Preparing teams for low-frequency emergencies in Norwegian hospitals

A Literature Study of Medical Simulations for Non-Technical Skills Training in Emergency Medicine: Twenty Years of Progress, an Integrated Research Framework, and Future Research Avenues

Medical simulations have led to extensive developments in emergency medicine. Apart from the growing number of applications and research efforts in patient safety, few studies have focused on modalities, research methods, and professions via a synthesis of simulation studies with a focus on non-technical skills training. Intersections between medical simulation, non-technical skills training, and emergency medicine merit a synthesis of progress over the first two decades of the 21st century. Drawing on research from the Web of Science Core Collection's Science Citation Index Expanded and Social Science Citation Index editions, results showed that medical simulations were found to be effective, practical, and highly motivating. More importantly, simulation-based education should be a teaching approach, and many simulations are utilised to substitute high-risk, rare, and complex circumstances in technical or situational simulations. (1) Publications were grouped by specific categories of non-technical skills, teamwork, communication, diagnosis, resuscitation, airway management, anaesthesia, simulation, and medical education. (2) Although mixed-method and quantitative approaches were prominent during the time period, further exploration of qualitative data would greatly contribute to the interpretation of experience. (3) High-fidelity dummy was the most suitable instrument, but the tendency of simulators without explicitly stating the vendor selection calls for a standardised training process. The literature study concludes with a ring model as the integrated framework of presently known best practices and a broad range of underexplored research areas to be investigated in detail.

Training residents to lead emergency teams: A qualitative review of barriers, challenges and learning goals

OBJECTIVE

An investigation to determine any consensus in opinions and views in the literature about challenges or barriers in training leadership for emergencies.

SUMMARY OF BACKGROUND DATA

Leadership in emergencies is reported as being very important for patient outcome. A systematic review failed in 2016 to find any focused leadership training. In the literature, the research has described and focused on developing tools to evaluate leadership.

METHOD

Articles identified in the systematic review combined with other reviews and opinions were included to incorporate experiences, perceptions and emotions connected with leadership training in emergency situations. Two qualitative content analyses were conducted. The first analysis searched for opinions about leadership and leadership training in emergencies. The method was abductive - inductive qualitative content analysis. The second analysis searched, on the basis of an article written in 1986, statements about challenges regarding leadership training in all articles. This method was directed qualitative content analysis.

FINDINGS

In total 40 articles covering the years 1986-2016 were analysed. An explicit need for workable leadership training of team leaders in emergencies was identified. The importance of the teamleader in emergencies was repeatedly stressed by 31/40 articles, leadership training is needed or required was stated by 30/40 articles, 27/40 articles described the emergency situation as stressful, complex, chaotic or unpredictable, 17/40 described the importance of self-confidence by the teamleader, and 8/40 described that the situation was perceived as creating concern, anxiety or panic.

CONCLUSIONS

The literature recommends finding a solution to teach residents to gain courage and confidence in stressful surroundings. The literature recommends finding a way to work with body language, non-verbal communication, attitude and appearance in order to radiate credibility in a setting separated from medical knowledge.

A search for training of practising leadership in emergency medicine: A systematic review

Objective

This systematic review examines the medical, psychological and educational literature for training in practising leadership of a team leader in emergencies. The objectives of this paper are (1) describe how literature addresses operational training in practising leadership for the emergency medical team-leader (2) enhance understanding of leadership training in the medical environment.

Background

Worldwide, medical supervisors find it difficult to get students to rise to the occasion as leaders of emergency teams. It appears that many residents feel unprepared to adopt the role as a leader in emergencies.

Method

A systematic review was conducted (May-December 2016) in accordance with the PRISMA 2009 Checklist. A literature search was conducted against a set of inclusion criteria. Databases searched included PubMed, Psycinfo (via Ovid), and ERIC.

Results

27 articles covering the period 1986-2016 were analysed. Four sources of data were identified: Intervention studies practising leadership, intervention studies on simulation and leadership assessment, observation studies assessing leadership, interview/survey studies about the need for leadership training. No workable training in practising leadership in emergencies for doctors was found. The majority of the research projects focused on various different types of taxonomies.

Conclusions

No consistent and workable leadership training for the emergency medical teamleader was identified. One study for paramedics succeeded in training empowering leadership skills. For many years multiple taxonomies and leadership assessment tools have been developed but failed to come to terms with workable leadership training. The literature describes lack of leadership as highly detrimental to performance during a critical, clinical situation.

An International Interprofessional Study of Mental Models and Factors Delaying Neuroimaging of Critically Head-Injured Children Presenting to Emergency Departments

OBJECTIVES

Thousands of head-injured children are cared for by interprofessional teams in emergency departments every day. Teams must balance performing time-consuming interventions with safe transport for neuroimaging. This study aims to describe and compare providers' perspectives on the transfer of head-injured children to neuroimaging and factors contributing to delays.

METHODS

Participants were interprofessional health care providers involved in the care of head-injured children at sites in the United Kingdom, the United States, and New Zealand. They first viewed a 3-minute video of a child with a severe head injury presenting to their resuscitation bay. Next, they were presented with 5 physiologically different simulated scenarios and asked to report whether interventions were required before transporting each patient to neuroimaging. Then, they reported team and system factors contributing to delays in neuroimaging.

RESULTS

Two hundred forty of 296 providers completed the intervention. The percentage of providers reporting that they would directly transport to neuroimaging without intervention was 89% for "stable," 49% for "Cushing's triad," 26% for "hypoxic," 25% for "tachycardic," and 5% for "extremis." There were differences noted in responses by profession for the hypoxia and tachycardia cases. No differences were noted between trainees and attending physicians for any cases. The most frequent factors reported as delaying neuroimaging were team decision making and waiting for equipment, medications, and scanner availability.

CONCLUSIONS

There is variability in providers' perspectives on the interventions required before transporting severely head-injured patients for imaging. Diverse team and system factors contribute to delays in imaging.

Conducting the emergency team: A novel way to train the team-leader for emergencies

INTRODUCTION

Worldwide, medical supervisors find it difficult to get students to rise to the occasion when called upon to act as leaders of emergency teams: many residents/rescuers feel unprepared to adopt the leadership role. The challenge is to address the residents very strong emotions caused by the extremely stressful context. No systematic leadership training takes this aspect into account.

AIM

The overall aim of the course is to investigate whether, in an emergency, a clinical team leader could apply a conductor's leadership skills.

BACKGROUND

An orchestral conductor is a specialist in practicing leadership focusing on non-verbal communication. The conductor works with highly trained specialists and must lead them to cooperate and put his interpretation into effect. The conductor works purposefully in order to appear calm, genuine and gain authority.

METHOD

A conductor and a consultant prepared a course for residents, medical students and nurses, n = 61. Ten × two course days were completed. The exercises were musical and thus safe for the students as there were no clinical skills at stake. The programme aimed to create stress and anxiety in a safe learning environment.

CONCLUSION

The transfer of a conductor's skills improved and profoundly changed the participating students', nurses' and residents' behaviour and introduced a method to handle anxiety and show calmness and authority.

PERSPECTIVES

If this course in leadership is to be introduced as a compulsory part of the educating of doctors, the ideal time would be after clinical skills have been acquired, experience gained and routines understood in the clinic.

Implementation of a trauma system in Norway: a national survey

BACKGROUND

Trauma systems have improved outcomes for injured patients, but might be challenging to implement. We assessed the implementation of a trauma system in Norway after recommendations for a national trauma system were published in 2007, with a focus on elements in acute care hospitals.

METHODS

All hospitals in Norway, except for the four regional trauma centres, admitting injured patients at the time of the study were included in a telephone survey. The questionnaire was administered during May 2013 by the regional trauma coordinators who interviewed the local trauma coordinator and/or the local doctor responsible for trauma care in all the acute care hospitals. The main categories were availability of the trauma team and team training, written procedures, preparedness and training of personnel. The compliance to a set of 17 predefined trauma system criteria was evaluated at each institution.

RESULTS

Of the 35 acute care hospitals in Norway admitting trauma patients at the time of the survey, all were included. The median number of fulfilled criteria was 14. Major deficiencies were found in fulfilling competence criteria, maintaining a local trauma registry, and trauma audits. The number of fulfilled criteria correlated strongly with the size of the hospital and the frequency of trauma team activation.

CONCLUSIONS

Shortcomings in requirements for lower-level trauma care hospitals correlate to hospital size and frequency with which the trauma team is activated. In order to fulfill the minimum requirements, smaller hospitals should receive more attention.

Teamwork skills, shared mental models, and performance in simulated trauma teams: an independent group design

Background

Non-technical skills are seen as an important contributor to reducing adverse events and improving medical management in healthcare teams. Previous research on the effectiveness of teams has suggested that shared mental models facilitate coordination and team performance. The purpose of the study was to investigate whether demonstrated teamwork skills and behaviour indicating shared mental models would be associated with observed improved medical management in trauma team simulations.

Methods

Revised versions of the 'Anesthetists' Non-Technical Skills Behavioural marker system' and 'Anti-Air Teamwork Observation Measure' were field tested in moment-to-moment observation of 27 trauma team simulations in Norwegian hospitals. Independent subject matter experts rated medical management in the teams. An independent group design was used to explore differences in teamwork skills between higher-performing and lower-performing teams.

Results

Specific teamwork skills and behavioural markers were associated with indicators of good team performance. Higher and lower-performing teams differed in information exchange, supporting behaviour and communication, with higher performing teams showing more effective information exchange and communication, and less supporting behaviours. Behavioural markers of shared mental models predicted effective medical management better than teamwork skills.

Conclusions

The present study replicates and extends previous research by providing new empirical evidence of the significance of specific teamwork skills and a shared mental model for the effective medical management of trauma teams. In addition, the study underlines the generic nature of teamwork skills by demonstrating their transferability from different clinical simulations like the anaesthesia environment to trauma care, as well as the potential usefulness of behavioural frequency analysis in future research on non-technical skills.

Keeping the spirit high: why trauma team training is (sometimes) implemented

BACKGROUND

Systematic and multiprofessional trauma team training using simulation was introduced in Norway in 1997. The concept was developed out of necessity in two district general hospitals and one university hospital but gradually spread to 45 of Norway's 50 acute-care hospitals over the next decade. Implementation in the hospitals has varied from being a single training experience to becoming a regular training and part of quality improvement. The aim of this study was to better understand why only some hospitals achieved implementation of regular trauma team training, despite the intentions of all hospitals to do so.

METHODS

Focus group interviews were conducted with multiprofessional respondents in seven hospitals, including small and large hospitals and hospitals with and without regular team training. Interviews were transcribed and analyzed using a Grounded Theory approach.

RESULTS

'Keeping the spirit high' appeared to be the way to achieve implementation. This was achieved through 'enthusiasm,''strategies and alliances,' and 'using spin-offs.' It seems that the combination of enthusiasts, managerial support, and strategic planning are key factors for professionals trying to implement new activities.

CONCLUSIONS

Committed health professionals planning to implement new methods for training and preparedness in hospitals should have one or more enthusiasts, secure support at the administrative level, and plan the implementation taking all stakeholders into consideration.

Simulated pediatric trauma team management: assessment of an educational intervention

OBJECTIVES

Trauma is the leading cause of death in children. The quality of initial medical care received by injured children contributes to outcomes. Our objective was to assess effectiveness of an educational intervention on performance of emergency department (ED) teams during simulated pediatric trauma resuscitations.

METHODS

A prospective, preinterventional and postinterventional study was performed on a random, convenience sample of 17% of EDs in North Carolina. An unannounced simulated pediatric trauma resuscitation was conducted at each site, followed by an educational intervention and a second visit 6 months later. The key outcome measure was team performance on a clinical assessment tool previously described that included 44 resuscitation tasks deemed critical to appropriate management of pediatric trauma resuscitation.

RESULTS

All 18 sites consented and completed the study. Interrater reliability was excellent, weighted kappa = 0.80 (95% confidence interval, 0.76-0.84). After the educational intervention, the mean (+/- SD) number of the 44 tasks passed by each ED team increased from 17.7 +/- 4.3 to 26.6 +/- 5.8 (P < 0.001). At the individual task level, the scores on 37 (84%) of the 44 tasks improved, of which 11 (25%) of the 44 tasks improved significantly.

CONCLUSIONS

This study demonstrated that an on-site educational intervention was effective in improving the performance of ED teams during simulated pediatric trauma resuscitations. Postintervention performance was more consistent with the Pediatric Advanced Life Support and Advanced Trauma Life Support guidelines. Further studies are needed to determine if improved performance in a simulated scenario leads to improved performance and better clinical outcomes of critically injured children.

Interprofessional education of medical students and paramedics in emergency medicine

BACKGROUND

Emergency medicine is team work from the field to the hospital and therefore it is also important for physicians to understand the work of paramedics, and vice versa. Interprofessional emergency medicine education for medical and paramedic students in Helsinki was started in 2001. It consisted of a 15 European credit transfer system (ECTS) credits programme combining 22 students in 2001. In 2005, the number of students had increased to 25. The programme consisted of three parts: acute illness in childhood and adults (AI), advanced life support (ALS) and trauma life support (TLS). In this paper, we describe the concept of interprofessional education of medical students and paramedics in emergency medicine.

METHODS

After finishing the programmes in 2001 and in 2005, the students' opinions regarding the education were collected using a standardized questionnaire.

RESULTS

There were good ratings for the courses in AI (2001 vs. 2005, whole group; 4.3 +/- 0.7 vs. 4.2 +/- 0.4, P = 0.44) ALS (4.7 +/- 0.5 vs. 4.4 +/- 0.5, P = 0.06) and TLS (3.9 +/- 0.7 vs. 4.4 +/- 0.5, P = 0.01) in both years. Most of the medical students considered that this kind of co-education should be arranged for all medical students (2001 vs. 2005; 4.8 +/- 0.6 vs. 4.4 +/- 0.5, P = 0.02) and should be obligatory (3.5 +/- 1.5 vs. 3.1 +/- 1.3, P = 0.35).

CONCLUSIONS

Co-education was well received and determined by the students as an effective way of improving their knowledge of emergency medicine and medical skills. The programme was rated as very useful and it should be included in the educational curriculum of both student groups.

Finnish Trauma Audit 2004: current state of trauma management in Finnish hospitals

There is great variation in the organisation of trauma care in European countries. The state of trauma care in Finnish hospitals has not been appropriately reviewed in the past. The aim of the present study conducted by the Finnish Trauma Association (FTA) was to assess the number of Finnish hospitals admitting severe trauma patients, and to evaluate the organisation and training of trauma care in those hospitals. In 2004, a telephone survey to all the Finnish hospitals was conducted, and information on the number of severe trauma patients treated per month, the organisation of acute trauma care, and the existence of multidisciplinary trauma care training was collected. Thirty-six Finnish hospitals admitted trauma patients. The range of estimated number of severely injured trauma patients treated in individual hospitals per month varied from 0.5 to 12, resulting in an estimated number of 1000-1300 patients with severe trauma treated in Finland every year (19-25/100.000 inhabitants). About 20% of the hospitals had a trauma team, and 25% had a systematic trauma education program. Only one hospital had established multidisciplinary and systematic trauma team training. The case load of severe trauma patients is low in most Finnish hospitals making it difficult to obtain and maintain sufficient experience. Too many hospitals admit too few patients, and only a few hospitals have been working on updating their trauma management protocols and education. There is an obvious need for leadership, discussion, legislation and initiatives by the professional organisations and the government to establish a modern trauma system in Finland.

Training multiprofessional trauma teams in Norwegian hospitals using simple and low cost local simulations

CONTEXT & OBJECTIVE

Norwegian hospitals' trauma teams are seldom exposed to severely injured patients. We developed and implemented a one-day multi-professional training course for hospital trauma teams in order to improve communication, cooperation and leadership.

METHODS

Training courses were held in 28 Norwegian hospitals with learning objectives: improved team work, common understanding of treatment priorities and principles, communication skills, and threats to efficient communication. Two trauma teams in each hospital had two consecutive simulations in their hospital's own emergency room, as part of the course. Simulation was based on real cases, with a low-fidelity mannequin as patient. Participants completed questionnaires before and after the training course.

RESULTS

A total of 2,860 trauma team members participated in the courses, of which 1,237 took part in the simulation. Independent of hospital size, the participants reported leadership and communication to be major obstacles during their last real trauma team participation. Immediately after the training, all participants reported highly fulfilled educational expectations and a high perception of learning, and taking part in the practical simulation improved the evaluation. Nurses scored their outcome significantly higher than physicians. Participants from minor hospitals reported as great a benefit from the training as personnel from major hospitals.

CONCLUSIONS

Local team training is a feasible approach and team simulation offers an excellent opportunity to practise demanding and infrequent challenges. The simulation format makes it possible to integrate training on interpersonal skills as well as communication and leadership under stress. Continued requests for such training in Norway support this conclusion.

Training trauma teams in the Nordic countries: an overview and present status

BACKGROUND

During the last decade there has been an increased interest in the organisation and quality of trauma care in the Nordic countries. Still, most patients are initially cared for at hospitals with low caseloads of severe trauma. More than 200 hospitals offer initial care to trauma patients. Training of trauma teams using simulators or simulated patients has evolved in the same period, as one important factor to overcome lack of practical training. This overview describes the present state of trauma team training in the Nordic countries.

METHODS

Members of a Nordic working group on the use of simulation in medicine reviewed present literature on training with simulation and described the present use of team training in their own countries during winter 2004.

RESULTS

There is an increasing amount of evidence indicating that training of teams with simulation reduces treatment errors and improves performance. The training activities do not need to be complex, but skilled debriefing seems necessary. Few Nordic hospitals train their trauma teams. The training activities vary considerably between and within countries.

CONCLUSION

There is considerable evidence supporting an increased use of experience gained in other high-risk domains where training in communication, leadership and decision-making is the focus for safety and improvement efforts. There is a need for more widespread training of trauma teams. The different training activities actually undertaken should be scientifically evaluated.

The development and implementation of a multidisciplinary neonatal resuscitation team in a Canadian perinatal centre

PURPOSE

To describe the implementation of a multidisciplinary neonatal resuscitation team (NRT) at a Canadian tertiary perinatal centre.

METHODS

In February 2002, the primary role of neonatal resuscitation was transferred from attending physicians (on-call off-site) to a NRT (consisting of a neonatal intensive care nurse, a respiratory therapist, and, when available, a resident, clinical associate (supervised licensed physician), or nurse practitioner). The NRT attended moderate- and high-risk deliveries (in the latter case, accompanied by a neonatologist). Normal, low-risk deliveries remained the responsibility of caseroom (delivery room) staff, assisted by the NRT when concerns arose. A prospective assessment was performed of resuscitation requirements and outcomes.

RESULTS

: Over 24 months, the NRT attended 2944 (64.5%) out of 4565 deliveries. The NRT attended 2497 moderate-risk deliveries, providing positive pressure ventilation (in 15.7% of cases), chest compressions (0.1%), and epinephrine (adrenaline) (0.08%). There were no neonatal deaths or morbidities related to resuscitation in this cohort. A small, but significant, proportion of babies with no identifiable risk factors required resuscitation by caseroom staff (in most cases with brief periods of positive pressure ventilation).

CONCLUSION

Assignment of level of risk provides a safe means of delivering neonatal resuscitation services, facilitating NRT attendance at the majority of deliveries that required resuscitation. A NRT can perform safely and effectively in a tertiary perinatal centre with off-site support from experienced neonatal staff at high-risk deliveries only. Caseroom (delivery room) staff should continue to be trained in neonatal resuscitation.