- Email: [email protected]
Surgical Team Assessment Training: improving surgical teams during deployment
Accepted Manuscript Surgical Team Assessment Training (STAT): Improving Surgical Teams During Deployment Dwight C. Kellicut , MD, FACS Eric Kuncir , MD, FACS Hope M. Williamson , ARNP, DNP Pamela C. Masella , DO Peter E. Nielsen , MD, FACOG PII:
S0002-9610(14)00211-6
DOI:
10.1016/j.amjsurg.2014.03.008
Reference:
AJS 11166
To appear in:
The American Journal of Surgery
Received Date: 23 September 2013 Revised Date:
27 January 2014
Accepted Date: 4 March 2014
Please cite this article as: Kellicut DC, Kuncir E, Williamson HM, Masella PC, Nielsen PE, Surgical Team Assessment Training (STAT): Improving Surgical Teams During Deployment, The American Journal of Surgery (2014), doi: 10.1016/j.amjsurg.2014.03.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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TITLE: Surgical Team Assessment Training (STAT): Improving Surgical Teams during Deployment LTC Dwight C. Kellicut, MD, FACS1, CAPT Eric Kuncir, MD, FACS2, MAJ Hope M. Williamson, RN, PhD3, COL Peter E. Nielsen, MD, FACOG4
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1. Tripler Army Medical Center, Honolulu, HI, 2. Naval Medical Center San Diego, San Diego, CA, 3. 86th Combat Support Hospital, Fort Campbell, KY, 4. Madigan Army Medical Center, Tacoma, WA The opinions expressed herein are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of the Navy, the Department of Defense, or the United States Government.
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INTRODUCTION: Simulation and team training are accepted as critical patient safety strategies to improve team performance, and can help achieve better outcomes. Standardized and realistic drills conducted by skilled physicians and nurses who demonstrate consistent use of principles which enhance communication and teamwork increase the likelihood of improved clinical outcomes.
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METHODS: Two, 4-member surgeon/nurse teams traveled to eight Army surgical resuscitation medical treatment facilities in Iraq during July and August 2011. At each site, a new program called Surgical Team Assessment Training (STAT) was introduced and implemented to 220 military personnel. Two multi-patient scenarios were designed to test resuscitative and operating room medical decisionmaking, communication, and coordination of care. In addition, 2 hours of didactic instruction emphasized principles of TeamSTEPPS applied emergency and operating rooms during care of patients with multiple, complex traumatic injuries. Anonymous surveys were completed by participants following the training. RESULTS: Participants were significantly more likely to rate this training as very helpful following training compared to their opinion before participation (53% vs. 37% p<0.05). Seventy-seven percent felt it would improve overall patient outcomes, 78% said it would likely contribute to saving lives in combat and 98% felt it should be provided to military Emergency Medicine and Surgical residents.
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CONCLUSION(S): Conclusion: Surgical Team Assessment Training(STAT) can be successfully implemented in an austere, hostile environment and improve trauma team function by incorporating simulation training models and TeamSTEPPs concepts. Expansion of this program for pre-deployment and resident training is currently under investigation based on the extremely positive responses.
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Surgical Team Assessment Training (STAT): Improving Surgical Teams During Deployment
CAPT Eric Kuncir, MD, FACS2 LTC Hope M. Williamson, ARNP, DNP3 CPT Pamela C. Masella, DO1
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COL Peter E. Nielsen, MD, FACOG4
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LTC Dwight C. Kellicut, MD, FACS1
1. Tripler Army Medical Center, Honolulu, HI, 2. Naval Medical Center San Diego, San Diego, CA, 3. 86th Combat Support Hospital, Fort Campbell, KY, 4. Madigan Army Medical Center, Tacoma, WA
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The opinions expressed herein are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of the Navy, the Department of Defense, or the United States Government.
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Corresponding author:
LTC Dwight C. Kellicut, MD, FACS
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Tripler Army Medical Center 1 Jarrett White Road
Honolulu, HI 96859-5000
Phone Number 808-433-3463 FAX: 808-433-3679 [email protected]
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Brief Title: Surgical Team Assessment Training
ABSTRACT
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Background: Simulation and team-training are accepted as critical patient safety strategies to improve team performance and achieve better clinical outcomes. Standardized and realistic drills conducted by skilled physicians and nurses who demonstrate consistent use of principles, which
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enhance communication and teamwork, may increase the likelihood of improved clinical results.
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Phone Number 808-433-3463 FAX: 808-433-3679
Methods: Using these principles, two, 4-member surgeon/nurse teams traveled to eight Army surgical resuscitation medical treatment facilities in Iraq during July and August 2011. At each site, the group implemented a new educational simulation and team-training program, which included standardized simulation scenarios and enhanced team-training instruction to deployed
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surgical teams. The program, called Surgical Team Assessment Training (STAT), included instruction, training, and feedback for 220 emergency, surgical and support personnel. Training
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included two, multi-patient scenarios designed to practice resuscitative and operating room medical decision-making, communication, and coordination of care. In addition, personnel
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received two hours of didactic instruction emphasizing principles of TeamSTEPPSTM applied specifically to the emergency and operating room during care of patients with multiple, complex traumatic injuries. Following training, participants completed anonymous surveys. Results: Based on the results of these surveys, participants were significantly more likely to rate this training as very helpful following training compared to their opinion before participation (53% vs. 37%; p<0.05). Seventy-seven percent felt it would improve overall patient outcomes,
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78% said it would likely contribute to saving lives in combat, and 98% felt it should be provided to military emergency medicine and surgical residents. Conclusion: Expansion of this program for pre-deployment and graduate medical education
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training is currently under investigation based on the positive responses.
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INTRODUCTION The current and future landscape of healthcare in the United States focuses on outcomes with an emphasis on patient safety at all levels. This focus is present at the national, regional, and local
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levels through programs such as the Surgical Care Improvement Project (SCIP) and the National Surgical Quality Improvement Project (NSQIP), as well as organizations like the Joint
Commission (JC) and the Accreditation Council for Graduate Medical Education (ACGME).
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Despite our best efforts, surgery-related safety concerns remain problematic. Summary data compiled by the Joint Commission between 2004 and 2012 reflect an overall sentinel event rate
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for surgery related procedures (anesthesia related event, operative/postoperative complication, unintended foreign body retention, wrong patient/wrong site/wrong procedure) of 36% of all reported sentinel events. Additionally, wrong patient/wrong site/wrong procedure events accounted for 34.7% of all surgery-related sentinel events in 2012; increasing from 31% in 2011
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and 29% in 2010.1 Although safety concerns are inherent to the surgical field due to the presence of complex procedures, increasing technology, personnel turnover, and increasing demands for efficiency and cost effectiveness, our goal is to create the safest environment possible.
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Teamwork has been shown to be important for maintaining a culture of safety. In fact, risk-adjusted surgical morbidity has been found to be directly related to levels of teamwork
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including communication and collaboration within surgical teams.2 Evidence has shown that when infrequent team behaviors were demonstrated, patients were more likely to experience death or major complication.3 In a deployed combat environment, factors contributing to team degradation are magnified due to constantly changing missions, varying degrees of experience, limited or fluctuating resources, high personnel turnover, and increased degree of injury. The
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importance of teamwork and maintaining a culture of safety while deployed cannot be overemphasized. TeamSTEPPSTM is an evidence-based teamwork system aimed at optimizing patient
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outcomes by improving communication and teamwork skills among healthcare professionals.4 This program was developed by the Department of Defense (DoD) Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ) and is based on
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many of the principles found in aviation crew resource management (CRM).5 Crew resource management, applied to the operating room, has been demonstrated to increase the use of
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preoperative checklists and promote a culture of safety.6 While implementation and application of TeamSTEPPSTM has been evaluated in the United States,7,8 its potential to affect patient safety has only recently been investigated in a combat theater of operations, with promising results.9 Using the principles of TeamSTEPPSTM, Surgical Team Assessment Training (STAT)
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was developed to evaluate existing trauma systems either in garrison or on the battlefield through the use of standardized trauma simulation scenarios and enhanced team-training instruction. Actual trauma scenarios form the basis of STAT to optimize training and evaluation. This form
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of instruction is based on the premise of the Army motto: "train as you fight". Combat trauma often occurs in chaotic, austere environments with limited personnel, resources, and complex
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injury patterns not experienced in civilian trauma centers. Each level of care for the injured warfighter requires an immense degree of cooperation and teamwork in order to rapidly evacuate to higher levels of care. This complex environment serves as a backdrop for STAT design in order to truly simulate combat injury scenarios and provide unique opportunities for evaluation and assessment of the trauma team. The purpose of this manuscript is to describe implementation of a
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new educational simulation and team-training program (STAT) in a combat theater and describe staff perception following training. METHODS
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Course design
The STAT training course is a multidisciplinary team-training program that teaches teamwork and trauma-specific resuscitation roles to deployed physicians, nurses, medics, operating room
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technicians and other medical support personnel using trauma simulation scenarios. Founded on the principles of TeamSTEPPS™, the course targets various types of learners through a
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combination of didactics, hands-on simulation-based training, video review, and evaluation. The course begins with a morning session of two trauma simulation scenarios followed by a video review and an after action review (AAR) where formal evaluations are discussed. After the morning session, a structured two-hour didactic session on STAT principles is delivered. To
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practice what was learned, a second trauma simulation scenario consisting of a mass casualty situation takes place. This afternoon session is followed by a video review and AAR. Finally, participants are asked to complete a course questionnaire.
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Didactics
The didactic session consists of a two-hour interactive lecture given between the morning and
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afternoon trauma simulation scenario sessions. This lecture serves to introduce the five core principles of TeamSTEPPS™; team structure, leadership, situation monitoring, mutual support, and communication while incorporating them with STAT, which focuses on caring for the injured war-fighter in the austere combat environment Simulation scenarios Twenty trauma scenarios were created from the Baghdad Combat Support Hospital trauma
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patient database. The scenarios were supported with actual radiologic data in the form of x-rays and computed tomography scans, as well as pertinent laboratory data provided in real-time during case evolution. Medical moulage application to simulated casualties enhanced realism.
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Activation of the trauma system occurred through normal communication channels with limited data regarding number and severity of injured to mimic real combat evacuation scenarios. Two trauma scenarios were completed in the morning session. The afternoon session consisted of a
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single more complex mass casualty scenario with 3 to 5 more severely wounded casualties in an
Feedback
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attempt to overwhelm existing trauma assets.
Formal feedback for all Level II Forward Surgical Team (FST) and Level III Combat Support Hospital (CSH) units was provided. The subjective feedback comments centered on the following phases of patient care: pre-hospital, arrival/triage, initial resuscitation, operating room
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(OR), recovery, and evacuation.
Feedback for the initial triage and resuscitation phases were provided using a standardized system developed at the Army Trauma Training Center (ATTC) in Miami. The first
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page (Figure 1) of the form focused on the pre-hospital phase in regard to facility wide notification of the incoming trauma, patient administration division (PAD), and ancillary support
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services. The second page (Figure 2) of the ATTC form focused on the arrival triage and initial resuscitation phases. Critical sections in this evaluation included: defined trauma team roles, specific provider tasks as defined by ATLS principles, and critical team concepts (structure, leadership, situation monitoring, communication, mutual support). Feedback was accomplished through an AAR.
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Once the patient moved from the resuscitation phase, a Surgery Brief Guide (Figure 3) was used through the operating room to recovery phases. This form was modeled after an existing one used for elective surgery at Madigan Army Medical Center. The form utilizes a
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universal protocol based checklist to improve communication between anesthesia, nursing, technician, and surgeon. It contains a preoperative checklist, a postoperative checklist, an
intraoperative critique, a recovery/ICU handoff, and a follow-up section to close the loop on
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issues identified during the case.
All deployed trauma units were provided STAT instruction and feedback in the country
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of Iraq during July and August 2011. The teams consisted of one board certified surgeon, one trauma nurse and one medic. The surgeon was placed in charge of the simulation and the nurse was responsible for documenting written feedback for the trauma team, which was used to craft the AAR. The medic was responsible for teaching each team medical moulage techniques to
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improve realism for each simulation. Summary AARs were sent to all units describing the evaluation with respect to items to sustain, items to train and all observational comments (Figure 4).
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After action review/video debriefing
After action reviews were conducted with 100% of the participants immediately following the
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simulation scenarios and lead by a team of four multi-disciplinary, multi-service evaluators trained in, and experienced with, combat casualty care and team training. Key areas analyzed were TeamSTEPPS™ core principles found to be integral to improving patient outcomes.3 The instructors and participants reported on team structure (defining your team, establishing a team leader, identifying and executing team roles), leadership (planning approach, problem solving, utilizing resources), communication (closed-loop, utilizing call outs and check backs, performing
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clear hand-offs) and mutual support (providing oversight, resolving disagreements, utilizing of time-outs). In addition, each AAR included a review of the evaluations and video captured during the simulations. These tools are used to illustrate the presence or absence of teamwork
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behaviors during the resuscitations and to identify strengths and weaknesses. Additionally, the afternoon AAR contrasted the morning and afternoon scenarios, highlighted improvements, and discussed strategies to incorporate STAT.
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Questionnaires
Upon completion of the course, each participant was provided an on-line questionnaire to assess
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perceived effectiveness of training (Figure 5). Professional role, number of deployments and previous teamwork training were queried. Questionnaires also assessed team use of checklists following the course, the utility of the course, and suggestions for improvement. Specifically, survey questions included single-choice selections from the following choices for questions
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related to team activities before and after STAT: yes, always; yes, some of the time; yes, rarely; no, never. Survey questions which addressed the individual’s perception of the value of STAT training were rated by a 5-point scale: not valuable at all; somewhat valuable; neutral; valuable;
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very valuable. Questions regarding the participant’s perception of the likelihood of trauma team training to improve outcomes or save lives were also rated by a 5-point scale: not likely at all;
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somewhat likely; neutral; likely; very likely. Statistical analysis
Data was analyzed using Student’s t test and Chi Square where appropriate and a p value of less than 0.05 was considered significant. RESULTS
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Two hundred twenty deployed personnel from FSTs and CSHs were trained and subsequently offered participation in an anonymous on-line survey comprised of 15 questions following STAT training. Sixty-one trainees (28%) completed the survey including: 11 physicians, 3 nurse
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anesthetists, 3 physician assistants, 22 nurses, 9 medics, 5 operating room technicians and 8 other medical support personnel. Forty-nine percent of respondents (29/61) were on their first
deployment, 31% (18/61) were on their second deployment, and 20% (12/61) had deployed three
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or more times.
All participants were queried regarding previous formal teamwork training in either
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TeamSTEPPSTM or other teamwork training. Forty-two percent (26/61) had previous training in TeamSTEPPSTM, 30% (18/61) had other teamwork training, and 28% (17/61) had no prior teamwork training. Approximately one-third (22/61) of participants surveyed felt that this course would be “very valuable” prior to completing STAT. However, after the course, statistically
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significantly more respondents felt it was “very valuable” compared to before the course (53% vs. 37%, p<0.05) despite more than 70% of all respondents having previously trained in a formal teamwork course. Seventy-seven percent reported it would improve overall patient safety and
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outcomes. Seventy-eight percent reported it would likely contribute to saving lives in combat. Moreover, 95% advocated STAT should be provided to surgical teams prior to deployment,
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including nurses and medics working in the emergency and operating rooms, scrub technicians, and military emergency medicine and surgical residents. Most importantly, 61% stated that STAT changed the way their team performed simulation for trauma training during deployment. Comments from respondents focused on praise for the high quality, realism and difficulty of the simulation scenarios. Others valued the ability to apply TeamSTEPPSTM in a practical manner (forcing reassessment of team dynamics), the ability to identify weak spots in the system,
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receiving instant feedback with the ability to “see themselves” through the use of video during the AAR, applying a standardized approach to OR communication, and the use of the preoperative brief and post-operative debrief tool. Suggested areas of improvement included
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incorporating intensive care unit and ward scenarios; the need for both pre-deployment
implementation of this course; as well as performance of regular drills using this curriculum. For most teams, the number one concern voiced was minimal coordinated teamwork training and
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instruction prior to deploying into the combat zone. Participants linked this issue to a fragmented timeline of rotations for deploying doctors, nurses and medics in both the reserve and active
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components. DISCUSSION
Surgical Team Assessment Training, a new educational simulation and team-training program, implemented in a combat theater improved team member’s perception of communication and
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subsequent performance of clinical drills in a group of deployed operating room personnel. In addition, based on participant feedback, TeamSTEPPSTM training, as implemented in the STAT curriculum, was felt to likely improve overall patient outcomes and save lives. The feedback
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also indicated that it should be offered to both surgical and emergency residents, as well as all surgical team members, prior to deployment.
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Improved communication in the OR is a prerequisite to reducing adverse outcomes. Lingard10, in his 2004 study, found communication failures in up to 30% of team exchanges and up to one third of these resulted in effects that compromised patient safety. In addition, Mazzocco4, in a study of surgical team behaviors and patient outcomes, showed that surgical teams who fail to share information, either intraoperatively or during handoffs, are more likely to have their patients experience death or major complications. In an analysis of communication
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breakdowns resulting in surgical patient injury, Greenberg11 demonstrated that breakdowns are equally likely to occur in the preoperative (38%), intraoperative (30%), and postoperative (32%) phases of care. Interestingly, he also reported that the prevalence of emergency cases was higher
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than expected when examining a set of 60 cases that resulted in a surgical malpractice claim. Combat surgery is nearly always performed under emergent circumstances, suggesting that communication errors may actually be more likely to occur in the preoperative or intraoperative
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settings during combat.11
Interdisciplinary collaboration also improves clinical outcomes. Davenport,2 in a 2007
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study on reported levels of communication and collaboration within surgical teams, emphasized the importance of physician’s coordination and decision-making roles on surgical teams in providing high quality and safe care. This observation was confirmed by their data which demonstrated surgical teams whose members reported higher levels of communication and
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collaboration between providers had decreased risk-adjusted morbidity.2 The only published randomized trial evaluating the effect of teamwork training on preventing adverse outcomes was performed in labor and delivery and demonstrated no
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difference in adverse clinical outcomes between the groups. However, there was likely a significant Hawthorne effect since improvements in clinical outcomes were seen in both groups.7
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In addition, the teamwork trained group demonstrated a clinically, and statistically significant, shorter decision to incision time for urgent cesarean delivery. This difference suggests that team-training did improve coordination of care as well as provide a more rapid and effective response to an emergent clinical situation.7 Other areas where improvements in clinical outcomes have been demonstrated with better communication include: the intensive care unit care,12 during neonatal resuscitation,13 and following recognition of shoulder dystocia.14
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Discrepancies in perception of patient safety and teamwork exist among, OR personnel. Gore15 observed that implementation of CRM in the OR improved perceptions of patient safety among resident physicians and nurses while attending physicians perceived no difference. In
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addition, using a standardized and validated questionnaire, Makary16 found that physicians most often rated teamwork as good while nurses perceived teamwork as only mediocre. Differences in perception between caregivers may be assessed using the Safety Attitudes Questionnaire which
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can assist in defining focused interventions for improving patient safety.17 Use of this
questionnaire to evaluate STAT should be considered to determine if this method of team
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training affects teamwork perception between caregivers in the OR.
Combat surgery, by nature, is complex and requires the coordinated effort of multiple providers, both credentialed and non-credentialed, that typically forward deploys to form a functioning surgical team or unit. To establish such a team, the Armed Forces deploy individuals
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that come together to make up the unit, and often these individuals have not previously worked together. At other times, unit members are well known to each other providing an opportunity to train together prior to deployment. The constitution of deploying units varies considerably based
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on the mission, and between the individual branches, of the DoD. It is imperative that all units, regardless of their composition and pre-deployment
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familiarity, function well and expertly apply the standard principles of triage and life-saving resuscitation and surgery in a timely and highly coordinated manner. Individual skill sets are critical and unit cohesion and efficiency may quickly develop after the individuals begin to work together in the heat of battle while supporting one another and looking beyond their own individual strengths and weaknesses. How rapidly this occurs in actual practice varies from unit to unit based on multiple factors, which may be difficult to quantify such as; leadership, esprit de
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corps, and personal motivation. Ideally, each unit arriving in theater should be ready, and able, to treat the sickest casualty immediately upon arrival on station. Department of Defense Trauma Registry data suggests that there is no significant degradation in clinical outcomes of patients
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cared for at the start of a unit’s deployment compared to later in that same unit’s deployment (verbal communication former Joint Trauma System Director COL G. Costanzo, August 2011). Overlap of the OR staff from one unit to the next, and simulation-based team-training, may help
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protect against degradation in clinical outcomes during these transitions.
Simulation training can also help guide best practices for patient safety and is an
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important addition to the TeamSTEPPS™ curriculum. Procedural skills simulations have been shown to be effective in reducing patient errors. For example, learning laparoscopic cholecystectomy surgery on virtual reality simulators led to a reduction in predefined errors on patients when compared with conventional instruction.18,19 Mannequin-based simulation is much
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more difficult to validate, however, multiple prospective trials are currently underway to evaluate the impact on patient safety and, as an important additional program, STAT should be evaluated for similar effects.
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Limitations to this study include that approximately 70% of participants had some type of formal teamwork training prior to participating in STAT, and completing the questionnaire,
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which may have biased their response. We speculate that this may have contributed to the lower than anticipated post-STAT participant perception, as STAT may not have been as extensive as their previous training. Conversely, it is also possible that participants rated the effectiveness high based on their lack of, or dissatisfaction with their previous, team-training experience. In addition, only 28% of eligible respondent’s completed the survey tool compromising the general application of our results. Surveys were completed within 45 days of the training. Prospective
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paper-based surveys were not given immediately post-training because permission to perform this survey was not obtained until after training at all sites had been completed. Finally, the lack of objective data and measures of improved proficiency, or subsequent patient outcomes, in these
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units is acknowledged. Future studies must evaluate these critical outcomes in deployed surgical units who undergo STAT training.
While combat surgery is performed in austere environments with limited resources, many
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of the principles and practices learned in theater can be applied to other settings. Based on the work presented here, the DoD is encouraged to consider further study of STAT training for the
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pre-deployment phase of both units and individuals. In addition, consideration should be given to applying this training to medical units from other government and civilian agencies who have a role as first responders to a civilian natural or humanitarian disasters, since STAT may be scaled for a variety of unit sizes and the clinical scenarios may be modified to include casualties more
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typical of natural disasters or humanitarian crises.
Rigorous training emphasizing individual, and some team, skills is already performed in collaboration with the DoD at civilian trauma centers across the United States such as the
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Army’s Ryder Trauma Training Center in Miami, the Navy’s Trauma Training Center at the University of Southern California, and the Air Forces’ Center for the Sustainment of Trauma and
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Readiness Skills programs. STAT could also serve as a means of reinforcing training offered at the various pre-deployment civilian trauma emersion sites when provided in theater. The next phase of study should focus on development of specific clinical metrics that could measure if STAT “in situ” training improves clinical outcomes, just as previous work in the delivery room found that “in situ” drills for shoulder dystocia events resulted in better coordination by teams and a reduction in neonatal birth injuries.14 Alternatively, surrogate
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measures for improved clinical outcomes to consider could include the number of times a circulating nurse leaves the operating room to retrieve equipment not specifically anticipated at the onset of surgery. Ultimately, however, the clinical outcome of the patient is the most critical
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measure and must be the principle outcome of interest.
Regardless of the method used to teach principles of teamwork and improve team
dynamics for the benefit of the patient, ultimate success or failure relies directly upon clinical
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leaders adopting and implementing the knowledge and attitudes of high performing teams. In most instances, this leadership is the responsibility of the primary surgeon who must ensure that
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the environment is one that permits a flattened hierarchy and the critical techniques and strategies of high performing teams including leadership, structure, situation monitoring, communication, and mutual support are consistently implemented and demonstrated by team
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members: especially the team leader.
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References 1. The Joint Commission. (2012). Summary Data of Sentinel Events Reviewed by The Joint Commission. Oakbrook Terrace, IL: Joint Commission. Retrieved May 8, 2013 from
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http://www.jointcommission.org/assets/1/18/2004_4Q_2012_SE_Stats_Summary.pdf 2. Davenport DL, Henderson WG, Mosca CL, et al. Risk-adjusted morbidity in teaching
hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am
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Coll Surg. 2007;205:778-84.
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3. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197:678-85.
4. Alsonso A, Baker D, Holtzman A, Day R. Reducing medical error in the military health system: How can team training help? Human Resource Management Review. 2006;16:396-415. 5. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management in
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commercial aviation. International Journal of Aviation Psychology. 1999;9:19-32. 6. Sax HC, Browne P, Mayewski RJ, et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144:1133-1137.
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7. Nielsen PE, Goldman M, Mann S, et al. Effects of teamwork training on adverse outcomes
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and process of care in labor and delivery: A randomized controlled trial. Obstet Gynecol. 2007;109:48-55.
8. Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. The Joint Commission Journal on Quality and Patient Safety. 2010;36:133-142.
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9. Deering S, Rosen MA, Ludi V, et al. On the front lines of patient safety: Implementation and evaluation of team training in Iraq. The Joint Commission Journal on Quality and Patient Safety. 2011;37:350-356.
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10. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: An
observational classification of recurrent types and effects. Qual Saf Health Care 2004;13:330334.
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11. Greenberg CC, Reganbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2004; 204:533-540.
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12. Baggs JG, Ryan SA, Phelps CE et al. The association between interdisciplinary collaboration and patient outcomes in a medical intensive care unit. Heart Lung. 1992; 21:18-24. 13. Thomas EJ, Sexton JB, Lasky RE et al. Teamwork and quality during neonatal care in the delivery room. J Perinatol 2006; 26:163-169.
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14. Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008; 112:14-20. 15. Gore DC, Powell JM, Baer JG, et al. Crew resource management improved perception of
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patient safety in the operating room. Am J Med Qual 2010; 25:60-3. 16. Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians
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and nurses: teamwork in the eye of the beholder. J Am Coll Surg 2006; 202:756-52. 17. Center for Healthcare Quality and Safety, University of Texas Health Science Center at Houston. Safety attitudes and safety climate questionnaire. Retrieved May 8, 2013 from https://med.uth.edu/chqs/surveys/safety-attitudes-and-safety-climate-questionnaire/
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18. Grantcharov TP, Kristiansen VB, Bendix J, Bardrum L, Rosenbery J, Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004; 91:146-50
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19. Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first ten laparoscopic
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cholecystectomies. Am J Surg 2007; 193:797-804
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Figure 1: Pre-Hospital Phase Trauma Evaluation Checklist (Adapted from USATTC, 2011).
NOTIFICATION
REMARKS
ANCILLARY SVCS
REMARKS
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X-Ray
• TOC
• Radiologist available
•PAD
•Portable X-ray present •Combat Liaison Team •CT scan ready •ER
Lab
•Trauma Team
• Blood component
•Specimen labeling
•ICU Team
Pharmacy
•Pharmacy
•Pharmacist present
•X-Ray
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•Code cart medications
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paperwork
•OR Team
•Lab
• Executed clear handoff
PAD
•Performed check backs
Observer Notes (continued)
•Patient identification
Three Items to Train
Three Items to Sustain
•Secure weapon
1. _________________________
1._________________________
•Secure valuables
2. _________________________
2._________________________
•Pt tracking
3. _________________________
3._________________________
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•Trauma packet
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Figure 2: Triage and Resuscitation Evaluation Checklist (Adapted from USATTC, 2011). Primary Survey
Team Roles TEAM LEADER
AIRWAY M A P F A S T
Applied Oxygen Secured airway
Critical Team Concepts
End Tidal CO2
Structure
BREATHING
• Defined the Team • Established Team LDR • Identified Team roles • Executed Team roles
Identified problem (s)
ANESTHESIA
Timely intervention (s)
O __Oxygen (applied oxygen) X __Exam Heart/Lungs Y __Yes/no (H&P/Vitals/Equip)
CIRCULATION
• Planned approach • Problem solved • Utilized resources
Pulse check
G
Identified problem (s)
E __Exam eyes/ears/head N __Nose/neck/GCS
Timely intervention (s)
DISABILITY Assessed GCS
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Assessed Pupils
Communication
EXPOSURE
• Verbalized Vital Signs • Performed Call outs • Performed Call back • Performed a clear hand-off
NURSE
V __ Vital signs I __ IV meds T __ Time / temperature A __ Alert key personnel L __ Lab results (call out) S __ Safety
Prevented hypothermia
Secondary Survey Head to toe assessment Log roll
Mutual Support
RIGHT MEDIC R I G H T
__Remove clothing __ Inline stabilization __Gear collected __Hold pressure __Tubes to lab
L E F T
__ Line (IV) placed __ Exposed patient __ Foley catheter __ Temp obtained
LEFT MEDIC
Reassessment (ABCDE)
• Provided overwatch
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• Resolved disagreements • Timeouts used as needed
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__Gauge (large bore IV)
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Leadership
__ Mechanism/manage __Assess GCS/TBI __Primary survey __FAST exam __ABG/labs __Secondary survey __Timeout / problem list
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Observer: ____________________________ Unit/Patient/Event:_____________________ Start: ____________ Primary Complete:____________ Secondary Completed: ________ Finish:_______
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Figure 3: Surgery Brief Guide
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Figure 4: After Action Rerport Formal Feedback Model Example Basic Trauma Scenario with One Patient Topic: Critical Team Concepts (Structure, Leadership, Communication, Mutual Support)
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Items to Sustain: • The team worked well together. • Structured, well defined team that executed their roles. • Good leadership utilizing a planned approach and utilization of resources. • Mutual support provided good overwatch and teamwork. Items to Train: • Continue to work on implementing critical team concepts of communication. • Communication tools and strategies to enhance patient safety. • Ensure tasks are directed towards a person, rather than making a general callout without assignment of responsibility (or generate a Somebody of the Day roster). • Train all-outs and check-backs. As a team, limited call-outs and check-backs were minimally employed prior to medication administration and essential task being completed. • Train coordination of the log-roll. Trauma TEAMwork System Core Instruction and Discussion
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Feedback from unit: • Truthfully, we did not receive a lot of trauma team work training and instruction prior to coming to theater, because of the fragmented timeline and rotation of deploying doctors, nurses and medics. This seems to be a common theme throughout theater. While this intra-theater training has been invaluable, “recommend your team report back to big Army that this type of team training and instruction needs to take place during the pre-deployment phase as well prior to getting into theater where we have time to rehearse.” We appreciate the training we received in this class, it was really done well. The speaker was knowledgeable and presented a team work methodology we can use during initial resuscitation of the trauma patient throughout the spectrum of care.
•
As a team we talked about using the communication strategies we learned such as the call-outs and check-backs during the advanced scenario. I think most teams can improve in the area of communication within the team and with ancillary staff.
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•
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Figure 5: Survey Tool Questions
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1. What is your professional role at this time? Physician/Nurse/Medic/OR Technician/Other 2. Please indicate how many times you have been deployed (including this deployment). 1/2/3/4/5/>5 3. Have you had formal teamwork training prior to this deployment in either of the following categories? TeamSTEPPS/Other teamwork training 4. If you had training other than TeamSTEPPS, please indicate what course you attended. 5. Prior to participating in this course did your team: a. Use a standard preoperative checklist b. Use a standard postoperative checklist c. Use a standard postoperative debriefing tool d. Use OR case preference lists 6. Following participation in this course does your team now: a. Use a standard preoperative checklist b. Use a standard postoperative checklist c. Use a standard postoperative debriefing tool d. Use OR case preference lists 7. Prior to participating in this course, how valuable did you feel this course would be for your team/you personally? 8. Following your participation in this course, how valuable did you feel this course will be for your team/you personally? 9. Please answer the following questions about the trauma team training: a. How likely do you feel this training is to improve overall patient outcomes? b. How likely do you feel this training is to save lives? 10. For each of the following groups, please indicate whether or not you feel that they should have this type of training: a. Surgical teams prior to deployment b. Surgical residents in training c. Emergency medicine residents in training d. Nurses and medics working in the ER e. Nurses and medics working in the OR f. Scrub technicians 11. For each of the following groups, please indicate how important you feel that the trauma team training program is for: a. Surgical teams prior to deployment b. Surgical residents in training c. Emergency medicine residents in training d. Nurses and medics working in the ER e. Nurses and medics working in the OR f. Scrub technicians 24
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12. Has this course changed the way your team now performs simulations for mass casualty exercises? 13. What did you find most valuable about this course? 14. What did you find least valuable about this course? 15. Do you have any suggestions for changes for future courses?
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S0002-9610(14)00211-6
DOI:
10.1016/j.amjsurg.2014.03.008
Reference:
AJS 11166
To appear in:
The American Journal of Surgery
Received Date: 23 September 2013 Revised Date:
27 January 2014
Accepted Date: 4 March 2014
Please cite this article as: Kellicut DC, Kuncir E, Williamson HM, Masella PC, Nielsen PE, Surgical Team Assessment Training (STAT): Improving Surgical Teams During Deployment, The American Journal of Surgery (2014), doi: 10.1016/j.amjsurg.2014.03.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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TITLE: Surgical Team Assessment Training (STAT): Improving Surgical Teams during Deployment LTC Dwight C. Kellicut, MD, FACS1, CAPT Eric Kuncir, MD, FACS2, MAJ Hope M. Williamson, RN, PhD3, COL Peter E. Nielsen, MD, FACOG4
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1. Tripler Army Medical Center, Honolulu, HI, 2. Naval Medical Center San Diego, San Diego, CA, 3. 86th Combat Support Hospital, Fort Campbell, KY, 4. Madigan Army Medical Center, Tacoma, WA The opinions expressed herein are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of the Navy, the Department of Defense, or the United States Government.
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INTRODUCTION: Simulation and team training are accepted as critical patient safety strategies to improve team performance, and can help achieve better outcomes. Standardized and realistic drills conducted by skilled physicians and nurses who demonstrate consistent use of principles which enhance communication and teamwork increase the likelihood of improved clinical outcomes.
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METHODS: Two, 4-member surgeon/nurse teams traveled to eight Army surgical resuscitation medical treatment facilities in Iraq during July and August 2011. At each site, a new program called Surgical Team Assessment Training (STAT) was introduced and implemented to 220 military personnel. Two multi-patient scenarios were designed to test resuscitative and operating room medical decisionmaking, communication, and coordination of care. In addition, 2 hours of didactic instruction emphasized principles of TeamSTEPPS applied emergency and operating rooms during care of patients with multiple, complex traumatic injuries. Anonymous surveys were completed by participants following the training. RESULTS: Participants were significantly more likely to rate this training as very helpful following training compared to their opinion before participation (53% vs. 37% p<0.05). Seventy-seven percent felt it would improve overall patient outcomes, 78% said it would likely contribute to saving lives in combat and 98% felt it should be provided to military Emergency Medicine and Surgical residents.
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CONCLUSION(S): Conclusion: Surgical Team Assessment Training(STAT) can be successfully implemented in an austere, hostile environment and improve trauma team function by incorporating simulation training models and TeamSTEPPs concepts. Expansion of this program for pre-deployment and resident training is currently under investigation based on the extremely positive responses.
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Surgical Team Assessment Training (STAT): Improving Surgical Teams During Deployment
CAPT Eric Kuncir, MD, FACS2 LTC Hope M. Williamson, ARNP, DNP3 CPT Pamela C. Masella, DO1
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COL Peter E. Nielsen, MD, FACOG4
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LTC Dwight C. Kellicut, MD, FACS1
1. Tripler Army Medical Center, Honolulu, HI, 2. Naval Medical Center San Diego, San Diego, CA, 3. 86th Combat Support Hospital, Fort Campbell, KY, 4. Madigan Army Medical Center, Tacoma, WA
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The opinions expressed herein are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of the Navy, the Department of Defense, or the United States Government.
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Corresponding author:
LTC Dwight C. Kellicut, MD, FACS
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Tripler Army Medical Center 1 Jarrett White Road
Honolulu, HI 96859-5000
Phone Number 808-433-3463 FAX: 808-433-3679 [email protected]
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Brief Title: Surgical Team Assessment Training
ABSTRACT
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Background: Simulation and team-training are accepted as critical patient safety strategies to improve team performance and achieve better clinical outcomes. Standardized and realistic drills conducted by skilled physicians and nurses who demonstrate consistent use of principles, which
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enhance communication and teamwork, may increase the likelihood of improved clinical results.
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Phone Number 808-433-3463 FAX: 808-433-3679
Methods: Using these principles, two, 4-member surgeon/nurse teams traveled to eight Army surgical resuscitation medical treatment facilities in Iraq during July and August 2011. At each site, the group implemented a new educational simulation and team-training program, which included standardized simulation scenarios and enhanced team-training instruction to deployed
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surgical teams. The program, called Surgical Team Assessment Training (STAT), included instruction, training, and feedback for 220 emergency, surgical and support personnel. Training
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included two, multi-patient scenarios designed to practice resuscitative and operating room medical decision-making, communication, and coordination of care. In addition, personnel
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received two hours of didactic instruction emphasizing principles of TeamSTEPPSTM applied specifically to the emergency and operating room during care of patients with multiple, complex traumatic injuries. Following training, participants completed anonymous surveys. Results: Based on the results of these surveys, participants were significantly more likely to rate this training as very helpful following training compared to their opinion before participation (53% vs. 37%; p<0.05). Seventy-seven percent felt it would improve overall patient outcomes,
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78% said it would likely contribute to saving lives in combat, and 98% felt it should be provided to military emergency medicine and surgical residents. Conclusion: Expansion of this program for pre-deployment and graduate medical education
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training is currently under investigation based on the positive responses.
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INTRODUCTION The current and future landscape of healthcare in the United States focuses on outcomes with an emphasis on patient safety at all levels. This focus is present at the national, regional, and local
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levels through programs such as the Surgical Care Improvement Project (SCIP) and the National Surgical Quality Improvement Project (NSQIP), as well as organizations like the Joint
Commission (JC) and the Accreditation Council for Graduate Medical Education (ACGME).
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Despite our best efforts, surgery-related safety concerns remain problematic. Summary data compiled by the Joint Commission between 2004 and 2012 reflect an overall sentinel event rate
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for surgery related procedures (anesthesia related event, operative/postoperative complication, unintended foreign body retention, wrong patient/wrong site/wrong procedure) of 36% of all reported sentinel events. Additionally, wrong patient/wrong site/wrong procedure events accounted for 34.7% of all surgery-related sentinel events in 2012; increasing from 31% in 2011
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and 29% in 2010.1 Although safety concerns are inherent to the surgical field due to the presence of complex procedures, increasing technology, personnel turnover, and increasing demands for efficiency and cost effectiveness, our goal is to create the safest environment possible.
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Teamwork has been shown to be important for maintaining a culture of safety. In fact, risk-adjusted surgical morbidity has been found to be directly related to levels of teamwork
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including communication and collaboration within surgical teams.2 Evidence has shown that when infrequent team behaviors were demonstrated, patients were more likely to experience death or major complication.3 In a deployed combat environment, factors contributing to team degradation are magnified due to constantly changing missions, varying degrees of experience, limited or fluctuating resources, high personnel turnover, and increased degree of injury. The
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importance of teamwork and maintaining a culture of safety while deployed cannot be overemphasized. TeamSTEPPSTM is an evidence-based teamwork system aimed at optimizing patient
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outcomes by improving communication and teamwork skills among healthcare professionals.4 This program was developed by the Department of Defense (DoD) Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ) and is based on
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many of the principles found in aviation crew resource management (CRM).5 Crew resource management, applied to the operating room, has been demonstrated to increase the use of
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preoperative checklists and promote a culture of safety.6 While implementation and application of TeamSTEPPSTM has been evaluated in the United States,7,8 its potential to affect patient safety has only recently been investigated in a combat theater of operations, with promising results.9 Using the principles of TeamSTEPPSTM, Surgical Team Assessment Training (STAT)
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was developed to evaluate existing trauma systems either in garrison or on the battlefield through the use of standardized trauma simulation scenarios and enhanced team-training instruction. Actual trauma scenarios form the basis of STAT to optimize training and evaluation. This form
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of instruction is based on the premise of the Army motto: "train as you fight". Combat trauma often occurs in chaotic, austere environments with limited personnel, resources, and complex
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injury patterns not experienced in civilian trauma centers. Each level of care for the injured warfighter requires an immense degree of cooperation and teamwork in order to rapidly evacuate to higher levels of care. This complex environment serves as a backdrop for STAT design in order to truly simulate combat injury scenarios and provide unique opportunities for evaluation and assessment of the trauma team. The purpose of this manuscript is to describe implementation of a
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new educational simulation and team-training program (STAT) in a combat theater and describe staff perception following training. METHODS
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Course design
The STAT training course is a multidisciplinary team-training program that teaches teamwork and trauma-specific resuscitation roles to deployed physicians, nurses, medics, operating room
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technicians and other medical support personnel using trauma simulation scenarios. Founded on the principles of TeamSTEPPS™, the course targets various types of learners through a
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combination of didactics, hands-on simulation-based training, video review, and evaluation. The course begins with a morning session of two trauma simulation scenarios followed by a video review and an after action review (AAR) where formal evaluations are discussed. After the morning session, a structured two-hour didactic session on STAT principles is delivered. To
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practice what was learned, a second trauma simulation scenario consisting of a mass casualty situation takes place. This afternoon session is followed by a video review and AAR. Finally, participants are asked to complete a course questionnaire.
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Didactics
The didactic session consists of a two-hour interactive lecture given between the morning and
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afternoon trauma simulation scenario sessions. This lecture serves to introduce the five core principles of TeamSTEPPS™; team structure, leadership, situation monitoring, mutual support, and communication while incorporating them with STAT, which focuses on caring for the injured war-fighter in the austere combat environment Simulation scenarios Twenty trauma scenarios were created from the Baghdad Combat Support Hospital trauma
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patient database. The scenarios were supported with actual radiologic data in the form of x-rays and computed tomography scans, as well as pertinent laboratory data provided in real-time during case evolution. Medical moulage application to simulated casualties enhanced realism.
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Activation of the trauma system occurred through normal communication channels with limited data regarding number and severity of injured to mimic real combat evacuation scenarios. Two trauma scenarios were completed in the morning session. The afternoon session consisted of a
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single more complex mass casualty scenario with 3 to 5 more severely wounded casualties in an
Feedback
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attempt to overwhelm existing trauma assets.
Formal feedback for all Level II Forward Surgical Team (FST) and Level III Combat Support Hospital (CSH) units was provided. The subjective feedback comments centered on the following phases of patient care: pre-hospital, arrival/triage, initial resuscitation, operating room
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(OR), recovery, and evacuation.
Feedback for the initial triage and resuscitation phases were provided using a standardized system developed at the Army Trauma Training Center (ATTC) in Miami. The first
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page (Figure 1) of the form focused on the pre-hospital phase in regard to facility wide notification of the incoming trauma, patient administration division (PAD), and ancillary support
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services. The second page (Figure 2) of the ATTC form focused on the arrival triage and initial resuscitation phases. Critical sections in this evaluation included: defined trauma team roles, specific provider tasks as defined by ATLS principles, and critical team concepts (structure, leadership, situation monitoring, communication, mutual support). Feedback was accomplished through an AAR.
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Once the patient moved from the resuscitation phase, a Surgery Brief Guide (Figure 3) was used through the operating room to recovery phases. This form was modeled after an existing one used for elective surgery at Madigan Army Medical Center. The form utilizes a
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universal protocol based checklist to improve communication between anesthesia, nursing, technician, and surgeon. It contains a preoperative checklist, a postoperative checklist, an
intraoperative critique, a recovery/ICU handoff, and a follow-up section to close the loop on
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issues identified during the case.
All deployed trauma units were provided STAT instruction and feedback in the country
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of Iraq during July and August 2011. The teams consisted of one board certified surgeon, one trauma nurse and one medic. The surgeon was placed in charge of the simulation and the nurse was responsible for documenting written feedback for the trauma team, which was used to craft the AAR. The medic was responsible for teaching each team medical moulage techniques to
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improve realism for each simulation. Summary AARs were sent to all units describing the evaluation with respect to items to sustain, items to train and all observational comments (Figure 4).
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After action review/video debriefing
After action reviews were conducted with 100% of the participants immediately following the
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simulation scenarios and lead by a team of four multi-disciplinary, multi-service evaluators trained in, and experienced with, combat casualty care and team training. Key areas analyzed were TeamSTEPPS™ core principles found to be integral to improving patient outcomes.3 The instructors and participants reported on team structure (defining your team, establishing a team leader, identifying and executing team roles), leadership (planning approach, problem solving, utilizing resources), communication (closed-loop, utilizing call outs and check backs, performing
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clear hand-offs) and mutual support (providing oversight, resolving disagreements, utilizing of time-outs). In addition, each AAR included a review of the evaluations and video captured during the simulations. These tools are used to illustrate the presence or absence of teamwork
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behaviors during the resuscitations and to identify strengths and weaknesses. Additionally, the afternoon AAR contrasted the morning and afternoon scenarios, highlighted improvements, and discussed strategies to incorporate STAT.
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Questionnaires
Upon completion of the course, each participant was provided an on-line questionnaire to assess
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perceived effectiveness of training (Figure 5). Professional role, number of deployments and previous teamwork training were queried. Questionnaires also assessed team use of checklists following the course, the utility of the course, and suggestions for improvement. Specifically, survey questions included single-choice selections from the following choices for questions
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related to team activities before and after STAT: yes, always; yes, some of the time; yes, rarely; no, never. Survey questions which addressed the individual’s perception of the value of STAT training were rated by a 5-point scale: not valuable at all; somewhat valuable; neutral; valuable;
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very valuable. Questions regarding the participant’s perception of the likelihood of trauma team training to improve outcomes or save lives were also rated by a 5-point scale: not likely at all;
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somewhat likely; neutral; likely; very likely. Statistical analysis
Data was analyzed using Student’s t test and Chi Square where appropriate and a p value of less than 0.05 was considered significant. RESULTS
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Two hundred twenty deployed personnel from FSTs and CSHs were trained and subsequently offered participation in an anonymous on-line survey comprised of 15 questions following STAT training. Sixty-one trainees (28%) completed the survey including: 11 physicians, 3 nurse
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anesthetists, 3 physician assistants, 22 nurses, 9 medics, 5 operating room technicians and 8 other medical support personnel. Forty-nine percent of respondents (29/61) were on their first
deployment, 31% (18/61) were on their second deployment, and 20% (12/61) had deployed three
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or more times.
All participants were queried regarding previous formal teamwork training in either
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TeamSTEPPSTM or other teamwork training. Forty-two percent (26/61) had previous training in TeamSTEPPSTM, 30% (18/61) had other teamwork training, and 28% (17/61) had no prior teamwork training. Approximately one-third (22/61) of participants surveyed felt that this course would be “very valuable” prior to completing STAT. However, after the course, statistically
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significantly more respondents felt it was “very valuable” compared to before the course (53% vs. 37%, p<0.05) despite more than 70% of all respondents having previously trained in a formal teamwork course. Seventy-seven percent reported it would improve overall patient safety and
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outcomes. Seventy-eight percent reported it would likely contribute to saving lives in combat. Moreover, 95% advocated STAT should be provided to surgical teams prior to deployment,
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including nurses and medics working in the emergency and operating rooms, scrub technicians, and military emergency medicine and surgical residents. Most importantly, 61% stated that STAT changed the way their team performed simulation for trauma training during deployment. Comments from respondents focused on praise for the high quality, realism and difficulty of the simulation scenarios. Others valued the ability to apply TeamSTEPPSTM in a practical manner (forcing reassessment of team dynamics), the ability to identify weak spots in the system,
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receiving instant feedback with the ability to “see themselves” through the use of video during the AAR, applying a standardized approach to OR communication, and the use of the preoperative brief and post-operative debrief tool. Suggested areas of improvement included
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incorporating intensive care unit and ward scenarios; the need for both pre-deployment
implementation of this course; as well as performance of regular drills using this curriculum. For most teams, the number one concern voiced was minimal coordinated teamwork training and
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instruction prior to deploying into the combat zone. Participants linked this issue to a fragmented timeline of rotations for deploying doctors, nurses and medics in both the reserve and active
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components. DISCUSSION
Surgical Team Assessment Training, a new educational simulation and team-training program, implemented in a combat theater improved team member’s perception of communication and
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subsequent performance of clinical drills in a group of deployed operating room personnel. In addition, based on participant feedback, TeamSTEPPSTM training, as implemented in the STAT curriculum, was felt to likely improve overall patient outcomes and save lives. The feedback
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also indicated that it should be offered to both surgical and emergency residents, as well as all surgical team members, prior to deployment.
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Improved communication in the OR is a prerequisite to reducing adverse outcomes. Lingard10, in his 2004 study, found communication failures in up to 30% of team exchanges and up to one third of these resulted in effects that compromised patient safety. In addition, Mazzocco4, in a study of surgical team behaviors and patient outcomes, showed that surgical teams who fail to share information, either intraoperatively or during handoffs, are more likely to have their patients experience death or major complications. In an analysis of communication
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breakdowns resulting in surgical patient injury, Greenberg11 demonstrated that breakdowns are equally likely to occur in the preoperative (38%), intraoperative (30%), and postoperative (32%) phases of care. Interestingly, he also reported that the prevalence of emergency cases was higher
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than expected when examining a set of 60 cases that resulted in a surgical malpractice claim. Combat surgery is nearly always performed under emergent circumstances, suggesting that communication errors may actually be more likely to occur in the preoperative or intraoperative
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settings during combat.11
Interdisciplinary collaboration also improves clinical outcomes. Davenport,2 in a 2007
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study on reported levels of communication and collaboration within surgical teams, emphasized the importance of physician’s coordination and decision-making roles on surgical teams in providing high quality and safe care. This observation was confirmed by their data which demonstrated surgical teams whose members reported higher levels of communication and
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collaboration between providers had decreased risk-adjusted morbidity.2 The only published randomized trial evaluating the effect of teamwork training on preventing adverse outcomes was performed in labor and delivery and demonstrated no
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difference in adverse clinical outcomes between the groups. However, there was likely a significant Hawthorne effect since improvements in clinical outcomes were seen in both groups.7
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In addition, the teamwork trained group demonstrated a clinically, and statistically significant, shorter decision to incision time for urgent cesarean delivery. This difference suggests that team-training did improve coordination of care as well as provide a more rapid and effective response to an emergent clinical situation.7 Other areas where improvements in clinical outcomes have been demonstrated with better communication include: the intensive care unit care,12 during neonatal resuscitation,13 and following recognition of shoulder dystocia.14
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Discrepancies in perception of patient safety and teamwork exist among, OR personnel. Gore15 observed that implementation of CRM in the OR improved perceptions of patient safety among resident physicians and nurses while attending physicians perceived no difference. In
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addition, using a standardized and validated questionnaire, Makary16 found that physicians most often rated teamwork as good while nurses perceived teamwork as only mediocre. Differences in perception between caregivers may be assessed using the Safety Attitudes Questionnaire which
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can assist in defining focused interventions for improving patient safety.17 Use of this
questionnaire to evaluate STAT should be considered to determine if this method of team
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training affects teamwork perception between caregivers in the OR.
Combat surgery, by nature, is complex and requires the coordinated effort of multiple providers, both credentialed and non-credentialed, that typically forward deploys to form a functioning surgical team or unit. To establish such a team, the Armed Forces deploy individuals
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that come together to make up the unit, and often these individuals have not previously worked together. At other times, unit members are well known to each other providing an opportunity to train together prior to deployment. The constitution of deploying units varies considerably based
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on the mission, and between the individual branches, of the DoD. It is imperative that all units, regardless of their composition and pre-deployment
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familiarity, function well and expertly apply the standard principles of triage and life-saving resuscitation and surgery in a timely and highly coordinated manner. Individual skill sets are critical and unit cohesion and efficiency may quickly develop after the individuals begin to work together in the heat of battle while supporting one another and looking beyond their own individual strengths and weaknesses. How rapidly this occurs in actual practice varies from unit to unit based on multiple factors, which may be difficult to quantify such as; leadership, esprit de
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corps, and personal motivation. Ideally, each unit arriving in theater should be ready, and able, to treat the sickest casualty immediately upon arrival on station. Department of Defense Trauma Registry data suggests that there is no significant degradation in clinical outcomes of patients
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cared for at the start of a unit’s deployment compared to later in that same unit’s deployment (verbal communication former Joint Trauma System Director COL G. Costanzo, August 2011). Overlap of the OR staff from one unit to the next, and simulation-based team-training, may help
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protect against degradation in clinical outcomes during these transitions.
Simulation training can also help guide best practices for patient safety and is an
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important addition to the TeamSTEPPS™ curriculum. Procedural skills simulations have been shown to be effective in reducing patient errors. For example, learning laparoscopic cholecystectomy surgery on virtual reality simulators led to a reduction in predefined errors on patients when compared with conventional instruction.18,19 Mannequin-based simulation is much
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more difficult to validate, however, multiple prospective trials are currently underway to evaluate the impact on patient safety and, as an important additional program, STAT should be evaluated for similar effects.
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Limitations to this study include that approximately 70% of participants had some type of formal teamwork training prior to participating in STAT, and completing the questionnaire,
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which may have biased their response. We speculate that this may have contributed to the lower than anticipated post-STAT participant perception, as STAT may not have been as extensive as their previous training. Conversely, it is also possible that participants rated the effectiveness high based on their lack of, or dissatisfaction with their previous, team-training experience. In addition, only 28% of eligible respondent’s completed the survey tool compromising the general application of our results. Surveys were completed within 45 days of the training. Prospective
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paper-based surveys were not given immediately post-training because permission to perform this survey was not obtained until after training at all sites had been completed. Finally, the lack of objective data and measures of improved proficiency, or subsequent patient outcomes, in these
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units is acknowledged. Future studies must evaluate these critical outcomes in deployed surgical units who undergo STAT training.
While combat surgery is performed in austere environments with limited resources, many
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of the principles and practices learned in theater can be applied to other settings. Based on the work presented here, the DoD is encouraged to consider further study of STAT training for the
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pre-deployment phase of both units and individuals. In addition, consideration should be given to applying this training to medical units from other government and civilian agencies who have a role as first responders to a civilian natural or humanitarian disasters, since STAT may be scaled for a variety of unit sizes and the clinical scenarios may be modified to include casualties more
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typical of natural disasters or humanitarian crises.
Rigorous training emphasizing individual, and some team, skills is already performed in collaboration with the DoD at civilian trauma centers across the United States such as the
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Army’s Ryder Trauma Training Center in Miami, the Navy’s Trauma Training Center at the University of Southern California, and the Air Forces’ Center for the Sustainment of Trauma and
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Readiness Skills programs. STAT could also serve as a means of reinforcing training offered at the various pre-deployment civilian trauma emersion sites when provided in theater. The next phase of study should focus on development of specific clinical metrics that could measure if STAT “in situ” training improves clinical outcomes, just as previous work in the delivery room found that “in situ” drills for shoulder dystocia events resulted in better coordination by teams and a reduction in neonatal birth injuries.14 Alternatively, surrogate
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measures for improved clinical outcomes to consider could include the number of times a circulating nurse leaves the operating room to retrieve equipment not specifically anticipated at the onset of surgery. Ultimately, however, the clinical outcome of the patient is the most critical
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measure and must be the principle outcome of interest.
Regardless of the method used to teach principles of teamwork and improve team
dynamics for the benefit of the patient, ultimate success or failure relies directly upon clinical
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leaders adopting and implementing the knowledge and attitudes of high performing teams. In most instances, this leadership is the responsibility of the primary surgeon who must ensure that
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the environment is one that permits a flattened hierarchy and the critical techniques and strategies of high performing teams including leadership, structure, situation monitoring, communication, and mutual support are consistently implemented and demonstrated by team
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members: especially the team leader.
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References 1. The Joint Commission. (2012). Summary Data of Sentinel Events Reviewed by The Joint Commission. Oakbrook Terrace, IL: Joint Commission. Retrieved May 8, 2013 from
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http://www.jointcommission.org/assets/1/18/2004_4Q_2012_SE_Stats_Summary.pdf 2. Davenport DL, Henderson WG, Mosca CL, et al. Risk-adjusted morbidity in teaching
hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am
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Coll Surg. 2007;205:778-84.
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3. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197:678-85.
4. Alsonso A, Baker D, Holtzman A, Day R. Reducing medical error in the military health system: How can team training help? Human Resource Management Review. 2006;16:396-415. 5. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management in
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commercial aviation. International Journal of Aviation Psychology. 1999;9:19-32. 6. Sax HC, Browne P, Mayewski RJ, et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144:1133-1137.
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7. Nielsen PE, Goldman M, Mann S, et al. Effects of teamwork training on adverse outcomes
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and process of care in labor and delivery: A randomized controlled trial. Obstet Gynecol. 2007;109:48-55.
8. Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. The Joint Commission Journal on Quality and Patient Safety. 2010;36:133-142.
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9. Deering S, Rosen MA, Ludi V, et al. On the front lines of patient safety: Implementation and evaluation of team training in Iraq. The Joint Commission Journal on Quality and Patient Safety. 2011;37:350-356.
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10. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: An
observational classification of recurrent types and effects. Qual Saf Health Care 2004;13:330334.
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11. Greenberg CC, Reganbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2004; 204:533-540.
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12. Baggs JG, Ryan SA, Phelps CE et al. The association between interdisciplinary collaboration and patient outcomes in a medical intensive care unit. Heart Lung. 1992; 21:18-24. 13. Thomas EJ, Sexton JB, Lasky RE et al. Teamwork and quality during neonatal care in the delivery room. J Perinatol 2006; 26:163-169.
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14. Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008; 112:14-20. 15. Gore DC, Powell JM, Baer JG, et al. Crew resource management improved perception of
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patient safety in the operating room. Am J Med Qual 2010; 25:60-3. 16. Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians
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and nurses: teamwork in the eye of the beholder. J Am Coll Surg 2006; 202:756-52. 17. Center for Healthcare Quality and Safety, University of Texas Health Science Center at Houston. Safety attitudes and safety climate questionnaire. Retrieved May 8, 2013 from https://med.uth.edu/chqs/surveys/safety-attitudes-and-safety-climate-questionnaire/
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18. Grantcharov TP, Kristiansen VB, Bendix J, Bardrum L, Rosenbery J, Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004; 91:146-50
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19. Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first ten laparoscopic
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cholecystectomies. Am J Surg 2007; 193:797-804
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Figure 1: Pre-Hospital Phase Trauma Evaluation Checklist (Adapted from USATTC, 2011).
NOTIFICATION
REMARKS
ANCILLARY SVCS
REMARKS
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X-Ray
• TOC
• Radiologist available
•PAD
•Portable X-ray present •Combat Liaison Team •CT scan ready •ER
Lab
•Trauma Team
• Blood component
•Specimen labeling
•ICU Team
Pharmacy
•Pharmacy
•Pharmacist present
•X-Ray
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•Code cart medications
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paperwork
•OR Team
•Lab
• Executed clear handoff
PAD
•Performed check backs
Observer Notes (continued)
•Patient identification
Three Items to Train
Three Items to Sustain
•Secure weapon
1. _________________________
1._________________________
•Secure valuables
2. _________________________
2._________________________
•Pt tracking
3. _________________________
3._________________________
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•Trauma packet
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Figure 2: Triage and Resuscitation Evaluation Checklist (Adapted from USATTC, 2011). Primary Survey
Team Roles TEAM LEADER
AIRWAY M A P F A S T
Applied Oxygen Secured airway
Critical Team Concepts
End Tidal CO2
Structure
BREATHING
• Defined the Team • Established Team LDR • Identified Team roles • Executed Team roles
Identified problem (s)
ANESTHESIA
Timely intervention (s)
O __Oxygen (applied oxygen) X __Exam Heart/Lungs Y __Yes/no (H&P/Vitals/Equip)
CIRCULATION
• Planned approach • Problem solved • Utilized resources
Pulse check
G
Identified problem (s)
E __Exam eyes/ears/head N __Nose/neck/GCS
Timely intervention (s)
DISABILITY Assessed GCS
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Assessed Pupils
Communication
EXPOSURE
• Verbalized Vital Signs • Performed Call outs • Performed Call back • Performed a clear hand-off
NURSE
V __ Vital signs I __ IV meds T __ Time / temperature A __ Alert key personnel L __ Lab results (call out) S __ Safety
Prevented hypothermia
Secondary Survey Head to toe assessment Log roll
Mutual Support
RIGHT MEDIC R I G H T
__Remove clothing __ Inline stabilization __Gear collected __Hold pressure __Tubes to lab
L E F T
__ Line (IV) placed __ Exposed patient __ Foley catheter __ Temp obtained
LEFT MEDIC
Reassessment (ABCDE)
• Provided overwatch
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• Resolved disagreements • Timeouts used as needed
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__Gauge (large bore IV)
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Leadership
__ Mechanism/manage __Assess GCS/TBI __Primary survey __FAST exam __ABG/labs __Secondary survey __Timeout / problem list
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Observer: ____________________________ Unit/Patient/Event:_____________________ Start: ____________ Primary Complete:____________ Secondary Completed: ________ Finish:_______
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Figure 3: Surgery Brief Guide
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Figure 4: After Action Rerport Formal Feedback Model Example Basic Trauma Scenario with One Patient Topic: Critical Team Concepts (Structure, Leadership, Communication, Mutual Support)
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Items to Sustain: • The team worked well together. • Structured, well defined team that executed their roles. • Good leadership utilizing a planned approach and utilization of resources. • Mutual support provided good overwatch and teamwork. Items to Train: • Continue to work on implementing critical team concepts of communication. • Communication tools and strategies to enhance patient safety. • Ensure tasks are directed towards a person, rather than making a general callout without assignment of responsibility (or generate a Somebody of the Day roster). • Train all-outs and check-backs. As a team, limited call-outs and check-backs were minimally employed prior to medication administration and essential task being completed. • Train coordination of the log-roll. Trauma TEAMwork System Core Instruction and Discussion
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Feedback from unit: • Truthfully, we did not receive a lot of trauma team work training and instruction prior to coming to theater, because of the fragmented timeline and rotation of deploying doctors, nurses and medics. This seems to be a common theme throughout theater. While this intra-theater training has been invaluable, “recommend your team report back to big Army that this type of team training and instruction needs to take place during the pre-deployment phase as well prior to getting into theater where we have time to rehearse.” We appreciate the training we received in this class, it was really done well. The speaker was knowledgeable and presented a team work methodology we can use during initial resuscitation of the trauma patient throughout the spectrum of care.
•
As a team we talked about using the communication strategies we learned such as the call-outs and check-backs during the advanced scenario. I think most teams can improve in the area of communication within the team and with ancillary staff.
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Figure 5: Survey Tool Questions
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1. What is your professional role at this time? Physician/Nurse/Medic/OR Technician/Other 2. Please indicate how many times you have been deployed (including this deployment). 1/2/3/4/5/>5 3. Have you had formal teamwork training prior to this deployment in either of the following categories? TeamSTEPPS/Other teamwork training 4. If you had training other than TeamSTEPPS, please indicate what course you attended. 5. Prior to participating in this course did your team: a. Use a standard preoperative checklist b. Use a standard postoperative checklist c. Use a standard postoperative debriefing tool d. Use OR case preference lists 6. Following participation in this course does your team now: a. Use a standard preoperative checklist b. Use a standard postoperative checklist c. Use a standard postoperative debriefing tool d. Use OR case preference lists 7. Prior to participating in this course, how valuable did you feel this course would be for your team/you personally? 8. Following your participation in this course, how valuable did you feel this course will be for your team/you personally? 9. Please answer the following questions about the trauma team training: a. How likely do you feel this training is to improve overall patient outcomes? b. How likely do you feel this training is to save lives? 10. For each of the following groups, please indicate whether or not you feel that they should have this type of training: a. Surgical teams prior to deployment b. Surgical residents in training c. Emergency medicine residents in training d. Nurses and medics working in the ER e. Nurses and medics working in the OR f. Scrub technicians 11. For each of the following groups, please indicate how important you feel that the trauma team training program is for: a. Surgical teams prior to deployment b. Surgical residents in training c. Emergency medicine residents in training d. Nurses and medics working in the ER e. Nurses and medics working in the OR f. Scrub technicians 24
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12. Has this course changed the way your team now performs simulations for mass casualty exercises? 13. What did you find most valuable about this course? 14. What did you find least valuable about this course? 15. Do you have any suggestions for changes for future courses?
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