Design and implementation of a “crisis resource management” training program for the initial assessment of polytrauma patients / Diseño e implementación de un programa de aprendizaje crisis resource management para la evaluación inicial del paciente politraumatizado

Introduction: To describe the design and implementation of a Crisis Resource Management (CRM) training program for the initial assessment of polytrauma patients. Methods: Prospectively implemented CRM training program in acute-care tertiary hospital by hospital personnel involved in the care of polytraumatisms. The program has a blended format and 23-h duration, including 11 h of online theoretical training followed by 12-h simulation modules and practical cases devoted to the roles of members of the trauma team, functioning of the polytrauma room, and key aspects of teamwork. The Human Factors Attitude Survey (HFAS) was used to assess attitudes related to non-technical skills, and the End-of-Course Critique (ECC) survey to evaluate satisfaction with training. We evaluated changes in the pre- and post-training assessments. Results: Eighty staff personnel (26% specialists, 16% residents, 29% nurses, 14% nursing assistant, 15% stretcher bearer) participated in three editions of the program. Theoretical knowledge improved from a mean (SD) of 5.95 (1.7) to 8.27 (2.1) (P < .0001). In the HFAS, statistically significant differences in 18 of 23 attitudinal markers were observed, with improvements in all items of “leadership” and “roles”, in 4 of 5 items of “situational awareness”, and in 4 of 8 items of “communication”. Mean values obtained in the ECC questionnaire were also very high. Conclusions: A CRM training model developed for the initial care of polytrauma patients improved theoretical knowledge and participants perceptions and attitudes regarding leadership, communication, roles, and situational awareness of members of the trauma team. (AU)

Introducción: Describir el diseño y la implementación de un programa de formación basado en Crisis Resource Management para la evaluación inicial de los pacientes con politraumatismos. Métodos: Implementación prospectiva de un programa CRM de formación en Hospital terciario con el personal del hospital involucrado en la asistencia de politraumatismos. El programa tenía un formato semipresencial de 23 horas de duración, incluyendo 11 horas de formación online de contenido teórico seguidas de 12 horas de módulos de simulación y casos prácticos referidos a los papeles de los miembros del equipo de trauma, funcionamiento del box de trauma y aspectos claves del trabajo en equipo. El Human Factors Attitude Survey (HFAS) se utilizó para evaluar las actitudes relacionadas con las habilidades no técnicas y el End-of-Course Critique (ECC) cuestionario para valorar la satisfacción con la formación. Se evaluaron los cambios antes y después de la formación. Resultados: Ochenta miembros del hospital (26% especialistas, 16% residentes, 29% enfermeras, 14% auxiliares de enfermería, 15% camilleros) participaron en tres ediciones del programa. El conocimiento teórico aumentó de una media (DE) de 5.95 (1.7) a 8.27 (2.1) (P < ,0001). En el HFAS, se observaron diferencias estadísticamente significativas en 18 de los 23 marcadores de actitud, con mejorías en todos los ítems de “liderazgo” y “roles”, en 4 de los 5 items de “consciencia situacional” y en 4 de los 8 ítems de “comunicación”. Los valores medios obtenidos en el cuestionario ECC tambien fueron muy altos. Conclusiones: Un modelo CRM de formación desarrollado para la atención inicial de los pacientes con politraumatismos mejoró el conocimiento teórico y las percepciones y actitudes de los participantes relacionadas con el liderazgo, la comunicación, los roles y la consciencia situacional de los miembros del equipo de trauma. (AU)

Design and implementation of a "crisis resource management" training program for the initial assessment of polytrauma patients.

INTRODUCTION: To describe the design and implementation of a Crisis Resource Management (CRM) training program for the initial assessment of polytrauma patients. METHODS: Prospectively implemented CRM training program in acute-care tertiary hospital by hospital personnel involved in the care of polytraumatisms. The program has a blended format and 23-h duration, including 11 h of online theoretical training followed by 12-h simulation modules and practical cases devoted to the roles of members of the trauma team, functioning of the polytrauma room, and key aspects of teamwork. The Human Factors Attitude Survey (HFAS) was used to assess attitudes related to non-technical skills, and the End-of-Course Critique (ECC) survey to evaluate satisfaction with training. We evaluated changes in the pre- and post-training assessments. RESULTS: Eighty staff personnel (26% specialists, 16% residents, 29% nurses, 14% nursing assistant, 15% stretcher bearer) participated in three editions of the program. Theoretical knowledge improved from a mean (SD) of 5.95 (1.7) to 8.27 (2.1) (P < .0001). In the HFAS, statistically significant differences in 18 of 23 attitudinal markers were observed, with improvements in all items of "leadership" and "roles", in 4 of 5 items of "situational awareness", and in 4 of 8 items of "communication". Mean values obtained in the ECC questionnaire were also very high. CONCLUSIONS: A CRM training model developed for the initial care of polytrauma patients improved theoretical knowledge and participants perceptions and attitudes regarding leadership, communication, roles, and situational awareness of members of the trauma team.

Improvement of Teamwork Nontechnical Skills Through Polytrauma Simulation Cases Using the Communication and Teamwork Skills (CATS) Assessment Tool.

OBJECTIVE: To assess acquisition of nontechnical skills (NTS) through clinical simulation cases by healthcare personnel who participated in a Crisis Resource Management (CRM) training program for the initial care of polytraumatisms. DESIGN: Pre-and postintervention study. SETTING: Acute-care teaching hospital in Sabadell, Barcelona (Spain). PARTICIPANTS: Healthcare personnel that composed teamworks providing initial care to polytraumatized patients attended 12-hour simulation training using a SimMan 3G manikin and performed exercises corresponding to 3 clinical scenarios. All simulations lasted 15 to 25 min and were video recorded. The CATS Assessment tool was used for analysis of teamwork NTS, which included 21 behaviors clustered into the categories of coordination, situational awareness, cooperation, communication, and crisis situation. RESULTS: Three editions of the CRM training course were carried out with 12 trauma team groups composed by team leader, anesthesiologist, general surgeon, traumatologist, registered nurses, nursing assistant, and stretcher bearer. There were statistically significant (p <0.001) improvements in the speed of key times of total duration of case resolution, transfusion of hemoderivatives, Focused Assessment Sonography for Trauma, and chest and pelvic X-rays. The percentage of cases correctly resolved improved from 75% to 91.7% but differences were not statistically significant (p = 0.625). Precourse and postcourse results of CATS scores showed a statistically significant increase in the weighted total score as well as in all behavioral categories of coordination, situational awareness, cooperation, communication, and crisis situation. CONCLUSIONS: Simulation-based training of NTS was associated with significant improvements in teamwork behaviors in the setting of the initial care of patients with polytraumatisms.

Receiving Notification of Unexpected and Violent Death: A Qualitative Study of Italian Survivors.

(1) Background: The loss of a significant person can be especially traumatic when death comes without warning and is due to causes such as suicide, murder and accidents. The way an individual is informed about the loss can affect the way of adapting to the loss and the quality of life of survivors. Communication modalities of the notifier may deeply influence the bereavement process. Aim: The present investigation aimed to explore the experience of those who received communication of such a type of death by a professional figure. (2) Method: Snowball sampling was used to recruit the participants to this qualitative study. Social networks, word of mouth and researchers' acquaintances were used, including clients of the NGO De Leo Fund. A total of 52 Italian people (eight males and forty four females, mean age = 49.44; SD = 14.23) who received notification of the death of a loved one by police officers or by health professionals participated in the study. Deaths involved cases of suicide, murder, road accident and mountain accident. (3) Results: The following four key themes were identified: (a) how the communication took place; (b) reactions; (c) support; and (d) coping strategies. Only 22 participants reported having received clear information about the dynamics of what happened; the rest of the sample obtained only poor or ambiguous information. The majority of participants sought or received informal support from family and friends immediately after notification; however, some participants experienced a total lack of support. The opportunity to see the body of the loved one for the last farewell, when denied, caused discomfort in recipients of the news. (4) Conclusions: Even the impactful notification of a traumatic death such as suicide or road accident can be mitigated by the appropriate behaviour and attitude of notifiers, who should always avoid providing generic or ambiguous information about what happened. The notification process should not end with the simple transmission of the communication, but should also look at the following phases by including referral to supportive networks or bereavement services, aimed at assisting individuals in the immediate aftermath but also in the long term.

Communicating Unexpected and Violent Death: The Experiences of Police Officers and Health Care Professionals.

BACKGROUND: The notification of unexpected and violent death represents a challenging experience for police officers and health workers. These professionals are exposed to very intense emotions during this task. AIM: We aimed to investigate the degree of preparation, and the emotions and attitudes of police officers and health professionals while communicating such a death. METHOD: An ad hoc online questionnaire was created and disseminated through Qualtrics software. The participants were recruited through the institutional channels of Police, the College of Physicians, the ONG De Leo Fund and the Department of General Psychology of the University of Padua. In this qualitative study, thematic content analysis was used to examine the responses. RESULTS: A total of 155 individuals participated in the study (44 females, 111 males): 102 individuals were police officers, 23 were doctors and were 30 nurses. Five main themes were identified: (1) how the communication took place; (2) the experiences during the communication; (3) the difficulties encountered; (4) coping strategies, and (5) forms of support. Most communications were performed in person, and most represented an intense emotional experience for the notifiers. There is a generalised lack of specific preparation and training for this practice. The recipient's characteristics (culture of origin, language, age, health conditions, psychological vulnerability) may add to the difficulties of the notification process. Professionals unload their tension by practicing sport, relying on their hobbies or interacting socially. The presence of other colleagues during and after the death notification is usually able to alleviate the burden of the communication. CONCLUSIONS: Communication modalities can have a profound impact on the recipients and intensify the trauma of the loss; however, they also have the possibility of mitigating it. The notification of a violent and unexpected death remains a difficult and challenging task for the notifier, which is potentially stressful and emotionally charged. The topic is of great relevance and more research should be promoted in this area.

Is restlessness best understood as a process? Reflecting on four boys' restlessness during music therapy in kindergarten.

ADHD can be considered an internationally recognized framework for understanding children's restlessness. In this context, children's restlessness is understood as a symptom of neurodevelopmental disorder. However, there are other possible understandings of children's restlessness. In this article, we explore four boys' collaborative and creative process as it is described and understood by three adults. The process is framed by a community music therapy project in a Norwegian kindergarten, and we describe four interrelated phases of this process: Exploring musical vitality and cooperation, Consolidating positions, Performing together, and Discovering ripple effects. We discuss these results in relation to seven qualities central to a community music therapy approach: participation, resource orientation, ecology, performance, activism, reflexivity and ethics. We argue that in contrast to a diagnostic approach that entails a focus on individual problems, a community music therapy approach can shed light on adult and systemic contributions to children's restlessness.

Correspondence in Stakeholder Assessment of Health, Work Capacity and Sick Leave in Workers with Comorbid Subjective Health Complaints? A Video Vignette Study.

Purpose The purpose of this study is to test if there is correspondence in stakeholders' assessments of health, work capacity and sickness certification in four workers with comorbid subjective health complaints based on video vignettes. Methods A cross sectional survey among stakeholders (N = 514) in Norway in 2009/2010. Logistic regression and multinomial logistic regression was used to obtain the estimated probability of stakeholders choosing 100 % sick leave, partial sick leave or work and the estimation of odds ratio of stakeholder assessment compared to the other stakeholders for the individual worker. Results The supervisors were less likely to assess poor health and reduced work capacity, and more likely to suggest partial sick leave and full time work compared to the GPs for worker 1. The public was less likely to assess comorbidity and reduced work capacity, and 6 and 12 times more likely to suggest partial sick leave and full time work compared to the GPs for worker 1. Stakeholders generally agreed in their assessments of workers 2 and 3. The public was more likely to assess poor health, comorbidity and reduced work capacity, and the supervisors more likely to assess comorbidity and reduced work capacity, compared to the GPs for worker 4. Compared to the GPs, all other stakeholders were less likely to suggest full time work for this worker. Conclusions Our results seem to suggest that stakeholders have divergent assessments of complaints, health, work capacity, and sickness certification in workers with comorbid subjective health complaints.

Do we understand children's restlessness? Constructing ecologically valid understandings through reflexive cooperation.

Attention-deficit/hyperactivity disorder (ADHD) is the most widely used children's mental health diagnosis today, but the validity of the diagnosis is controversial, for instance, because it might conceal relational and ecological dimensions of restlessness. We invited parents and professionals from one local community in western Norway to participate in cooperative group discussions on how to conceptualize and understand children's restlessness. We carried out a thematic and reflexive analysis of the cooperative group discussions on ADHD and children's restlessness, and present findings related to three ecological levels inspired by Bronfenbrenner's ecological systems model. At the level of the individual, restlessness was discussed as individual trait, as the expectation to be seen and heard, and as a result of traumatization. At the level of dyad, group or family, restlessness was discussed as a relational phenomenon and as parents' problems. At the level of community, restlessness was discussed as lack of cooperation and lack of structures or resources. Our findings show how contextualized and cooperative reflexivity can contribute to more valid understandings of children's restlessness, and how cooperative inquiry can stimulate reflections about solidarity and sustainability in relation to adult's actions.

N-acyl-l-homoserine lactones (AHLs) affect microbial community composition and function in activated sludge.

The role of intercellular signalling in the regulation of genes and phenotypes in a broad range of bacterial species is now firmly established. In contrast, the impact of intercellular signalling on microbial community parameters, such as species diversity and function, is less well understood. In this study the role of N-acyl-l-homoserine lactones (AHLs) in microbial community dynamics in an industrial wastewater treatment system is addressed. Seven proteobacterial strains producing compounds with AHL-like activity were isolated from the treatment plant. Three of these belong to genera with no previously identified AHL producing species. Addition of AHLs at 2 micro M to sludge samples generated changes in both community function (phenol degradation) and composition as determined by length heterogeneity PCR and denaturing gradient gel electrophoresis. Phenol degradation was more stable as a result of the AHL augmentation. A dominant functional member of the Thauera genus was transiently supplanted by a member of the Comomonas genus in response to AHL addition. This suggests that AHLs can play a role in mediating microbial community parameters and has implications for ecosystem function and industrial wastewater treatment.

Solid phase treatment of an aged soil contaminated by polycyclic aromatic hydrocarbons.

Laboratory scale tests were carried out in order to evaluate the removal efficiency of polyaromatic hydrocarbons (PAHs) during the different biological treatments of a Manufacturing Gas Plant site aged soil, heavily contaminated by high molecular weight compounds. Biodegradation studies were carried out at nearly 25 degrees C in solid phase reactors. Three tests were performed, over a period of 100 days for each test. In the first test (P1-bioaugmentated), soil was mixed with wood chips and urea at the start of the treatment and after six weeks from the beginning of the test was also periodically inoculated (at 42, 54, 69, 82, and 96 days) with selected consortia of autochthonous PAH-degrading bacteria. The second test (P2-biostimulated) was performed similarly to the previous one, but without any inoculations. In the third test (P3-control) only soil was introduced. All systems were aerated daily and humidified at the occurrence. PAH concentration, total cultivable heterotrophs, PAH-degrading bacteria, mycetes, pH, ATP concentration, and enzymatic activities were monitored every two weeks during the treatments. Tests showed that nearly 50% of light (three rings) PAHs, 35% of benzo-PAHs and 40% of the total PAHs could be removed in the reactor P2 following 100 days of treatment. Lower removal efficiency could be observed for light PAHs (28%) in the inoculated reactor (P1) at the end of the treatment: comparable abatements were obtained for benzo- and total PAHs. In the reactor P3 (control), the concentration of all polyaromatic hydrocarbons was nearly always constant, suggesting that the physical losses were negligible during the solid phase treatments. Therefore the C to N ratio balance resulted to be the key factor in promoting the biodegradation process of all PAHs.

Biodegradation of chlorsulfuron and metsulfuron-methyl by Aspergillus niger in laboratory conditions.

Two sulfonylurea herbicides, chlorsulfuron and metsulfuron-methyl, were studied under laboratory conditions, in order to elucidate the biodegradation pathway operated by Aspergillus niger, a common soil fungus, which is often involved in the degradation of xenobiotics. HPLC-UV was used to study the kinetic of degradation, whereas LC-MS was used to identify the metabolites structure. In order to avoid the chemical degradation induced by a decrease in pH, due to the production of citric acid by the fungus, the experiments were performed in a buffered neutral medium. No significant degradation for both compounds was observed in mineral medium with 0.2% sodium acetate. On the contrary, in a rich medium, after 28 days the degradations, chemical degradation excluded, were about 30% for chlorsulfuron and 33% for metsulfuron-methyl. The main microbial metabolites were obtained via cleavage of the sulfonylurea bridge. In addition the fungus seems to be able to hydroxylate the aromatic ring of chlorsulfuron. In the case of metsulfuron-methyl the only detected metabolite was the triazine derivative, while the aromatic portion was completely degraded. Finally, the demethylation of the methoxy group on the triazine ring, previously observed with a Pseudomonas fluorescens strain, was not observed with A. niger.

Biodegradation of chlorsulfuron and metsulfuron-methyl by Aspergillus niger.

In this work, investigations were performed under laboratory conditions of the degradation ability by a common soil fungus, Aspergillus niger, toward chlorsulfuron and metsulfuron-methyl. The results were very encouraging (79% for chlorsulfuron and 61% for metsulfuron-methyl of total degradation), especially compared to those registered in our previous studies with a Pseudomonas fluorescens strain B2 (about 21 to 32%). Furthermore, the chemical degradation of the two compounds was studied and two products (1[2-methoxy-benzene-1-sulfonyl]-7-acetyltriuret and 1[2-chlorobenzene-1-sulfonyl]-7-acetyltriuret) were isolated and characterised by hydrolysis in acidic conditions. Our aim in the future will be the identification of intermediate metabolites by HPLC and LC-MS analyses in order to identify the degradative pathway by the fungal strain and to compare this to those obtained by chemical degradation and by P. fluorescens strain.