Factors influencing diagnostic accuracy among intensive care unit clinicians - an observational study

OBJECTIVES

Diagnostic errors are a source of morbidity and mortality in intensive care unit (ICU) patients. However, contextual factors influencing clinicians' diagnostic performance have not been studied in authentic ICU settings. We sought to determine the accuracy of ICU clinicians' diagnostic impressions and to characterize how various contextual factors, including self-reported stress levels and perceptions about the patient's prognosis and complexity, impact diagnostic accuracy. We also explored diagnostic calibration, i.e. the balance of accuracy and confidence, among ICU clinicians.

METHODS

We conducted an observational cohort study in an academic medical ICU. Between June and August 2019, we interviewed ICU clinicians during routine care about their patients' diagnoses, their confidence, and other contextual factors. Subsequently, using adjudicated final diagnoses as the reference standard, two investigators independently rated clinicians' diagnostic accuracy and on each patient on a given day ("patient-day") using 5-point Likert scales. We conducted analyses using both restrictive and conservative definitions of clinicians' accuracy based on the two reviewers' ratings of accuracy.

RESULTS

We reviewed clinicians' responses for 464 unique patient-days, which included 255 total patients. Attending physicians had the greatest diagnostic accuracy (77-90 %, rated as three or higher on 5-point Likert scale) followed by the team's primary fellow (73-88 %). Attending physician and fellows were also least affected by contextual factors. Diagnostic calibration was greatest among ICU fellows.

CONCLUSIONS

Additional studies are needed to better understand how contextual factors influence different clinicians' diagnostic reasoning in the ICU.

[In situ simulation training of medical-surgical teams in the management of severe trauma patients]

In the management of severe trauma, the aim is to assess the patient's clinical stability as quickly as possible, enabling referral to imaging (whole-body CT scan, embolization if necessary) or the operating room, or even the decision to perform in situ surgery (resuscitation thoracotomy). To cope with these critical situations, team training is essential, with the aim of ensuring the reproducibility of the difficulties encountered. High-fidelity in situ simulation is the ideal tool for meeting this training challenge.

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.

Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings

BACKGROUND

Debriefings help teams learn quickly and treat patients safely. However, many clinicians and educators report to struggle with leading debriefings. Little empirical knowledge on optimal debriefing processes is available. The aim of the study was to evaluate the potential of specific types of debriefer communication to trigger participants' reflection in debriefings.

METHODS

In this prospective observational, microanalytic interaction analysis study, we observed clinicians while they participated in healthcare team debriefings following three high-risk anaesthetic scenarios during simulation-based team training. Using the video-recorded debriefings and INTERACT coding software, we applied timed, event-based coding with DE-CODE, a coding scheme for assessing debriefing interactions. We used lag sequential analysis to explore the relationship between what debriefers and participants said. We hypothesised that combining advocacy (ie, stating an observation followed by an opinion) with an open-ended question would be associated with participants' verbalisation of a mental model as a particular form of reflection.

RESULTS

The 50 debriefings with overall 114 participants had a mean duration of 49.35 min (SD=8.89 min) and included 18 486 behavioural transitions. We detected significant behavioural linkages from debriefers' observation to debriefers' opinion (z=9.85, p<0.001), from opinion to debriefers' open-ended question (z=9.52, p<0.001) and from open-ended question to participants' mental model (z=7.41, p<0.001), supporting our hypothesis. Furthermore, participants shared mental models after debriefers paraphrased their statements and asked specific questions but not after debriefers appreciated their actions without asking any follow-up questions. Participants also triggered reflection among themselves, particularly by sharing personal anecdotes.

CONCLUSION

When debriefers pair their observations and opinions with open-ended questions, paraphrase participants' statements and ask specific questions, they help participants reflect during debriefings.

The Influence of Human Factors Training in Air Rescue Service on Patient Safety in Hospitals: Results of an Online Survey

Background: Air rescue crew members work equally in aviation and medicine, and thus occupy an important interface between the two work environments of aviation and medicine. The aim of this study was to obtain responses from participants to a validated online-based questionnaire regarding whether hospitals may benefit from the commitment of a medical hospital staff which is also professionally involved in the aviation system as emergency physicians and Helicopter Emergency Medical Services Technical Crew Members (HEMS TC). Furthermore, it focused on the question of whether the skills acquired through Crew Resource Management (CRM) training in the air rescue service might also be used in the ground-based rescue service and, if so, whether they may have a positive effect. Methods: Medical air rescue staff of 37 German air rescue stations was included. Between 27 November 2020 and 03 March 2021, 253 out of 621 employees (response rate: 40.7%) participated voluntarily in a validated anonymized online survey. A quantitative test procedure was performed using the modified questionnaire on teamwork and patient safety (German version). Results: The examination and interpretation of the internal consistency (Cronbach's alpha) resulted in the following reliabilities: Factor I (Cooperation): α = 0.707 (good); Factor II (Human factors): α = 0.853 (very good); Factor III (Communication): α = 0.657 (acceptable); and Factor IV (Safety): α = 0.620 (acceptable). Factor analysis explained 53.1% of the variance. Conclusions: The medical clinicians participating in this online survey believed that the skills they learned in human factors training such as CRM are helpful in their daily routine work in hospitals or other medical facilities, as well as in their ground-based rescue service activities. These findings may result in the recommendation to make CRM available on a regular to the medical staff in all medical facilities and also to ground-based rescue service staff aiming to increase patient safety and employee satisfaction.

Instruments to evaluate non-technical skills during high fidelity simulation: A systematic review

INTRODUCTION

High Fidelity Simulations (HFS) are increasingly used to develop Non-Technical Skills (NTS) in healthcare providers, medical and nursing students. Instruments to measure NTS are needed to evaluate the healthcare providers' (HCPs) performance during HFS. The aim of this systematic review is to describe the domains, items, characteristics and psychometric properties of instruments devised to evaluate the NTS of HCPs during HFS.

METHODS

A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Studies were retrieved from PubMed, Cinahl, Web of Science, Cochrane Library, ProQuest and PubPsych. Studies evaluating the measurement properties of instruments used to assess NTS during HFS training were included. Pairs of independent reviewers determined the eligibility, extracted and evaluated the data. Risk of bias and appraisal of the methodological quality of the studies was assessed using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist, and the quality of the evidence with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

A total of 3,953 articles were screened. A total of 110 reports were assessed for eligibility and 26 studies were included. Studies were conducted in Europe/United Kingdom (n = 13; 50%), North America/Australia (n = 12; 46%) and Thailand (n = 1; 4%). The NTS instruments reported in this review included from 1 to 14 domains (median of 4, Q1 = 3.75, Q3 = 5) and from 3 to 63 items (median of 15, Q1 = 10, Q3 = 19.75). Out of 19 NTS assessment instruments for HFS, the Team Emergency Assessment Measure (TEAM) can be recommended for use to assess NTS. All the other instruments require further research to assess their quality in order to be recommended for use during HFS training. Eight NTS instruments had a positive overall rating of their content validity with at least a moderate quality of evidence.

CONCLUSION

Among a large variety of published instruments, TEAM can be recommended for use to assess NTS during HFS. Evidence is still limited on essential aspects of validity and reliability of all the other NTS instruments included in this review. Further research is warranted to establish their performance in order to be reliably used for HFS.

What Do We Really Know About Crew Resource Management in Healthcare?: An Umbrella Review on Crew Resource Management and Its Effectiveness

OBJECTIVE

The aim of this article was to present an overview of the crew resource management (CRM) literature in healthcare. The first aim was to conduct an umbrella review on CRM literature reviews. The second aim was to conduct a new literature review that aims to address the gaps that were identified through the umbrella review.

METHODS

First, we conducted an umbrella review to identify all reviews that have focused on CRM within the healthcare context. This step resulted in 16 literature reviews. Second, we conducted a comprehensive literature review that resulted in 106 articles.

RESULTS

The 16 literature reviews showed a high level of heterogeneity, which resulted in discussing 3 ambiguities: definition, outcome, and information ambiguity. As a result of these ambiguities, a new comprehensive review of the CRM literature was conducted. This review showed that CRM seems to have a positive effect on outcomes at Kirkpatrick's level 1, 2, and 3. In contrast, whether CRM has a positive effect on level 4 outcomes and how level 4 should be measured remains undetermined. Recommendations on how to implement and embed CRM training into an organization to achieve the desired effects have not been adequately considered.

CONCLUSIONS

The extensive nature of this review demonstrates the popularity of CRM in healthcare, but at the same time, it highlights that research tends to be situated within certain settings, focuses on particular outcomes, and has failed to address the full scope of CRM as a team intervention and a management concept.

A Delphi study identifying operating room nurses' non-technical skills

AIM

To identify the non-technical skills of operating room nurses. This is the first empirical study that includes scrub and circulating operating room nurses.

DESIGN

A three-round modified online Delphi technique was used for this study.

METHODS

Eligible participants (n = 106) with a minimum of 2 years of operating room nursing experience were selected for the expert panel by self-recruitment from a population (N = 1640) of operating room nurses. Data were collected through online surveys, based on crew recourse management theory, between April and September 2020. Descriptive statistics analysis was used for the quantitative data, and deductive thematic analysis for the qualitative data. Consensus was determined using stability between the survey rounds.

RESULTS

A consensus was obtained to maintain the non-technical skills categories of situation awareness, leadership, decision-making, communication and teamwork. The qualitative data revealed several novel non-technical skills, including independent decision-making and leadership skills.

CONCLUSION

The non-technical skills of operating room nurses are more extensive than previously identified. This study has contributed to a verbalization of the tacit knowledge and skills of the operating room nurses. In addition, a list of non-technical skills that should be included in the education of operating room nurses to ensure patient safety in the operating room has been prepared.

IMPACT

This study addresses the lack of research on the non-technical skills of operating room nurses. When exploring the non-technical skills of scrub and circulating nurses, a diversity of novel non-technical skills was uncovered. This research will provide input for the development of a new training, supervision and assessment tool for accelerated development of the non-technical skills of operating room nurses. This contribution to the verbalization of the formerly tacit non-technical skills may facilitate clinical and formal teaching of such skills and may subsequently impact surgery-related patient safety.

Improving Incident Reporting in a Hospital-Based Radiation Oncology Department: The Impact of a Customized Crew Resource Training and Event Reporting Intervention

Background

Radiation oncology (RO) is a high-risk environment with an increased potential for error due to the complex automated and manual interactions between heterogeneous teams and advanced technologies. Errors involving procedural deviations­­ can adversely impact patient morbidity and mortality. Under-reporting of errors is common in healthcare for reasons such as fear of retribution, liability, embarrassment, etc. Incident reporting is a proven tool for learning from errors and, when effectively implemented, can improve quality and safety. Crew resource management (CRM) employs just culture principles with a team-based safety system. The pillars of CRM include mandatory error reporting and structured training to proactively identify, learn from, and mitigate incidents. High-reliability organizations, such as commercial aviation, have achieved exemplary safety performance since adopting CRM strategies.

Objective

Our aim was to double the rate of staff error reporting from baseline rates utilizing CRM strategies during a six-month study period in a hospital-based radiation oncology (RO) department.

Methods

This quasi-experimental study involved a retrospective review of reported radiation oncology incidents between January 2015 and March 2016, which helped inform the development and implementation of a two-step custom CRM training and incident learning system (ILS) intervention in May 2016. A convenience sample of approximately 50 RO staff (Staff) performing over 100 external beam and daily brachytherapy treatments participated in weekly training for six months while continuing to report errors on a hospital-enterprise system. A discipline-specific incident learning system (ILS) customized for the department was added during the last three months of the study, enabling staff to identify, characterize, and report incidents and potential errors. Weekly process control charts used to trend incident reporting rates (total number of reported incidents in a given month /1000 fractions), and custom reports characterizing the potential severity as well as the location of incidents along the treatment path, were reviewed, analyzed, and addressed by an RO multidisciplinary project committee established for this study.

Results

A five-fold increase in the monthly reported number of incidents (n = 9.3) was observed during the six-month intervention period as compared to the 16-month pre-intervention period (n = 1.8). A significant increase (>3 sigma) was observed when the custom reporting system was added during the last three study months.

Conclusion

A discipline-specific electronic ILS enabling the characterization of individual RO incidents combined with routine CRM training is an effective method for increasing staff incident reporting and engagement, leading to a more systematic, team-based mitigation process. These combined strategies allowed for real-time reporting, analysis, and learning that can be used to enhance patient safety, improve teamwork, streamline communication, and advance a culture of safety.

Learning from safety incidents in high-reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare

OBJECTIVE

A high-reliability organization (HRO) is an organization that has sustained almost error-free performance, despite operating in hazardous conditions where the consequences of errors could be catastrophic. A number of tools and initiatives have been used within HROs to learn from safety incidents, some of which have the potential to be adapted and used in healthcare. We conducted a systematic review to identify any learning tools deemed to be effective that could be adapted and used by multidisciplinary teams in healthcare following a patient safety incident.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and MetaAnalyses for Protocols reporting guidelines and was registered with the PROSPERO (CRD42017071528). A search of databases was carried out in January 2021, from the date of their commencement. We conducted a search on electronic databases such as Web of Science, Science Direct, MEDLINE in Process Jan 1950-present, EMBASE Jan 1974-present, CINAHL 1982-present, PsycINFO 1967-present, Scopus and Google Scholar. We also searched the grey literature including reports from government agencies, relevant doctoral dissertations and conference proceedings. A customized data extraction form was used to capture pertinent information from included studies and Critical Appraisal Skills Programme tool to appraise on their quality.

RESULTS

A total of 5921 articles were identified, with 964 duplicate articles removed and 4932 excluded at the title (4055), abstract (510) and full-text (367) stages. Twenty-five articles were included in the review. Learning tools identified included debriefing, simulation, crew resource management and reporting systems to disseminate safety messages. Debriefing involved deconstructing incidents using reflective questions, whilst simulation training involved asking staff to relive the event again by performing the task(s) in a role-play scenario. Crew resource management is a set of training procedures that focus on communication, leadership and decision-making. Sophisticated incident-reporting systems provide valuable information on hazards and were widely recommended as a way of disseminating key safety messages following safety incidents. These learning tools were found to have a positive impact on learning if conducted soon after the incident with efficient facilitation.

CONCLUSION

Healthcare organizations should find ways to adapt to the learning tools or initiatives used in HROs following safety incidents. It is challenging to recommend any specific one as all learning tools have shown considerable promise. However, the way these tools or initiatives are implemented is critical, and so further work is needed to explore how to successfully embed them into healthcare organizations so that everyone at every level of the organization embraces them.

Hospital medication errors: a cross-sectional study

BACKGROUND

Medication errors (MEs) are among the most common types of incidents reported in Australian and international hospitals. There is no uniform method of reporting and reducing these errors. This study aims to identify the incidence, time trends, types and factors associated with MEs in a large regional hospital in Australia.

METHODS

A 5-year cross-sectional study.

RESULTS

The incidence of MEs was 1.05 per 100 admitted patients. The highest frequency of errors was observed during the colder months of May-August. When distributed by day of the week, Mondays and Tuesdays had the highest frequency of errors. When distributed by hour of the day, time intervals from 7 am to 8 am and from 7 pm to 8 pm showed a sharp increase in the frequency of errors. One thousand and eighty-eight (57.8%) MEs belonged to incidence severity rating (ISR) level 4 and 787 (41.8%) belonged to ISR level 3. There were six incidents of ISR level 2 and only one incident of ISR level 1 reported during the five-year period 2014-2018. Administration-only errors were the most common accounting for 1070 (56.8%) followed by prescribing-only errors (433, 23%). High-risk medications were associated with half the number of errors, the most common of which were narcotics (17.9%) and antimicrobials (13.2%).

CONCLUSIONS

MEs continue to be a problem faced by international hospitals. Inexperience of health professionals and nurse-patient ratios might be the fundamental challenges to overcome. Specific training of junior staff in prescribing and administering medication and nurse workload management could be possible solutions to reducing MEs in hospitals.

Approaching the Evidence Basis for Aviation-Derived Teamwork Training in Medicine

The Institute of Medicine has suggested that training in team behavior, leadership, communication, and other human factors could reduce medical errors and improve patient safety. Training on such topics has been adapted from teamwork training programs used in military and commercial aviation, called crew resource management (CRM). The principles behind CRM programs have been deployed in a number of clinical settings over the past 2 decades, and there are now several CRM vendors. Little is known about this nascent industry, and the emerging research supporting CRM programs lacks standardization and conclusive evidence. The objectives of this study were to report on the body of empirical data about CRM training in clinical settings and to provide a conceptual framework for evaluating its effectiveness in medicine. Using the proposed conceptual framework, the authors further examine currently published methods of measuring effectiveness and identify future directions for the use of teamwork training in medicine.

Psychological aptitude for surgery: The importance of non-technical skills

INTRODUCTION

Psychological aptitude for surgery includes all the non-technical abilities that are necessary for the surgeons. However, differently from the other careers, these skills are not considered in the selection process and their role is definitively underestimated in the field of surgery. We perform a literature review of non-technical skills for surgery to identify their role and to understand how to train and evaluate these abilities among the surgeons.

RESULTS

Different methods have been presented for the evaluation and training of non-technical skills for surgeons; based on the model of aviation and anesthesia a wide range of simulated scenarios have been proposed to practice these aptitudes and abilities. Different behavioral markers systems have been developed for correct identification and definition of these skills, these can be used in the real surgical room and even learned and trained in the simulated operating theatre.

CONCLUSION

This article shows the importance of non-practical abilities in the surgical performance and in defining the aptitude for surgery. Learning these skills and introducing them in surgical education can be useful to improve the surgical performance.

Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study

OBJECTIVE

To study the effect of an intervention based on Crew Resource Management team training, including a tool for structured communication, on adverse perinatal and maternal outcomes.

DESIGN

Stepped wedge.

SETTING

The Netherlands.

POPULATION OR SAMPLE

Registry data of 8123 women referred from primary care to a hospital during childbirth, at ≥ 32.0 weeks of singleton gestation and with no congenital abnormalities, in the period 2012-15.

METHODS

Obstetric teams of five hospitals and their surrounding primary-care midwifery practices participated in the intervention. In total, 49 team training sessions were organised for 465 care professionals (75.5% participated). Adverse perinatal and maternal outcomes before, during and after the intervention were analysed using multivariate logistic regression analyses.

MAIN OUTCOME MEASURES

Adverse Outcome Index (AOI-5), a composite measure involving; intrapartum or neonatal death, admission to neonatal intensive care unit, Apgar < 7 at 5 minutes, postpartum haemorrhage and/or perineal tear.

RESULTS

In total, an AOI-5 score was reported in 11.3% of the study population. No significant difference was found in the incidence of the AOI-5 score after the intervention compared with before the intervention (OR 1.07: 95% CI 0.92-1.24).

CONCLUSIONS

We found no effect of the intervention on adverse perinatal and maternal outcomes for women who were referred during childbirth. Team training is appreciated in practice, but evidence on the long-term impact is still limited. Upcoming studies should build on previous research and consider more sensitive outcome measures.

TWEETABLE ABSTRACT

A cluster randomised team training intervention showed no effect on adverse perinatal and maternal outcomes for women referred during childbirth.

Tools for your stroke team: adapting crew-resource management for acute stroke care

Crew-resource management is an approach to work and training that focuses on non-technical skills and strategies to prevent human error in complex procedures. It was initially termed 'cockpit-resource management' and developed for aviation in the 1970s after several severe accidents; it has contributed to a measurable increase in flight safety. In recent years, this approach has been successfully implemented in other high-reliability environments; surgical disciplines have made particular use of crew-resource management strategies and training, with resulting reduced mortality rates. The stepwise implementation of different crew-resource management strategies in stroke care at our tertiary stroke centre has helped to speed up process times significantly, and to improve patient safety and staff satisfaction. Here, we summarise our experience in adapting different crew-resource management tools to acute stroke care, sharing specific tools that have proven valuable in our hands, and we encourage colleagues to implement such strategies in acute stroke care.

Short 2-H in Situ Trauma Team Simulation Training Effectively Improves Non-Technical Skills of Hospital Trauma Teams

BACKGROUND AND AIMS

As conducting the regular trauma team simulation training is expensive and time-consuming, its effects must be explored. The objective was to evaluate the efficacy of a structured 2-h in situ multiprofessional trauma team simulation training course on non-technical skills.

MATERIALS AND METHODS

This prospective study comprised 90 trauma teams with 430 participants. The structured, 2-h course consisted of an introductory lecture and two different simulations with debriefings. Data were collected using a pre-post self-assessment questionnaire. In addition, the expert raters used the T-NOTECHS scale.

RESULTS

The following non-technical skills improved significantly among both medical doctors and nurses: knowledge of the trauma resuscitation guidelines, problem identification, decision making, situation awareness/coping with stress, communication and interaction, time management, being under authority, and confidence in one's role in a team. The teams improved significantly in leadership, cooperation and resource management, communication and interaction, assessment and decision making, and situation awareness/coping with stress.

CONCLUSION

A short, structured 2-h in situ trauma team simulation training course is effective in improving non-technical skills.

Safer paediatric surgical teams: A 5-year evaluation of crew resource management implementation and outcomes

Objective

Evaluate longitudinal changes in technical and non-technical skills (teamwork, situation monitoring, communication and leadership), safety culture, and clinical outcomes before and after implementation of a crew resource management (CRM) safety program.

Design

A multi-level prospective single case study in accordance with the SQUIRE-guidelines for reporting quality improvement efforts.

Setting

Large university paediatric surgical service.

Participant(s)

All 153 managers and staff.

Interventions

Training of staff in CRM, systematic risk assessments, and the redesign of work practices captured and reinforced through the development, implementation and refinement of SOPs.

Main Outcome Measure(s)

Data were collected related to: 1) Relevance of CRM training (survey), 2) Safety culture (survey), 3) Team behaviours in clinical practice (non-participatory observations with MedPACT protocol) and 4) Effects on perioperative care for laparoscopic appendectomies-a representative and frequently performed surgical procedure (electronic medical records and administrative data for length of stay, unplanned readmissions and returns to the Operating Room).

Results

Non-technical skills, the use of safety tools, as well as adherence to guidelines for appendectomies all improved significantly over time. Significant safety culture improvements were found in teamwork across and within units, supervisors' expectations and actions, non-punitive response to adverse events, and perceptions of overall patient safety. Unplanned readmissions following appendectomy declined significantly.

Conclusions

Implementation of a comprehensive CRM program including associated safety tools created sustained adherence to new work practices and improved non-technical and technical skills, surgical outcomes and safety culture.

Improvement of polytrauma management-quality inspection of a newly introduced course concept

RATIONALE, AIMS, AND OBJECTIVES

A systematic literature search for training course concepts for care of severely injured and severely ill patients respecting improvement of process and outcome yielded little data. For several years, the University Hospital of Bonn has hosted a shock-room management course which, on the one hand, communicates human factor aspects and, on the other hand, pursues interdisciplinary and interprofessional team training. The Bonn shock-room management course (BSM-course®) differs from other courses in both format and principles. The aim of this study was to evaluate the quality of the structure of the course based on course evaluations of participants and its impact on the quality of the process and results for polytrauma care.

METHODS

Single-center retrospective evaluation study (2011 to 2014). It was based on data from simulator training and records from the German Trauma Registry (DGU)®.

RESULTS

Subjective evaluation of participants (n = 188) of the structure quality of Bonn's shock-room management course was overall positive. Objective measures of course participant performance also improved during simulation training (P = 0.012). An increasing number of trained employees also had a positive influence in reducing process time for shock-room care. Further, the course likewise had a positive impact on documentation quality (degree of completion), with regard to 4 relevant predictive parameters. Early mortality during the first 24 hours remained constant at 6.0-6.5% between 2011 and 2013, yet it decreased to 3.1% in 2014.

CONCLUSION

The BSM-course® represents a symbiosis of horizontal team approach of trauma care and human factor training. The course format is able to ensure interdisciplinary and interprofessional team training with a high degree of efficiency. Furthermore, the presented work shows that a modern course concept can improve the quality of trauma care.

Defining Components of Team Leadership and Membership in Prehospital Emergency Medical Services

BACKGROUND

Teamwork is critical for patient and provider safety in high-stakes environments, including the setting of prehospital emergency medical services (EMS).

OBJECTIVE

We sought to describe the components of team leadership and team membership on a single patient call where multiple EMS providers are present.

METHODS

We conducted a two-day focus group with nine subject matter experts in crew resource management (CRM) and EMS using a structured nominal group technique (NGT). The specific question posed to the group was, "What are the specific components of team leadership and team membership on a single patient call where multiple EMS providers are present?" After round-robin submission of ideas and in-depth discussion of the meaning of each component, participants voted on the most important components of team leadership and team membership.

RESULTS

Through the NGT process, we identified eight components of team leadership: a) creates an action plan; b) communicates; c) receives, processes, verifies, and prioritizes information; d) reconciles incongruent information; e) demonstrates confidence, compassion, maturity, command presence, and trustworthiness; f) takes charge; g) is accountable for team actions and outcomes; and h) assesses the situation and resources and modifies the plan. The eight essential components of team membership identified included: a) demonstrates followership, b) maintains situational awareness, c) demonstrates appreciative inquiry, d) does not freelance, e) is an active listener, f) accurately performs tasks in a timely manner, g) is safety conscious and advocates for safety at all times, and h) leaves ego and rank at the door.

CONCLUSIONS

This study used a highly structured qualitative technique and subject matter experts to identify components of teamwork essential for prehospital EMS providers. These findings and may be used to help inform the development of future EMS training and assessment initiatives.

Simulation Testing for Selection of Critical Care Medicine Trainees. A Pilot Feasibility Study

RATIONALE

Selection of physicians into anesthesiology, intensive care, and emergency medicine training has traditionally relied on evaluation of curriculum vitae, letters of recommendation, and interviews, despite these methods being poor predictors of subsequent workplace performance.

OBJECTIVES

In this study, we evaluated the feasibility and face validity of incorporating assessment of nontechnical skills in simulation and personality traits into an existing junior doctor selection framework.

METHODS

Candidates short-listed for a critical care residency position were invited to participate in the study. On the interview day, consenting candidates participated in a simulation scenario and debriefing and completed a personality test (16 Personality Factor Questionnaire) and a survey. Timing of participants' progression through the stations and faculty staff numbers were evaluated. Nontechnical skills were evaluated and candidates ranked using the Ottawa Crisis Resource Management Global Rating Scale (Ottawa GRS). Nontechnical skills ranking and traditional selection method ranking were compared using the concordance correlation coefficient. Interrater reliability was assessed using the concordance correlation coefficient.

MEASUREMENTS AND MAIN RESULTS

Thirteen of 20 eligible participants consented to study inclusion. All participants completed the necessary stations without significant time delays. Eighteen staff members were required to conduct interviews, simulation, debriefing, and personality testing. Participants rated the simulation station to be acceptable, fair, and relevant and as providing an opportunity to demonstrate abilities. Personality testing was rated less fair, less relevant, and less acceptable, and as giving less opportunity to demonstrate abilities. Participants reported that simulation was equally as stressful as the interview, whereas personality testing was rated less stressful. Assessors rated both personality testing and simulation as acceptable and able to provide additional information about candidates. The Ottawa GRS showed moderate interrater concordance. There was moderate concordance between rankings based on traditional selection methods and Ottawa GRS rankings (ρ = 0.52; 95% confidence interval, -0.02 to 0.82; P = 0.06).

CONCLUSIONS

A multistation selection process involving interviews, simulation, and personality testing is feasible and has face validity. A potential barrier to adoption is the high number of faculty required to conduct the process.

Cultural Transformation After Implementation of Crew Resource Management: Is It Really Possible?

Crew resource management (CRM) has the potential to improve safety culture and reduce patient safety errors across different hospitals and inherent cultures, but hospital-wide implementations have not been studied. The authors examined the impact of a systematic CRM implementation across 8 departments spanning 3 hospitals and 2 campuses. The Hospital Survey on Patient Safety Culture (HSOPS) was administered electronically to all employees before CRM implementation and about 2 years after; changes in percent positive composite scores were compared in pre-post analyses. Across all respondents, there was a statistically significant increase in composite score for 10 of the 12 HSOPS dimensions ( P < .05). These significant results persisted across the 8 departments studied and among both practitioners and staff. Consideration of score changes across dimensions reveals that the teamwork and communication dimensions of patient safety culture may be more highly influenced by CRM training than supervisor and management dimensions.

Does classroom-based crew resource management training have an effect on attitudes between doctors and nurses?

OBJECTIVE

To evaluate participant reactions and attitudes to crew resource management teamwork classroom-based training by comparing Likert responses before and after the intervention and exploring potential differences in attitudes across the different healthcare professionals.

METHODS

Between 26 January and 27 March, 2015, a randomly selected sample of 240 frontline healthcare professionals offering direct patient care were recruited to undergo a 4-hour crew resource management classroom-based training programme. Participants were asked to complete a 22-item human factors attitude survey before and after training and a 10-item end-of-programme evaluation. Paired samples t-test was used to assess differences between the participants' pretest and posttest scores on each item.

RESULTS

A total of 167 (70%) from 17 different specialties underwent the training and 164 (68.3%) completed (139 nurses, 25 doctors) the survey. The nurses were of similar age to the doctors (38.2 vs 36.9, p=0.83) and were more likely to be women (75.6% vs 24.6%, p <0.001). Human factors attitude survey findings indicated that nurses valued the experience highly compared to doctors. The responses among the nurses revealed significant attitude shifts (p <0.05) in 20 of the 22 items whereas this was the case only for 9 items among the doctors.

CONCLUSIONS

Overall, the crew resource management classroom-based training programme appeared to have a positive effect on frontline healthcare professionals' attitudes. The implementation of such programme is feasible and acceptable, especially for nurses, in a public hospital setting in Hong Kong.

High Reliability Organizations--Medication Safety

High reliability organizations (HROs), such as the aviation industry, successfully engage in high-risk endeavors and have low incidence of adverse events. HROs have a preoccupation with failure and errors. They analyze each event to effect system wide change in an attempt to mitigate the occurrence of similar errors. The healthcare industry can adapt HRO practices, specifically with regard to teamwork and communication. Crew resource management concepts can be adapted to healthcare with the use of certain tools such as checklists and the sterile cockpit to reduce medication errors. HROs also use The Swiss Cheese Model to evaluate risk and look for vulnerabilities in multiple protective barriers, instead of focusing on one failure. This model can be used in medication safety to evaluate medication management in addition to using the teamwork and communication tools of HROs.

Simulation in the operating room

Simulation has become a significant training tool in the operating room (OR). It can be used in both simple task training and complex scenarios. The challenge for simulation in the OR is how to translate that which is learned, and perceived to beneficial, into behavioral change and improved patient outcomes. Simulation in the developing world is progressing, but is still hampered by a shortage of material, personnel funding.

The impact of transmural multiprofessional simulation-based obstetric team training on perinatal outcome and quality of care in the Netherlands

BACKGROUND

Perinatal mortality and morbidity in the Netherlands is relatively high compared to other European countries. Our country has a unique system with an independent primary care providing care to low-risk pregnancies and a secondary/tertiary care responsible for high-risk pregnancies. About 65% of pregnant women in the Netherlands will be referred from primary to secondary care implicating multiple medical handovers. Dutch audits concluded that in the entire obstetric collaborative network process parameters could be improved. Studies have shown that obstetric team training improves perinatal outcome and that simulation-based obstetric team training implementing crew resource management (CRM) improves team performance. In addition, deliberate practice (DP) improves medical skills. The aim of this study is to analyse whether transmural multiprofessional simulation-based obstetric team training improves perinatal outcome.

METHODS/DESIGN

The study will be implemented in the south-eastern part of the Netherlands with an annual delivery rate of over 9,000. In this area secondary care is provided by four hospitals. Each hospital with referring primary care practices will form a cluster (study group). Within each cluster, teams will be formed of different care providers representing the obstetric collaborative network. CRM and elements of DP will be implemented in the training. To analyse the quality of care as perceived by patients, the Pregnancy and Childbirth Questionnaire (PCQ) will be used. Furthermore, self-reported collaboration between care providers will be assessed. Team performance will be measured by the Clinical Teamwork Scale (CTS). We employ a stepped-wedge trial design with a sequential roll-out of the trainings for the different study groups.Primary outcome will be perinatal mortality and/or admission to a NICU. Secondary outcome will be team performance, quality of care as perceived by patients, and collaboration among care providers.

CONCLUSION

The effect of transmural multiprofessional simulation-based obstetric team training on perinatal outcome has never been studied. We hypothesise that this training will improve perinatal outcome, team performance, and quality of care as perceived by patients and care providers.

TRIAL REGISTRATION

The Netherlands National Trial Register, http://www.trialregister.nl/NTR4576, registered June 1, 2014.

Crew resource management in the ICU: the need for culture change

Intensive care frequently results in unintentional harm to patients and statistics don't seem to improve. The ICU environment is especially unforgiving for mistakes due to the multidisciplinary, time-critical nature of care and vulnerability of the patients. Human factors account for the majority of adverse events and a sound safety climate is therefore essential. This article reviews the existing literature on aviation-derived training called Crew Resource Management (CRM) and discusses its application in critical care medicine. CRM focuses on teamwork, threat and error management and blame free discussion of human mistakes. Though evidence is still scarce, the authors consider CRM to be a promising tool for culture change in the ICU setting, if supported by leadership and well-designed follow-up.

High-fidelity simulation in the nonmedical domain: practices and potential transferable competencies for the medical field

Simulation is a promising pedagogical tool in the area of medical education. High- fidelity simulators can reproduce realistic environments or clinical situations. This allows for the practice of teamwork and communication skills, thereby enhancing reflective reasoning and experiential learning. Use of high-fidelity simulators is not limited to the medical and aeronautical fields, but has developed in a large number of nonmedical organizations as well. The techniques and pedagogical tools which have evolved through the use of nonmedical simulations serve not only as teaching examples but also as avenues which can help further the evolution of the concept of high-fidelity simulation in the field of medicine. This paper presents examples of high-fidelity simulations in the military, maritime, and aeronautical fields. We compare the implementation of high-fidelity simulation in the medical and nonmedical domains, and discuss the possibilities and limitations of simulators in medicine, based on recent nonmedical applications.

Improving patient safety in hospitals: Contributions of high-reliability theory and normal accident theory

OBJECTIVE

To identify the distinctive contributions of high-reliability theory (HRT) and normal accident theory (NAT) as frameworks for examining five patient safety practices.

DATA SOURCES/STUDY SETTING

We reviewed and drew examples from studies of organization theory and health services research.

STUDY DESIGN

After highlighting key differences between HRT and NAT, we applied the frames to five popular safety practices: double-checking medications, crew resource management (CRM), computerized physician order entry (CPOE), incident reporting, and root cause analysis (RCA).

PRINCIPAL FINDINGS

HRT highlights how double checking, which is designed to prevent errors, can undermine mindfulness of risk. NAT emphasizes that social redundancy can diffuse and reduce responsibility for locating mistakes. CRM promotes high reliability organizations by fostering deference to expertise, rather than rank. However, HRT also suggests that effective CRM depends on fundamental changes in organizational culture. NAT directs attention to an underinvestigated feature of CPOE: it tightens the coupling of the medication ordering process, and tight coupling increases the chances of a rapid and hard-to-contain spread of infrequent, but harmful errors.

CONCLUSIONS

Each frame can make a valuable contribution to improving patient safety. By applying the HRT and NAT frames, health care researchers and administrators can identify health care settings in which new and existing patient safety interventions are likely to be effective. Furthermore, they can learn how to improve patient safety, not only from analyzing mishaps, but also by studying the organizational consequences of implementing safety measures.

Problem-Based Learning in Entry-Level Athletic Training Professional-Education Programs: A Model for Developing Critical-Thinking and Decision-Making Skills

OBJECTIVE: To establish the underlying theory and benefits and describe the implementation of a problem-based learning curriculum. DATA SOURCES: I searched MEDLINE, SPORT Discus, and nursing, evidence-based medicine, and educational psychology databases from 1987 through 2002 using the terms problem-based learning, physical therapy, nursing, and medicine. DATA SYNTHESIS: In the problem-based learning process, students encounter a problem, bring to it their preconceived understanding (accurate or not), learn to identify what they need to learn to better understand the problem, engage in self-directed study, and begin to resolve the problem. Problem-based learning has its origins in medical education but is widely used in K-12 education, social sciences, health professions education, law, business administration, engineering, and aviation. An entry-level master of science degree program in athletic training based on problem-based learning and integrated clinical education is described. CONCLUSIONS/RECOMMENDATIONS: Problem-based learning curricula, if implemented correctly, can facilitate the entry-level athletic training student's professional development into that of a life-long learner who bases clinical decisions and procedures on the best available evidence.