The development and measurement properties of the trauma NOn-TECHnical skills (T-NOTECHS) scale: A scoping review

From Emergency Room to Operating Room: Multidisciplinary Simulation Training in Emergency Laparotomy for Ruptured Abdominal Aortic Aneurysm - Learning Outcomes and Costs

BACKGROUND

Opportunities to practice emergency laparotomy (EL) and open surgical repair (OSR) for a ruptured abdominal aortic aneurysm (rAAA) are limited. While simulation-based training (SBT) is effective in educating healthcare professionals in medical emergencies, SBT specifically in EL and OSR for rAAA is scarce. It takes a team to diagnose a patient with massive abdominal bleeding, such as in rAAA, to organize primary care, and to provide definite treatment without unnecessary delays. This study investigated the effects of multidisciplinary EL simulation training in OSR for rAAA, from the emergency room (ER) to the operating room (OR), on trainees' learning outcomes and the costs of the training.

METHODS

A total of 162 healthcare professionals in 21 simulated emergency laparotomy teams participated in a structured 2-hour course consisting of an introductory lecture and a simulation scenario followed by debriefing. Data were collected using a pre-post self-assessment questionnaire and the T-NOTECHS scale. Implementation costs and the cost of education were calculated.

RESULTS

Simulation training improved knowledge, skills, and attitudes of both physicians and nurses. Most of the non-technical skills studied were significantly enhanced in both professional groups. The total cost of the simulation training was €29 415, cost per team €1,400 and cost per participant €182.

CONCLUSIONS

Multidisciplinary EL simulation training in OSR for rAAA from the ER to the OR is effective in improving knowledge, skills, and attitudes, as well as non-technical skills among both physicians and nurses. The overall costs of training seem reasonable given the significant learning outcomes.

Prospective multi-centre analysis of rural trauma team development training for medical trainees and traffic law enforcement professionals in Uganda: an interrupted time series study

BACKGROUND

Research shows that trauma team formation could potentially improve effectiveness of injury care in rural settings. The aim of this study was to determine the feasibility of rural trauma team training amongst medical trainees and traffic law enforcement professionals in Uganda.

METHODS

Prospective multi-centre interrupted time series analysis of an interventional training based on the 4th edition of rural trauma team development course of the American College of Surgeons. Trauma related multiple choice questions (MCQs), and trauma non-technical skills were assessed pre-and post-training between September 2019- August 2023. Acceptability of the training for promulgation to other rural regions and its relevance to participants' work needs were evaluated on 5- and 3-point Likert scales respectively. The median MCQ scores (IQR) were compared before and after training at 95% CI, regarding p < 0.05 as statistically significant. Triangulation with open-ended questions was obtained. Time series regression models were applied to test for autocorrelation in performance using Stata 15.0. Ethical approval was obtained from Uganda National Council for Science and Technology (Ref: SS 5082).

RESULTS

A total of 500 participants including: 66 (13.2%) traffic police officers, 30 (6.0%) intern doctors, 140 (28.0%) fifth year and 264 (52.8%) third-year medical students were trained. Among the 434 medical trainees who completed the trauma-based MCQ assessment, the median pre- and post-test scores were 60%, IQR (50-65) and 80%, IQR (70-85) respectively. Overall, the mean difference between pre- and post-test scores was statistically significant (z = 16.7%, P|z|=<0.0001). Most participants strongly agreed to promulgate 389 (77.8%), relevance to their educational 405 (81.0%), and work needs 399 (79.8%). Each of the course components was rated above 76.0% as being very relevant. There was an overall increment in median (IQR) trauma-nontechnical skills team performance scores from 12 (9-14) to 17 (15-20) after the training (p < 0.001), with police teams advancing from 9.5 (6.0-12.5) to 19.5 (17.0-21.5) (p < 0.001).

CONCLUSION

This study demonstrates that rural trauma team development training had a positive effect on the test scores of course participants. The training is feasible, highly acceptable and regarded as relevant amongst medical trainees and traffic law enforcement professionals who provide first-aid to trauma patients in resource-limited settings. The findings could inform the design of future trauma teams in rural communities.

TRIAL REGISTRATION

Retrospective registration (UIN: researchregistry9450).

Study protocol for a Prospective Observational study of Safety Threats and Adverse events in Trauma (PrO-STAT): a pilot study at a level-1 trauma centre in Canada

INTRODUCTION

Traumatic injuries are a significant public health concern globally, resulting in substantial mortality, hospitalisation and healthcare burden. Despite the establishment of specialised trauma centres, there remains considerable variability in trauma-care practices and outcomes, particularly in the initial phase of trauma resuscitation in the trauma bay. This stage is prone to preventable errors leading to adverse events (AEs) that can impact patient outcomes. Prior studies have identified common causes of these errors, including delayed diagnostics, disorganisation of staff, equipment issues and communication breakdowns, which collectively contribute to AEs. This study addresses gaps in understanding the root causes of these errors by evaluating the most frequent AEs in trauma care through real-time video reviews of resuscitations in the trauma bay. Insights from this evaluation will inform targeted interventions to improve procedural adherence, communication and overall team performance, ultimately reducing preventable errors and improving patient safety.

METHODS AND ANALYSIS

A prospective observational study will be conducted at St. Michael's Hospital, a level-1 trauma centre, to evaluate resuscitations in the trauma bay. All consecutive trauma team activations over 12 months will be included, with data collected using audio-visual recordings and physiological monitoring. A synchronised data capture and analysis platform will comprehensively assess AEs, errors and human and environmental factors during trauma resuscitations. The study aims to detect recurring error patterns, evaluate practice variations and correlate trauma team performance with in-hospital outcomes. Statistical analyses will include descriptive statistics, logistic regression models and multivariable analyses to identify associations and predictors of AEs and patient outcomes.

ETHICS AND DISSEMINATION

Institutional research ethics approval was obtained (SMH REB # 21-009). A modified consent model will be employed for participants. Staff, physicians and learners will be provided with information regarding the study and will have the option to opt-out or withdraw consent. Similarly, trauma patients and their next of kin will be informed about the study, with provisions for opting out or withdrawing consent within 48 hours of recording. Measures will be implemented to ensure data confidentiality, anonymity and respect for participants' autonomy and privacy. The study results will be shared through peer-reviewed journal publications and conference presentations, and key institutional stakeholders will be informed about developing strategies to improve patient safety in trauma care.

Nontechnical Skills Assessment in Acute Care Trauma Simulations: A Mixed Methods Approach Using Eye Tracking and Behavioral Marker Systems

INTRODUCTION

The condition of trauma patients and the urgent need for timely resuscitation present unique challenges to trauma teams. These difficulties are exacerbated for military trauma teams in combat environments. Consequently, there is a need for continued improvement of nontechnical skills (NTS) training for trauma teams. However, current approaches to NTS assessment rely on subjective ratings, which can introduce bias. Accordingly, objective methods of NTS evaluation are needed. Eye-tracking (ET) methods have been applied to studying communication, situation awareness, and leadership in many health care settings, and could be applied to studying physicians' NTS during trauma situations. In this study, we aimed to assess the relationship between trauma team leaders' objective gaze patterns and subjective expert NTS ratings during patient care simulations.

MATERIALS AND METHODS

After Institutional Review Board approval, 9 trauma teams from first-year post-graduate general surgery and emergency medicine residents were recruited to participate in 1 of 2 trauma simulations (a difficult airway case and a multi-patient trauma). Each scenario lasted approximately 15 minutes. All team leaders wore a mobile ET system to evaluate gaze metrics-time to first fixation (TTFF), average fixation duration (AFD), and total percentage of the scenario (TPS) focused on Areas of Interest (AOI), which included patient, care team, diagnostic equipment, and patient care equipment. Trained faculty raters completed the Non-Technical Skills for Surgeons (NOTSS) assessment tool and the Trauma Non-Technical Skills (T-NOTECHS) scale. One-way analysis of variance, Kruskal-Wallis, and appropriate post-hoc pairwise comparison tests were run to assess differences between ET metrics across AOI groups. Spearman's Rho tests were used to assess correlations between ET and subjective NTS ratings.

RESULTS

Compared to other NTS domains, trauma teams scored relatively poorly on communication across both T-NOTECHS (3.29$ \pm $0.61, maximum = 5) and NOTSS (2.87$ \pm $0.66, maximum = 4). We found significant differences in trauma team leaders' TTFF between teammates and the patient (Team: 1.56 vs Patient: 29.82 seconds, P < .001). TTFF on the diagnostic equipment was negatively correlated (P < .05) to multiple measures of subjective NTS assessments. There were no significant differences in AFD between AOIs, and AFD on teammates was positively correlated (P < .05) to communication and teamwork. There were significant differences in TPS across most AOI pairs (P < .05), and the average TPS fixated was highest on the patient (32%). Finally, there were several significant correlations between additional ET and NTS metrics.

CONCLUSIONS

This study utilized a mixed methods approach to assess trauma team leaders' NTS in simulated acute care trauma simulations. Our results provide several objective insights into trauma team leaders' NTS behaviors during patient care simulations. Such objective insights provide a more comprehensive understanding of NTS behaviors and can be leveraged to guide NTS training of trauma physicians in the future. More studies are needed to apply these methods to capture NTS from a larger sample of teams in both simulated and real trauma environments.

Mastering multicasualty trauma care with the Trauma Non-technical Skills Scale

BACKGROUND

Multicasualty events present complex medical challenges. This is the first study to investigate the role of nontechnical skills in prehospital multicasualty trauma care. We assessed the feasibility of using the Trauma Nontechnical Skills Scale (T-NOTECHS) instrument, which has not yet been investigated to evaluate these scenarios.

METHODS

We conducted an observational study involving military medical teams with Israel Defense Forces Military Trauma Life Support training to assess the T-NOTECHS' utility in predicting prehospital medical team performance during multicasualty event simulations. These teams were selected from a pool of qualified military Advanced Life Support providers. Simulations were conducted in a dedicated facility resembling a field setting, with video recordings to ensure data accuracy. Teams faced a single multicasualty scenario, assessed by two instructors, and were evaluated using a 37-item checklist. The T-NOTECHS scores were analyzed using regression models to predict simulation performance.

RESULTS

We included 27 teams for analysis, led by 28% physicians and 72% paramedics. Interrater reliability for simulation performance and T-NOTECHS scores showed good agreement. Overall T-NOTECHS scores were positively correlated with simulation performance scores ( R = 0.546, p < 0.001). Each T-NOTECHS domain correlated with simulation performance. The Communication and Interaction domain explained a unique part of the variance ( β = 0.406, p = 0.047). Assessment and Decision Making had the highest correlation ( R = 0.535, p < 0.001). These domains significantly predicted specific items on the simulation performance checklist. Cooperation and Resource Management showed the least correlation with checklist items.

CONCLUSION

This study confirms the T-NOTECHS' reliability in predicting prehospital trauma team performance during multicasualty scenarios. Key nontechnical skills, especially Communication and Interaction, and Assessment and Decision Making, play vital roles. These findings underscore the importance of training in these skills to enhance trauma care in such scenarios, offering valuable insights for medical team preparation.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level III.

Enhancing patient safety in trauma: Understanding adverse events, assessment tools, and the role of trauma video review

OBJECTIVES

This study aimed to investigate adverse events (AEs) in trauma resuscitation, evaluate contributing factors, and assess methods, such as trauma video review (TVR), to mitigate AEs.

BACKGROUND

Trauma remains a leading cause of global mortality and morbidity, necessitating effective trauma care. Despite progress, AEs during trauma resuscitation persist, impacting patient outcomes and the healthcare system. Identifying and analyzing AEs and their determinants are crucial for improving trauma care.

METHODS

This narrative review explored the definition, identification, and assessment of AEs associated with trauma resuscitation within the trauma system. It includes various studies and assessment tools such as STAT Taxonomy and T-NOTECHs. Additionally, it assessed the role of TVR in detecting AEs and strategies to enhance patient safety.

CONCLUSION

Integrated with standardized tools, TVR shows promise for identifying AEs. Challenges include ensuring reporting consistency and integrating approaches into existing protocols. Future research should prioritize linking trauma team performance to patient outcomes, and develop sustainable TVR programs to enhance patient safety.

Impact of video recordings review with structured debriefings on trauma team performance: a prospective observational cohort study

PURPOSE

To determine the impact of structured debriefings (SD) with audio/video review of trauma patients' resuscitation events on trauma team (TT) technical and non-technical skills.

METHODS

Single-center prospective observational cohort study. The study included all emergency department patients aged 18 years or older who received resuscitation from the TT. Virtual meeting was held with the TT using SD to review one trauma patient resuscitation video. Technical skills improvement was based on adherence to the ATLS protocol and non-technical skills based on T-NOTECHS scale.

RESULTS

There was statistically significant improvement in adherence to the ATLS protocol: 73% [55-82%] vs 91% [82-100%] (p < 0.001); and improvement in T-NOTECHS scale: 12 [10-14] vs 16 [14-19] points (p < 0.001).

CONCLUSION

In this study, we found that structured debriefings with review of patients' resuscitation video recordings can have a significant positive impact on trauma team performance in the emergency department in both technical and non-technical skills.

Reliability of the safety threats and adverse events in trauma (STAT) taxonomy using trauma video review

PURPOSE

The STAT (Safety Threats and Adverse Events in Trauma) taxonomy was developed through expert consensus, and groups 65 identified trauma resuscitation adverse events (AEs) into nine distinct categories. It provides a framework for standardized analysis of trauma resuscitations and creates a foundation for targeted quality improvement and patient safety initiatives. This study aims to evaluate the reliability of the STAT taxonomy in identifying AEs during video-recorded trauma resuscitations.

METHODS

High-definition audiovisual data from 30 trauma resuscitations were reviewed. Videos were assessed and scored by four independent reviewers (two trainees and two staff). The STAT taxonomy was used to identify AEs based on binary responses: yes and no. Inter-rater reliability was calculated using Gwet's AC1. The frequencies of AEs were tallied and reported as counts and percentages.

RESULTS

The most common AEs identified in the videos were failure to measure temperature (86.7%) and inadequate personal protective equipment (86.7%), followed by inability to use closed-loop communication (76.7%). The agreement on all AEs between reviewers was 0.94 (95% CI: 0.93-0.95). The Gwet's AC1 agreement across the 9 AE categories was paramedic handover (0.82), airway and breathing (0.99), circulation (0.95), assessment of injuries (0.91), management of injuries (0.96), procedure-related (0.97), patient monitoring and IV access (0.99), disposition (0.98), team communication and dynamics (0.87).

CONCLUSION

The STAT taxonomy demonstrated excellent inter-rater reliability between reviewers and can be used to identify AEs in video-recorded trauma resuscitations. These results provide a foundation for adapting video review to objectively quantify and assess AEs in the trauma bay.

European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities

BACKGROUND

European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature.

METHODS

Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society.

RESULTS

Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training.

CONCLUSIONS

This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.

Rural trauma team development training amongst medical trainees and traffic law enforcement professionals in a low-income country: a protocol for a prospective multicenter interrupted time series

Background

Road traffic injuries and their resulting mortality disproportionately affect rural communities in low-middle-income countries (LMICs) due to limited human and infrastructural resources for postcrash care. Evidence from high-income countries show that trauma team development training could improve the efficiency, care, and outcome of injuries. A paucity of studies have evaluated the feasibility and applicability of this concept in resource constrained settings. The aim of this study protocol is to establish the feasibility of rural trauma team development and training in a cohort of medical trainees and traffic law enforcement professionals in Uganda.

Methods

Muticenter interrupted time series of prospective interventional trainings, using the rural trauma team development course (RTTDC) model of the American College of Surgeons. A team of surgeon consultants will execute the training. A prospective cohort of participants will complete a before and after training validated trauma related multiple choice questionnaire during September 2019-November 2023. The difference in mean prepost training percentage multiple choice questionnaire scores will be compared using ANOVA-test at 95% CI. Time series regression models will be used to test for autocorrelations in performance. Acceptability and relevance of the training will be assessed using 3 and 5-point-Likert scales. All analyses will be performed using Stata 15.0. Ethical approval was obtained from Research and Ethics Committee of Mbarara University of Science and Technology (Ref: MUREC 1/7, 05/05-19) and Uganda National Council for Science and Technology (Ref: SS 5082). Retrospective registration was accomplished with Research Registry (UIN: researchregistry9490).

Exploring the characteristics of successful prehospital trauma care teams: Insights from military trauma care simulations

BACKGROUND

Trauma care teams play a crucial role in determining the outcomes of trauma victims. The composition and training of these teams can vary. Our study seeks to examine the characteristics of successful military Advanced Life Support (ALS) teams and the factors that affect them.

METHODS

A retrospective study was conducted at the Israel Defense Force (IDF) Military Medical Academy throughout 2021, where prehospital medical teams were observed in trauma care simulations. Teams were led by ALS providers (military physicians or paramedics) trained in IDF Military Trauma Life Support. Demographic and training data were collected. Teams were categorized into high or subpar performance groups based on simulation scores. Specific skills were assessed by trauma instructors using a points system. Scores were compared between the groups and analyzed for correlations with demographic and training data.

RESULTS

Overall, 63 team simulations were analyzed, with teams led by a military paramedic in 78% of simulations. The mean overall simulation performance was 81% ±6.2, and there were no differences in scores of single or multicasualty simulations. A total 3% of the teams achieved successful results and were more likely to have a paramedic as the ALS provider ( p = 0.028). A sensitivity analysis excluding physicians was conducted and showed that high-performance teams had significantly higher skill assessments for primary survey ( p = 0.004), injury recognition ( p = 0.002), exposure ( p = 0.006), adherence to clinical practice guidelines ( p = 0.032), and medical device use ( p = 0.002).

CONCLUSION

Our study found that ALS provider is associated with overall simulation performance in prehospital ALS teams, with military paramedics more likely to be successful. These findings have implications for the training and staffing of prehospital ALS teams, suggesting that teams should be composed accordingly and that training should focus on skills affected by the ALS provider type.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Variation of in-hospital trauma team staffing: new resuscitation, new team

Background

Non-technical errors, such as insufficient communication or leadership, are a major cause of medical failures during trauma resuscitation. Research on staffing variation among trauma teams on teamwork is still in their infancy. In this study, the extent of variation in trauma team staffing was assessed. Our hypothesis was that there would be a high variation in trauma team staffing.

Methods

Trauma team composition of consecutive resuscitations of injured patients were evaluated using videos. All trauma team members that where part of a trauma team during a trauma resuscitation were identified and classified during a one-week period. Other outcomes were number of unique team members, number of new team members following the previous resuscitation and new team members following the previous resuscitation in the same shift (Day, Evening, Night).

Results

All thirty-two analyzed resuscitations had a unique trauma team composition and 101 unique members were involved. A mean of 5.71 (SD 2.57) new members in teams of consecutive trauma resuscitations was found, which was two-third of the trauma team. Mean team members present during trauma resuscitation was 8.38 (SD 1.43). Most variation in staffing was among nurses (32 unique members), radiology technicians (22 unique members) and anesthetists (19 unique members). The least variation was among trauma surgeons (3 unique members) and ER physicians (3 unique members).

Conclusion

We found an extremely high variation in trauma team staffing during thirty-two consecutive resuscitations at our level one trauma center which is incorporated in an academic teaching hospital. Further research is required to explore and prevent potential negative effects of staffing variation in trauma teams on teamwork, processes and patient related outcomes.