LDI SUMR Symposium August 11 th, 2011 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 Emmanuel Martinez Alcaraz The College of New Jersey
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
Too many TLAs* ICU Intensive Care Unit *Dr. Rob Burns SICU Surgical MICU Medical NICU Neurosurgical Other specialties Neonatal
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 Surgical Intensive Care Unit Multi-disciplinary team Beginnings stem from advancements in critical care: Patient triage, infection-control Artificial ventilation & its automation Resuscitation, anesthesiology
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 & satisfaction 2,3 Links between nurses and other co-workers job satisfaction, collaboration, and decision-making inclusion; hospital hierarchies 4,5,6 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 rooms 7, nonemergent activities (ICU rounds) 8, or in the trauma bay 9 Topic Provide insight on the extent clinicians interaction with nurses, patients, and family members real behaviors Patient/family satisfaction; Patient/family anxiety 10 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?
Characteristics of 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
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 teamwork 6,11,12,13, and to improve patient outcomes 2,3 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 highintensity 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 collaboration 2,3 Pilot Study showed a disparity between team members (nurses, attendings, fellows, residents) in perceived composition of the trauma team (McCunn) The role a team hierarchy 6 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 established 13,14 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 conflictresolution, and other quantifiable small group characteristics Extensively tested for both validity and reliability; used in many industries including healthcare 7 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 1 st 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 Mentors Dr. Maureen McCunn, Dr. Jose Pascual-Lopez, Dr. Joseph Sakran HUP 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 UPenn LDI TCNJ, Friends & Family Joanne Levy, Lissy My mom, dad, and Madden, Megan brother Luis Pellegrino, Hoag Krupa Jani Levins, and rest of LDI Christine Scaduto All the SUMR Scholars! TCNJ Mentors: Totem Poles! Dr. Michelle Bunagan All orientation & and Dr. Rachel Adler luncheon academic All my other presenters supportive friends Other supporters of the My Lions EMS Squad LDI SUMR program
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.