Emmanuel Martinez Alcaraz The College of New Jersey

Characteristics of an ad hoc trauma resuscitation team and patient outcomes Mentor: Dr. Maureen McCunn Anesthesiology and Critical Care

LIVE eye Video Review: An analysis of

clinician involvement Mentors: Dr. Jose Pascual-Lopez;

Dr. Joseph Sakran Traumatology, Surgical Critical Care,

and Emergency Surgery

LDI SUMR Symposium August 11th, 2011

Agenda

I. LIVE eye: SICU Study Overview

II. Characterization of ad hoc team:

Trauma Bay Study Overview

III.Lessons Learned

LIVE eye Video Review: An analysis of clinician involvement

Mentors: Dr. Jose Pascual-Lopez; Dr. Joseph Sakran HUP Department of Traumatology, Surgical Critical Care, and Emergency Surgery

LIVE eye: SICU Study Overview

Using video in SICU rooms to evaluate

the extent of clinician’s interaction with

nurses, patients, and family members

ICU Intensive Care Unit

SICU Surgical

MICU Medical

NICU Neurosurgical

Other specialties

Neonatal

Too many TLAs* *Dr. Rob Burns

What is a SICU? Area where patients who need constant attention for

life threatening conditions are cared for

SICU pre- and post-operative recovery for critical

patients

Multi-disciplinary team

Beginnings stem from advancements in critical care:

Patient triage, infection-control

Artificial ventilation & its automation

Resuscitation, anesthesiology

Surgical

Intensive

Care

Unit

Research Process* *Simplified

Aims of Study Video record events (procedures/emergent) when a Nurse

Practitioner or Physician is needed: e.g. central line

Part of other observational studies — use same video

Analyze extent of clinician interaction

Based on latest research literature, determine if factors that could affect the following are present:

Links between communication and patient outcomes & satisfaction2,3

Links between nurses’ and other co-workers’ job satisfaction, collaboration, and decision-making inclusion; hospital hierarchies4,5,6

2. Baggs, JG, et.al., 1999. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine, 27, pp. 1991-1998. 3. Wheelan, Susan A., et.al., 2003. The Link Between Teamwork and Patient’s Outcomes in Intensive Care Units. American Journal of Critical Care, 12, pp. 527-534. 4. Baggs, JG, et.al., 1997. Nurse-physician collaboration and satisfaction with the decision-making process in three critical care units. American Journal of Critical Care, 6, pp. 393-399. 5. Larson, Elaine, et.al., 1999. The Impact of Physician-Nurse Interaction on Patient Care. Holistic Nursing Practice, 13, pp. 38-46. 6. Manthous, C.A., et.al., 2011. Team Science and Critical Care. American Journal of Respiratory and Critical Care Medicine, 184, pp.17-25.

Study Population & Data Collection Methods

HUP Rhodes 5 SICU care providers and patients All are consented to participate

Use existing eICU system with real-time patient monitoring

Bedside nurse hits eICU button in room UPHS eICU team receives request

Receive phone call from eICU to commence

Record live-video through eICU room cameras and real-time patient vital signs w/ secure computer

Methodology Checklist to evaluate the extent of clinician’s interaction:

Reason for clinician request: e.g. respiratory issues

Did eICU team intervene?

If and how the clinician speaks w/ nurse, patient, & visitors

What the clinician does: e.g. performs physical examination

If patient has specific intervention, does the clinician evaluate it:

e.g. patient has a central line, clinician does not evaluate it

Whether and to whom does the clinician verbalizes a plan of action?

What does it look like?

Significance Methodology

New use of video analysis in ICU patient rooms Previous studies focus on

interactions outside of patient rooms7, non-emergent activities (ICU rounds)8, or in the trauma bay9

Topic Provide insight on the extent

clinicians interaction with nurses,

patients, and family members —

real behaviors

Patient/family satisfaction;

Patient/family anxiety10

Other observations while study is in

progress

7. Carroll, Katherine, 2009. Outsider, insider, alongsider: Examining reflexivity in hospital-based video research. International Journal of Multiple Research Approaches, 3, pp. 246-263. 8. Carroll, Katherine, et.al., 2008. Reshaping ICU Ward Round Practices Using Video-Reflexive Ethnography. Qualitative Health Research, 18, pp. 380-390. 9. Lubbert, Pieter H.W., et.al., 2009. Video Registration of Trauma Tram Performance in the Emergency Department: The Results of a 2-Year Analysis in a Level 1 Trauma Center. The Journal of Trauma, 67, pp. 1412-1420. 10. Azoulay, Elie, et.al., 2000. Half the families of intensive care unit patients experience inadequate communication with physicians. Critical Care Medicine, 28, pp. 3044-3049.

Characteristics of an ad hoc trauma resuscitation team and patient outcomes

Mentor: Dr. Maureen McCunn HUP Department of Anesthesiology and Critical Care

Trauma Bay Research Overview

Identify characteristics and qualities of high

functioning teams in the trauma bay

Then, whether they affect patient outcome

Using two instrument-questionnaires

What is unique about work in the trauma bay?

Part of a Trauma Network

PENNStar Flight program

In-house trauma surgeons & ED

physicians, trauma nurses, & others

Most seriously injured patients

Wide range: from car crashes to assaults

High intensity environment

Access to multi-disciplinary teams e.g. Anesthesia, orthopedics, neurosurgery

Characteristics of Trauma Bay

Research Process* *Simplified

Aims of Study Determine how ad hoc team functioning and team

dynamics affect patient outcome Pilot Study: Identify characteristics of high functioning

teams in the trauma bay Subgroup analyses of responses of different team member

positions: nurse, resident, fellow, attending

Long-term: Develop a training model for physician, nurse, and student trauma team members To foster collaboration and teamwork6,11,12,13, and to improve

patient outcomes2,3

2. Baggs, JG, et.al., 1999. Association beteen nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine, 27, pp. 1991-1998. 3. Wheelan, Susan A., et.al., 2003. The Link Between Teamwork and Patient’s Outcomes in Intensive Care Units. American Journal of Critical Care, 12, pp. 527-534. 6. Manthous, C.A., et.al., 2011. Team Science and Critical Care. American Journal of Respiratory and Critical Care Medicine, 184, pp.17-25. 11. Keenan, G.M., et.al., 1998. Management of Conflicts: Keys to Understanding Nurse-Physician Collaboration. Research in Nursing & Health, 21, pp. 59-72. 12. Bergs, E.A.G., et.al., 2005. Communication during trauma resuscitation: do we know what is happening?. International Journal of the Care of the Injured, 36, pp. 905-911. 13. Maxson, Pamela M., et.al., 2011. Enhancing Nurse and Physician Collaboration in Clinical Decision Making Through High-fidelity Interdisciplinary Simulation Training. Mayo Clinic Proceedings, 86, 31-36.

Model for Study

An ad hoc crisis group: Team comes together for this one time, interacts in a high-

intensity environment, then disperses

Seek to determine the characteristics of this group that are not part of a fixed team

Trauma evaluation is measurable since: Everyone should know their role and everyone else’s role.

Specific Aim #1 & Background

To assess the views of collaboration of trauma team members

Better patient outcome has been associated with better nurse-physician collaboration2,3

Pilot Study showed a disparity between team members (nurses, attendings, fellows, residents) in perceived composition of the trauma team (McCunn)

The role a team hierarchy6 plays in the functioning of a trauma team and patient outcome

2. Baggs, JG, et.al., 1999. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine, 27, pp. 1991-1998. 3. Wheelan, Susan A., et.al., 2003. The Link Between Teamwork and Patient’s Outcomes in Intensive Care Units. American Journal of Critical Care, 12, pp. 527-534. 6. Manthous, C.A., et.al., 2011. Team Science and Critical Care. American Journal of Respiratory and Critical Care Medicine, 184, pp.17-25.

Methods to Evaluate Aim #1 Assessment Tool: Collaboration and Satisfaction

About Care Decisions Instrument (CSACD) Has been used to measures physician-nurse

collaboration and satisfaction Originally used in the ICU has been adapted for

use in the trauma bay Validity and reliability metrics have been

established13,14

13. Maxson, Pamela M., et.al., 2011. Enhancing Nurse and Physician Collaboration in Clinical Decision Making Through High-fidelity Interdisciplinary Simulation Training. Mayo Clinic Proceedings, 86, 31-36. 14. Baggs, Judith Gedney, 1994. Development of an instrument to measure collaboration and satisfaction about care decisions. Journal of Advanced Nursing, 20, 176-182.

Wheelan’s Integrated Model of Group Development

Implies a team has been working together for an extended period of time

Gradual linear development through 4 stages Stage 1: Dependency and inclusion Stage 2: Counterdependency and fight Stage 3: Trust and structure Stage 4: Work

Specific Aim #2 & Background

To determine if ad hoc trauma teams exhibit the four stages of group development If teams exhibit the same developmental characteristics of fixed

groups

One marker of a high-functioning group common goal Groups at last stage of development experience a time of

intense team productivity and effectiveness Focus its energy on goal achievement and task accomplishment

Methods to Evaluate Aim #2

Group Development Questionnaire (GDQ) Integrated Model: Groups move through stages of

development as they continue to work together Measures members’ perceptions of clarity of group

goals, individual goals, effectiveness of conflict-resolution, and other quantifiable small group characteristics

Extensively tested for both validity and reliability; used in many industries including healthcare7

7. Wheelan, Susan A., et.al., 2003. The Link Between Teamwork and Patient’s Outcomes in Intensive Care Units. American Journal of Critical Care, 12, pp. 527-534.

Subject Population — Recruitment

Population: Trauma team members Nurses, attendings, fellows, residents, and ED techs

Site: Hospital of the University of Pennsylvania trauma bay

By completing survey, a member consents to participate in this research protocol

Team member and group demographics will be collected along with each instrument

Methods of Data Collection

Team members are asked to fill questionnaire following a resuscitation

Responses are collected with the other team members in the group for the respective resuscitation

Subjects may participate in more than one survey if they are a member of multiple resuscitation teams

Each member will be given a Participant Information Sheet By completing survey, a member consents to participate in

this research protocol

Significance

Methodology 1st time either

Collaboration and

Group Development

Questionnaires are used

in Trauma Bay teams

Patient Care High stakes environment:

team leadership,

communication, and

collaboration vital

Characteristics of team with

better outcomes

Develop training model for

future care givers

Trauma Bay Study—Summary

The composition and high-intensity characteristics of trauma teams create a unique environment for group dynamics & development.

Using two separate instruments to: 1) Assess views of collaboration of trauma team members 2) Determine if ad hoc team exhibit the four stages of group development

Studies will elucidate the characteristics of trauma resuscitation teams and patient outcomes Help develop a research-based training model for trauma bay nurses,

physicians, technicians, and students

Lessons Learned Role of camera: empowering or disempowering for

participants

Importance of the way video is incorporated in a hospital setting

Video: capture actual behavior rather than simplified behavior

Fine line between video use as a surveillance and objectification

method, and use as quality improvement

Difficulty of administering questionnaires in trauma bay

Difficulties of their repeated use

Patience with the research process

Acknowledgements

Dr. Maureen McCunn,

Dr. Jose Pascual-Lopez,

Dr. Joseph Sakran

Dr. Chris Burchill, Emily

Bohm, Mary Hammond,

Carole McMonagle and

rest of Anesthesiology &

CC Department, Trauma

Center teams

Trauma fellows and the

rest of the LIVE eye Team,

the entire Rhodes 5 SICU

Joanne Levy, Lissy

Madden, Megan

Pellegrino, Hoag

Levins, and rest of LDI

All the SUMR Scholars!

Totem Poles!

All orientation &

luncheon academic

presenters

Other supporters of the

LDI SUMR program

My mom, dad, and

brother Luis

Krupa Jani

Christine Scaduto

TCNJ Mentors:

Dr. Michelle Bunagan

and Dr. Rachel Adler

All my other

supportive friends

My Lions’ EMS Squad

UPenn LDI Mentors

HUP

TCNJ, Friends & Family

References 1. Studdert, David M., et.al., 2003. Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors. Intensive

Care Medicine, 29, pp. 1489-1497. 2. Carroll, Katherine, 2009. Outsider, insider, alongsider: Examining reflexivity in hospital-based video research. International Journal of

Multiple Research Approaches, 3, pp. 246-263. 3. Carroll, Katherine, et.al., 2008. Reshaping ICU Ward Round Practices Using Video-Reflexive Ethnography. Qualitative Health Research,

18, pp. 380-390. 4. Lubbert, Pieter H.W., et.al., 2009. Video Registration of Trauma Tram Performance in the Emergency Department: The Results of a 2-

Year Analysis in a Level 1 Trauma Center. The Journal of Trauma, 67, pp. 1412-1420. 5. Azoulay, Elie, et.al., 2000. Half the families of intensive care unit patients experience inadequate communication with physicians.

Critical Care Medicine, 28, pp. 3044-3049. 6. Baggs, JG, et.al., 1999. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical

Care Medicine, 27, pp. 1991-1998. 7. Wheelan, Susan A., et.al., 2003. The Link Between Teamwork and Patient’s Outcomes in Intensive Care Units. American Journal of

Critical Care, 12, pp. 527-534. 8. Baggs, JG, et.al., 1997. Nurse-physician collaboration and satisfaction with the decision-making process in three critical care units.

American Journal of Critical Care, 6, pp. 393-399. 9. Larson, Elaine, et.al., 1999. The Impact of Physician-Nurse Interaction on Patient Care. Holistic Nursing Practice, 13, pp. 38-46. 10. Manthous, C.A., et.al., 2011. Team Science and Critical Care. American Journal of Respiratory and Critical Care Medicine, 184, pp.17-25. 11. Keenan, G.M., et.al., 1998. Management of Conflicts: Keys to Understanding Nurse-Physician Collaboration. Research in Nursing &

Health, 21, pp. 59-72. 12. Bergs, E.A.G., et.al., 2005. Communication during trauma resuscitation: do we know what is happening?. International Journal of the

Care of the Injured, 36, pp. 905-911. 13. Maxson, Pamela M., et.al., 2011. Enhancing Nurse and Physician Collaboration in Clinical Decision Making Through High-fidelity

Interdisciplinary Simulation Training. Mayo Clinic Proceedings, 86, 31-36. 14. Baggs, Judith Gedney, 1994. Development of an instrument to measure collaboration and satisfaction about care decisions. Journal of

Advanced Nursing, 20, 176-182.