Given the findings of this study and evidence in the literature, the consistent presence of a TTL during resuscitations of major trauma patients is important for maintaining compliance with ATLS protocols. Although one can postulate that better compliance rates for performing the primary and secondary surveys in the TTL group compared to the non-TTL group were based on increased

leadership abilities, it is possible click here that the non-TTL group had less resources and manpower available leading to lower compliance. At the time of the study, TTLs were composed of a multidisciplinary group of ED physicians, general surgeons, and one neurosurgeon. All of the TTLs have ATLS certification, and are involved in ATLS education, quality assurance, and research. As a whole, this group is more likely to be familiar with up to date ATLS protocols and evidence-based

trauma studies, and see a higher volume of major trauma patients. The TTL serves an important role in trauma resuscitations by promoting leadership, team cohesiveness, and communication within the multidisciplinary team, to ensure efficiency and efficacy of the resuscitation [19]. TTLs can also reinforce protocol-driven approaches to trauma care that improve patient care [39]. Gerardo et al.[19] demonstrated a reduction in mortality rate, most notably in the most severely injured patients, when a dedicated trauma team was implemented in a Level I trauma center. During the time period examined in our institution, a TTL was present in only half of the trauma resuscitations. Reports from UK and Australia found similar rates of involvement by the trauma team and TTL [40, 41]. We believe there are two contributing high throughput screening assay factors: gaps in the TTL call scheduling, and lack of TTL notification as a part of activation of the trauma team. Reviewing the TTL call schedule at the study period, an average of 31% of shifts were not covered by a TTL (data not shown). At times when a TTL was not scheduled, the leadership role fell onto the attending ED physician, the attending surgeon, or senior general surgery resident. At our institution, TTL coverage can be very improved by recruitment and

retention of qualified physicians interested in trauma, and by including non-surgeons such as anesthetists, emergency physicians and intensivists. Although this study was not designed to measure the appropriateness of TTL or trauma team activation, there appears to be an element of under triage regarding trauma team activation and involvement of the TTL on call. Some of the current barriers include the lack of understanding surrounding the role of a TTL, interruptions in trauma resuscitations especially when a TTL arrives late, as well as the impression of chaos and “too many people” when the trauma team is activated. Various studies have demonstrated that appropriate activation of the trauma team can improve outcomes [42, 43], and under-triaged trauma patients are associated with a high risk of mortality [42].