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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