Teammate Familiarity, Teamwork, and Risk of Workplace Injury in Emergency Medical Services Teams.

INTRODUCTION: Increased teammate familiarity in emergency medical services (EMS) promotes development of positive teamwork and protects against workplace injury. METHODS: Measures were collected using archival shift records, workplace injury data, and cross-sectional surveys from a nationally representative sample of 14 EMS agencies employing paramedics, prehospital nurses, and other EMS clinicians. One thousand EMS clinicians were selected at random to complete a teamwork survey for each of their recent partnerships and tested the hypothesized role of teamwork as a mediator in the relationship between teammate familiarity and injury with the PROCESS macro. RESULTS: We received 2566 completed surveys from 333 clinicians, of which 297 were retained. Mean participation was 40.5% (standard deviation [SD] = 20.5%) across EMS agencies. Survey respondents were primarily white (93.8%), male (67.3%), and ranged between 21-62 years of age (M = 37.4, SD = 9.7). Seventeen percent were prehospital nurses. Respondents worked a mean of 3 shifts with recent teammates in the 8 weeks preceding the survey (M = 3.06, SD = 4.4). We examined data at the team level, which suggest positive views of teamwork (M = 5.92, SD = 0.69). Our hypothesis that increased teammate familiarity protects against adverse safety outcomes through development of positive teamwork was not supported. Teamwork factor Partner Adaptability and Backup Behavior is a likely mediator (odds ratio = 1.03, P = .05). When dyad familiarity is high and there are high levels of backup behavior, the likelihood of injury is increased. DISCUSSION: The relationship between teammate familiarity and outcomes is complex. Teammate adaptation and backup behavior is a likely mediator of this relationship in EMS teams with greater familiarity.

Teammate familiarity and risk of injury in emergency medical services.

OBJECTIVE: We investigated the association between teammate familiarity and workplace injury in the emergency medical services (EMS) setting. METHODS: From January 2011 to November 2013, we abstracted a mean of 29 months of shift records and Occupational Safety Health Administration injury logs from 14 EMS organisations with 37 total bases located in four US Census regions. Total teammate familiarity was calculated for each dyad as the total number of times a clinician dyad worked together over the study period. We used negative binomial regression to examine differences in injury incidence rate ratios (IRRs) by familiarity. RESULTS: We analysed 715 826 shift records, representing 4197 EMS clinicians and 60 701 unique dyads. We determined the mean shifts per dyad was (5.9, SD 19.7), and quartiles of familiarity were 1 shift worked together over the study period, 2-3 shifts, 4-9 shifts and ≥10 shifts worked together. More than half of all dyads worked one shift together (53.9%, n=32 739), 24.8% of dyads 2-3 shifts, 11.8% worked 4-9 shifts and 9.6% worked ≥10 shifts. The overall incidence rate of injury across all organisations was 17.5 per 100 full-time equivalent (FTE), range 4.7-85.6 per 100 FTE. The raw injury rate was 33.5 per 100 FTEs for dyads with one shift of total familiarity, 14.2 for 2-3 shifts, 8.3 for 4-9 shifts and 0.3 for ≥10 shifts. Negative binomial regression confirmed that dyads with ≥10 shifts had the lowest incidence of injury (IRR 0.03; 95% CI 0.02 to 0.04). CONCLUSIONS: Familiarity between teammates varies in the EMS setting, and less familiarity is associated with greater incidence of workplace injury.

How familiar are clinician teammates in the emergency department?

OBJECTIVES: Lack of familiarity between teammates is linked to worsened safety in high risk settings. The emergency department (ED) is a high risk healthcare setting where unfamiliar teams are created by diversity in clinician shift schedules and flexibility in clinician movement across the department. We sought to characterise familiarity between clinician teammates in one urban teaching hospital ED over a 22 week study period. METHODS: We used a retrospective study design of shift scheduling data to calculate the mean weekly hours of familiarity between teammates at the dyadic level, and the proportion of clinicians with a minimum of 2, 5, 10 and 20 h of familiarity at any given hour during the study period. RESULTS: Mean weekly hours of familiarity between ED clinician dyads was 2 h (SD 1.5). At any given hour over the study period, the proportions of clinicians with a minimum of 2, 5, 10 and 20 h of familiarity were 80%, 51%, 27% and 0.8%, respectively. CONCLUSIONS: In our study, few clinicians could be described as having a high level of familiarity with teammates. The limited familiarity between ED clinicians identified in this study may be a natural feature of ED care delivery in academic settings. We provide a template for measurement of ED team familiarity.

A comparative assessment of adverse event classification in the out-of-hospital setting.

OBJECTIVES: We sought to test reliability of two approaches to classify adverse events (AEs) associated with helicopter EMS (HEMS) transport. METHODS: The first approach for AE classification involved flight nurses and paramedics (RN/Medics) and mid-career emergency physicians (MC-EMPs) independently reviewing 50 randomly selected HEMS medical records. The second approach involved RN/Medics and MC-EMPs meeting as a group to openly discuss 20 additional medical records and reach consensus-based AE decision. We compared all AE decisions to a reference criterion based on the decision of three senior emergency physicians (Sr-EMPs). We designed a study to detect an improvement in agreement (reliability) from fair (kappa = 0.2) to moderate (kappa = 0.5). We calculated sensitivity, specificity, percent agreement, and positive and negative predictive values (PPV/NPV). RESULTS: For the independent reviews, the Sr-EMP group identified 26 AEs while individual clinician reviewers identified between 19 and 50 AEs. Agreement on the presence/absence of an AE between Sr-EMPs and three MC-EMPs ranged from κ = 0.20 to κ = 0.25. Agreement between Sr-EMPs and three RN/Medics ranged from κ = 0.11 to κ = 0.19. For the consensus/open-discussion approach, the Sr-EMPs identified 13 AEs, the MC-EMP group identified 18 AEs, and RN/medic group identified 36 AEs. Agreement between Sr-EMPs and MC-EMP group was (κ = 0.30 95%CI -0.12, 0.72), whereas agreement between Sr-EMPs and RN/medic group was (κ = 0.40 95%CI 0.01, 0.79). Agreement between all three groups was fair (κ = 0.33, 95%CI 0.06, 0.66). Percent agreement (58-68%) and NPV (63-76%) was moderately dissimilar between clinicians, while sensitivity (25-80%), specificity (43-97%), and PPV (48-83%) varied. CONCLUSIONS: We identified a higher level of agreement/reliability in AE decisions utilizing a consensus-based approach for review rather than independent reviews.

Network analysis of team communication in a busy emergency department.

BACKGROUND: The Emergency Department (ED) is consistently described as a high-risk environment for patients and clinicians that demands colleagues quickly work together as a cohesive group. Communication between nurses, physicians, and other ED clinicians is complex and difficult to track. A clear understanding of communications in the ED is lacking, which has a potentially negative impact on the design and effectiveness of interventions to improve communications. We sought to use Social Network Analysis (SNA) to characterize communication between clinicians in the ED. METHODS: Over three-months, we surveyed to solicit the communication relationships between clinicians at one urban academic ED across all shifts. We abstracted survey responses into matrices, calculated three standard SNA measures (network density, network centralization, and in-degree centrality), and presented findings stratified by night/day shift and over time. RESULTS: We received surveys from 82% of eligible participants and identified wide variation in the magnitude of communication cohesion (density) and concentration of communication between clinicians (centralization) by day/night shift and over time. We also identified variation in in-degree centrality (a measure of power/influence) by day/night shift and over time. CONCLUSIONS: We show that SNA measurement techniques provide a comprehensive view of ED communication patterns. Our use of SNA revealed that frequency of communication as a measure of interdependencies between ED clinicians varies by day/night shift and over time.

Do your friends stress you out? A field study of the spread of stress through a community network.

In this study, we seek to understand how stress changes in dynamic social systems. Where prior work on the interpersonal transmission of stress focused on pairs of individuals and small groups, we adopt a network perspective to investigate how the distribution of stress in an individual's social environment influences their stress appraisal process. We conducted a 6-month longitudinal study of 315 early to midcareer adults in professional master's programs as they encountered the stress of everyday academic life. We follow the dynamics of the participants' networks and their concomitant stress at four key time points during those 6 months. We find that the perceived stress of one's social contacts affects their experience of stress in this setting. Yet, not everyone is equally susceptible to this social influence. In particular, we find that social influence is substantially amplified under conditions of relative consensus among one's social contacts. Also, a low level of neuroticism, a high level of conscientiousness, and a high level of internal control orientation help buffer the transmission of stress. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Measuring teamwork and conflict among emergency medical technician personnel.

OBJECTIVE: We sought to develop a reliable and valid tool for measuring teamwork among emergency medical technician (EMT) partnerships. METHODS: We adapted existing scales and developed new items to measure components of teamwork. After recruiting a convenience sample of 39 agencies, we tested a 122-item draft survey tool (EMT-TEAMWORK). We performed a series of exploratory factor analyses (EFAs) and confirmatory factor analysis (CFA) to test reliability and construct validity, describing variation in domain and global scores using descriptive statistics. RESULTS: We received 687 completed surveys. The EFAs identified a nine-factor solution. We labeled these factors 1) Team Orientation, 2) Team Structure & Leadership, 3) Partner Communication, Team Support, & Monitoring, 4) Partner Trust and Shared Mental Models, 5) Partner Adaptability & Back-Up Behavior, 6) Process Conflict, 7) Strong Task Conflict, 8) Mild Task Conflict, and 9) Interpersonal Conflict. We tested a short-form (30-item SF) and long-form (45-item LF) version. The CFAs determined that both the SF and the LF possess positive psychometric properties of reliability and construct validity. The EMT-TEAMWORK-SF has positive internal consistency properties, with a mean Cronbach's alpha coefficient ≥0.70 across all nine factors (mean = 0.84; minimum = 0.78, maximum = 0.94). The mean Cronbach's alpha coefficient for the EMT-TEAMWORK-LF was 0.87 (minimum = 0.79, maximum = 0.94). There was wide variation in weighted scores across all nine factors and the global score for the SF and LF. Mean scores were lowest for the Team Orientation factor (48.1, standard deviation [SD] 21.5, SF; 49.3, SD 19.8, LF) and highest (more positive) for the Interpersonal Conflict factor (87.7, SD 18.1, for both SF and LF). CONCLUSIONS: We developed a reliable and valid survey to evaluate teamwork between EMT partners.

Networked for change? Identifying obstetric opinion leaders and assessing their opinions on caesarean delivery.

The objective was to determine whether obstetric opinion leaders can be identified and to characterize them in terms of their demographic and professional characteristics and their attitudes toward caesarean delivery. In late 1998, we surveyed 527 obstetricians, 138 family physicians, and 80 certified nurse midwives (overall response rate, 57.8%) practicing in a stratified random sample of California hospitals with at least 1000 annual deliveries (n=52). Participants reported on demographic and professional characteristics and attitudes towards caesarean delivery; they also checked off those hospital colleagues from whom they had sought or would seek advice on labour and delivery. A composite measure of nomination frequency was used to characterize each respondent's degree of "opinion leadership". All analyses were corrected for the complex survey design. Using a nomination cutoff of 0.4 (0-1 scale), opinion leaders were identified in 31% of California hospitals; they were identified in 81% of hospitals using a cutoff of 0.2. Compared with their peers in the lowest fifth of the nomination distribution, clinicians in the top fifth were younger and more likely to be male, to speak English as a first language, to practice obstetrics, to have a maternal-foetal medicine subspecialty, and to practice in higher volume hospitals (p<0.05). Regardless of discipline, opinion leaders held attitudes concordant with reducing the caesarean delivery rate more often than non-opinion leaders. However, only 48% of obstetrical opinion leaders would support reducing the caesarean delivery rate to levels targeted by Healthy People 2000. In conclusion, obstetric opinion leaders could be identified in many California hospitals. However, they did not consistently support policies designed to reduce the caesarean delivery rate. The results have implications for the generalizability of opinion leader strategies.

Identification of adverse events in ground transport emergency medical services.

The purpose of this study was to develop a method to define and rate the severity of adverse events (AEs) in emergency medical services (EMS) safety research. They used a modified Delphi technique to develop a consensus definition of an AE. The consensus definition was as follows: "An adverse event in EMS is a harmful or potentially harmful event occurring during the continuum of EMS care that is potentially preventable and thus independent of the progression of the patient's condition." Physicians reviewed 250 charts from 3 EMS agencies for AEs. The authors examined physician agreement using κ, Fleiss's κ, and corresponding 95% confidence intervals (CIs). Overall physician agreement on presence of an AE per chart was fair (κ = 0.24; 95% CI = 0.19, 0.29). These findings should serve as a basis for refining and implementing an AE evaluation instrument.

Variation in emergency medical technician partner familiarity.

OBJECTIVE: To characterize patterns of Emergency Medical Technician (EMT) partner familiarity in three Emergency Medical Services (EMS) agencies. STUDY DESIGN/DATA SOURCES: We utilized a case study design and retrospective review of administrative data from three EMS agencies and 182 EMTs over 12 months. We used the Kruskal-Wallis test and Bonferroni corrected p-values to compare measures of partner familiarity. Measures included the annual mean number of partners, rate of partners per 10 shifts, mean shifts per EMT, and proportion of shifts worked with same partner. We standardized select measures by size of agency to account for a greater number of possible partnerships in larger agencies. PRINCIPAL FINDINGS: Across all agencies, the mean number of shifts worked annually by EMTs was (mean [SD]) 77.3 (59.8). The unstandardized mean number of EMT partnerships was 19.3 (12.4) and did not vary across EMS agencies after standardizing by agency size (p=.328). The unstandardized mean rate of EMT partnerships for every 10 shifts worked was 4.0 (2.7) and varied across agencies after standardizing (p<.001). The mean proportion of shifts worked with the same partner was 34.8 percent and varied across agencies (p<.001). CONCLUSIONS: There was wide variation in select measures of EMT partner familiarity.

Social networks and physician adoption of electronic health records: insights from an empirical study.

OBJECTIVE: To study how social interactions influence physician adoption of an electronic health records (EHR) system. DESIGN: A social network survey was used to delineate the structure of social interactions among 40 residents and 15 attending physicians in an ambulatory primary care practice. Social network analysis was then applied to relate the interaction structures to individual physicians' utilization rates of an EHR system. MEASUREMENTS: The social network survey assessed three distinct types of interaction structures: professional network based on consultation on patient care-related matters; friendship network based on personal intimacy; and perceived influence network based on a person's perception of how other people have affected her intention to adopt the EHR system. EHR utilization rates were measured as the proportion of patient visits in which sentinel use events consisting of patient data documentation or retrieval activities were recorded. The usage data were collected over a time period of 14 months from computer-recorded audit trail logs. RESULTS: Neither the professional nor the perceived influence network is correlated with EHR usage. The structure of the friendship network significantly influenced individual physicians' adoption of the EHR system. Residents who occupied similar social positions in the friendship network shared similar EHR utilization rates (p<0.05). In other words, residents who had personal friends in common tended to develop comparable levels of EHR adoption. This effect is particularly prominent when the mutual personal friends of these 'socially similar' residents were attending physicians (p<0.001). CONCLUSIONS: Social influence affecting physician adoption of EHR seems to be predominantly conveyed through interactions with personal friends rather than interactions in professional settings.

Sensitivity of MRQAP Tests to Collinearity and Autocorrelation Conditions.

Multiple regression quadratic assignment procedures (MRQAP) tests are permutation tests for multiple linear regression model coefficients for data organized in square matrices of relatedness among n objects. Such a data structure is typical in social network studies, where variables indicate some type of relation between a given set of actors. We present a new permutation method (called "double semi-partialing", or DSP) that complements the family of extant approaches to MRQAP tests. We assess the statistical bias (type I error rate) and statistical power of the set of five methods, including DSP, across a variety of conditions of network autocorrelation, of spuriousness (size of confounder effect), and of skewness in the data. These conditions are explored across three assumed data distributions: normal, gamma, and negative binomial. We find that the Freedman-Lane method and the DSP method are the most robust against a wide array of these conditions. We also find that all five methods perform better if the test statistic is pivotal. Finally, we find limitations of usefulness for MRQAP tests: All tests degrade under simultaneous conditions of extreme skewness and high spuriousness for gamma and negative binomial distributions.