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

Scale for Trauma

Supported by a grant from the American College of Surgeons and Medical Education Technologies, Inc.

Alexandra DiTulio (MSIII), Susan Steinemann, MD, Alisha Skinner (MSIII), Kara Terada, CCRN, Kathleen Anzelon, CCRN, Hao Chih Ho, MD, Benjamin Berg, MD

University of Hawaii and The Queen’s Medical Center, Honolulu, HI

Trauma Resuscitation

• Time-critical enterprise involving multidisciplinary team members

• Value of teams and teamwork long appreciated– Video review

• Hoyt DB, J Trauma 1988

– Simulation• Holcomb, J Trauma 2002

• No widely accepted tool for evaluating trauma teamwork

Optimal tool• Multidisciplinary trauma teams• Relationship to teamwork eval tools in other settings (O.R.)• User friendly– Easy to learn– Quick to perform

• Actual or simulated settings, real time or in video review

• Self-assessment and debriefing• Reliable• Ratings correlate with objective measures of

performance and/or patient outcome

Trauma Teamwork Rating ToolsTool Year Author Inter-rater

ReliabilityCorrelation w/ other performance metrics

TTET 2002 Holcomb n/a Includes clinical metrics. Expert > novice in simulated video review

ACS/APDS 2008 Knudson n/a n/a

TPOT 2010 Capella Good : Surgeon video review

Sample of clinical resuscitations which showed trend to improved performance

Development of T-NOTECHS• 5 Essential behavioral domains from Modified

NOTECHS (Sevdalis 2008)1. Leadership and Managerial Skills2. Cooperation and Team Skills3. Communication and Interaction4. Decision Making5. Situation Awareness and Vigilance

• Coping With Stress (DaRosa: ACS-APDS Curriculum) • Ability to Handle Distractions (Holcomb)

5 Behavioral Domains

27 Exemplar Behaviors

Rater Training• Raters– 13 Critical Care (“Crisis”)

RNs (CRN)– Research assistants (3

med students, one MD)

• One hour training session– Pre-reading on

teamwork skills– Teamwork skills didactic– Review and rating of a

range of simulated trauma resuscitations

• Rated by CRN ± RA• Clinical data collected– Time in ED– Reporting of tasks of primary survey and

adjuncts (e.g. BP, pupil exam, FAST)

• Independent rating of T-NOTECHS after leaving the ED

Real-life Trauma Resuscitations

Simulation-based Team Training• Simulated trauma resuscitations– Multidisciplinary team members– 3 10-minute blunt trauma cases

• Each with 8 “key” and 3 “common” tasks• Team blinded to clinical tasks

• Teamwork rated using T-NOTECHS– Audience response system– After each scenarios, before video review– Team debriefed using T-NOTECHS

– Later, video review by investigators looking at time to completion of interventions

– Clinical data and T-NOTECHS scores again collected for 6 months post-training

Reliability• Cronbach’s alpha >0.90 for the 5 domains– Did not improve with elimination of any domain

• Intraclass correlation coefficient (ICC) for Real life = 0.48– 2 raters (CRN, RA)– n = 69 (48 before, 21 after team training)

• ICC for Simulated = 0.44– 3 raters (CRN, attending, debriefer)– n = 33

Reliability issues

• Minimal rater training• All assessments done in real-time• CRN had to multi-task• Clinical action is difficult for

inexperienced clinicians to follow• Simulated setting– Surgeons may not accurately self-assess

• Arora, Am J Surg in press

– Attendings had received no prior training

Correlation with Performance in Simulated Resuscitations

• Higher mean T-NOTECHS scores by all of the raters correlated with improved clinical performance

• Debriefer’s overall T-NOTECHS ratings correlated with– Greater % of tasks completed (r=.5, p<.05)– Faster completion of 3 common tasks (r=-.38, p<.05)

Correlation with Performance in Real-life Resuscitations

• 235 resuscitations were assessed by CRN – 136 before, and 99 after team training– Mean T-NOTECHS scored improved significantly

after team training (p<.001)

• Higher T-NOTECHS reflected better clinical performance:

• Faster time to leave ED (r=-.13, p<.05)• Fewer # of unreported resuscitation tasks (r=-.16, p<.05)

Conclusions

• Needs further study and efforts to improve reliability

• T-NOTECHS is user friendly– Rapidly adopted after minimal rater

training– Quick to perform (< 5 minutes)

• Useful for debriefing in simulated and actual clinical setting

• Ratings correlated with objective measures of clinical performance

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