IN-SITU, MULTIDISCIPLINARY, SIMULATION-BASED Trauma Team TRAINING IMPROVES THE EARLY CARE OF TRAUMA PATIENTS Susan 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 tubes Advantages: 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 teamwork ??? ?? 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

Demographics of trauma patients   Pre-training (n=141) Post-training (n=103) p Mean age 38.9 39.7 NS % male 76% 75% Mean ISS 13.4 10.6 Mean Probability of survival 0.96 (n=123) 0.97 (n=87) # patients intubated 14 12 # patients with other physician-performed bedside procedures 21 11 # “full” trauma 15 Mean ml blood transfused 97 32

Clinical Outcomes Pre-training (n=141) Post-training (n=103) p   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 Mean ICU days (survivors) 1.9 0.3 Dramatic in number of “near perfect” resuscitations from 23% to 60% Overall resuscitation time decreased by 19%

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

Improved trainee performance 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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