Capability to identify and manage critical conditions: effects of an interprofessional training intervention.

BACKGROUND: The burden of critical illness is a global issue. Healthcare systems often fail to provide essential emergency and critical care for deteriorating patients, and the optimal strategy for ensuring safe care is not fully known. This study aimed to explore the capability to identify and manage critical conditions and to evaluate how an interprofessional training intervention that included theory as well as high-fidelity simulation (proACT) in the short and long term affected the capability. METHODS: A questionnaire study was performed. A cross-sectional survey of all in-hospital nurses and physicians in a Swedish region (n538) and a longitudinal cohort of participants entering the proACT course during a six-month period (n99) were included. Descriptive and comparative statistics were generated. Additionally, qualitative content analysis was performed for free text answers. RESULTS: The findings demonstrated that the intervention improved the individual healthcare professionals' competence with a sustained effect over time. The coverage of proACT trained staff increased from 13.2% to 26.5%, but no correlation was observed with workplace conditions that support safe care. Collaboration and workplace climate were perceived to be mainly positive, but for safer care, an overall need for improved competence and staffing was emphasized. CONCLUSIONS: The present study confirms previously identified issues and the need for improvements in the care of critically ill patients in general hospital wards. It supports the notion that a training intervention, such as proACT, can increase the capability to identify and manage patients with critical conditions. All healthcare professions increased the competence. Hence, more effort is needed to enable staff of all professions to participate in such training. Studies of interventions cover higher number of trained staff in the setting are warranted to clarify whether the training can also improve workplace conditions that support safe care of deteriorating and critically ill patients.

[In situ simulation training of medical-surgical teams in the management of severe trauma patients]. / La formation par simulation in situ des équipes médico-chirurgicales à la prise en charge des traumatisés sévères.

In the management of severe trauma, the aim is to assess the patient's clinical stability as quickly as possible, enabling referral to imaging (whole-body CT scan, embolization if necessary) or the operating room, or even the decision to perform in situ surgery (resuscitation thoracotomy). To cope with these critical situations, team training is essential, with the aim of ensuring the reproducibility of the difficulties encountered. High-fidelity in situ simulation is the ideal tool for meeting this training challenge.

Expanding the non-technical skills vocabulary of operating room nurses: a qualitative study.

BACKGROUND: Operating room nurses have specialised technical and non-technical skills and are essential members of the surgical team. The profession's dependency of tacit knowledge has made their non-technical skills difficult to access for researchers, thus, creating limitations in the identification of the non-technical skills of operating room nurses. Non-technical skills are categorised in the crew resource management framework, and previously, non-technical skills of operating room nurses have been identified within the scope of the framework. The purpose of this study is to explore operating room nurses' descriptions of their practices in search for non-technical skills not included in the crew resource management framework. METHODS: This study has a qualitative design. An expert panel of experienced operating room nurses (N = 96) in Norway provided qualitative descriptions of their practice in a Delphi survey. The data were analysed in an inductive thematic analysis. This study was conducted and reported in line with Standards for Reporting Qualitative Research (SRQR). RESULTS: The inductive thematic analysis developed two themes, 'Ethical competence' and 'Professional accountability', that encompass operating room nurses' novel descriptions of their non-technical skills. The participants take pride in having the patients' best interest as their main objective even if this may threaten their position in the team. CONCLUSIONS: This study has identified novel non-technical skills that are not described in the crew resource management framework. These findings will contribute to the development of a new behavioural marker system for the non-technical skills of operating room nurses. This system will facilitate verbalisation of tacit knowledge and contribute to an increased knowledge about the operating room nursing profession.

The development of the helicopter non-technical skills (HeliNOTS) behavioural marker systems.

Behavioural marker systems (observational frameworks geared towards the assessment of non-technical skills by way of behavioural markers) exist across a variety of high-risk occupations, however, no identifiable system currently exists developed from rotary operative data. In this study, discussion groups (n = 9) were undertaken with subject matter experts (n = 20)-including pilots and technical crew operating across search and rescue and offshore transport environments-with the objective of identifying role-specific behavioural markers. Systems were reviewed on an iterative basis by the academic team and received final reviews by additional subject matter experts (n = 6). Two behavioural marker systems were constructed: HeliNOTS (O) for offshore transport pilots and HeliNOTS (SAR) for search and rescue crews; each with domain-specific behavioural markers. Both represent a significant step towards a nuanced approach to training and assessment of helicopter flight crews' non-technical skills and are the first publicly available systems tailored to these distinct mission types.Practitioner summary: There is no publicly available behavioural marker system based on data from rotary operatives. Across this study, two prototype systems were developed: HeliNOTS (SAR) for helicopter search and rescue, and HeliNOTS (O) for helicopter offshore transport. Both HeliNOTS systems represent a nuanced approach towards rotary CRM training and assessment.

Prone during pandemic: development and implementation of a quality-based protocol for proning severe COVID-19 hypoxic lung failure patients in situationally or historically low resource hospitals.

BACKGROUND: Intermittent Prone Positioning (IPP) for Acute Respiratory Distress Syndrome (ARDS) decreases mortality. We present a program for IPP using expedient materials for settings of significant limitations in both overwhelmed established ICUs and particularly in low- and middle-income countries (LMICs) treating ARDS due to COVID-19 caused by SARS CoV-2. METHODS: The proning program evolved based on the principles of High Reliability Organizations (HROs) and Crew Resource Management (CRM). Patients with severe ARDS [PaO2:FiO2 ratio (PFr) ≤ 150 on FiO2 ≥ 0.6 and PEEP ≥ 5 cm H2O] received IPP. Patients were placed prone 16 h each day. When PFr was ≥ 200 for > 8 h supine IPP ceased. IPP used available materials without requiring additional work from the bedside team. Changes in PFr, PaCO2, and the SaO2:FiO2 ratio (SaFr) positionally were evaluated using t-statistics and ANOVA with Bonferroni correction (p < 0.017). RESULTS: Between 14APR2020 and 09MAY2020, at the peak of deaths in New York, there were 202 IPPs in 29 patients. Patients were 58.5 ± 1.7 years of age (37, 73), 76% male and had a body mass index (BMI) of 27.8 ± 0.8 (21, 38). Pressor agents were used in 76% and 17% received dialysis. The PFr prior to IPP was 107.5 ± 5.6 and 1 h after IPP was 155.7 ± 11.2 (p < 0.001 compared to pre-prone). PFr after the patients were placed supine was 131.5 ± 9.1 (p = 0.02). Pre-prone PaCO2 was 60.0 ± 2.5 and the 1-h post-prone PaCO2 was 67.2 ± 3.1 (p = 0.02). Supine PaCO2 after IPP was 60.4 ± 3.4 (p = 0.90). The SaFr prior to IPP was 121.3 ± 4.2 and the SaFr 1 h after positioning was 131.5 ± 5.1 (p = 0.03). The post-IPP supine SaFr was 139.7 ± 5.9 (p < 0.001). With ANOVA and Bonferroni correction there were statistically significant changes in PFr (p < 0.001) and SaFr (p < 0.001) and no significant changes in PaCO2 over the four time points measured. Using regression coefficients, the SaFrs predicted by PFrs of 150 and 200 at baseline are 133.2 and 147.3, respectively. CONCLUSIONS: An IPP program for patients with COVID-19 ARDS can be instituted rapidly, safely, and effectively during an overwhelming mass casualty scenario. This approach may be equally applicable in both traditionally austere environments in LMICs and in otherwise capable centers facing situational resource limitations.

Learning from safety incidents in high-reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare.

OBJECTIVE: A high-reliability organization (HRO) is an organization that has sustained almost error-free performance, despite operating in hazardous conditions where the consequences of errors could be catastrophic. A number of tools and initiatives have been used within HROs to learn from safety incidents, some of which have the potential to be adapted and used in healthcare. We conducted a systematic review to identify any learning tools deemed to be effective that could be adapted and used by multidisciplinary teams in healthcare following a patient safety incident. METHODS: This review followed the Preferred Reporting Items for Systematic Reviews and MetaAnalyses for Protocols reporting guidelines and was registered with the PROSPERO (CRD42017071528). A search of databases was carried out in January 2021, from the date of their commencement. We conducted a search on electronic databases such as Web of Science, Science Direct, MEDLINE in Process Jan 1950-present, EMBASE Jan 1974-present, CINAHL 1982-present, PsycINFO 1967-present, Scopus and Google Scholar. We also searched the grey literature including reports from government agencies, relevant doctoral dissertations and conference proceedings. A customized data extraction form was used to capture pertinent information from included studies and Critical Appraisal Skills Programme tool to appraise on their quality. RESULTS: A total of 5921 articles were identified, with 964 duplicate articles removed and 4932 excluded at the title (4055), abstract (510) and full-text (367) stages. Twenty-five articles were included in the review. Learning tools identified included debriefing, simulation, crew resource management and reporting systems to disseminate safety messages. Debriefing involved deconstructing incidents using reflective questions, whilst simulation training involved asking staff to relive the event again by performing the task(s) in a role-play scenario. Crew resource management is a set of training procedures that focus on communication, leadership and decision-making. Sophisticated incident-reporting systems provide valuable information on hazards and were widely recommended as a way of disseminating key safety messages following safety incidents. These learning tools were found to have a positive impact on learning if conducted soon after the incident with efficient facilitation. CONCLUSION: Healthcare organizations should find ways to adapt to the learning tools or initiatives used in HROs following safety incidents. It is challenging to recommend any specific one as all learning tools have shown considerable promise. However, the way these tools or initiatives are implemented is critical, and so further work is needed to explore how to successfully embed them into healthcare organizations so that everyone at every level of the organization embraces them.

Hospital medication errors: a cross-sectional study.

BACKGROUND: Medication errors (MEs) are among the most common types of incidents reported in Australian and international hospitals. There is no uniform method of reporting and reducing these errors. This study aims to identify the incidence, time trends, types and factors associated with MEs in a large regional hospital in Australia. METHODS: A 5-year cross-sectional study. RESULTS: The incidence of MEs was 1.05 per 100 admitted patients. The highest frequency of errors was observed during the colder months of May-August. When distributed by day of the week, Mondays and Tuesdays had the highest frequency of errors. When distributed by hour of the day, time intervals from 7 am to 8 am and from 7 pm to 8 pm showed a sharp increase in the frequency of errors. One thousand and eighty-eight (57.8%) MEs belonged to incidence severity rating (ISR) level 4 and 787 (41.8%) belonged to ISR level 3. There were six incidents of ISR level 2 and only one incident of ISR level 1 reported during the five-year period 2014-2018. Administration-only errors were the most common accounting for 1070 (56.8%) followed by prescribing-only errors (433, 23%). High-risk medications were associated with half the number of errors, the most common of which were narcotics (17.9%) and antimicrobials (13.2%). CONCLUSIONS: MEs continue to be a problem faced by international hospitals. Inexperience of health professionals and nurse-patient ratios might be the fundamental challenges to overcome. Specific training of junior staff in prescribing and administering medication and nurse workload management could be possible solutions to reducing MEs in hospitals.

A Delphi study identifying operating room nurses' non-technical skills.

AIM: To identify the non-technical skills of operating room nurses. This is the first empirical study that includes scrub and circulating operating room nurses. DESIGN: A three-round modified online Delphi technique was used for this study. METHODS: Eligible participants (n = 106) with a minimum of 2 years of operating room nursing experience were selected for the expert panel by self-recruitment from a population (N = 1640) of operating room nurses. Data were collected through online surveys, based on crew recourse management theory, between April and September 2020. Descriptive statistics analysis was used for the quantitative data, and deductive thematic analysis for the qualitative data. Consensus was determined using stability between the survey rounds. RESULTS: A consensus was obtained to maintain the non-technical skills categories of situation awareness, leadership, decision-making, communication and teamwork. The qualitative data revealed several novel non-technical skills, including independent decision-making and leadership skills. CONCLUSION: The non-technical skills of operating room nurses are more extensive than previously identified. This study has contributed to a verbalization of the tacit knowledge and skills of the operating room nurses. In addition, a list of non-technical skills that should be included in the education of operating room nurses to ensure patient safety in the operating room has been prepared. IMPACT: This study addresses the lack of research on the non-technical skills of operating room nurses. When exploring the non-technical skills of scrub and circulating nurses, a diversity of novel non-technical skills was uncovered. This research will provide input for the development of a new training, supervision and assessment tool for accelerated development of the non-technical skills of operating room nurses. This contribution to the verbalization of the formerly tacit non-technical skills may facilitate clinical and formal teaching of such skills and may subsequently impact surgery-related patient safety.

Exploring the role of simulation to foster interprofessional teamwork among medical and nursing students: A mixed-method pilot investigation in Hong Kong.

Effective teamwork is a critical component of maintaining patient safety. However, there is lack of clarity on the best teaching approach to interprofessional teamwork training in medical and nursing curricula. This study aimed to compare the effects of blended classroom plus clinical simulation versus clinical simulation alone on teamwork attitudes, perceptions and performance in medical and nursing students in Hong Kong. This was a pilot study with a mixed-method research design, with both quantitative and qualitative evaluations. Students who studied medicine or nursing courses at a university in Hong Kong were invited to this study. They were assigned into two groups: clinical simulation alone versus blended classroom plus clinical simulation. The primary outcome was attitudinal change related to teamwork behaviours, which was measured using the Human Factors Attitude Survey. The secondary outcomes were perceptions of team-based learning and teamwork performance, which were accessed by the Team-Based Learning Student Assessment Instrument and Ottawa Global Rating Scale, respectively. Four focus group interviews were conducted after the training sessions. Conventional content analysis using inductive coding was performed with the qualitative data. Forty-six students participated in this study. There was a significant increase in the participants' positive attitudes on teamwork for both groups (intervention: MD = 5.36 and control: MD = 3.6, p <.05); however, there was no significant difference on increasing positive attitudes between the groups (estimate = 1.76, 95% CI [-8.59, 5.06], p = .61). Qualitative analysis identified four themes: (1) reconsidering professional roles in managing patients; (2) embodying the experience to share responsibility and complement each other's skills; (3) realizing the importance of trust and communication; and (4) engaging to achieve the mission within a limited time. This pilot study found that a blended classroom did not further improve teamwork attitudes, perceptions and performance in medical and nursing students compared with clinical simulation alone. Qualitative findings showed that students had reconsidered their professional roles in managing patients and realized the importance of teamwork in caring patients.

Impact of TeamSTEPPS on patient safety culture in a Swiss maternity ward.

OBJECTIVE: To assess the impact of implementation of the TeamSTEPPS teamwork improvement concept on patient safety culture. DESIGN: Pre-post culture assessment using the Hospital Survey on Patient Safety Culture, at baseline and one year after implementation of TeamSTEPPS. SETTING: Two maternity wards within the same 480-bed multisite teaching hospital. INTERVENTION: Implementation of the TeamSTEPPS teamwork improvement concept. MAIN OUTCOME MEASURES: Analysis of variation of the percentage of positive responses (score) in both wards (intervention and control) was conducted. RESULTS: There was a significant increase in scores in three dimensions of patient safety culture in the intervention ward: Supervisor/Manager Expectations and Actions Promoting Safety increased from 48.7% in 2015 to 70.8% in 2016 (P < 0.005); Teamwork Within Units increased from 35.5% in 2015 to 54.5% in 2016 (P < 0.005); Nonpunitive Response to Errors increased from 16.7% in 2015 to 32.3% in 2016 (P < 0.005). Other dimensions showed no significant changes. In the control ward, there was a significant decrease in scores in one dimension. A secondary analysis of differences in differences still shows significant improvement in one dimension (Supervisor/Manager Expectations and Actions Promoting Safety P < 0.005). CONCLUSION: After implementing the TeamSTEPPS teamwork concept, patient safety culture significantly improved for three of twelve dimensions in the intervention group. When controlling for differences in baseline scores between implementation and control wards, a significant improvement remains in one dimension. This suggests that TeamSTEPPS could be considered when seeking to enhance patient safety culture, especially in high-risk environments such as maternity wards.

Failure to rescue and 30-day in-hospital mortality in hospitals with and without crew-resource-management safety training.

Failure to rescue (FTR) occurs when a clinician is unable to save a hospitalized patient's life when they experience a complication that was not present on admission. Research suggests that a focus on patient safety, including implementing airline-industry-based-crew-resource management (CRM) training, can improve patient outcomes, however, the effects of CRM on FTR are unknown. This study examined FTR and 30-day in-hospital mortality (IM) outcomes in two hospitals to determine if differences existed in the treatment hospital (received CRM training) and the comparison hospital (did not receive CRM training). Researchers expected there would be lower rates of FTR and IM in the treatment hospital than the comparison hospital. The study utilized a matched two-group comparison, cross-sectional quasi-experimental design. Over 10,000 patients (n = 10,823) comprised the study with 1,764 having at least one FTR complication. Adjusted odds of FTR were 2.9% higher for treatment versus comparison but these results did not reach significance. The adjusted odds of IM were 0.4% higher for treatment versus comparison but not significantly higher. Although the reasons for our findings remain unclear, previous researchers also found that CRM training improved staff outcomes but unexpectedly did not improve patient outcomes. CRM training may best be used to target changes in staff behaviors and improvement in staff outcomes. Refresher CRM training may be needed to prevent drifting back into longstanding behaviors. Reductions in FTR and patients with IM outcomes may require more comprehensive, multipronged interventions in addition to CRM training.

Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study.

OBJECTIVE: To study the effect of an intervention based on Crew Resource Management team training, including a tool for structured communication, on adverse perinatal and maternal outcomes. DESIGN: Stepped wedge. SETTING: The Netherlands. POPULATION OR SAMPLE: Registry data of 8123 women referred from primary care to a hospital during childbirth, at ≥ 32.0 weeks of singleton gestation and with no congenital abnormalities, in the period 2012-15. METHODS: Obstetric teams of five hospitals and their surrounding primary-care midwifery practices participated in the intervention. In total, 49 team training sessions were organised for 465 care professionals (75.5% participated). Adverse perinatal and maternal outcomes before, during and after the intervention were analysed using multivariate logistic regression analyses. MAIN OUTCOME MEASURES: Adverse Outcome Index (AOI-5), a composite measure involving; intrapartum or neonatal death, admission to neonatal intensive care unit, Apgar < 7 at 5 minutes, postpartum haemorrhage and/or perineal tear. RESULTS: In total, an AOI-5 score was reported in 11.3% of the study population. No significant difference was found in the incidence of the AOI-5 score after the intervention compared with before the intervention (OR 1.07: 95% CI 0.92-1.24). CONCLUSIONS: We found no effect of the intervention on adverse perinatal and maternal outcomes for women who were referred during childbirth. Team training is appreciated in practice, but evidence on the long-term impact is still limited. Upcoming studies should build on previous research and consider more sensitive outcome measures. TWEETABLE ABSTRACT: A cluster randomised team training intervention showed no effect on adverse perinatal and maternal outcomes for women referred during childbirth.

Measuring situation awareness and team effectiveness in pediatric acute care by using the situation global assessment technique.

Situation awareness (SA) is an important human factor and necessary for effective teamwork and patient safety. Human patient simulation (HPS) with video feedback allows for a safe environment where health care professionals can develop both technical and teamwork skills. It is, however, very difficult to observe and measure SA directly. The Situation Global Assessment Technique (SAGAT) was developed by Endsley to measure SA during real-time simulation. Our objective was to measure SA among team members during simulation of acute pediatric care scenarios on the medical ward and its relationship with team effectiveness. Twenty-four pediatric teams, consisting of two nurses, one resident, and one consultant, participated in three acute care scenarios, using high-fidelity simulation. Individual SAGAT scores contained shared and complimentary knowledge questions on different levels of SA. Within each scenario, two "freezes" were incorporated to assess SA of each team members' clinical assessment and decision-making. SA overlap within the team (team SA) was computed and compared to indicators of team effectiveness (time to goal achievement, consensus on primary problem, diagnosis, task prioritization, leadership, and teamwork satisfaction). In 13 scenarios (18%), the team failed to reach the primary goals within the prescribed time of 1200 s. There was no significant difference in failure of goal completion between the scripted scenarios; however, there was a significant difference between scenario 3 and the other scenarios in time to goal completion. In all three scenarios, SA overlap level 2 (consensus on primary problem during the first freeze and consensus on diagnosis during the second freeze) leads to significantly faster achievement of the predefined goals. There was a strong relationship between team SA on the primary problem and diagnosis and team SA on task prioritization. Consensus on leadership within the team was low. Teamwork satisfaction was more influenced by knowledge about the importance of the assigned task than outcome of the scenario.Conclusion: The use of SAGAT enables us to measure SA of team members during real-time simulation of acute care scenarios. Although there is no direct connection between team SA and goal achievement, SAGAT provides insight in differences in SA among team members, and the process of shared mental model formation. By measuring SA, issues that may improve team effectiveness (prioritizing tasks, enhancing shared mental models, and providing leadership) can be trained and assessed during medical team simulation, enhancing teamwork in health care settings. What is known? • Teamwork skills such as communication, leadership, and situational awareness have become increasingly recognized as essential for good performance in pediatric resuscitation. However, the assessment of pediatric team performance in these clinical situations has been traditionally difficult. • The Situation Awareness Global Assessment Technique (SAGAT) is a method of objectively and directly measuring SA during a team simulation using "freezes" at predetermined points in time with participants reporting on "what is going on" from their perspective on the situation. What is new? • We assessed SA, and its relationship with team effectiveness, in multidisciplinary pediatric teams performing simulated critical events in critically ill children on the medical ward using the SAGAT model, outside the emergency room setting. • In all three scenarios, consensus on the primary problem (shared mental model) leads to faster achievement of predefined goals. Consensus on leadership was overall low, without a significant impact on goal achievement.

[Transfer of a cockpit strategy to anesthesiology : Clinical example: introduction of canned decisions to solve cannot intubate cannot oxygenate situations]. / Übertragung einer "Cockpit-Strategie" in die Anästhesie : Klinisches Beispiel: Einführung von "canned decisions" zur Lösung von Atemwegsnotfällen.

BACKGROUND: Safety strategies in civil aviation are well-established. The authors present a possible structure for induction of anesthesia, which includes elements of the so-called cockpit strategy. The objective is to reduce anesthesia-related mortality caused by the unexpected difficult airway through early detection and solution of cannot intubate cannot oxygenate (CICO) situations. METHODS: After approval by the responsible ethics committee, a prospective pilot study was conducted to analyze the process quality of uncomplicated induction of anesthesia on a simulator using audiovisual recording. An evaluation list with 44 items was created, which met the following requirements: items were dichotomous, accessible to an audiovisual evaluation and according to current scientific consensus should be considered during induction of anesthesia. Standard induction of anesthesia was supplemented by several crew resource management elements (cockpit strategy). Two canned decisions (CD, CD 1: end tidal CO2, etCO2 < 10 mm Hg, CD 2: SpO2 < 80%) signaled the emergency of an unexpected difficult airway and CICO with emergency coniotomy. This concept was repetitively trained and transferred to the daily routine. After 6 months the process quality was re-evaluated in simulated scenarios. In order to review whether the effect of the cockpit strategy with the CD can contribute to solving the CICO situation, all emergency coniotomies carried out in this clinic between 2010 and 2016 were retrospectively analyzed. RESULTS: The cockpit strategy significantly improved the process quality during the simulated induction of anesthesia (78% vs. 36% items fulfilled), while the duration of induction was reduced by 36%. In the subsequent 6­year study period, 7 CICO situations with emergency coniotomy occurred. All teams performed in accordance with the algorithm and with respect to the CDs. No patient suffered from hypoxia or any other damage. CONCLUSION: The transfer and implementation of a cockpit strategy in anesthesiology for improvement of patient safety is possible. The acceptance of the aviation safety strategy in medicine is a necessary prerequisite. A profound training in technical and non-technical skills and regular team training to solve CICO situations must be an integral part of advanced training in anesthesiology.

The training and practice of crew resource management: recommendations from an inductive in vivo study of the flight deck.

Crew resource management (CRM) is credited with saving 185 lives at Sioux City. While the theory behind CRM is well documented, there are few studies of how CRM manifests on the line. This inductive in vivo study had three objectives. First, to describe how CRM manifests. Secondly, to evaluate the efficacy of CRM vis-à-vis flight safety. Thirdly, to suggest improvements to the CRM training syllabus. The study produced five conclusions: First, CRM is durable under conditions of moderate strain. Secondly, crews embed and refine CRM through reflection and action. Thirdly, CRM facilitates and shapes social relations. Fourthly, mindlessness (Langer 1989 ) undermines CRM. Finally, the interruption of flight-deck routines by third-parties poses a threat to flight-safety. The paper recommends multi-profession CRM training as a means of improving communication and co-ordination in and around aircraft. The study's limitations include a monocultural flight-deck: flights were operated by pilots with European backgrounds. Mindful of Hofstede's ( 1980 ), Engle's ( 2000 ) and Helmreich and Merritt's ( 2001 ) examination of the relationship between culture and performance, the author suggests the study be repeated with carriers that employ pilots from a variety of cultures. Practitioner Summary: This in vivo study evaluates the efficacy of CRM vis-à-vis flight safety and supports a critique of the CRM syllabus. The author observed twenty sectors and attended a CRM training day. To improve safety and efficiency, it is recommended that airlines run multi-profession (inclusive) CRM training courses.

Tools for your stroke team: adapting crew-resource management for acute stroke care.

Crew-resource management is an approach to work and training that focuses on non-technical skills and strategies to prevent human error in complex procedures. It was initially termed 'cockpit-resource management' and developed for aviation in the 1970s after several severe accidents; it has contributed to a measurable increase in flight safety. In recent years, this approach has been successfully implemented in other high-reliability environments; surgical disciplines have made particular use of crew-resource management strategies and training, with resulting reduced mortality rates. The stepwise implementation of different crew-resource management strategies in stroke care at our tertiary stroke centre has helped to speed up process times significantly, and to improve patient safety and staff satisfaction. Here, we summarise our experience in adapting different crew-resource management tools to acute stroke care, sharing specific tools that have proven valuable in our hands, and we encourage colleagues to implement such strategies in acute stroke care.

Prevalence and Perceptions of Team Training Programs for Pediatric Surgeons and Anesthesiologists.

BACKGROUND: Team training programs adapt crew resource management principles from aviation to foster communication and prevent medical errors. Although multiple studies have demonstrated that team training programs such as TeamSTEPPS improve patient outcomes and safety across medical disciplines, limited data exist about their application to pediatric surgical teams. The purpose of this study was to investigate usage and perceptions of team training programs by pediatric surgeons and anesthesiologists. We hypothesized that team training programs are not widely available to pediatric surgical teams. MATERIALS AND METHODS: We performed an online survey of Pediatric Surgery (General, Plastic, Urologic, Orthopedic, Otolaryngologic, and Ophthalmologic) and Anesthesiology members of the American Academy of Pediatrics. The survey inquired about completion and perceptions regarding efficacy of team training programs. Simple descriptive statistics and a Student t-test were used to evaluate the data. RESULTS: One hundred fifty-two pediatric surgeons and 12 anesthesiologists completed the survey with a 10% response rate. Over half of the respondents were general pediatric surgeons. Home institutions offered TeamSTEPPS or another crew resource management style team training program for 39% of respondents. Of those with a program, 77% of respondents had completed training. Although most (76%) who participated in team training programs did so by requirement, 90% found it helpful. Of the 61% of surgeons who said their institution did not offer team training programs, 60% said they would participate if one were offered and an additional 32% said they might participate. The biggest barriers to participation were not enough free time or that the team training program was not offered to their department. CONCLUSIONS: Team training programs are considered beneficial among pediatric surgeons and anesthesiologists who have completed them. Unfortunately, despite substantial evidence showing training for team work improves team functioning and patient outcomes, many pediatric surgical teams do not have team training programs at their institutions. Further expansion of team training programs may be valuable to improving a culture of safety in children's hospitals.

A Network-Wide Stroke Team Program Reduces Time to Treatment for Endovascular Stroke Therapy in a Regional Stroke-Network.

BACKGROUND AND PURPOSE: Driven by the positive results of randomized, controlled trials of endovascular stroke therapies (EVT) in stroke patients with large vessel occlusion, different approaches to speed up the workflow for EVT candidates are currently being implemented worldwide. We aimed to assess the effect of a simple stroke network-wide workflow improvement project, primarily focusing on i.v. thrombolysis, on process times for patients undergoing EVT. METHODS: In 2015, we conducted a network-wide, peer-to-peer acute stroke workflow improvement program for i.v. thrombolysis with the main components of implementing a binding team-based algorithm at every stroke unit of the regional network, educating all stroke teams about non-technical skills and providing a stroke-specific simulation training. Before and after the intervention we recorded periprocedural process times, including patients undergoing EVT at the 3 EVT-capable centers (January - June 2015, n = 80 vs. July 2015 - June 2016, n = 184). RESULTS: In this multi-centric evaluation of 268 patients receiving EVT, we observed a relevant shortening of the median time from symptom onset to EVT specifically in patients requiring secondary transfer by almost an hour (300 min, 25-75% interquartile range [IQR] 231-381 min to 254 min, IQR 215.25-341 min; p = 0.117), including a reduction of the median door-to-groin time at the EVT-capable center in this patient group by 15.5 min (59 min, IQR 35-102 min to 43.5 min, IQR 27.75-81.25 min; p = 0.063). In patients directly admitted to an EVT-capable center, the median door-to-groin interval was reduced by 10.5 min (125 min, IQR 83.5-170.5 min to 114.5 min, IQR 66.5-151 min; p = 0.167), but a considerable heterogeneity between the centers was observed (p < 0.001). CONCLUSIONS: We show that a simple network-wide workflow improvement program primarily directed at fast i.v. thrombolysis also accelerates process times for EVT candidates and is a promising measure to improve the performance of an entire stroke network.

Implementation of surgical debriefing programs in large health systems: an exploratory qualitative analysis.

BACKGROUND: The role of the "debrief" to address issues related to patient safety and systematic flaws in care is frequently overlooked. In our study, we interview surgical leaders who have developed successful strategies of debriefing within a comprehensive program of quality improvement. METHODS: Semi-structured interviews of four implementation leaders were performed. The observations, beliefs and strategies of surgical leaders are compared and contrasted. Common themes are identified related to program success and failure. Quality and safety researchers performed, coded and categorized the interviews and coordinated the analysis and interpretation of the results. The authors from the four institutions aided in interpretation and framing of the results. RESULTS: The debriefing programs evaluated were part of comprehensive quality improvement projects. Seven high-level themes and 24 subthemes were identified from the interviews. Themes related to leadership included early engagement, visible ongoing commitment and enforcement. Success appeared to depend upon meaningful and early debriefing feedback. The culture of safety that promoted success included a commitment to open and fair communication and continuous improvement. There were many challenges to the success of debriefing programs. The loss of institutional commitment of resources and personnel was the instigating factor behind the collapse of the program at Michigan. Other areas of potential failure included communication issues and loss of early and meaningful feedback. CONCLUSIONS: Leaders of four surgical systems with strong debriefing programs report success using debriefing to improve system performance. These findings are consistent with previously published studies. Success requires commitment of resources, and leadership engagement. The greatest gains may be best achieved by programs that provide meaningful debriefing feedback in an atmosphere dedicated to open communication.

Improving staff perception of a safety climate with crew resource management training.

BACKGROUND: Communication failure is one of the top root causes in patient safety adverse events. Crew resource management (CRM) is a team building communication process intended to improve patient safety by improving team dynamics. First, to describe implementation of CRM in a Veterans Affair (VA) surgical service. Second, to assess whether staff CRM training is related to improvement in staff perception of a safety climate. MATERIAL AND METHODS: Mandatory CRM training was implemented for all surgical service staff at a VA Hospital at 0 and 12 mo. Safety climate questionnaires were completed by operating room staff at a baseline, 6 and 12 mo after the initial CRM training. RESULTS: Participants reported improvement on all 27 points on the safety climate questionnaire at 6 mo compared with the baseline. At 12 mo, there was sustained improvement in 23 of the 27 areas. CONCLUSIONS: This is the first published report about the effect of CRM training on staff perception of a safety climate in a VA surgical service. We demonstrate that CRM training can be successfully implemented widespread in a surgical program. Overall, there was improvement in 100% of areas assessed on the safety climate questionnaire at 6 mo after CRM training. By 1 y, this improvement was sustained in 23 of 27 areas, with the areas of greatest improvement being the performance of briefings, collaboration between nurses and doctors, valuing nursing input, knowledge about patient safety, and institutional promotion of a patient safety climate.