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Assessing Teamwork in the Trauma Bay: Introduction of a Modified NOTECHS Scale for Trauma

Assessing Teamwork in the Trauma Bay: Introduction of a Modified NOTECHS Scale for Trauma. Alexandra DiTulio (MSIII), Susan Steinemann, MD, Alisha Skinner (MSIII), Kara Terada, CCRN, Kathleen Anzelon, CCRN, Hao Chih Ho, MD, Benjamin Berg, MD

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Assessing Teamwork in the Trauma Bay: Introduction of a Modified NOTECHS Scale for Trauma

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  1. Assessing Teamwork in the Trauma Bay: Introduction of a Modified NOTECHS Scale for Trauma Alexandra DiTulio (MSIII), Susan Steinemann, MD, Alisha Skinner (MSIII), Kara Terada, CCRN, Kathleen Anzelon, CCRN, Hao Chih Ho, MD, Benjamin Berg, MD University of Hawaii and The Queen’s Medical Center, Honolulu, HI Supported by a grant from the American College of Surgeons and Medical Education Technologies, Inc.

  2. Trauma Resuscitation • Time-critical enterprise involving multidisciplinary team members • Value of teams and teamwork long appreciated • Video review • Hoyt DB, J Trauma 1988 • Simulation • Holcomb, J Trauma 2002 • No widely accepted tool for evaluating trauma teamwork

  3. Optimal tool • Multidisciplinary trauma teams • Relationship to teamwork eval tools in other settings (O.R.) • User friendly • Easy to learn • Quick to perform • Actual or simulated settings, real time or in video review • Self-assessment and debriefing • Reliable • Ratings correlate with objective measures of performance and/or patient outcome

  4. Trauma Teamwork Rating Tools

  5. Development of T-NOTECHS • 5 Essential behavioral domains from Modified NOTECHS (Sevdalis 2008) • Leadership and Managerial Skills • Cooperation and Team Skills • Communication and Interaction • Decision Making • Situation Awareness and Vigilance • Coping With Stress (DaRosa: ACS-APDS Curriculum) • Ability to Handle Distractions (Holcomb)

  6. 5 Behavioral Domains

  7. 27 Exemplar Behaviors

  8. Rater Training • Raters • 13 Critical Care (“Crisis”) RNs (CRN) • Research assistants (3 med students, one MD) • One hour training session • Pre-reading on teamwork skills • Teamwork skills didactic • Review and rating of a range of simulated trauma resuscitations

  9. Real-life Trauma Resuscitations • Rated by CRN ± RA • Clinical data collected • Time in ED • Reporting of tasks of primary survey and adjuncts (e.g. BP, pupil exam, FAST) • Independent rating of T-NOTECHS after leaving the ED

  10. Simulation-based Team Training • Simulated trauma resuscitations • Multidisciplinary team members • 3 10-minute blunt trauma cases • Each with 8 “key” and 3 “common” tasks • Team blinded to clinical tasks • Teamwork rated using T-NOTECHS • Audience response system • After each scenarios, before video review • Team debriefed using T-NOTECHS • Later, video review by investigators looking at time to completion of interventions • Clinical data and T-NOTECHS scores again collected for 6 months post-training

  11. Reliability • Cronbach’s alpha >0.90 for the 5 domains • Did not improve with elimination of any domain • Intraclass correlation coefficient (ICC) for Real life = 0.48 • 2 raters (CRN, RA) • n = 69 (48 before, 21 after team training) • ICC for Simulated = 0.44 • 3 raters (CRN, attending, debriefer) • n = 33

  12. Reliability issues • Minimal rater training • All assessments done in real-time • CRN had to multi-task • Clinical action is difficult for inexperienced clinicians to follow • Simulated setting • Surgeons may not accurately self-assess • Arora, Am J Surg in press • Attendings had received no prior training

  13. Correlation with Performance in Simulated Resuscitations • Higher mean T-NOTECHS scores by all of the raters correlated with improved clinical performance • Debriefer’s overall T-NOTECHS ratings correlated with • Greater % of tasks completed (r=.5, p<.05) • Faster completion of 3 common tasks (r=-.38, p<.05)

  14. Correlation with Performance in Real-life Resuscitations • 235 resuscitations were assessed by CRN • 136 before, and 99 after team training • Mean T-NOTECHS scored improved significantly after team training (p<.001) • Higher T-NOTECHS reflected better clinical performance: • Faster time to leave ED (r=-.13, p<.05) • Fewer # of unreported resuscitation tasks (r=-.16, p<.05)

  15. Conclusions • Needs further study and efforts to improve reliability • T-NOTECHS is user friendly • Rapidly adopted after minimal rater training • Quick to perform (< 5 minutes) • Useful for debriefing in simulated and actual clinical setting • Ratings correlated with objective measures of clinical performance

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