Measuring teamwork performance: Validity testing of the Team Emergency Assessment Measure (TEAM) with clinical resuscitation teams

Leadership factors for cardiopulmonary resuscitation for clinicians in-hospital; behaviours, skills and strategies: A systematic review and synthesis without meta-analysis

AIM

To identify leadership factors for clinicians during in-hospital cardiopulmonary resuscitation.

DESIGN

Systematic review with synthesis without meta-analysis.

METHODS

The review was guided by SWiM, assessed for quality using CASP and reported with PRISMA.

DATA SOURCES

Cochrane, EMBASE, PubMed, Medline, Scopus and CINAHL (years of 2013-2023) and a manual reference list search of all included studies.

RESULTS

A total of 60 papers were identified with three major themes of useful resuscitation leadership; 'social skills', 'cognitive skills and behaviour' and 'leadership development skills' were identified. Main factors included delegating effectively, while being situationally aware of team members' ability and progress during resuscitation, and being empathetic and supportive, yet 'controlling the room' using a hands-off style. Shared decision-making to reduce cognitive load for one leader was shown to improve effective teamwork. Findings were limited by heterogeneity of studies and inconsistently applied tools to measure leadership.

CONCLUSION

Traditional authoritarian leadership styles are not wanted by team members with preference for shared leadership and collaboration. Balancing this with the need for team members to see leaders in 'control of the room' brings new challenges for leaders and trainers of resuscitation.

IMPLICATIONS FOR NURSING PROFESSION

All clinicians need effective leadership skills for cardiopulmonary resuscitation in-hospital. Nurses provide first response and ongoing leadership for cardiopulmonary resuscitation. Nurses typically display suitable skills that align with useful resuscitation leader factors.

IMPACT

What were the main findings? Collaboration rather than an authoritarian approach to leadership is preferred by team members. Nurses are suitable to 'control the room'. Restricting resuscitation team size will manage disruptive behaviour of team members.

TRIAL REGISTRATION

PROSPERO Registration: CRD42022385630.

PATIENT OF PUBLIC CONTRIBUTION

No patient of public contribution.

Training for a mass casualty incident: Conception, development, and implementation of a crew-resource management course for forward surgical teams

BACKGROUND

Since 2021, the predeployment training of French FSTs has included a simulation-based curriculum consisting of organizational and human factors. The purpose of this article is to describe the development of a crew-resource management (CRM) training course dedicated for the forward surgical teams (FSTs) of the French Military Health Service.

METHODS

The approach was based on three steps: (1) establishment of a conceptual framework of FSTs deployment; (2) development of an aircrew-like CRM training combining lectures, laboratory exercises, and situational training exercises to consider four fundamental "nontechnical" (cognitive and social) skills for effective and safe combat casualty care: (a) leadership, (b) decision-making, (c) coordination, and (d) situational awareness; (3) Implementation of teamwork evaluation tools.

RESULTS

A multidisciplinary team designed a conceptual framework for FST preparedness, 24 French FSTs completed a high-quality training that takes into account both technical and nontechnical skills to maintain quality of combat care during mass-casualty incidents, FSTs' CRM skills were assessed using an audio/video recording of a simulated mass-casualty incident.

Using a telemedicine-assisted airway model to improve the communication and teamwork of tracheal intubation during the coronavirus disease 2019 pandemic

INTRODUCTION

Isolated spaces impair communication and teamwork during tracheal intubation (TI) in suspected coronavirus disease 2019 patients. We thus aimed to evaluate the telemedicine-assisted airway model (TAM) to improve communication and teamwork during the pandemic.

METHODS

This two-stage prospective study included adult patients intubated in the emergency department of the National Taiwan University Hospital between 1 August 2020 and 31 July 2021. First, we randomised patients receiving TI in the standard setting into the conventional group (Con-G) and the isolation area into the isolation group (Iso-G). We evaluated the obstacles to communication and teamwork in an isolation scenario. Second, we developed the TAM to facilitate communication and teamwork between staff in separate spaces during TI and assigned patients to the TAM group (TAM-G). Communication and teamwork were evaluated using the Team Emergency Assessment Measure (TEAM). Subjective evaluations were conducted using a questionnaire administered to medical staff.

RESULTS

Eighty-nine patients were enrolled: 17, 34, and 38 in the Con-G, Iso-G, and TAM-G, respectively. The communication frequency (CF) of the Con-G and Iso-G was the highest and lowest, respectively. The CF of the TAM-G increased and approached that of the Con-G. The overall TEAM score was the highest in the Con-G and the lowest in the Iso-G, while the overall score in the TAM-G was comparable to that of the Con-G.

DISCUSSION

The TAM may improve communication and teamwork for TIs without compromising efficacy during the pandemic. This study was registered at ClinicalTrials.gov; registration numbers: NCT04479332 and NCT04591873.

Attributes of leadership skill development in high-performance pre-hospital medical teams: results of an international multi-service prospective study

BACKGROUNDS

Team leadership skills of physicians working in high-performing medical teams are directly related to outcome. It is currently unclear how these skills can best be developed. Therefore, in this multi-national cross-sectional prospective study, we explored the development of these skills in relation to physician-, organization- and training characteristics of Helicopter Emergency Medicine Service (HEMS) physicians from services in Europe, the United States of America and Australia.

METHODS

Physicians were asked to complete a survey regarding their HEMS service, training, and background as well as a full Leader Behavior Description Questionnaire (LBDQ). Primary outcomes were the 12 leadership subdomain scores as described in the LBDQ. Secondary outcome measures were the association of LBDQ subdomain scores with specific physician-, organization- or training characteristics and self-reported ways to improve leadership skills in HEMS physicians.

RESULTS

In total, 120 HEMS physicians completed the questionnaire. Overall, leadership LBDQ subdomain scores were high (10 out of 12 subdomains exceeded 70% of the maximum score). Whereas physician characteristics such as experience or base-specialty were unrelated to leadership qualities, both organization- and training characteristics were important determinants of leadership skill development. Attention to leadership skills during service induction, ongoing leadership training, having standards in place to ensure (regular) scenario training and holding structured mission debriefs each correlated with multiple LBDQ subdomain scores.

CONCLUSIONS

Ongoing training of leadership skills should be stimulated and facilitated by organizations as it contributes to higher levels of proficiency, which may translate into a positive effect on patient outcomes.

TRIAL REGISTRATION

Not applicable.

Association between out-of-hospital cardiac arrest quality indicator and prehospital management and clinical outcomes for major trauma

INTRODUCTION

It is unclear whether emergency medical service (EMS) agencies with good out-of-hospital cardiac arrest (OHCA) quality indicators also perform well in treating other emergency conditions. We aimed to evaluate the association of an EMS agency's non-traumatic OHCA quality indicators with prehospital management processes and clinical outcomes of major trauma.

METHODS

This retrospective cross-sectional study analyzed data from registers of nationwide, population-based OHCA (adult EMS-treated non-traumatic OHCA patients from 2017 to 2018) and major trauma (adult, EMS-treated, and injury severity score ≥16 trauma patients in 2018) in South Korea. We developed a prehospital ROSC prediction model to categorize EMS agencies into quartiles (Q1-Q4) based on the observed-to-expected (O/E) ROSC ratio for each EMS agency. We evaluated the national EMS protocol compliance of on-scene management according to O/E ROSC ratio quartile. The association between O/E ROSC ratio quartiles and trauma-related early mortality was determined in a multi-level logistic regression model by adjusted odds ratios (OR) and 95 % confidence intervals (95 % CI).

RESULTS

Among 30,034 severe trauma patients, 4,836 were analyzed. Patients in Q4 showed the lowest early mortality rate (5.6 %, 5.5 %, 4.8 %, and 3.4 % in Q1, Q2, Q3, and Q4, respectively). In groups Q1 to Q4, increasing compliance with the national EMS on-scene management protocol (trauma center transport, basic airway management for patients with altered mentality, spinal motion restriction for patients with spinal injury, and intravenous access for patients with hypotension) was observed (p for trend <0.05). Multivariable multi-level logistic regression analysis showed significantly lower early mortality in Q4 than in Q1 (adjusted OR [95 % CI] 0.56 [0.35-0.91]).

CONCLUSION

Major trauma patients managed by EMS agencies with high success rates in achieving prehospital ROSC in non-traumatic OHCA were more likely to receive protocol-based care and exhibited lower early mortality.

Structured Callouts, the Shared Mental Model, and Teamwork: A Video-Based Study in a Pediatric Emergency Department

OBJECTIVES

The shared mental model is essential to high-quality resuscitations. A structured callout (SCO) is often performed to establish the shared mental model, but the literature on SCOs is limited. The objectives of this study are to describe performance of SCOs during pediatric medical emergencies and to determine whether a SCO is associated with better teamwork.

METHODS

This was a retrospective study in the resuscitation area of an academic pediatric emergency department, where performance of a SCO is a standard expectation. Only medical or nontrauma patients were eligible for inclusion. Data collection was performed by structured video review by 2 observers and verified by a third blinded observer. A SCO was defined as team leader (Pediatric Emergency Medicine fellow or faculty physician) verbalization of at least 1 element of the patient history/examination or an assessment of patient physiology and 1 element of the diagnostic or therapeutic plan. We independently measured teamwork using the Teamwork Emergency Assessment Measure (TEAM) tool.

RESULTS

We reviewed 60 patient encounters from the pediatric emergency department resuscitation area between April 2018 and June 2020. Median patient age was 6 years; the team leader was a Pediatric Emergency Medicine fellow in 55% of encounters. The physician team leader performed a SCO in 38 (63%) of patient encounters. The TEAM scores were collected for 46 encounters. Mean TEAM score (SD) was 42.3 (1.7) in patients with a SCO compared with 40.0 (3.0) in those without a SCO ( P = 0.007).

CONCLUSIONS

Performance of a SCO was associated with better teamwork, but the difference was of unclear clinical significance.

"Trust people you've never worked with" - A social network visualization of teamwork, cohesion, social support, and mental health in NHS Covid personnel

Background

The unprecedented rapid re-deployment of healthcare workers from different care pathways into newly created and fluid COVID-19 teams provides a unique opportunity to examine the interaction of many of the established non-technical factors for successful delivery of clinical care and teamwork in healthcare settings. This research paper therefore aims to address these gaps by qualitatively exploring the impact of COVID work throughout the pandemic on permanent and deployed personnel's experiences, their ability to effectively work together, and the effect of social dynamics (e.g., cohesion, social support) on teamwork and mental health.

Methods

Seventy-five interviews were conducted across the UK between March and December 2021 during wave 2 and 3 of COVID-19 with 75 healthcare workers who were either permanent staff on Intensive Care/High Dependency Units used as COVID wards, had been rapidly deployed to such a ward, or had managed such wards. Work Life Balance was measured using the WLB Scale. Interview transcripts were qualitatively coded and thematic codes were compared using network graph modeling.

Results

Using thematic network analysis, four overarching thematic clusters were found, (1) teamwork, (2) organizational support and management, (3) cohesion and social support, and (4) psychological strain. The study has three main findings. First, the importance of social factors for teamwork and mental health, whereby team identity may influence perceptions of preparedness, collaboration and communication, and impact on the collective appraisal of stressful events and work stressors. Secondly, it demonstrates the positive and negative impact of professional roles and skills on the development of teamwork and team identity. Lastly the study identifies the more pronounced negative impact of COVID work on deployed personnel's workload, mental health, and career intentions, exacerbated by reduced levels of social support during, and after, their deployment.

Conclusion

The thematic network analysis was able to highlight that many of the traditional factors associated with the successful delivery of patient care were impeded by pandemic constraints, markedly influencing personnel's ability to work together and cope with pandemic work stressors. In this environment teamwork, delivery of care and staff well-being appear to depend on relational and organizational context, social group membership, and psycho-social skills related to managing team identity. While results hold lessons for personnel selection, training, co-location, and organizational support during and after a pandemic, further research is needed into the differential impact of pandemic deployment on HCWs mental health and teamwork.

The bricolage mode of emergency medical teams in China: deficient and in urgent need of transformation-A qualitative study

Introduction

Emergency medical rescue plays a vital role in alleviating the harm of all kinds of emergencies to people's physical and mental health and life safety. The current emergency medical teams (EMTs) formation model is not unified. We focused on the disadvantages of the bricolage mode of China EMTs and put forward empirical-based countermeasures to improve the emergency management ability of EMTs.

Methods

From March to September 2022, 23 leaders of EMTs in North China (Tianjin) were selected by objective sampling method to conduct one-to-half structured in-depth interviews. Nvivo12.0 software was used for three-level coding. The disadvantages of the bricolage model of EMT were analyzed.

Results

Based on the three-level coding, 150 initial concepts, 36 sub-coding, 17 main coding, six categories, and two core categories were sorted out. Management structure, internal stability, and support are recognized as the crucial elements armed with the EMTs.

Discussion

The bricolage EMTs have disadvantages such as a chaotic management structure, weak internal stability, and inadequate support. It is necessary to construct full-time EMTs that incorporate a standardized personnel admission mechanism, full-time training and exercise mechanism, diversified incentive mechanism, and multi-agent cooperation mechanism, etc.

A comparison of rapid cycle deliberate practice and traditional reflective debriefing on interprofessional team performance

BACKGROUND

In simulation-based education, debriefing is necessary to promote knowledge acquisition and skill application. Rapid Cycle Deliberate Practice (RCDP) and Traditional Reflective Debriefing (TRD) are based in learning theories of deliberate practice and reflective learning, respectively. In this study, we compared the effectiveness of TRD versus RCDP on acquisition of conceptual knowledge and teamwork skills among interdisciplinary learners in the pediatric emergency department.

METHODS

One hundred sixty-four learners including emergency department attending physicians, fellows, nurses, medical technicians, paramedics, and respiratory therapists, participated in 28 in-situ simulation workshops over 2 months. Groups were quasi-randomized to receive RCDP or TRD debriefing. Learners completed a multiple-choice test to assess teamwork knowledge. The TEAM Assessment Tool assessed team performance before and after debriefing. Primary outcomes were teamwork knowledge and team performance.

RESULTS

Average pre-intervention baseline knowledge assessment scores were high in both groups (TRD mean 90.5 (SD 12.7), RCDP mean 88.7 (SD 15.5). Post-test scores showed small improvements in both groups (TRD mean 93.2 (SD 12.2), RCDP mean 89.9 (SD 13.8), as indicated by effect sizes (ES = 0.21 and 0.09, for TRD and RCDP, respectively). Assessment of team performance demonstrated a significant improvement in mean scores from pre-assessment to post-assessment for all TEAM Assessment skills in both TRD and RCDP arms, based on p-values (all p < 0.01) and effect sizes (all ES > 0.8). While pre-post improvements in TEAM scores were generally higher in the RCDP group based on effect sizes, analysis did not indicate either debriefing approach as meaningfully improved over the other.

CONCLUSIONS

Our study did not demonstrate that either TRD versus RCDP was meaningfully better in teamwork knowledge acquisition or improving skill application and performance. As such, we propose Reflective Deliberate Practice as a framework for future study to allow learners to reflect on learning and practice in action.

Pediatric Tracheostomy Emergency Readiness Assessment Tool: International Consensus Recommendations

OBJECTIVE

To achieve consensus on critical steps and create an assessment tool for actual and simulated pediatric tracheostomy emergencies that incorporates human and systems factors along with tracheostomy-specific steps.

METHODS

A modified Delphi method was used. Using REDCap software, an instrument comprising 29 potential items was circulated to 171 tracheostomy and simulation experts. Consensus criteria were determined a priori with a goal of consolidating and ordering 15 to 25 final items. In the first round, items were rated as "keep" or "remove". In the second and third rounds, experts were asked to rate the importance of each item on a 9-point Likert scale. Items were refined in subsequent iterations based on analysis of results and respondents' comments.

RESULTS

The response rates were 125/171 (73.1%) for the first round, 111/125 (88.8%) for the second round, and 109/125 (87.2%) for the third round. 133 comments were incorporated. Consensus (>60% participants scoring ≥8, or mean score >7.5) was reached on 22 items distributed across three domains. There were 12, 4, and 6 items in the domains of tracheostomy-specific steps, team and personnel factors, and equipment respectively.

CONCLUSIONS

The resultant assessment tool can be used to assess both tracheostomy-specific steps as well as systems factors affecting hospital team response to simulated and clinical pediatric tracheostomy emergencies. The tool can also be used to guide debriefing discussions of both simulated and clinical emergencies, and to spur quality improvement initiatives.

LEVEL OF EVIDENCE

5 Laryngoscope, 133:3588-3601, 2023.

Evaluation of video review tools for assessing non-technical skills in emergency department resuscitation teams: a systematic review

BACKGROUND AND IMPORTANCE

Use of video review in medicine is established in contexts such as surgery. Although not widely used in the emergency department (ED), some centres use it to evaluate non-technical skills (NTS) to support teaching and quality improvement.

OBJECTIVE

There is no consensus on assessment of NTS using video review in the ED and the purpose of this review was to identify tools used in this context.

DESIGN, SETTING AND PARTICIPANTS

Studies were identified using Embase, Medline, CINAHL and Google Scholar. Inclusion criterion for the review was NTS of resuscitation teams working within the ED were assessed using video review. A systematic search method was used, and results were synthesised after search criteria was checked by two independent reviewers. Authors settled on the same 9 studies eligible for inclusion.

OUTCOME MEASURES AND ANALYSIS

Reliability and validity of tools identified for use in this context. Due to the heterogeneity of studies, no meta-analysis occurred.

MAIN RESULTS

There are 9 studies included in the review. The review was registered with PROSPERO (Ref No: CRD42022306129). Four unique tools were identified - 6 studies used T-NOTECHS, 1 used TTCA-24, 1 used CALM and 1 used the Communication tool. T-NOTECHS is validated in the literature for use in this context.

CONCLUSION

T-NOTECHS is the tool of choice for assessing ED teams in this context.

Coleadership in Maternity Teams, a Randomized, Counterbalanced, Crossover Trial in Simulation

OBJECTIVE

This study aimed to measure the effect of a coleadership model on team performance compared with singular leadership model in simulated maternity emergencies.

METHODS

A randomized, counterbalanced, crossover trial was performed at 2 tertiary maternity hospitals. Teams of obstetric physicians and nurse/midwives responded to 2 simulated maternity emergencies in either a singular or coleadership model. The primary outcome measure was teamwork rated with the Auckland Team Behavior tool. Secondary outcome measures included clinical performance (completion of critical tasks, time to critical intervention, documentation), self-rated teamwork (TEAM tool) and workload. Participants also answered a survey assessing their views on the coleadership model. Paired t tests and mixed-effects linear regression considering team as a random effect were used to estimate the unadjusted and adjusted associations between leadership model and the outcomes of interest.

RESULTS

There was no difference between leadership models for the primary outcome of teamwork (5.3 vs. 5.3, P = 0.91). Clinical outcome measures and self-rated teamwork scores were also similar. Team leaders reported higher workload than other team members, but these were not different between the leadership models. Participants viewed coleadership positively despite no measured objective evidence of benefit.

CONCLUSIONS

A coleadership model did not lead to a difference in team performance within simulated maternity emergencies. Despite this, participants viewed coleadership positively.

Bilingual resuscitation training does not affect adherence to resuscitation guidelines but reduces leadership skills and overall team performance. An observational study with cross-border German-Polish training

Aim of study

This study aims to investigate feasibility and quality of a bilingual cardiopulmonary resuscitation training with interprofessional emergency teams from Germany and Poland.

Methods

As part of a cross-border European Territorial Cooperation (Interreg-VA) funded project a combined communication and simulation training was organised. Teams of German and Polish emergency medicine personnel jointly practised resuscitation. The course was held in both languages with consecutive translation.Quality of chest compression was assessed using a simulator with feedback application. Learning objectives (quality of cardiopulmonary resuscitation, adherence to guidelines, closed loop communication), and team performance were assessed by an external observer. Coopeŕs Team Emergency Assessment Measure questionnaire was used.

Results

Twenty-one scenarios with 17 participants were analysed. In all scenarios, defibrillation and medication were delivered with correct dosage and at the right time. Mean fraction of correct hand position was 85.7% ± 25.7 [95%-CI 74.0; 97.4], mean fraction of compression depth 75.1% ± 21.0 [95%-CI 65.6; 84.7], compression rate 117.7 min-1 ± 7.1 [95%-CI 114.4; 120.9], and chest compression fraction 83.3% ± 3.8 [95%-CI 81.6; 85.0].Quality of cardiopulmonary resuscitation was rated as "fair" to "good", adherence to guidelines as "good", and closed loop communication as "fair". Bilingual teams demonstrated good situational awareness, but lack of leadership and suboptimal overall team performance.

Conclusion

Bilingual and interprofessional cross-border resuscitation training in German and Polish tandem teams is feasible. It does not affect quality of technical skills such as high-quality chest compression but does affect performance of non-technical skills (e.g. closed loop communication and leadership).

Successful implementation of a rater training program for medical students to evaluate simulated pediatric emergencies

Introduction

Simulation-based training is increasingly used in pediatrics to teach technical skills, teamwork, and team communication, and to improve potential deficiencies in pediatric emergency care. Team performance must be observed, analyzed, and evaluated by trained raters. The structured training of medical students for the assessment of simulated pediatric emergencies has not yet been investigated.

Methods

We developed a rater training program for medical students to assess guideline adherence, teamwork, and team communication in simulated pediatric emergencies. Interrater reliability was measured at each training stage using Kendall tau coefficients.

Results

In 10 out of 15 pairs of raters interrater reliability was moderate to high (tau>0.4), whereas it was low in the remaining 5 pairs of raters.

Discussion

The interrater reliability showed good agreement between medical students and expert raters at the end of the rater training program. Medical students can be successfully involved in the assessment of guideline adherence as well as teamwork and team communication in simulated pediatric emergencies.

Impact and effectiveness of a mandatory competency-based simulation program for pediatric emergency medicine faculty

Introduction

Pediatric emergency medicine physicians struggle to maintain their critical procedural and resuscitation skills. Continuing professional development programs incorporating simulation and competency-based standards may help ensure skill maintenance. Using a logic model framework, we sought to evaluate the effectiveness of a mandatory annual competency-based medical education (CBME) simulation program.

Methods

The CBME program, evaluated from 2016 to 2018, targeted procedural, point-of-care ultrasound (POCUS) and resuscitation skills. Delivery of educational content included a flipped-classroom website, deliberate practice, mastery-based learning, and stop-pause debriefing. Participants' competence was assessed using a 5-point global rating scale (GRS; 3 = competent, 5 = mastery). Statistical process control charts were used to measure the effect of the CBME program on team performance during in situ simulations (ISS), measured using the Team Emergency Assessment Measure (TEAM) scale. Faculty completed an online program evaluation survey.

Results

Forty physicians and 48 registered nurses completed at least one course over 3 years (physician mean ± SD 2.2 ± 0.92). Physicians achieved competence on 430 of 442 stations (97.3%). Mean ± SD GRS scores for procedural, POCUS, and resuscitation stations were 4.34 ± 0.43, 3.96 ± 0.35, and 4.17 ± 0.27, respectively. ISS TEAM scores for "followed standards and guidelines" improved significantly. No signals of special cause variation emerged for the other 11 TEAM items, indicating skills maintenance. Physicians rated CBME training as highly valuable (mean question scores 4.15-4.85/5). Time commitment and scheduling were identified as barriers to participation.

Conclusions

Our mandatory simulation-based CBME program had high completion rates and very low station failures. The program was highly rated and faculty improved or maintained their ISS performance across TEAM scale domains.

A study of validity and usability evidence for non-technical skills assessment tools in simulated adult resuscitation scenarios

BACKGROUND

Non-technical skills (NTS) assessment tools are widely used to provide formative and summative assessment for healthcare professionals and there are now many of them. This study has examined three different tools designed for similar settings and gathered evidence to test their validity and usability.

METHODS

Three NTS assessment tools designed for use in the UK were used by three experienced faculty to review standardized videos of simulated cardiac arrest scenarios: ANTS (Anesthetists' Non-Technical Skills), Oxford NOTECHS (Oxford NOn-TECHnical Skills) and OSCAR (Observational Skill based Clinical Assessment tool for Resuscitation). Internal consistency, interrater reliability and quantitative and qualitative analysis of usability were analyzed for each tool.

RESULTS

Internal consistency and interrater reliability (IRR) varied considerably for the three tools across NTS categories and elements. Intraclass correlation scores of three expert raters ranged from poor (task management in ANTS [0.26] and situation awareness (SA) in Oxford NOTECHS [0.34]) to very good (problem solving in Oxford NOTECHS [0.81] and cooperation [0.84] and SA [0.87] in OSCAR). Furthermore, different statistical tests of IRR produced different results for each tool. Quantitative and qualitative examination of usability also revealed challenges in using each tool.

CONCLUSIONS

The lack of standardization of NTS assessment tools and training in their use is unhelpful for healthcare educators and students. Educators require ongoing support in the use of NTS assessment tools for the evaluation of individual healthcare professionals or healthcare teams. Summative or high-stakes examinations using NTS assessment tools should be undertaken with at least two assessors to provide consensus scoring. In light of the renewed focus on simulation as an educational tool to support and enhance training recovery in the aftermath of COVID-19, it is even more important that assessment of these vital skills is standardized, simplified and supported with adequate training.

Review article: Use of the Team Emergency Assessment Measure in the rating of emergency teams' non-technical skills: A mapping review

The present study aims to explore the utility of the Team Emergency Assessment Measure (TEAM) in relation to the enhancement of emergency team non-technical skills based on research conducted over the last decade. In this mapping review, a citation mining process identified 22 primary studies for inclusion, published between 2012 and 2022. It provides outcome data on emergency teams' non-technical skills following team training and/or real-life patient emergencies. Emergency team studies related to resuscitation teams (adult, paediatric, newborn and obstetric cases) and medical emergency team (MET) management of patient deterioration. Team performance ratings varied, ranging from approximately 90% for experienced clinical teams down to 38% for students. Statistically significant improvements in performance were notable following training and/or repeated practice. Validity evidence, across 11 studies that provided change data described positive learning outcomes and moderate intervention effects. However, according to Kirkpatrick's model of educational evaluation the studies were limited to professional development phases of learning and immediate post-training assessments rather than care quality improvement. The review highlights a lack of studies evidencing quality improvement or clinical impact such as change of patient care practice or health service performance. There is a need to conduct well-designed studies that explore both technical and non-technical skills of resuscitation teams and METs. Currently, non-technical skills training and repeated performance evaluations using the TEAM contribute immensely to the proficiency of emergency teams.

Team effectiveness: epidemiologists' perception of collective performance during emergency response

BACKGROUND

To describe epidemiologists' experience of team dynamics and leadership during emergency response, and explore the utility of the Team Emergency Assessment Measure (TEAM) tool during future public health emergency responses. The TEAM tool included categories for leadership, teamwork, and task management.

METHODS

We conducted a cross-sectional survey between October 2019 and February 2020 with the global applied field epidemiology workforce. To validate the TEAM tool for our context, we used exploratory and confirmatory factor analysis.

RESULTS

We analysed 166 completed surveys. Respondents included national and international emergency responders with representation of all WHO regions. We were unable to validate the TEAM tool for use with epidemiology teams involved in emergency response, however descriptive analysis provided insight into epidemiology emergency response team performance. We found female responders were less satisfied with response leadership than male counterparts, and national responders were more satisfied across all survey categories compared to international responders.

CONCLUSION

Functional teams are a core attribute of effective public health emergency response. Our findings have shown a need for a greater focus on team performance. We recommend development of a fit-for-purpose performance management tool for teams responding to public health emergencies. The importance of building and supporting the development of the national workforce is another important finding of this study.

[Simulation in healthcare during COVID-19: An experience with residents in Anaesthesiology]

BACKGROUND

The restrictions to stop COVID-19 pandemic have had a negative impact in simulation. However, it is imperative to develop new strategies that facilitate healthcare education.

OBJECTIVE

To describe a simulation in healthcare based on the learning of non-technical skills and performed under the restrictions of COVID-19 pandemic.

METHODS

Quasi-experimental study of an educational activity performed through simulation with Anaesthesiology residents in November 2020. Twelve residents participated in 2 consecutive days. A questionnaire was filled related to the performance of non-technical skills that encompasses leadership, teamwork and decision making. The complexity of the scenarios and the non-technical skills results obtained between the 2 days were analysed. Advantages and challenges were documented when a clinical simulation is performed under COVID-19 restrictions.

RESULTS

The global performance of the teams improved when comparing first and second day (79.5 vs. 88.6%, P < .01). Leadership was the worst section rated, however, was the one that showed the best improvement (70 vs. 87.5%, P < .01). The complexity of the simulation cases had no relation with the group performance in leadership and teamwork but affected task management results. General satisfaction was over 75%. The main challenges to develop the activity were the technology required to adapt virtuality to simulation and the time spent for the preparation of it. No cases of COVID-19 were reported within the first month after the activity.

CONCLUSION

Clinical simulation can be done in the context of COVID-19 pandemic, obtaining satisfactory learning results but requiring the adaptation of institutions to the new challenges it implies.

Simulation in healthcare during COVID-19: An experience with residents in Anaesthesiology

BACKGROUND

The restrictions to stop COVID-19 pandemic have had a negative impact in simulation, however, it is imperative to develop new strategies that facilitate healthcare education.

OBJECTIVE

To describe a simulation in healthcare based on the learning of Non-Technical Skills (NTS) and performed under the restrictions of COVID-19 Pandemic.

METHODS

Quasi-experimental study of an educational activity performed through simulation with anaesthesiology residents in November 2020. Twelve residents participated in two consecutive days. A questionnaire was filled related to the performance of NTS that encompasses leadership, teamwork and decision making. The complexity of the scenarios and the NTS results obtained between the two days were analysed. Advantages and challenges were documented when a clinical simulation is performed under COVID-19 restrictions.

RESULTS

The global performance of the teams improved when comparing first and second day (79.5% vs 88.6%, p<0.01). Leadership was the worst section rated, however, was the one that showed the best improvement (70% vs 87.5%, p<0.01). The complexity of the simulation cases had no relation with the group performance in leadership and teamwork but affected task management results. General satisfaction was over 75%. The main challenges to develop the activity were the technology required to adapt virtuality to simulation and the time spent for the preparation of it. No cases of COVID-19 were reported within the first month after the activity.

CONCLUSION

Clinical simulation can be done in the context of COVID-19 Pandemic, obtaining satisfactory learning results but requiring the adaptation of institutions to the new challenges it implies.

The Concise Assessment of Leader Management Tool: Evaluation of Healthcare Provider Leadership During Real-Life Pediatric Emergencies

INTRODUCTION

Resuscitation events in pediatric critical and emergency care are high risk, and strong leadership is an important component of an effective response. The Concise Assessment of Leadership Management (CALM) tool, designed to assess the strength of leadership skills during pediatric crises, has shown promising validity and reliability in simulated settings. The objective of this study was to generate further validity and reliability evidence for the CALM by applying it to real-life emergency events.

METHODS

A prospective, video-based study was conducted in an academic pediatric emergency department. Three reviewers independently applied the CALM tool to the assessment of pediatric emergency department physicians as they led both a cardiac arrest and a sepsis event. Time to critical event (epinephrine, fluid, and antibiotic administration) was collected via video review. Based on Kane's framework, we conducted fully crossed, person × event × rater generalizability (G) and decision (D) studies. Interrater reliability was calculated using Gwet AC 2 and intraclass correlation coefficients. Time to critical events was correlated with CALM scores using Spearman coefficient.

RESULTS

Nine team leaders were assessed in their leadership of 2 resuscitations each. The G coefficient was 0.68, with 26% subject variance, 20% rater variance, and no case variance. Thirty-three percent of the variance (33%) was attributed to third-order interactions and unknown factors. Gwet AC 2 was 0.3 and intraclass correlation was 0.58. The CALM score and time to epinephrine correlated at -0.79 ( P = 0.01). The CALM score and time to fluid administration correlated at -0.181 ( P = 0.64).

CONCLUSIONS

This study provides additional validity evidence for the CALM tool's use in this context if used with multiple raters, aligning with data from the previous simulation-based CALM validity study. Further development may improve reliability. It also serves as an exemplar of the rigors of conducting validity work within medical simulation.

Development and psychometric properties of teamwork scale in resuscitation: A sequential exploratory mixed-method study

BACKGROUND

Non-technical skills as a complement to technical skills have become increasingly important in cardio-pulmonary resuscitation, and teamwork is one of the most prominent of these skills. Because of the limited number of tools introduced and validated for measuring teamwork in resuscitation, this study was conducted to develop and evaluate the psychometric properties of the Teamwork Scale in Resuscitation (TSR).

MATERIALS AND METHODS

This study was a sequential exploratory mixed-method study and was conducted between March 2020 and April 2021 and in two phases. In the first phase (qualitative), semi-structured interviews were performed with resuscitation team members who were selected using a purposeful sampling method with maximum variation in terms of experience, level of education, age, and gender. Using directed qualitative content analysis, the data were analyzed and the primary item pool was developed. In the second phase (quantitative), assessing face, content, and construct validity as well as reliability via the internal consistency and stability, the psychometric properties of the instrument are evaluated.

RESULTS

The initial tool consisted of 54 items; after assessing the face validity, ten items were removed during content validity, and the final tool consisted of 44 items and three main categories including the essential prerequisites for resuscitation, leadership, and teamwork, which was scored based on a 5-point Likert scale from strongly disagree to strongly agree. The convergent validity and concurrent validity of the tool were confirmed. The reliability of the instrument was also confirmed using Cronbach's alpha test and re-test and the intra-class correlation coefficient (ICC) between raters.

CONCLUSION

The validity and reliability of TSR for measuring teamwork in resuscitation in a simulated environment are approved. Further studies are suggested for different contexts of resuscitation and with trained raters to evaluate its use in real resuscitation situations.

Reliability and validity testing of team emergency assessment measure in a distributed team context

Medical multi-professional teams are increasingly collaborating via telemedicine. In distributed team settings, members are geographically separated and collaborate through technology. Developing improved training strategies for distributed teams and finding appropriate instruments to assess team performance is necessary. The Team Emergency Assessment Measure (TEAM), an instrument validated in traditional collocated acute-care settings, was tested for validity and reliability in this study when used for distributed teams. Three raters assessed video recordings of simulated team training scenarios (n = 18) among teams with varying levels of proficiency working with a remotely located physician via telemedicine. Inter-rater reliability, determined by intraclass correlation, was 0.74-0.92 on the TEAM instrument's three domains of leadership, teamwork, and task management. Internal consistency (Cronbach's alpha) ranged between 0.89-0.97 for the various domains. Predictive validity was established by comparing scores with proficiency levels. Finally, concurrent validity was established by high correlations, >0.92, between scores in the three TEAM domains and the teams' overall performance. Our results indicate that TEAM can be used in distributed acute-care team settings and consequently applied in future-directed learning and research on distributed healthcare teams.

Influence of airway trolley organization on efficiency and team performance: A randomized, crossover simulation study

BACKGROUND

Failed management of unanticipated difficult airway situations contributes to significant anesthesia-related morbidity and mortality. Optimization of design and layout of difficult airway trolleys (DATs) may influence outcomes during airway emergencies. The main objective of the current study was to evaluate whether a difficult airway algorithm-based DAT with integrated cognitive aids improves efficiency and team performance in difficult airway scenarios.

METHODS

In a crossover design, 16 teams (anesthetist, nurse anesthetist, assistant nurse) completed two high-fidelity simulated unanticipated difficult airway scenarios. Teams used both an algorithm-based DAT and a comparison, standard DAT, in the scenarios and were randomized to order of trolley type. Outcome measures included objective efficiency parameters, team performance assessment and subjective user-ratings. Linear mixed models ANOVA, including DAT type and order of condition as main factors, was utilized for the primary analyses of the team results.

RESULTS

Usage of the algorithm-based DAT was associated with fewer departures from the difficult airway algorithm (p = .010), and reduced number of unnecessary drawer openings (p = .002), but no significant differences in time to retrieval of airway devices or time to first effective ventilation, compared to the standard DAT. There were no significant differences in team performance, although participants expressed strong preference for the algorithm-based DAT (all user-rated measures p < .0001). Higher percentage of female members of the team improved adherence to the difficult airway algorithm (p = .043).

CONCLUSIONS

Algorithm-based DATs with integrated cognitive aids may improve efficiency in difficult airway situations, compared to traditional DATs. These findings have implications for improvement of anesthetic practice.

Preparing and Presenting Validation Studies: A Guide for the Perplexed

SUMMARY STATEMENT

Simulated environments are frequently used for learner assessment, and a wide array of assessment instruments have been created to assist with this process. It is important, therefore, that clear, compelling evidence for the validity of these assessments be established. Contemporary theory recognizes instrument validity as a unified construct that links a construct to be assessed with a population, an environment of assessment, and a decision to be made using the scores. In this article, we present a primer on 2 current frameworks (Messick and Kane), define the elements of each, present a rubric that can be used by potential authors to structure their work, and offer examples of published studies showing how each framework has been successfully used to make a validity argument. We offer this with the goal of improving the quality of validity-related publications, thereby advancing the quality of assessment in healthcare simulation.

Assessing team behaviours and time to defibrillation during simulated cardiac arrest: a pilot study of internal medicine trainees

Understanding team behaviours leading to successful outcomes in resuscitation could help guide future training. Guidelines recommend defibrillation for shockable rhythm cardiac arrests within 2 minutes. This observational pilot study aimed to determine whether teamwork behaviours among medical trainees differed when time to defibrillation (TTD) was less than 2 minutes, versus 2 minutes or more.

Following ethical approval, groups of six internal medicine trainee (IMT) doctors in Scotland formed an

Twenty-three videos involving 138 trainees were scored using the TEAM tool. Scores ranged from 19–39.5/44 (mean 28.2). Mean TTD was 86.2 seconds (range 24–224), with 17/23 teams achieving defibrillation in under 2 minutes. Those achieving fast TTD achieved higher TEAM scores, and the result was statistically significant (30.1 ± 5.0 vs 22.9 ± 3.3,

This observational pilot study found that improved team performance, as measured by the TEAM tool, was associated with faster defibrillation by IMT doctors in simulated cardiac arrest. It highlighted the importance of adaptability as a team behaviour associated with successful performance, which is of interest to those involved in training high stakes emergency teams.

How things changed during the COVID-19 pandemic's first year: A longitudinal, mixed-methods study of organisational resilience processes among healthcare workers

COVID-19 had a huge impact on healthcare systems globally. Institutions, care teams and individuals made considerable efforts to adapt their practices. The present longitudinal, mixed-methods study examined a large sample of healthcare institution employees in Switzerland. Organisational resilience processes were assessed by identifying problematic real-world situations and evaluating how they were managed during three phases of the pandemic's first year. Results highlighted differences between resilience processes across the different types of problematic situations encountered by healthcare workers. Four configurations of organisational resilience were identified depending on teams' performance and ability to adapt over time: "learning from mistakes", "effective development", "new standards" and "hindered resilience". Resilience trajectories differed depending on professional categories, hierarchical status and the problematic situation's perceived severity. Factors promoting or impairing organisational resilience are discussed. Findings highlighted the importance of individuals', teams' and institutions' meso- and micro-level adaptations and macro-level actors' structural actions.

Application of the Team Emergency Assessment Measure for Prehospital Cardiopulmonary Resuscitation

Introduction: Communication and teamwork are critical for ensuring patient safety, particularly during prehospital cardiopulmonary resuscitation (CPR). The Team Emergency Assessment Measure (TEAM) is a tool applicable to such situations. This study aimed to validate the TEAM efficiency as a suitable tool even in prehospital CPR. Methods: A multi-centric observational study was conducted using the data of all non-traumatic out-of-hospital cardiac arrest patients aged over 18 years who were treated using video communication-based medical direction in 2018. From the extracted data of 1494 eligible patients, 67 sample cases were randomly selected. Two experienced raters were assigned to each case. Each rater reviewed 13 or 14 videos and scored the TEAM items for each field cardiopulmonary resuscitation performance. The internal consistency, concurrent validity, and inter-rater reliability were measured. Results: The TEAM showed high reliability with a Cronbach’s alpha value of 0.939, with a mean interitem correlation of 0.584. The mean item–total correlation was 0.789, indicating significant associations. The mean correlation coefficient between each item and the global score range was 0.682, indicating good concurrent validity. The mean intra-class correlation coefficient was 0.804, indicating excellent agreement. Discussion: The TEAM can be a valid and reliable tool to evaluate the non-technical skills of a team of paramedics performing CPR.

Improve Cardiac Emergency Preparedness by Building a Team-Based Cardiopulmonary Resuscitation Educational Plan

Objective

To design an innovative team-based cardiopulmonary resuscitation (CPR) educational plan for multiple bystanders and evaluate whether it was associated with better teamwork and higher quality of resuscitation.

Methods

The team-based CPR plan defined the process for a three-person team, emphasize task allocation, leadership, and closed-loop communication. Participants qualified for single-rescuer CPR skills were randomized into teams of 3. The teamwork performance and CPR operation skills were evaluated in one simulated cardiac arrest scenario before and after training on the team-based CPR plan. The primary outcomes were measured by the Team Emergency Assessment Measure (TEAM) scale and chest compression fraction (CCF).

Results

Forty-three teams were included in the analysis. The team-based CPR plan significantly improved the team performance (global rating 6.7 ± 1.3 vs. 9.0 ± 0.7, corrected p < 0.001 after Bonferroni's correction). After implementing the team-based CPR plan, CCF increased [median 59 (IQR 48–69) vs. 64 (IQR 57–71%)%, corrected p = 0.002], while hands-off time decreased [median 233.2 (IQR 181.0–264.0) vs. 207 (IQR 174–222.9) s, corrected p = 0.02]. We found the average compression depth was significantly improved through the team-based CPR training [median 5.1 (IQR 4.7–5.6) vs. 5.3 (IQR 4.9–5.5) cm, p = 0.03] but no more significantly after applying the Bonferroni's correction (corrected p = 0.35). The compression depths were significantly improved by collaborating and exchanging the role of compression among the participants after the 6th min.

Conclusion

The team-based CPR plan is feasible for improving bystanders teamwork performance and effective for improving resuscitation quality in prearrival care. We suggest a wide application of the team-based CPR plan in the educational program for better resuscitation performance in real rescue events.

Impact of a Digital Cognitive Aid on the Performance of Military Healthcare Teams During Critical Care Management in a Warfront Injury Situation: A Simulation Randomized Controlled Study

INTRODUCTION

Initial healthcare delivery after warfront injury is unpredictably challenging for military forces. As preparatory training, healthcare providers use simulation to improve their performance in stressful critical situations. This study investigated whether a digital CA held by the team leader improved performance in simulated combat casualty care.

METHODS

This randomized controlled trial was performed during a combat casualty training course for military physicians and nurses in France. Each pair of care providers completed 2 scenarios randomized to be undertaken either with or without a digital CA. The primary end point was the technical performance evaluated from a video recording by 2 independent raters using a pre-established score grid (up to 100%) according to military protocols. The secondary end point was the nontechnical performance (TEAM scale, maximum: 54 points).

RESULTS

Thirty-six pairs of participants were included. Use of the digital CA improved both technical (74% vs 53%, P < 0.001) and nontechnical (42 vs 32, P < 0.001) performance.

CONCLUSIONS

The digital CA improved technical and nontechnical performance during training of medical care for military combat casualties. Use of a dedicated digital CA might improve care in a combat environment.

STUDY TYPE

This study is a randomized controlled trial.

Non-technical skills in pre-hospital care in the Czech Republic: a prospective multicentric observational study (NTS study)

Background

Non-technical skills (NTS) are important for the proper functioning of emergency medical ambulance crews but have hardly been researched in the conditions of clinical pre-hospital care.

The primary objective of this study, therefore, is to describe the use of NTS in practice. The secondary objective is to compare if the performance of NTS varies according to the type of case.

Methods

In this multicentric observational study the modified Team Emergency Assessment Measure (TEAM) score was used to assess the performed NTS of two or more crews on site. The evaluation consisted of leadership, teamwork and task management, rated by a field supervisor.

The study observations took place in real clinical pre-hospital emergency medical cases when two or more crews were dispatched between October 2019 and August 2020. The sample size was determined by researchers prior to the study to at least 100 evaluated events per each of the three participating emergency medical services.

The results are presented as median and interquartile range. The internal reliability, consistency and validity of test items and results were evaluated. The Kruskal–Wallis test and the post hoc Mann-Whitney U test with Bonferroni correction were used for multiple comparisons of three groups.

Results

A total of 359 events were evaluated. Surprisingly, the median value for all eight items was as high as 3.0 with a similar interquartile range of 1.0. There were no differences observed by case type (CPR vs. TRAUMA vs. MEDICAL) except from item 1. A post hoc analysis revealed that this difference is in favour of a higher rated performance of non-technical skills in CPR.

Conclusions

The overall result of the performance of non-technical skills can be regarded as very good and can serve for further evaluations. The crews achieved better parameters of NTS in leadership in resuscitation situations in comparison with general medical events.

Trial Registration

The study is registered at Clinical Trials under the ID: NCT04503369.

Integrative Review of Non-Technical Skills Frameworks to Apply for Air Medical Transfer of Pregnant Women

OBJECTIVE

To identify the most suitable non-technical skills framework to adapt and apply to the air medical transfer of pregnant women.

DATA SOURCES

Embase, PsycINFO, PubMed, MEDLINE, Web of Science, CINAHL, Science Direct, and Google Scholar.

STUDY SELECTION

We retrieved potentially relevant articles using a predefined combination of keywords extended with truncation and Boolean operators. Database and manual reference searches yielded 569 peer-reviewed articles. We included articles if they presented empirical data and described non-technical or cognitive competency skills frameworks for health care professionals. We discussed any ambiguities regarding inclusion, and they were resolved by consensus. We retained 71 full-text articles for final review.

DATA EXTRACTION

We coded extracted data under four criteria: non-technical skill categories, context of use, psychometric properties, and rating system. We generated descriptive summary tables of the characteristics of existing non-technical skills frameworks based on publication year, method of development, clinical setting, clinical specialty, routine/crisis-based performance, and team/individual performance.

DATA SYNTHESIS

We identified 42 non-technical skills frameworks from a variety of health care settings. We critically examined context of use and how use in various clinical settings may align with air transfers of pregnant women. Our findings illustrate the importance of team-based and routine performance rather than crisis-focused skills. Maintaining situational awareness throughout all stages of the transfer and communicating effectively with team members, the pregnant woman, and her partner are skills that are particularly important to ensure good outcomes.

CONCLUSION

We selected the Global Assessment of Obstetric Team Performance as the most suitable non-technical skills framework to adapt to the clinical setting of air medical transfer of pregnant women. We considered the clinical specialty, specific non-technical skills required in the setting, the framework's properties, and the requirement to focus on routine team performance.

Measuring non-technical skills during prehospital advanced cardiac life support: A pilot study

Aim

To analyse non-technical skills of mobile medical teams during out-of-hospital cardiac arrests (OHCA) using the validated Team Emergency Assessment Measure (TEAM) tool. To research the correlation between non-technical skills and patient outcome.

Methods

Adult patients who experienced an out-of-hospital cardiac arrest between July 2016, and June 2018, and were treated by a mobile medical team from the University Hospital Leuven, were eligible for the study. Resuscitations were video recorded from the team leader’s perspective. Video recordings were reviewed and scored by emergency physicians, using the TEAM evaluation form.

Results

In total 114 OHCAs were analysed. The mean TEAM score was 34.4/44 (SD = 5.5). The mean item score was 3.1/4 (SD = 0.8). On average, ‘effective team communication’ had the lowest score (2.4), while ‘acting with composure and control’ and ‘following of approved standards/guidelines’ scored the highest (3.4). The average non-technical skills theme scores were 2.9 (SD = 0.9) for ‘Leadership’, 3.1 (SD = 0.8) for ‘Teamwork’ and 3.3 (SD = 0.7) for ‘Task management’. ‘Leadership’ was rated significantly lower than ‘Teamwork’ (p = 0.004) and ‘Task management’ (p < 0.001). No significant correlation was found between TEAM and return of spontaneous circulation (p = 0.574) or one month survival (p = 0.225).

Conclusion

The mean overall TEAM score was categorized as good. Task management scored high, while leadership and team communication received lower scores. Future training programs should thus focus on improving leadership and communication. In this pilot study no correlation was found between non-technical skills and survival.

The TEAM instrument for measuring emergency team performance: validation of the Swedish version at two emergency departments

BACKGROUND

The Team Emergency Assessment Measure (TEAM) questionnaire is designed for rating the non-technical performance of emergency medical teams during emergencies, e.g., resuscitation or trauma management. Originally developed in Australia it has today been translated and validated into eleven languages, but a Swedish version is lacking. The aim was therefore to cross-culturally translate and evaluate the reliability and validity of the TEAM questionnaire in a Swedish health care setting.

METHODS

The instrument was forward and backward translated and adapted into a Swedish context according to established guidelines for cross-cultural adaptation of survey-based measures. The translated version was tested through 78 pairwise assessments of 39 high-priority codes at the emergency departments of two major hospitals. The raters observed the teams at work in real time and filled in the questionnaires immediately afterwards independently of each other. Psychometric properties of the instrument were evaluated.

RESULTS

The original instrument was translated by pairs of translators independently of each other and reviewed by an expert committee of researchers, nurses and physicians from different specialties, a linguist and one of the original developers of the tool. A few adaptations were needed for the Swedish context. A principal component factor analysis confirmed a single 'teamwork' construct in line with the original instrument. The Swedish version showed excellent reliability with a Cronbach's alpha of 0.955 and a mean inter-item correlation of 0.691. The mean item-scale correlation of 0.82 indicated high internal consistency reliability. Inter-rater reliability was measured by intraclass correlation and was 0.74 for the global score indicating good reliability. Individual items ranged between 0.52 and 0.88. No floor effects but ceiling effects were noted. Finally, teams displaying clear closed-loop communication had higher TEAM scores than teams with less clear communication.

CONCLUSIONS

Real time observations of authentic, high priority cases at two emergency departments show that the Swedish version of the TEAM instrument has good psychometric properties for evaluating team performance. The TEAM instrument is thus a welcome tool for assessing non-technical skills of emergency medical teams.

Reflection on the Fly: Development of the Team Reflection Behavioral Observation (TuRBO) System for Acute Care Teams

PURPOSE

Acute care teams work in dynamic and complex environments and must adapt to changing circumstances. A team process that helps teams process information and adapt is in-action team reflection (TR), defined as concurrent collective reflection on group objectives, strategies, or processes during an ongoing care event. However, the health care field lacks a means for systematically observing and ultimately training in-action TR in acute care teams. To bridge this gap, the authors developed a theoretically and empirically informed framework, Team Reflection Behavioral Observation (TuRBO), for measuring in-action TR.

METHOD

In 2018 at ETH, Zurich, Switzerland, the authors developed a theoretical framework based on the literature and theory. They then conducted exploratory reviews of preexisting videos of acute care teams training simulated emergencies. The authors adapted observation codes using an iterative approach. Using the developed coding framework, they coded 23 video recordings of acute care teams and provided validity evidence from the 3 sources: content, internal structure (interrater reliability), and relations to other variables.

RESULTS

The final TuRBO framework consists of 3 general dimensions-seeking information, evaluating information, and planning-that are further specified in 7 subcodes. Interrater agreement of the coding was substantial (κ = 0.80). As hypothesized, the data showed a positive relationship between in-action TR and team performance. Also, physicians spent significantly more time on in-action TR than nurses.

CONCLUSIONS

The TuRBO framework for assessing in-action TR in acute care teams provides positive validity evidence of the data. TuRBO integrates different team communication and calibration processes under the overarching concept of in-action TR and provides descriptive behavioral markers. TuRBO taps into powerful cultural and normative components of patient safety. This tool can augment team training that allows all team members to serve as an important resource for flexible, resilient, and safer patient care.

Implementation of a postarrest debriefing tool in a veterinary university hospital

OBJECTIVE

To describe the use of a postarrest debriefing tool (DBT) within a university teaching hospital and to evaluate user perceptions of the tool.

DESIGN

Observational study over a 1-year period and associated hospital clinical personnel survey.

SETTING

University teaching hospital.

INTERVENTIONS

Qualitative data surrounding the use and utility of the DBT were analyzed, as well as survey results.

MEASUREMENTS AND MAIN RESULTS

Forty-four arrests occurred during the study period. Debriefing was performed after 26 of 44 (59%) cardiopulmonary resuscitation (CPR) events, of which 22 of 26 (85%) were recorded using the DBT and four without the DBT. Return of spontaneous circulation did not significantly affect the use of the DBT (p = 0.753). Most events in which debriefing was not performed occurred outside of business hours (13/18; 72%). The most frequent positive debriefing comments related to cooperation/coordination within the team (22/167; 13%). The most frequent negative debriefing comments concerned equipment issues (36/167; 22%). Of the action points generated, 57% (34/60) were directed at equipment use/availability. Teams reported that emergency drugs were appropriately administered in 21 of 22 (95%) cases. In contrast, closed loop communication was reportedly only used during 6 of 22 (27%) events. The hospital survey response rate was 56 of 338 (17%) clinical staff, of whom 37 of 56 (66%) agreed or strongly agreed that debriefing had improved team performance during CPR. Overall, 33 of 56 (60%) staff felt that the DBT had improved the debriefing process at the hospital. However, 3 of 56 (5%) staff members felt that they were unable to state their opinions in a blame-free environment during debriefing.

CONCLUSIONS

Implementation of a DBT enabled formal identification of strengths and training needs of resuscitation teams, and its implementation was viewed positively by the majority of hospital staff. However, further refinement of the tool and prospective studies evaluating its efficacy in improving outcome are warranted.

Identifying teamwork-related needs of the medical emergency team: Nurses' perspectives

BACKGROUND

The role of medical emergency team (MET) in managing deteriorating patients and enhancing patient safety is greatly affected by teamwork.

AIMS

To identify teamwork-related needs of the MET from MET nurses' perspectives. To assess the associations between MET nurses' perceptions of teamwork and their work experience and education.

STUDY DESIGN

A quantitative, descriptive correlational design.

METHODS

Registered intensive care unit (ICU) nurses (n = 50) who were members of the MET in an acute tertiary care hospital answered a modified version of the team assessment questionnaire in 2017. Data were analysed using descriptive statistics, the Kruskal-Wallis test, and the univariate analysis of variance method. The reporting of this study adheres to the strengthening the reporting of observational studies (STROBE) guidelines.

RESULTS

Participants showed least agreement with the items presenting leadership skills (mean = 2.6, SD = 0.68). Approximately 50% nurses disagreed that the MET had adequate resources, training, and skills. The majority of nurses (80%) felt that their responsibilities as a MET member interfered with taking care of their own ICU patients. Many nurses (64%) felt that they did not have a voice in MET's decision-making process. Approximately 50% nurses felt that they were not recognized for their individual contribution, and they were uncertain regarding MET's policies for dealing with conflicts. The amounts of MET nurses' work experience and education were associated with MET skills and function, respectively.

CONCLUSION

Key teamwork elements of the MET that need improvements include decision-making and conflict resolution skills, valuing team members, and team leadership. Practicing shared mental models, implementing the TeamSTEPPS curricula at hospitals for training ICU nurses, and simulation-based team-training programmes may be beneficial in improving teamwork of MET members.

RELEVANCE TO CLINICAL PRACTICE

This study revealed key teamwork elements of the MET that need improvements. Our findings may contribute to improve teamwork, thereby optimizing MET function, and enhancing patient outcomes.

Effects of using a cognitive aid on content and feasibility of debriefings of simulated emergencies

Background: Adverse events in patient care are often caused by failures in teamwork. Simulation training and its debriefing can contribute to improving teamwork and thus patient care. When conducting debriefings, there are several design factors that can potentially influence learning outcomes. This study examines the use of a cognitive aid to help structure the content of debriefings and compares it with debriefings that are merely roughly structured. In addition, the feasibility of the debriefing, the satisfaction of the participants and their teamwork during the training are investigated. Methods: In a simulated night shift, seven teams of four to five medical students (n=32) took part in six cases that simulated common situations in an emergency medicine environment and received a debriefing on their teamwork after each case, either in the intervention condition with the help of the TeamTAG tool - a cognitive aid focusing on selected teamwork principles from Crisis Resource Management (CRM) - or in the control condition without it. The facilitators noted the topics of the debriefings and rated their experience of conducting them; the participants indicated their satisfaction with the debriefings, as well as their assessment of the importance of CRM principles. In addition, the quality of teamwork was assessed using the Team Emergency Assessment Measure (TEAM). Results: The analysis showed no difference in the number of teamwork principles discussed between the control and intervention conditions, but topics were repeated more frequently in the control group. The TeamTAG guideline was focused on and implemented by the tutors, who discussed the CRM principles included in the TeamTAG more consistently than in the control condition. The tutors in both conditions were satisfied with the implementation, and the use of TeamTAG facilitated time management. There were no differences in participants' satisfaction, their assessment of the importance of the teamwork principles, or the quality of teamwork between conditions. Conclusion: The use of a cognitive aid can help to direct the focus on certain topics or learning objectives and facilitate time management through pre-structuring; however, a difference in learning outcomes (in terms of the quality of teamwork) could not be identified. Besides the influence of a certain structure or script, a strong influence from the individual guiding the debriefing is likely.

[Education for resuscitation]

Diese Leitlinien des European Resuscitation Council basieren auf dem internationalen wissenschaftlichen Konsens 2020 zur kardiopulmonalen Reanimation mit Behandlungsempfehlungen (International Liaison Committee on Resuscitation 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations [ILCOR] 2020 CoSTR). Dieser Abschnitt bietet Bürgern und Angehörigen der Gesundheitsberufe Anleitungen zum Lehren und Lernen der Kenntnisse, der Fertigkeiten und der Einstellungen zur Reanimation mit dem Ziel, das Überleben von Patienten nach Kreislaufstillstand zu verbessern.

Validating the Team Emergency Assessment Measure (TEAM) in obstetric and gynaecologic resuscitation teams

BACKGROUND

Simulation-based training is an effective method of enhancing the knowledge, skill, and technical abilities of individuals and teams encountering obstetric and gynaecologic emergencies. Simulation may also enhance the non-technical performance of teams resulting in improved patient outcomes. Although simulation-based training is widely recognised as an effective educational approach, issues around feasibility - the lack of simulation experts and malleable outcome measures of team performance - remain critical barriers to their implementation.

AIM

To evaluate the psychometric properties of the Team Emergency Assessment Measure (TEAM) when used by medical professionals in simulated obstetric and gynaecological emergencies.

METHODS

There were 151 participants (63% female; 60% consultants; 69% no previous simulation-based training) who observed three live high-fidelity obstetric and gynaecological resuscitation simulations and completed the TEAM.

RESULTS

Confirmatory factor analysis evaluated the construct validity of the TEAM, yielding a second-order structure identified by 'leadership', 'teamwork', and 'team management'. Convergent validity was supported by the average item-to-scale total correlation which was 0.75, P < 0.001 and the average analysis of variance extracted (AVE) 0.88. The individual factors also yielded high factor-to-scale total correlations (mean [M] = 0.87), and AVE (M = 0.89). The internal reliability was high for the whole scale (average alpha = 0.92) and across the sub-factors (average alpha = 0.80). The inter-rater reliability was excellent (inter-class correlation coefficient 1 = 0.98). Participants with differing levels of simulation training experience did not significantly differ.

CONCLUSION

The TEAM is a viable instrument for the assessment of non-technical performance during simulated obstetric and gynaecologic emergencies, thus enhancing the feasibility of simulation-based training.

European Resuscitation Council Guidelines 2021: Education for resuscitation

These European Resuscitation Council education guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidance to citizens and healthcare professionals with regard to teaching and learning the knowledge, skills and attitudes of resuscitation with the ultimate aim of improving patient survival after cardiac arrest.

Development and Evaluation of the Taxonomy of Trauma Leadership Skills-Shortened for Observation and Reflection in Training: A Practical Tool for Observing and Reflecting on Trauma Leadership Performance

INTRODUCTION

Trauma leadership skills are increasingly being addressed in trauma courses, but few resources are available to systematically observe and debrief trainees' performances. The authors therefore translated their previously developed, extensive Taxonomy of Trauma Leadership Skills (TTLS) into a practical observation tool that is tailored to the vocabulary of clinician instructors and their workflow and workload during simulation-based training.

METHODS

In 2016 to 2018, the TTLS was subjected to practical evaluation in an iterative process of 2 stages. In the first stage, testing panels of trauma specialists observed excerpts from videotaped simulations and indicated from the list of elements which behaviors they felt were being shown. Any ambiguities or redundancy were addressed by rephrasing or combining elements. In the second stage, iterations were used in actual scenario training to observe and debrief trainees' performances. The instructors' recommendations resulted in further improvements of clarity, ease of use, and usefulness, until no new suggestions were raised.

RESULTS

The resultant "TTLS-Shortened for Observation and Reflection in Training" was given a simpler structure and more concrete and self-explanatory benchmarks. It contains 6 skill categories for evaluation, each with 4 to 6 benchmark behaviors.

CONCLUSIONS

The TTLS-Shortened for Observation and Reflection in Training is an important addition to other trauma assessment tools because of its specific focus on leadership skills. It helps set concrete performance expectations, simplify note taking, and target observations and debriefings. One central challenge was striking a balance between its conciseness and specificity. The authors reflected on how the decisions for the resultant structure ease and leverage the conduct of observations and performance debriefing.

Tools for Assessing the Performance of Pediatric Perioperative Teams During Simulated Crises: A Psychometric Analysis of Clinician Raters' Scores

INTRODUCTION

The pediatric perioperative setting is a dynamic clinical environment where multidisciplinary interprofessional teams interact to deliver complex care to patients. This environment requires clinical teams to possess high levels of complex technical and nontechnical skills. For perioperative teams to identify and maintain clinical competency, well-developed and easy-to-use measures of competency are needed.

METHODS

Tools for measuring the technical and nontechnical performance of perioperative teams were developed and/or identified, and a group of raters were trained to use the instruments. The trained raters used the tools to assess pediatric teams managing simulated emergencies. A psychometric analysis of the trained raters' scores using the different instruments was performed and the agreement between the trained raters' scores and a reference score was determined.

RESULTS

Five raters were trained and scored 96 recordings of perioperative teams managing simulated emergencies. Scores from both technical skills assessment tools demonstrated significant reliability within and between ratings with the scenario-specific performance checklist tool demonstrating greater interrater agreement than scores from the global rating scale. Scores from both technical skills assessment tools correlated well with the other and with the reference standard scores. Scores from the Team Emergency Assessment Measure nontechnical assessment tool were more reliable within and between raters and correlated better with the reference standard than scores from the BARS tool.

CONCLUSIONS

The clinicians trained in this study were able to use the technical performance assessment tools with reliable results that correlated well with reference scores. There was more variability between the raters' scores and less correlation with the reference standard when the raters used the nontechnical assessment tools. The global rating scale used in this study was able to measure the performance of teams across a variety of scenarios and may be generalizable for assessing teams in other clinical scenarios. The Team Emergency Assessment Measure tool demonstrated reliable measures when used to assess interprofessional perioperative teams in this study.

Sim for Life: Foundations-A Simulation Educator Training Course to Improve Debriefing Quality in a Low Resource Setting: A Pilot Study

INTRODUCTION

Despite the importance of debriefing, little is known about the effectiveness of training programs designed to teach debriefing skills. In this study, we evaluated the effectiveness of a faculty development program for new simulation educators at Mbarara University of Science and Technology in Uganda, Africa.

METHODS

Healthcare professionals were recruited to attend a 2-day simulation educator faculty development course (Sim for Life: Foundations), covering principles of scenario design, scenario execution, prebriefing, and debriefing. Debriefing strategies were contextualized to local culture and focused on debriefing structure, conversational strategies, and learner centeredness. A debriefing worksheet was used to support debriefing practice. Trained simulation educators taught simulation sessions for 12 months. Debriefings were videotaped before and after initial training and before and after 1-day refresher training at 12 months. The quality of debriefing was measured at each time point using the Objective Structured Assessment of Debriefing (OSAD) tool by trained, calibrated, and blinded raters.

RESULTS

A total of 13 participants were recruited to the study. The mean (95% confidence interval) OSAD scores pretraining, posttraining, and at 12 months before and after refresher were 18.2 (14.3-22.1), 26.7 (22.8-30.6), 25.5 (21.2-29.9), and 27.0 (22.4-31.6), respectively. There was a significant improvement from pretraining to posttraining (P < 0.001), with no significant decay from posttraining to 12 months (P = 0.54). There was no significant difference in OSAD scores pre- versus post-refresher training at 12 months (P = 0.49).

CONCLUSIONS

The Sim for Life Foundations program significantly improves debriefing skills with retention of debriefing skills at 12 months.

Stress Management Training Improves Overall Performance during Critical Simulated Situations: A Prospective Randomized Controlled Trial

BACKGROUND

High-fidelity simulation improves participant learning through immersive participation in a stressful situation. Stress management training might help participants to improve performance. The hypothesis of this work was that Tactics to Optimize the Potential, a stress management program, could improve resident performance during simulation.

METHODS

Residents participating in high-fidelity simulation were randomized into two parallel arms (Tactics to Optimize the Potential or control) and actively participated in one scenario. Only residents from the Tactics to Optimize the Potential group received specific training a few weeks before simulation and a 5-min reactivation just before beginning the scenario. The primary endpoint was the overall performance during simulation measured as a composite score (from 0 to 100) combining a specific clinical score with two nontechnical scores (the Ottawa Global Rating Scale and the Team Emergency Assessment Measure scores) rated for each resident by four blinded independent investigators. Secondary endpoints included stress level, as assessed by the Visual Analogue Scale during simulation.

RESULTS

Of the 134 residents randomized, 128 were included in the analysis. The overall performance (mean ± SD) was higher in the Tactics to Optimize the Potential group (59 ± 10) as compared with controls ([54 ± 10], difference, 5 [95% CI, 1 to 9]; P = 0.010; effect size, 0.50 [95% CI, 0.16 to 0.91]). After specific preparation, the median Visual Analogue Scale was 17% lower in the Tactics to Optimize the Potential group (52 [42 to 64]) than in the control group (63 [50 to 73]; difference, -10 [95% CI, -16 to -3]; P = 0.005; effect size, 0.44 [95% CI, 0.26 to 0.59].

CONCLUSIONS

Residents coping with simulated critical situations who have been trained with Tactics to Optimize the Potential showed better overall performance and a decrease in stress level during high-fidelity simulation. The benefits of this stress management training may be explored in actual clinical settings, where a 5-min Tactics to Optimize the Potential reactivation is feasible prior to delivering a specific intervention.

Emergencies within hospital wards: An observational study of the non-technical skills of medical emergency teams

BACKGROUND

Medical emergency teams are essential in responding to acute deterioration of patients in hospitals, requiring both clinical and non-technical skills. This study aims to assess the non-technical skills of medical emergency teams during hospital ward emergencies and explore team members perceptions and experiences of the use non-technical skills during medical emergencies.

METHODS

A multi-methods study was conducted in two phases. During phase one observation and assessment of non-technical skills used in medical emergencies using the Team Emergency Assessment Measure (TEAM™) was conducted; and in the phase two in-depth interviews were undertaken with medical emergency team members.

RESULTS

Based on 20 observations, mean TEAM™ ratings for non-technical skill domains were: 'leadership' 5.0 out of 8 (±2.0); 'teamwork' 21.6 out of 28 (±3.6); and 'task management' 6.5 out of 8 (±1.4). The mean 'global' score was 7.5 out of 10 (±1.5). The qualitative findings identified three areas, 'individual', 'team' and 'other' contributing factors, which impacted upon the non-technical skills of medical emergency teams.

CONCLUSION

Non-technical skills of hospital medical emergency teams differ, and the impact of the skill mix on resuscitation outcomes was recognised by team members. These findings emphasize the importance non-technical skills in resuscitation training and well-developed processes for medical emergency teams.

An observational study of self-monitoring in ad hoc health care teams

BACKGROUND

Working in ad hoc teams in a health care environment is frequent but a challenging and complex undertaking. One way for teams to refine their teamwork could be through post-resuscitation reflection and debriefing. However, this would require that teams have insight into the quality of their teamwork. This study investigates (1) the accuracy of the self-monitoring of ad hoc resuscitation teams and their leaders relative to external observations of their teamwork and (2) the relationship of team self-monitoring and external observations to objective performance measures.

METHODS

We conducted a quantitative observational study of real-world ad hoc interprofessional teams responding to a simulated cardiac arrest in an emergency room. Teams consisting of residents, consultants, and nurses were confronted with an unexpected, simulated, standardized cardiac arrest situation. Their teamwork was videotaped to allow for subsequent external evaluation on the team emergency assessment measure (TEAM) checklist. In addition, objective performance measures such as time to defibrillation were collected. All participants completed a demographic questionnaire prior to the simulation and a questionnaire tapping their perceptions of teamwork directly after it.

RESULTS

22 teams consisting of 115 health care professionals showed highly variable performance. All performance measures intercorrelated significantly, with the exception of team leaders' evaluations of teamwork, which were not related to any other measures. Neither team size nor cumulative experience were correlated with any measures, but teams led by younger leaders performed better than those led by older ones.

CONCLUSION

Team members seem to have better insight into their team's teamwork than team leaders. As a practical consequence, the decision to debrief and the debriefing itself after a resuscitation should be informed by team members, not just leaders.

Team performance training for medical students: Low vs high fidelity simulation

Objectives

The aim of this study is to evaluate a simulation-based team performance course for medical students and compare its low- and high-fidelity components.

Study design

This is a prospective crossover observational study. Groups participated in one low- and one high-fidelity session twice. Low-fidelity scenarios included management of an emergency case on a simulated-patient, whereas high-fidelity scenarios constituted of multiple-trauma cases where simulated-patients wore a hyper-realistic suit. Team performance was assessed objectively, using the TEAM™ tool, and subjectively using questionnaires. Questionnaires were also used to assess presence levels, stress levels and evaluate the course.

Results

Participants’ team performance was higher in the low-fidelity intervention as assessed by the TEAM™ tool. An overall mean increase in self-assessed confidence towards non-technical skills attitudes was noted after the course, however there was no difference in self-assessed performance between the two interventions. Both reported mean stress and presence levels were higher for the high-fidelity module. Evaluation scores for all individual items of the questionnaire were ≥4.60 in both NTS modules. Students have assessed the high-fidelity module higher (4.88 out of 5, SD = 0.29) compared to low-fidelity module (4.74 out of 5, SD = 0.67).

Conclusions

Both the low- and high-fidelity interventions demonstrated an improvement in team performance of the attending medical students. The high-fidelity intervention was more realistic, yet more stressful. Furthermore, it proved to be superior in harvesting leadership, teamwork and task management skills. Both modules were evaluated highly by the students, however, future research should address retention of the taught skills and adaptability of such interventions.

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The high-fidelity intervention was superior in harvesting leadership, teamwork and task management skills, yet more stressful.

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We set the group to develop a novel group of team-based OSCE performance.

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The next step is to adapt such taught skills to different specialties and implement initiatives in the medical school curricula.