchange facilitate the seamless
and instant creation of comprehensive, information-rich
trauma databases.
A notable example of the power of digital technology in
trauma research is the successful implementation of the electronic Trauma Health Record (eTHR) pilot in Groote Schuur
Hospital, in Cape Town, South Africa [8]. Over the course of
a year, the eTHR pilot generated an extensive dataset comprising more than 11, 000 trauma admissions, offering
researchers valuable insights and opportunities for analyzing
injury patterns, identifying trends, and evaluating clinical
outcomes (Fig. 38.7) [20]. For instance, researchers were
able to conduct in-depth analyses of a large cohort of 800+
patients with penetrating abdominal trauma to identify indicators predictive of successful nonoperative management
[21]. These analyses were facilitated by leveraging the digital database created through the eTHR pilot project.
The success of the eTHR pilot exemplies how digital
technology can overcome barriers in injury surveillance
and data collection for research purposes, even in
resource- constrained settings. By enhancing the speed
and ease of data retrieval and analysis, the eTHR pilot
contributed to evidence-based decision-making and
advancing trauma care practices. The transformative
potential of mobile digital technology in trauma research
is evident, as it improves the efciency and effectiveness
of research efforts in the eld.
330
70
Daily No. of Consults
Date
60
50
40
30
20
10
0
Dec 1Jan 1Feb 1 Mar 1 Apr 1May 1Jun 1Jul 1
2013
J. Kroeker et al.
Aug 1 Sep 1 Oct 1Nov 1 Dec 1
2014
Fig. 38.7 Dashboard view of daily trauma center volumes showcasing
the implementation of an iPad-based electronic trauma health record
(eTHR) at a bustling South African trauma center. The eTHR facilitated
the population of an electronic database, enabling data visualization,
real-time reporting, and research-oriented data analysis. (Source:
Authors original research, also published [Zargaran E, Spence R,
Trauma Systems
The pinnacle of data ow in trauma care is achieved when
data captured through digital technology informs trauma
systems performance improvement, including injury prevention strategies, trauma education, healthcare policy, and economics. This transformative opportunity lies in harnessing
the continuously owing data, leveraging analytics and data
visualization strategies, and fusing creative innovations
together to improve health equity.
One instance where digital technology is currently being
utilized to address health equity by improving access to
trauma care is through trauma education and mentoring.
Using video-conferencing applications, trauma surgeons can
provide remote guidance and instruction to non-surgeon
physicians in performing critical procedures, such as a
decompressive fasciotomy [22, 23]. Studies have demonstrated the effectiveness of telementoring in improving practitioner condence and trauma team dynamics, paving the
way for improving trauma patient outcomes in rural and
resource-limited settings [22, 23]. The fusion of augmented
reality (AR) technology with telementoring further elevates
the potential of remote mentoring and guidance. For example, the United States military has explored its use for damage control procedures in battleeld situations where
immediate access to a trauma surgeon may be challenging
[24]. By using AR glasses and telestrated instructions, a
remote surgeon can guide a nonsurgeon through critical procedures, effectively providing real-time support and guidance. AR telementoring allows participants to complete tasks
with greater accuracy and fewer distractions, presenting
Adolph L, Nicol A, Schuurman N, Navsaria P, Ramsey D, Hameed SM.
Association Between Real-time Electronic Injury Surveillance
Applications and Clinical Documentation and Data Acquisition in a
South African Trauma Center. JAMA Surg. 2018 May 16;153
(5):e180087. doi: 10.1001/jamasurg.2018.0087. Epub 2018 May 16.
PMID: 29541765; PMCID: PMC5875377.)
exciting possibilities for future telementoring in real-life
trauma scenarios [25]. Remote telementoring is discussed
further in Chaps. 39 and 40.
While the above digital innovations have demonstrated
positive impacts on a smaller scale, it is crucial to address the
larger problem of the global burden of injury, which has
gained international attention as a signicant public health
issue. Consensus among experts emphasizes two key factors
for successful implementation of a global injury-prevention
initiative using digital technology: (1) establishing seamless
pathways for data linkage and analysis to enable real-time
data ow to guide action in injury prevention and trauma
care improvement/education, and (2) fostering strong partnerships among data scientists, health economists, data engineers, injury prevention workers, trauma clinicians, and
policymakers to ensure analytical capacity keeps pace with
the growing inux of data, leading to meaningful improvements in society’s safety [26]. Currently, this goal of leveraging digital technology to address the global burden of injury
has not been fully realized.
In an increasingly globalized world, the use of digital
technology has the potential to shrink distances and open
doors to new opportunities, addressing trauma system
inequalities and inefciencies.
Conclusion
We stand on the threshold of unprecedented transformations
in healthcare propelled by digital technology. Looking
ahead, we anticipate remarkable transformations in trauma
38 Trauma Resuscitation intheHealth Information Technology Age
331
care as advances in HIT drive innovations such as augmented
reality (AR) with telementoring and the integration of AI/
ML into clinical practice.
Advancements in data integration, mobile digital technology, and achieving both intraoperability (i.e., complete integration with existing electronic platforms within a hospital
or healthcare setting) and interoperability (i.e., sharing a
transfer of anonymized data sets between healthcare systems) will revolutionize trauma care and enable a collective
global effort to reduce the burden of injury and improve
trauma outcomes [26]. However, challenges such as generating incompatible data sets, ensuring privacy and data security, and carefully considering the potential harms and
benets of technology must be addressed to facilitate widespread adoption [26].
As we navigate this exciting journey, it is crucial to
remember that technology is a tool, not a panacea, and that a
deep understanding of the challenges in trauma care should
guide our pursuit of innovative solutions. The integration of
technology into clinical practice should be done thoughtfully
so as to ensure solutions address the unique needs of patients,
clinicians, and systems. By leveraging design thinking—an
iterative process involving dening problems, ideating solutions, and continuous analysis to gain actionable insights—
we can foster meaningful, transformative progress in the
eld of trauma. The future of trauma care is ours to shape
with thoughtful and purposeful application of technology.
Key Points
• Advances in computing power, data storage, data
analysis, and clinical informatics have created new
opportunities for the evolution of trauma systems.
• Clinical data captured in near real time can be
applied to clinical decision support and to enhance
trauma team dynamics.
• Unprecedented access to high-resolution data can
inform design thinking approaches to trauma systems quality improvement.
• High-quality data collected at the point of care
holds the promise of driving more sophisticated
analytic and risk prediction strategies for trauma
care.
• Technological advances in telehealth can increase
the reach and impact of trauma systems to rural and
remote communities and vulnerable populations.
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Telemedicine andFuture Innovation
CorryJ.Kucik, J.JonasCarmichael, andWilliamP.Mulvoy III
39
… and yet a true creator is necessity, which is the mother of our
invention. (Plato, The Republic, Book II, 369c)
Introduction: TheNeed
Trauma remains a leading cause of death and disability
throughout the world, including developed nations. Despite
the rigorous construction of advanced trauma systems throughout the United States, regional differences persist and can be
exacerbated by supply and geography constraints. Mismatches
exist between the incidence of trauma throughout the United
States and the number of traumatologists, Level 1 trauma centers, or even adequate community hospitals existing to service
this need (Fig.39.1). Due to multiple reasons (costs, inability
to recruit and retain clinicians, rarity of certain types of
trauma), there may never be a day that enough fully staffed
and qualied centers will exist to enhance care in austere locations. Further, the “tyranny of distance” imposed not only on
rural locations but also on special populations (e.g., correctional facilities, home health care settings, nursing homes,
military populations overseas or at sea, cruise ship passengers)
can never be fully alleviated by the construction of US trauma
centers, exacerbating the shortfall all the more.
The Promise ofInnovation andTelemedicine
Bridges to the future are needed not only to service this great
need of trauma care, but perhaps, in time and with game-
C. J. Kucik (*)
Department of Anesthesiology and Pain Medicine, University of
Washington School of Medicine, Seattle, WA, USA
J. J. Carmichael · W. P. Mulvoy III
Department of Anesthesiology, Division of Cardiac Anesthesiology
and Critical Care Medicine, University of Florida College of
Medicine, Gainesville, FL, USA
e-mail: wmulvoy@anest.u.edu
changing technologies, to prevent and obviate it. The use of
the word “innovation” is common in medicine today, where
everyone from startup companies to the boards of established
companies ceaselessly searches to prot from the next “big
thing” in medicine. Telemedicine, the delivery of health care
and the exchange of health-care information across distances, holds particular promise in trauma care, particularly
when existing limitations (supply, distance, etc.) render it
either more acceptable than existing conventional services or
indeed the only option available.
Telemedicine is dened by the Telemedicine Information
Exchange (1997) as the “use of electronic signals to transfer
medical data (photographs, x-ray images, audio, patient
records, videoconferences, etc.) from one site to another via
the Internet, Intranets, PCs, satellites, or videoconferencing
telephone equipment in order to improve access to health
care.” According to the Telemedicine Report to Congress
(1997), “telemedicine can mean access to health care where
little had been available before. In emergency cases, this
access can mean the difference between life and death. In particular, in those cases where fast medical response time and
specialty care are needed, telemedicine availability can be
critical. For example, a specialist at a North Carolina
University Hospital was able to diagnose a rural patient’s
hairline spinal fracture at a distance, using telemedicine video
imaging. The patient’s life was saved because treatment was
done on-site without physically transporting the patient to the
specialist who was located a great distance away.”
Telemedicine interactions are generally classied as
either prerecorded (also called “store-and-forward”) or real
time (also called “synchronous”). In the former, information
is acquired and stored before being sent to an expert for
interpretation at some later time. E-mail is a common method
of store-and-forward interaction today. In contrast, in realtime interactions, there is minimal appreciable delay between
the information’s collection, transmission, and display.
Interactive communication between individuals at the sites is
therefore possible. Videoconferencing is a common method
of real-time interaction.
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_39
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Fig. 39.1 Map of CONUS with relative population sizes and proximities to a civilian level 1 or level 2 trauma center. Every dot represents a
single ZCTA. Smaller dots represent sparsely populated ZCTAs,
whereas larger dots represent densely populated ZCTAs. Blue dots are
relatively close to a civilian trauma center, whereas yellow dots are relatively distant. CONUS, continental USA; ZCTA, Zip Code Tabulation
The common thread for all telemedicine applications is
that a client (e.g., patient or health-care worker) obtains
advice or—as we will likely see in the future with haptics
(tactile feedback technologies that recreate the sense of
touch) and robotics—direct intervention from someone with
more expertise, even when the parties are separated by space,
time, or both.
History andDevelopment
As human beings spread throughout every environment on
the globe and even into space, the need for technology to
push health care to the patient has followed. Telemedicine
has thus developed into many different entities that at their
core deliver information over great distances thus improving
access to medical care. Describing its broad scope, Reid
denes telemedicine as “the use of advanced telecommunications technologies to exchange health information and provide health care services across geographic, time, social, and
cultural barriers” [1]. The need to overcome these varied barriers has driven the growth of telemedicine into multiple outlets and practices.
Telemedicine can be classied by the type of interaction
between the client and health care expert in contrast with the
Area. Building trauma capability: using geospatial analysis to consider
military treatment facilities for trauma center development—Scientic
Figure on ResearchGate. (Available from: https://www.researchgate.
net/figure/Map- of- CONUS- with- relative- population- sizes- andproximities- to- a- civilian- level- 1- or_g 1_360816379 [accessed 26 Oct
2024])
content of the information being transmitted [2]. In “store
and forward” telemedicine, the necessary information is
compiled and then sent to an expert for evaluation later.
There is an inherent delay in the interpretation of the data but
access to advanced technologies aids the denitive care of
the patient. Cardiology event monitors, diagnostic images, or
expert e-mail consultation are examples of “store-andforward” technologies. Real-time interactions allow an
immediate assessment of the patient, data, and situation to
expedite appropriate care with the remote assistance of a
subject matter expert. One such example is simple audio
feeds broadcast over various networks that provide rst
responders the ability to interact with Emergency Medicine
physicians and appropriately triage patients to specialty centers. Tertiary care hospitals use networked programs to link
with rural or suburban areas over high-speed lines or private
point-to-point connections for telecommunication among
providers. The information transmitted can range from text
and audio to more sophisticated interactions such as images,
video, or robotic interfaces that may allow a combination of
several interfaces.
The term “telepresence” describes the ability of health
care providers to interact in real time with telecommunication equipment, allowing for immediate feedback and assistance. Adapted for trauma, telepresence allows experienced