1. 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

2. Were we trained wrong? Medical professional training done in isolation
“Root cause” analysis of sentinel events : 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

3. 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)

4. 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: $$$

5. 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

6. 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)

7. 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

8. Trauma NOTECHS (T-NOTECHS)
Developed for aviation
Validated for use in assessing operative surgical teams (Sevdalis 2008)
27 behavioral exemplars

9. 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

10. Improved Team Performance with Each Scenario** ** *

11. 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

12. 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

13. 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%

14. 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

15. Study limitations
Not designed for high- stakes, individual assessment

16. Decay in teamwork

17. 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

18. Mahalo to: