Assessing Teamwork in the Trauma Bay: Introduction of a Modified NOTECHS Scale for Trauma Supported by a grant from the American College of Surgeons and Medical Education Technologies, Inc. Alexandra DiTulio (MSIII), Susan Steinemann, MD, Alisha Skinner (MSIII), Kara Terada, CCRN, Kathleen Anzelon, CCRN, Hao Chih Ho, MD, Benjamin Berg, MD University of Hawaii and The Queen’s Medical Center, Honolulu, HI

Trauma Resuscitation Time-critical enterprise involving multidisciplinary team members Value of teams and teamwork long appreciated – Video review Hoyt DB, J Trauma 1988 – Simulation Holcomb, J Trauma 2002 No widely accepted tool for evaluating trauma teamwork

Optimal tool Multidisciplinary trauma teams Relationship to teamwork eval tools in other settings (O.R.) User friendly – Easy to learn – Quick to perform Actual or simulated settings, real time or in video review Self-assessment and debriefing Reliable Ratings correlate with objective measures of performance and/or patient outcome

Trauma Teamwork Rating Tools ToolYearAuthorInter-rater Reliability Correlation w/ other performance metrics TTET2002Holcombn/aIncludes clinical metrics. Expert > novice in simulated video review ACS/APDS2008Knudsonn/a TPOT2010CapellaGood : Surgeon video review Sample of clinical resuscitations which showed trend to improved performance

Development of T-NOTECHS 5 Essential behavioral domains from Modified NOTECHS (Sevdalis 2008) 1.Leadership and Managerial Skills 2.Cooperation and Team Skills 3.Communication and Interaction 4.Decision Making 5.Situation Awareness and Vigilance Coping With Stress (DaRosa: ACS-APDS Curriculum) Ability to Handle Distractions (Holcomb)

5 Behavioral Domains

27 Exemplar Behaviors

Rater Training Raters – 13 Critical Care (“Crisis”) RNs (CRN) – Research assistants (3 med students, one MD) One hour training session – Pre-reading on teamwork skills – Teamwork skills didactic – Review and rating of a range of simulated trauma resuscitations

Rated by CRN ± RA Clinical data collected – Time in ED – Reporting of tasks of primary survey and adjuncts (e.g. BP, pupil exam, FAST) Independent rating of T-NOTECHS after leaving the ED Real-life Trauma Resuscitations

Simulation-based Team Training Simulated trauma resuscitations – Multidisciplinary team members – 3 10-minute blunt trauma cases Each with 8 “key” and 3 “common” tasks Team blinded to clinical tasks Teamwork rated using T-NOTECHS – Audience response system – After each scenarios, before video review – Team debriefed using T-NOTECHS – Later, video review by investigators looking at time to completion of interventions – Clinical data and T-NOTECHS scores again collected for 6 months post-training

Reliability Cronbach’s alpha >0.90 for the 5 domains – Did not improve with elimination of any domain Intraclass correlation coefficient (ICC) for Real life = 0.48 – 2 raters (CRN, RA) – n = 69 (48 before, 21 after team training) ICC for Simulated = 0.44 – 3 raters (CRN, attending, debriefer) – n = 33

Reliability issues Minimal rater training All assessments done in real-time CRN had to multi-task Clinical action is difficult for inexperienced clinicians to follow Simulated setting – Surgeons may not accurately self-assess Arora, Am J Surg in press – Attendings had received no prior training

Correlation with Performance in Simulated Resuscitations Higher mean T-NOTECHS scores by all of the raters correlated with improved clinical performance Debriefer’s overall T-NOTECHS ratings correlated with – Greater % of tasks completed (r=.5, p<.05) – Faster completion of 3 common tasks (r=-.38, p<.05)

Correlation with Performance in Real-life Resuscitations 235 resuscitations were assessed by CRN – 136 before, and 99 after team training – Mean T-NOTECHS scored improved significantly after team training (p<.001) Higher T-NOTECHS reflected better clinical performance: Faster time to leave ED (r=-.13, p<.05) Fewer # of unreported resuscitation tasks (r=-.16, p<.05)

Conclusions Needs further study and efforts to improve reliability T-NOTECHS is user friendly – Rapidly adopted after minimal rater training – Quick to perform (< 5 minutes) Useful for debriefing in simulated and actual clinical setting Ratings correlated with objective measures of clinical performance

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