Delphi Method Consensus-Based Identification of Primary Trauma Care Skills Required for General Surgeons in Japan

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J Acute Care Surg. 2023;13(2):58-65

Publication date (electronic) : 2023 July 24

doi : https://doi.org/10.17479/jacs.2023.13.2.58

Kazuyuki Hirose^a, Soichi Murakami^a,, Yo Kurashima^a, Nagato Sato^b, Saseem Poudel^a, Kimitaka Tanaka^a, Aya Matsui^a, Yoshitsugu Nakanishi^a, Toshimichi Asano^a, Takehiro Noji^a, Yuma Ebihara^a, Toru Nakamura^a, Takahiro Tsuchikawa^a, Toshiaki Shichinohe^a, Kazufumi Okada^c, Isao Yokota^c, Naoto Hasegawa^b, Satoshi Hirano^a

^aDepartment of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Sapporo, Japan

^bDepartment of Surgery, Kushiro City General Hospital, Kushiro, Japan

^cDepartment of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, Japan

^*Corresponding Author: Soichi Murakami, Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, Hokkaido 060-8638, Japan, Email: so-ichi@huhp.hokudai.ac.jp

Received 2023 February 18; Revised 2023 May 12; Accepted 2023 June 29.

Abstract

Introduction

In many countries, established trauma care systems use the “Hub-and-Spokes” model of care [1–3] consisting of a bypass protocol that results in the direct transport of severely injured patients to major trauma centers (MTCs) where there are trauma surgeons and other organ specialists [3].

In the US, the American College of Surgeons Committee on Trauma set the criteria for hospitals to gain trauma center status whereby function and education is assessed, and certification is based on strict criteria [4]. Level III trauma centers function as secondary acute care hospitals (SACHs) in rural areas. The surgeon in charge of trauma treatment has the skills and knowledge necessary for resuscitation, stabilization, and transfer of patients, and maintains an adequate level of treatment supported by regular re-education.

The current trauma emergency medical care system in Japan was established in the mid-1970s and is stratified into primary, secondary, and tertiary hospitals [5,6]. However, there is no system in place to assure its quality, and the requirements and training systems for staff vary widely according to the conditions at each hospital. Furthermore, the number of trauma surgeries has decreased recently; this is in part due to a reduced number of traffic accidents [7], and improvements in interventional radiology. Because of these factors, it has become difficult to provide radical treatment for patients with severe trauma in regional SACHs. However, a comprehensive trauma treatment system for trunk injuries (including transfer to MTCs) has not yet been established, and its introduction is urgently needed.

To address these concerns, there is a need to establish a “Hub-and-Spokes” type consolidation system of trauma care. To this end, it is necessary to clarify the trauma care skills that general surgeons working in SACHs, which can be referred to as the “Spoke To this end it is necessary to clarify the trauma care skills that general surgeons working in SACHs, which can be referred to as the “Spoke”, should possess to transport severe trauma patients to the MCTs, as well as to train them to be able to perform these skills. The present study was conducted to evaluate and reach a consensus regarding the essential trauma care skills required for general surgeons by conducting expert interviews and a Delphi survey.

Materials and Methods

2. Compilation and review of a list of trauma care skills

A total of 31 items regarding trauma care skills undertaken by general surgeons were compiled through research team discussions including a researcher, surgical educator, and acute care surgeon. In this study, the term “general surgeon” included surgeons who practice digestive, cardiovascular, or thoracic surgery. Six experts certified as acute care surgeons by the Japanese Association for Acute Medicine were chosen for the experts to be interviewed. The compiled list of 31 items was sent to these experts via e-mail, and they provided feedback on whether each trauma care skill would be primarily required by general surgeons. This resulted in 33 items being included in the Delphi consensus survey (Table 1).

Table 1

Primary trauma care skills selected by the research team and through interviews with experts.

4. Survey process

The Delphi consensus survey was conducted using web-based software (Google Forms). All invited specialists completed the survey rounds.

In the 1^st round, participants were presented with a predefined list of 33 items and asked to rate how strongly they agreed or disagreed [using a 5-point Likert scale (1 Strongly disagree, 2 Disagree, 3 Undecided, 4 Agree, and 5 Strongly agree)] with the necessity of each procedure. Moreover, the participants could provide comments/revisions to each item, and add additional relevant trauma care skills which they thought a general surgeon should possess. All survey participants were asked to respond within five weeks, and reminder letters were sent to non-responders approximately two weeks before the deadline.

In the 2^nd round, participants (1^st -round responders) were asked to rate the same 33-item list again, after the results of the 1^st round (graphs of group ratings for each item) were shared. Furthermore, these participants were asked to rate new skills that had been suggested for inclusion by more than two participants during the 1^st round (Figure 1).

Figure 1

Flowchart of the Delphi consensus survey.

Results

1. First round Delphi survey

There were 117 specialists initially contacted, of whom 85 participated in the 1^st round of the Delphi survey (response rate: 72.6%). Table 2 shows participant characteristics. In this round, two or more respondents suggested the inclusion of three additional items, “diaphragm repair,” “ostomy,” and “temporary abdominal closure,” to the list.

Table 2

Characteristics of the Delphi survey participants (n = 85).

2. Second round Delphi survey

In the 2^nd round of the survey, the 85 specialists who responded in the 1^st round were contacted, and 66 participated and rated the skill items in the revised list (response rate: 77.6%). The consensus achieved after two rounds of the survey was reliable (Cronbach’s α score of 0.94), and there were 34 items regarding trauma care skills retained that had responses rated 4 or 5 by ≥ 80% participants (Table 3).

Table 3

Developed consensus-based skill list.

Discussion

A consensus-based list of trauma care procedural skills required for general surgeons was developed by using interviews with experts and a Delphi survey which returned a high response rate and showed internal consistency. Following expert approval, “tracheal intubation,” “intraosseous infusion,” “focused assessment with sonography for trauma (FAST),” and “non-invasive external pelvic compression” were included in the required trauma care skills for general surgeons. Based on the recommendations from the 1^st round of the Delphi survey, “diaphragm repair,” “ostomy,” and “temporary abdominal closure” were included in the final list. Since abdominal trauma surgery often involves cases of open abdominal non-closure, the addition of “temporary abdominal closure” was considered to be reasonable. Finally, the included 34 items were classified into the following four groups: basic, thoracic, abdominal and pelvic, and vascular skills.

Basic skills (No’s. 1–6; Table 3) are included in the Japan Advanced Trauma Evaluation and Care (JATEC) simulation training programs [10], which is the original Japanese trauma training course that was developed in 2002 to inculcate basic process knowledge and skills in trauma care. The JATEC training program was developed with reference to the clinical theory of Advanced Trauma Life Support [11] which is managed by the American College of Surgeons Committee on Trauma. Although basic process skills are required by all physicians involved in trauma care, general surgeons do not always practice these skills, therefore, we have included them in the list.

The purpose of thoracic surgery in trauma cases is to control intrathoracic or pericardial bleeding as well as lung air leaks, and perform decompression for reducing excessive pericardial or intrathoracic pressure [12,13]. “Pericardiostomy,” “heart injury repair,” “pulmonary hilum clamp,” “pulmonary injury repair,” “open cardiac massage,” and “open aorta cross-clamping” are essential skills to fulfill the aims mentioned above and are generically called “resuscitative thoracotomy (RT)” [14,15]. It seemed reasonable for these skills to be retained in the list. However, “median sternotomy” and “clamshell thoracotomy” were rated 4 or 5 by < 80% participants in both rounds of the Delphi consensus survey and therefore were considered “rejected skills.”

In the clinical management strategy for abdominal trauma, it is important to control hemorrhagic shock caused by acute bleeding, and peritonitis secondary to digestive tract injuries. Intraperitoneal bleeding is detected using “FAST;” moreover, a “crash laparotomy” is required in patients with a positive FAST who are in a state of shock refractory to intravenous infusion. Therefore, “FAST” and “crash laparotomy” were considered to be essential skills for treatment of patients with abdominal trauma. Moreover, “five-point gauze packing” to control abdominal bleeding and “peri-hepatic gauze packing” to control hepatic bleeding are important skills in damage control surgery (DCS). “Peri-hepatic gauze packing” is an effective technique for severe liver injury [16]; however, it requires adequate training because, if incorrectly performed, it may cause inadequate hemostasis or complications such as edema of the intestinal tract or venous embolism [17]. Furthermore, “temporary abdominal closure” is an essential skill following surgery. In the case of DCS for massive intestinal tract injury, only hemostasis and resection should be undertaken; intestinal anastomosis should be delayed until reoperation 24–48 hours later [18]. Therefore, “intestinal injury repair” and “bowel resection” were considered important skills for DCS. In case of DCS for colonic injury, “ostomy” was not mandatory. Some prospective studies reported that the rate of anastomotic leak for colonic anastomoses was 2.5%, which is acceptable [19,20]. Another study recommended the construction of an artificial anus in patients with severe complications [21]. “Ostomy” was necessary in case of extraperitoneal rectal injury that could not be sutured [22,23]; therefore, this skill was included.

The “resuscitative endovascular balloon occlusion of the aorta (REBOA)” technique has recently emerged as an alternative method of RT with aortic cross-clamping for non-compressible torso hemorrhage (NCTH). Some studies have compared REBOA and RT. Abe et al [24], and DuBose et al [25] reported that the in-hospital mortality of patients who received REBOA or RT for NCTH did not differ significantly. Conversely, Aso et al [26] reported that the REBOA group had lower mortality and fewer severe chest complications than the RT group. Therefore, REBOA may be another choice for NCTH among general surgeons.

In the US, medical residents are required to undergo a 5-year surgical training program certified by the Accreditation Council for Graduate Medical Education to be board-certified general surgeons [27], and registration of surgical and nonsurgical cases is required for trauma surgery. The American College of Surgeons (ACS)/Association of Program Directors in Surgery surgical resident skills curriculum was developed jointly and includes 16 basic surgical skills, 15 advanced skills, and 10 team-based skills [28]. The list developed in this survey is mostly consistent with this curriculum and partially includes skills in advanced trauma training courses such as Advanced Trauma Operative Management [29] which is provided by the ACS fellowship programs (Table 4). Therefore, our list orders the trauma skill levels of American surgical residents who are part of the ACS fellowship program.

Table 4

A comparison of consensus-based skill list with essential education in US, and existing training courses in trauma care.

Since trauma training based on the Japanese surgical specialist program includes points from off-the-job training, the required points can be obtained even if there are not enough clinical cases in trauma surgery. The off-the-job training includes specific simulation training programs such as JATEC, Advanced Trauma Operative Management and advanced surgical skills for exposure in trauma [30], as well as trauma workshops sponsored at conferences. Table 4 shows a comparison between the skills for which consensus was obtained in this Delphi survey, and the skills included in each course program. We believe that program development, based on these consensus-based skills, will contribute to the construction of an optimal training system that can supplement procedures that general surgeons cannot learn in the existing courses.

There is a limitation to this study. Since some councilors of the JSACS participating in this survey may not be directly involved in trauma care, there is a possibility that not all participants accurately selected the trauma care skills currently required in clinical cases.

Conclusion

This study determined the trauma care skills required by general surgeons at regional hospitals. This was achieved using a Delphi consensus survey with respondents who were specialists in trauma surgery. These findings facilitate an “essential need assessment” to develop a novel trauma-training program that is optimized for general surgeons. Future research should investigate the proficiency of general surgeons in the primary trauma care skills identified in this study.

Data Availability

All relevant data are included in this manuscript.

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