fabrice brunet, md m.i.c.u-e.d cochin, paris c.c.d. st michael’s, toronto teamwork training in...
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Fabrice Brunet, MDM.I.C.U-E.D Cochin, Paris
C.C.D. St Michael’s, Toronto
Teamwork Training in Critical Care
Training in Critical Care• Education system in nursing and medicine give
clinical skills to individuals
• Superb individual skills do not guarantee effective team performance in care delivery
• Effective teamwork does not arise spontaneously and needs behavior changes
• Teaching of teamwork as integral in critical care is uncommon
Teamwork Training is:
• A novel education model derived from aviation organisations
• Designed to train professionals
• Behavior-based teamwork course
• Using Problem-based learning
• Multidisciplinary groups
• Formal training program
Teamwork training is not
• An individual education system
• Focused on clinical skills
• Designed to teach students
• A transdisciplinary training
Teamwork training: Rationale
• C.C.Ds are at risk environments
• Patients conditions are complex
• Technologies are always evolving
• Care needs multidisciplinary interactions
• Consequences of errors are severe
• Burn-out Syndrome is common
Teamwork training: Goals
• Enhance department performance
• Improve Quality of Patient Care
• Reduce errors and litigation risks
• Improve patients/relatives comfort
• Develop multidisciplinary approach
• Increase staff satisfaction and as a result retention and recruitment of staff
Teamwork system: a standardized program
• Teaching teamwork behavior and skills
• Designed for a « core team »
• Group animation concept
• Multidisciplinary teaching approach
• Interactive teaching method
• Topics selected on team needs
Organisation of seminars• Same team during the whole duration
• A coordinator following the team
• Multidisciplinary teachers
• Location: outside/inside the I.C.U
• Three kind of topics: medical, ethics, organisation
• Methods of training: lectures, simulation, clinical situation
Methods of training• Expert lecture: state-of-the art adapted for a
multidisciplinary audience: Evidence-based
• Simulation: Workshop allowing to adjust
recommendations to real practice and to define
local protocols: Experience-based
• Clinical situation: confrontation with current
practice: Real life
Factors of success
• Involvement of the Head of the C.C.D
• Steering committee
• Motivation of the team
• Training of the teachers
• Choice of appropriate topics
• Financial support by the institution
• Frequent reports of results
Evaluation
• Evaluation of training itself– Questionnaire of satisfaction
– Assessment of team performance
• Evaluation of its results on practice– Implementation of new advances
– Quality indicators
– Analysis of adverse events
Performance assessment
• Team and not individual performance
• Measurement of performance indicators during repeated simulations S.O.C.E.
• Assessment of team performance in clinical situations and novel techniques
• Decrease of adverse events
• Quality indicators: Audits and M.I.T
Protocol of bedside surgery in ARDS
• Preparation before operation
• Patient stabilization and information
• Equipment verification
• Team organization
• Surgical procedure
• Incision and Dissection of pleural adhesion
• Insertion of chest tube
• Pulmonary, pleural and cutaneous repair
• Postoperative detection of surgical complicationsPostoperative detection of surgical complications
• Surgical procedure – Dissection of pleural adhesions 11 pts– Insertion of chest tube 3.4 ± 1.2 /BT (1-
7)– Pulmonary repair 11 pts– Pulmonary biopsy 3 pts
Bedside surgery: Results 1.
• Re-operationRe-operation– Postoperative bleedingPostoperative bleeding 4 pts4 pts– Persisting air leak / bleedingPersisting air leak / bleeding 8 pts8 pts
• Postoperative complicationsPostoperative complications– HemothoraxHemothorax 7 pts7 pts– Hemodynamic instabilityHemodynamic instability 2 pts2 pts– Septic shockSeptic shock 3 pts3 pts
• 66 bedside thoracotomies in 33 patients– Elective / emergency 45 / 21
• Indication – Pneumothorax / BPF 39 (59 %)– Hemothorax 27 (41 %)
• Ventilatory support during thoracotomy– CMV 16 BT– ECCO2R 36 BT– HFO 12 BT– Partial liquid ventilation 2 BT
• Intervention outcome – Resolution of PTX /HTX 41 (62 %)– Failure 25 (38 %)– Survival 15 (46.8 %)
Bedside surgery: Results 2.
Quality of care markers• Previously identified indicators
– Time between admission and treatment
– Patients or relatives satisfaction
– Global cost of a care for given diseases
• Followed in a C.Q.I approach– Evidence based protocols
– Medical Information Technology
– Case and disease management
Quality
Research
Education
Communication
Care
Continuous Quality Improvement
Experience- based
Protocols
Corrections
Continuing Measurementsof indicators
Dysfunctioning
Evidence-based
Reduction of errors
• Number of adverse events
• Spontaneous report of human errors
• Design of multidisciplinary protocols
• Analysis of critical situation
• Benchmarking with other C.C.Ds
Teamwork in restructuring E.Ds
• Tested in Cochin ED with teamwork training– 4 seminars of 1 week each – Repeated for 4 teams (140 h / team / yr)– Evaluated by C.Q.I with M.I.T
• Same program used in 3 other E.Ds– 1 pediatrician with adapted topics to children– 2 adults with adapted topics to environment
Teamwork in E.Ds: results• Successful introduction of a new organisation
– Triage, Observation units– Electronic patient chart
• Increased department and team performance– Reducing waiting time for each step of the circuit– Designing Fast tracks for severely patients
• Improving patient and team satisfaction– Decrease in patient complaints– Increased attractiveness of the E.Ds
Perspectives
• Develop multicenter international studies on teamwork training sytems in C.C.Ds
• Implement teamwork training early in the course of medical and nursing education
• Design new systems of training to improve transdisciplinary teams performance
A few references
• Brennan TA et al: The nature of adverse events in hospitalized patients. N Engl J Med 1991;324:370-376.
• Brennan TA et al: Hospital characteristics associated with adverse
events and substandard care. JAMA 1991;264:3265-3269.• Classen DC et al: Computerized surveillance of adverse drug events in
hospital patients. JAMA 1991;266:2847-2851.• Helmreich R: Managing human error in aviation. Sci Am 1997;5:62-67.• Leape L. Error in medicine. JAMA 1994;272:1851-1857.• Phillips K: The Power of Health Care Teams: Strategies for Success.
Oakbrook, IL: Joint Commission on Accreditation of Health Care Organizations, 1997.
• Risser DTet al: The potential for improved teamwork to reduce errors in the emergency department. Ann Emerg Med 1999;34:373-383.