susan steinemann, md, facs benjamin berg, md, alisha skinner, alexandra ditulio, kathleen anzelon,...
TRANSCRIPT
IN-SITU, MULTIDISCIPLINARY, SIMULATION-BASED TRAUMA TEAM TRAINING IMPROVES THE EARLY CARE OF TRAUMA PATIENTSSusan Steinemann, MD, FACS
Benjamin Berg, MD, Alisha Skinner, Alexandra DiTulio, Kathleen Anzelon, RN, Kara Terada, RN, Hao Chih Ho, MD, FACS, Cora Speck, MS
University of Hawaii Dept of Surgery and The Queen’s Medical Center, Honolulu
Supported by grants from the American College of Surgeons – Medical Education Technologies, Inc., and the Queen Emma Research Foundation
Were we trained wrong?
Medical professional training done in isolation
• “Root cause” analysis of sentinel events 1995-2002: 1o cause (63%) is failure in communication (JACHO)
• 74% of medical errors involving trainees related to teamwork (Singh, Arch Int Med 2007)
• ACGME Competencies• Work effectively as a member or leader of a health care team. • Communicate effectively with other health care professionals.• Work in interprofessional teams to enhance patient safety and
improve patient care quality
Surgeons as Team Players• APDS-ACS Phase III
Curriculum• O.R., ICU, Code teams,
Trauma• Ad hoc teams• Time –critical
2.5% of trauma deaths involve errors (Gruen 2006)
Majority of these in ED and ICU
Up to 2/3 of communication during a trauma resuscitation is not understandable (Bergs 2005)
Human Patient Simulators (HPS) Programmable
Physiology: vitals, pupils, breath sounds, pulses
Can intubate, put in i.v.s and chest tubesAdvantages:
No risk to patients Deliberate practice with real-time feedback
Reinforce key steps in treatment of rare, potentially fatal injuries
Disadvantage: $$$
HPS for Trauma Training
Surgery residents in trauma curriculum +/- HPS (Knudson 2008) HPS-trained residents performed better in actual
resuscitations Exhibited better teamwork, despite lack of specific
“teamwork” training. Team training for surgery residents, attendings, and
trauma nurses (Capella 2010) Subjective improvement in teamwork Retrospective review of trauma data before and after training
↓ time to CT scan , O.R., intubation BUT, patients less severely injured, and residents more
seasoned, post-training
Education
?? Better teamwor
k???
?? Better patient
care
University of Hawaii Team Training Curriculum
Trauma Team members Residents, ED and trauma
attendings, RTs, nurses, ED techs (n=137)
97% attendings, 100% surgical residents
I hr online didactic program w/ pretest Teamwork principles Trauma team roles
3-hour HPS session (x 19)
HPS Sessions
3 10-min blunt trauma scenarios
Multidisciplinary trauma team in ED resuscitation room
• Roles same as in real life• Each scenario had 8 key interventions and
3 common interventions• Debriefing focused only on teamwork skills• Team “blinded” to clinical tasks
Trauma NOTECHS (T-NOTECHS)
Developed for aviation
Validated for use in assessing operative surgical teams (Sevdalis 2008)
27 behavioral exemplars
Does training make a difference?
Teamwork assessed after each simulated training scenario Audience Response
System All team members and
debriefer Increase in T-NOTECHS
scores between scenarios #1 and #3 (p<.001)
Videos later reviewed with recording of # of tasks completed and time to completion
Improved Team Performance with Each Scenario
**
**
*
Impact of team training on actual clinical performance Trauma team performance during
trauma resuscitations observed for ~6 months before and after training Multisystem, blunt trauma
Teamwork skills via Trauma NOTECHS Critical care trauma RN (Trauma Scribe)
Clinical process measures Data reported to Trauma Scribe Time in the ED
Pre-training (n=141)
Post-training (n=103)
p
Mean age 38.9 39.7 NS% male 76% 75% NSMean ISS 13.4 10.6 NSMean Probability of survival
0.96 (n=123)
0.97 (n=87)
NS
# patients intubated 14 12 NS# patients with other physician-performed bedside procedures
21 11 NS
# “full” trauma 15 12 NSMean ml blood transfused
97 32 NS
Demographics of trauma patients
Pre-training (n=141)
Post-training (n=103)
p
Mean T-NOTECHS score
16.7 (n =136 ) 17.7 (n= 99)
< .05
# with ≤1 unreported task
48 62 <.001
Mean resuscitation time (min)
32 26 <.05
# died 8 4 NS
Mean hospital LOS days (survivors)
5.1 3.4 NS
Mean ICU days (survivors)
1.9 0.3 NS
Clinical Outcomes
Discussion of results
Decrease in mortality associated with 9% reduction in resuscitation time
(Townsend, J Trauma)
Improvement not due to more “seasoned” residents on team No ∆ over the 6 month
intervals pre- and post-training
Study limitations
Not designed for high-stakes, individual assessment
Decay in teamwork
Summary A 4-hour curriculum can improve
teamwork of resident-based multidisciplinary trauma teams
Improved observer ratings of team leadership, coordination and communication
Improved clinical process Better task completion and reporting Decreased time in the ED
Education
Improved trainee
performance
Better patient care
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