Impact of Rank, Provider Specialty, and Unit Sustainment Training Frequency on Military Critical Care Air Transport Team Readiness.

BACKGROUND: The Critical Care Air Transport (CCAT) Advanced Course utilizes fully immersive high-fidelity simulations to assess personnel readiness for deployment. This study aims to determine whether simple well-defined demographic identifiers can be used to predict CCAT students' performance at CCAT Advanced. MATERIALS AND METHODS: CCAT Advanced student survey data and course status (pass/fail) between March 2006 and April 2020 were analyzed. The data included students' Air Force Specialty Code (AFSC), military status (active duty and reserve/guard), CCAT deployment experience (yes/no), prior CCAT Advanced training (yes/no), medical specialty, rank, and unit sustainment training frequency (never, frequency less often than monthly, and frequency at least monthly). Following descriptive analysis and comparative tests, multivariable regression was used to identify the predictors of passing the CCAT Advanced course for each provider type. RESULTS: A total of 2,576 student surveys were analyzed: 694 (27%) physicians (MDs), 1,051 (40%) registered nurses (RNs), and 842 (33%) respiratory therapists (RTs). The overall passing rates were 92.2%, 90.3%, and 85.4% for the MDs, RNs, and RTs, respectively. The students were composed of 579 (22.5%) reserve/guard personnel, 636 (24.7%) with CCAT deployment experience, and 616 (23.9%) with prior CCAT Advanced training. Regression analysis identified groups with lower odds of passing; these included (1) RNs who promoted from Captain to Major (post-hoc analysis, P = .03), (2) RTs with rank Senior Airman, as compared to Master Sergeants (post-hoc analysis, P = .04), and (3) MDs with a nontraditional AFSC (P = .0004). Predictors of passing included MDs and RNs with CCAT deployment experience, odds ratio 2.97 (P = .02) and 2.65 (P = .002), respectively; and RTs who engaged in unit CCAT sustainment at least monthly (P = .02). The identifiers prior CCAT Advanced training or reserve/guard military status did not confer a passing advantage. CONCLUSION: Our main result is that simple readily available metrics available to unit commanders can identify those members at risk for poor performance at CCAT Advanced readiness training; these include RNs with rank Major or above, RTs with rank Senior Airman, and RTs who engage in unit sustainment training less often than monthly. Finally, MD specialties which are nontraditional for CCAT have significantly lower CCAT Advanced passing rates, reserve/guard students did not outperform active duty students, there was no difference in the performance between different RN specialties, and for MD and RN students' previous deployment experience was a strong predictor of passing.

An automated content-based measure of closed loop communication among critical care air transport teams.

Successful teamwork is essential to ensure critical care air transport (CCAT) patients receive effective care. Despite the importance of team performance, current training methods rely on subjective performance assessments and do not evaluate performance at the team level. Researchers have developed the Team Dynamics Measurement System (TDMS) to provide real-time, objective measures of team coordination to assist trainers in providing CCAT aircrew with feedback to improve performance. The first iteration of TDMS relied exclusively on communication flow patterns (i.e., who was speaking and when) to identify instances of various communication types such as closed loop communication (CLC). The research presented in this paper significantly advances the TDMS project by incorporating natural language processing (NLP) to identify CLC. The addition of NLP to the existing TDMS resulted in greater accuracy and fewer false alarms in identifying instances of CLC compared to the previous flow-based implementation. We discuss ways in which these improvements will facilitate instructor feedback and support further refinement of the TDMS.

Team Coordination Style Is an Adaptive, Emergent Property of Interactions Between Critical Care Air Transport Team Personnel.

OBJECTIVE: Critical Care Air Transport (CCAT) teams care for critically ill or injured patients during long-duration flights. Despite the differences between the CCAT domain and a more traditional clinical setting, CCAT clinicians are not explicitly trained how to coordinate care in the aircraft environment. We characterized the team coordination patterns adopted by CCAT teams and explored any links between team coordination style and performance. METHODS: This retrospective study used transcripts from 91 CCAT teams as they completed simulated patient care scenarios during an advanced training course. Qualitative and quantitative measures were used to characterize team behavior. RESULTS: Vocalized content varied by team role, with physicians acting as leaders. The type of content verbalized by each team role depended on the team coordination style. The team coordination style and the content of vocalized messages were not affected by prior team member deployment or the characteristics of particular scenarios, and the team coordination style did not predict measures related to patient status. CONCLUSION: Individual team member coordination behaviors vary depending on the coordination style used by the team as a whole. Coordination style appears to arise from the interactions among individual team members rather than in response to situational factors external to the team.

Descriptive Analysis of Intratheater Critical Care Air Transport Team Patient Movements During Troop Drawdown: Afghanistan (2017-2019).

BACKGROUND: The majority of critical care air transport (CCAT) flights are regulated, meaning that a theater-validating flight surgeon has confirmed that the patient is medically cleared for flight and that evacuation is appropriate. If the conditions on the ground do not allow for this process, the flight is unregulated. Published data are limited regarding CCAT unregulated missions to include the period of troop drawdown at the end of the Afghanistan conflict. The objective of our study was to characterize the unregulated missions within Afghanistan during troop drawdown and compare them to regulated missions during the same timeframe. STUDY DESIGN: We performed a retrospective review of all CCAT medical records of patients transported via CCAT within Afghanistan between January 2017 and December 2019. We abstracted data from the records, including mission characteristics, patient demographics, injury descriptors, preflight military treatment facility procedures, CCAT procedures, in-flight CCAT treatments, in-flight events, and equipment issues. Following descriptive and comparative analysis, a Cochran-Armitage test was performed to evaluate the statistical significance of the trend in categorical data over time. Multivariable regression was used to assess the association between vasopressors and preflight massive transfusions, preflight surgical procedures, injury patterns, and age. RESULTS: We reviewed 147 records of patients transported via CCAT: 68 patients were transported in a regulated fashion and 79 on an unregulated flight. The number of patients evacuated increased year-over-year (n = 22 in 2017, n = 57 in 2018, and n = 68 in 2019, P < .001), and the percentage of missions that were unregulated grew geometrically (14%, n = 3 in 2017; 37%, n = 21 in 2018; and 81%, n = 55 in 2019, P < .001). During the time studied, CCAT teams were being used more to decompress forward surgical teams (FST) and, therefore, they were transporting patients just hours following initial damage control surgery in an unregulated fashion. In 2 instances, CCAT decompressed an FST following a mass casualty, during which aeromedical evacuation (AE) crews assisted with patient care. For the regulated missions, the treatments that were statistically more common were intravenous fluids, propofol, norepinephrine, any vasopressors, and bicarbonate. During unregulated missions, the statistically more common treatments were ketamine, fentanyl, and 3% saline. Additional analysis of the mechanically ventilated patient subgroup revealed that vasopressors were used twice as often on regulated (38%) vs. unregulated (13%) flights. Multivariable regression analysis demonstrated that traumatic brain injury (TBI) was the only significant predictor of in-flight vasopressor use (odds ratio = 3.53, confidence interval [1.22, 10.22], P = .02). CONCLUSION: During the troop drawdown in Afghanistan, the number of unregulated missions increased geometrically because the medical footprint was decreasing. During unregulated missions, CCAT providers used ketamine more frequently, consistent with Tactical Combat Casualty Care guidelines. In addition, TBI was the only predictor of vasopressor use and may reflect an attempt to adhere to unmonitored TBI clinical guidelines. Interoperability between CCAT and AE teams is critical to meet mass casualty needs in unregulated mission environments and highlights a need for joint training. It remains imperative to evaluate changes in mission requirements to inform en route combat casualty care training.

Components of aircraft life support systems interact with each other and the user.

The life support system in a tactical aircraft provides necessary supplemental oxygen to the aircrew. However, interactions among its various components may generate unexpected breathing loads. We focus here on the interactions between a regulator and breathing mask commonly used together in the U.S. Navy, the CRU-103 regulator and MBU 23/P mask, and some effects of the interactions on the user. The data reported were collected during a larger research effort examining potential physiological and cognitive effects of low regulator inlet pressures. Seventeen participants completed a series of tasks under mild exercise while breathing 40% O2 (balance N2) from an MBU-23/P mask supplied by a CRU-103 regulator with supply pressures 10, 6, 4, and 2 psig (CRU-103 specifications are for inlet pressures from 5 to 120 psig). Variables measured included flow to the mask and pressures at the regulator supply, in the hose to the mask, and in the mask. In addition to restricting inspiratory flow, low inlet pressure to the CRU-103 caused a counterintuitive overshoot in gas delivery pressure at end-inspiration, a mean increase of 1.5 cm H2O between the 10- and 2 psig conditions. The added pressure to the exhalation valve increased the expiratory threshold, the pressure to start expiratory flow, by approximately 2 cm H2O, increasing the effort needed to exhale.

Relevance of Deployment Experience and Clinical Practice Characteristics on Military Critical Care Air Transport Team Readiness: A Study of Simulation Construct Validity.

INTRODUCTION: The Critical Care Air Transport Team (CCATT) Advanced course utilizes fully immersive high-fidelity simulations to train CCATT personnel and assess their readiness for deployment. This study aims to (1) determine whether these simulations correctly discriminate between students with previous deployment experience ("experienced") and no deployment experience ("novices") and (2) examine the effects of students' clinical practice environment on their performance during training simulations. MATERIALS AND METHODS: Critical Care Air Transport Team Advanced student survey data and course status (pass/no pass) between March 2006 and April 2020 were analyzed. The data included students' specialty, previous exposure to the CCATT Advanced course, previous CCATT deployment experience, years in clinical practice (<5, 5-15, and >15 years), and daily practice of critical care (yes/no), as well as a description of the students' hospital to include the total number of hospital (<100, 100-200, 201-400, and >400) and intensive care unit (0, 1-10, 11-20, and >20) beds. Following descriptive analysis and comparative tests, multivariable regression was used to identify the predictors of passing the CCATT Advanced course. RESULTS: A total of 2,723 surveys were analyzed: 841 (31%) were physicians (MDs), 1,035 (38%) were registered nurses, and 847 (31%) were respiratory therapists (RTs); 641 (24%) of the students were repeating the course for sustainment training and 664 (24%) had previous deployment experience. Grouped by student specialty, the MDs', registered nurses', and RTs' pass rates were 92.7%, 90.6%, and 85.6%, respectively. Multivariable regression results demonstrated that deployment experience was a robust predictor of passing. In addition, the >15 years in practice group had a 47% decrease in the odds of passing as compared to the 5 to 15 years in practice group. Finally, using MDs as the reference, the RTs had a 61% decrease in their odds of passing. The daily practice of critical care provided a borderline but nonsignificant passing advantage, whereas previous CCATT course exposure had no effect. CONCLUSION: Our primary result was that the CCATT Advanced simulations that are used to evaluate whether the students are mission ready successfully differentiated "novice" from "experienced" students; this is consistent with valid simulation constructs. Finally, novice CCATT students do not sustain their readiness skills during the period between mandated refresher training.

Preliminary Study of the Effects of Sequential Hypoxic Exposures in a Simulated Flight Task.

BACKGROUND: Previous studies of acute hypoxia have largely examined different altitudes in isolation. Pilots, however, receive two exposures during in-flight hypoxic emergencies (IFHEs): the initial exposure at altitude, followed by a second mild exposure after descending and removing the breathing mask. Conventional wisdom holds that performance recovers with blood oxygen saturation and that exposure to mild hypoxia is safe. This study examined the possibility that the effects of moderate hypoxia may linger to overlap with the effects of mild hypoxia during sequential exposures such as those experienced by pilots during an IFHE.METHODS: Subjects performed a simulated flight task and secondary task while being exposed to normobaric hypoxia via the ROBD-2.RESULTS: Average error on the flight task during exposure to 3048 m (10,000 ft) was marginally worse when preceded by exposure to 7620 m (25,000 ft; 7.40 ± 3.32) than when experienced in isolation (6.42 ± 3.82). Performance on the secondary task was likewise worse when the mild exposure followed the moderate exposure (0.27 ± 0.30 lapses per minute) than when the mild exposure occurred by itself (0.19 ± 0.20 lapses per minute). Minimum Spo2 showed a similar pattern of results (84.87 ± 4.37 vs. 86.61 ± 2.47).DISCUSSION: We believe our results are most likely due to a failure to recover from the original moderate exposure rather than an additive effect between the exposures. Even so, our findings suggest that pilot impairment following an IFHE may be worse than previously believed.Robinson FE, Horning D, Phillips JB. Preliminary study of the effects of sequential hypoxic exposures in a simulated flight task. Aerosp Med Hum Perform. 2018; 89(12):1050-1059.

Navigating the Decision Space: Shared Medical Decision Making as Distributed Cognition.

Despite increasing prominence, little is known about the cognitive processes underlying shared decision making. To investigate these processes, we conceptualize shared decision making as a form of distributed cognition. We introduce a Decision Space Model to identify physical and social influences on decision making. Using field observations and interviews, we demonstrate that patients and physicians in both acute and chronic care consider these influences when identifying the need for a decision, searching for decision parameters, making actionable decisions Based on the distribution of access to information and actions, we then identify four related patterns: physician dominated; physician-defined, patient-made; patient-defined, physician-made; and patient-dominated decisions. Results suggests that (a) decision making is necessarily distributed between physicians and patients, (b) differential access to information and action over time requires participants to transform a distributed task into a shared decision, and (c) adverse outcomes may result from failures to integrate physician and patient reasoning. Our analysis unifies disparate findings in the medical decision-making literature and has implications for improving care and medical training.

The impact of medical record technologies on collaboration in emergency medicine.

PURPOSE: Electronic medical records (EMR) promise potential benefits for the practice of medical care. However, individual technologies such as EMR must interact with the work system as a whole - including people, technology and work practices - to enable or hinder the coordination of dynamic work demands. Based on this extended perspective, we address in this paper how support technologies (should) impact the coordination of work across multiple agents, controlling a dynamic domain with multiple, interacting processes. The technology we address is the medical record and the dynamic domain is emergency medicine as it is practiced in the U.S. METHOD: We performed 500 hours of naturalistic observations of physicians in two different hospital emergency departments in the Midwestern U.S differing in their reliance on paper or electronic medical records. RESULTS AND CONCLUSIONS: An analysis of work practice across the two hospitals revealed the role of medical records in facilitating or hindering the coordination of time sensitive and context dependent distributed work, as well as the specific influence of EMR. Recognizing that work practice compensates for the limitations of technology, we suggest four requirements for the design of EMR to promote workplace efficiency: facilitation of locally customized data presentations; support for integration of hitherto fragmented record systems and data formats; support for effective multi-user coordination of control tasks; and guidance for standardizing a level of detail in planning and documenting care.