Acta Anaesthesiol Scand 2014; 58: 775–787 Printed in Singapore. All rights reserved
© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12336
Review Article
Efficacy of simulation-based trauma team training of non-technical skills. A systematic review K. Gjeraa, T. P. Møller and D. Østergaard Danish Institute for Medical Simulation, Herlev Hospital, Capital Region of Denmark and Copenhagen University, Copenhagen, Denmark
Trauma resuscitation is a complex situation, and most organisations have multi-professional trauma teams. Non-technical skills are challenged during trauma resuscitation, and they play an important role in the prevention of critical incidents. Simulationbased training of these is recommended. Our research question was: Does simulation-based trauma team training of nontechnical skills have effect on reaction, learning, behaviour or patient outcome? The authors searched PubMed, EMBASE and the Cochrane Library and found 13 studies eligible for analysis. We described and compared the educational interventions and the evaluations of effect according to the four Kirkpatrick levels: reaction, learning (knowledge, skills, attitudes), behaviour (in a clinical setting) and patient outcome. No studies were randomised, controlled and blinded, resulting in a moderate to high risk of bias. The multi-professional trauma teams had positive reactions to simulation-based training of non-technical skills. Knowledge and skills improved in all
T
rauma resuscitation and management are complex tasks, in which time is an important factor for survival. It is often characterised by uncertain or insufficient information flow as well as multiple and concurrent tasks. Most organisations have established multi-professional health-care teams to handle the critically ill patients, and they need to perform a broad range of different and urgent tasks and make many management decisions based on clinical evaluation.1–3 Coordination and rapid assessment of the trauma patients by a multi-professional trauma team have been shown to reduce mortality.4 The multi-professional trauma team is a so-called ‘action team’, with high intensity, velocity and risk, that only exists briefly as it often assembles ad hoc, which consists of different specialities affecting interpersonal relations. Communication during trauma resuscitation is therefore challenging, and one study found that communication errors occurred in 50% of these situations.4 Even with a
studies evaluating the effect on learning. Three studies found improvements in team performance (behaviour) in the clinical setting. One of these found difficulties in maintaining these skills. Two studies evaluated on patient outcome, of which none showed improvements in mortality, complication rate or duration of hospitalisation. A significant effect on learning was found after simulationbased training of the multi-professional trauma team in nontechnical skills. Three studies demonstrated significantly increased clinical team performance. No effect on patient outcome was found. All studies had a moderate to high risk of bias. More comprehensive randomised studies are needed to evaluate the effect on patient outcome. Accepted for publication 07 April 2014 © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
trauma surgeon present, knowledge transfer from team leader to other team members can be suboptimal.5 On top of these challenges, the frequency of severe trauma resuscitations is low in many countries resulting in a lack of routine and experience in handling the difficult trauma patient.6 Studies have shown that teamwork plays an important role in the prevention of critical incidents and errors.7,8 For years, it has been recommended to train health-care professionals in teamwork and other non-technical skills (NTS).9,10 NTS can be defined as ‘the cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance’.11 NTS include situational awareness, decisionmaking, communication, teamwork, leadership and management of stress, fatigue and disturbances.11 Simulation-based training has been proposed as a safe and effective learning method providing the opportunity to video record the simulations. After-
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4. Patient outcome (beneit for the patient)
3. Behaviour (translation of learning to clinical setting)
2. Learning (knowledge, skills, attitudes)
1. Reaction (participants satisfaction)
Fig. 1. Kirkpatrick’s model for evaluating effects of educational courses.
wards, in the debriefing session where the team’s handling of the patient is discussed, excerpts from the recordings are used to illustrate performance. This has been shown to promote reflection and thereby learning.12 In addition, adult learning theories support simulation-based training as adults prefer to learn through experience.10,13,14 Simulationbased training has the potential to facilitate communication, cooperation and leadership skills, which are all essential in trauma resuscitation.4 Multiprofessional team training allows for more natural team interactions and reinforces understanding However, although across disciplines.1,8,13,14 simulation-based training of the multi-professional trauma team is recommended, the question is whether the initiative has an effect. In medical education, Kirkpatrick’s four-level model is often used to evaluate learning.15 The levels are reaction (participant satisfaction), learning (knowledge, skills and attitudes), behaviour (translation of learning to clinical setting) and patient outcome. See Fig. 1. This systematic review was carried out based on the following research question: Does simulationbased trauma team training of NTS have an effect on reaction, learning, behaviour or patient outcome?
Methods In July 2013, we carried out a search of PubMed (including Medical Subject Headings terms), EMBASE and the Cochrane Library with no historic time limit and using these search words: trauma team, training, simulation, Crew Resource Management, Crisis Resource Management and teamwork. Only articles in English were considered. See Fig. 2. Unpublished studies were not included. A priori, a list of inclusion and exclusion criteria was established. Inclusion criteria: interventional studies,
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training of trauma teams, training using simulation and evaluation of NTS (e.g. communication, leadership, teamwork). Exclusion criteria: training of other teams (e.g. unspecified emergency teams, heart resuscitation teams), mono-disciplinary teams or individuals, no training intervention specified, only evaluation of technical skills or no evaluation at all and simulation used only as an evaluation (assessment) tool. We included both actual trauma teams and pseudo teams. The latter are teams of different health-care providers that, unlike the actual trauma teams, do not normally work together as teams and/or at the same department/institution. Data were extracted into a table according to the predetermined characteristics of the educational intervention, see Table 1, and into a second table according to characteristics concerning the evaluation of effect, including the four Kirkpatrick levels,15 see Table 2. In regard to the design of the studies, we differentiated between prospective/retrospective, randomised/not randomised, controlled/ uncontrolled and blinded/not blinded, but as none were randomised, this aspect does not appear in the table. We also considered whether there had been any assessors and whether they were trained and/or blinded. The risk of bias was evaluated based on study design, loss of participants to follow-up, evaluation tool (validated/not validated) and training and blinding of assessors, which allowed for a categorisation of each report’s risk of bias as high, moderate or low. A meta-analysis of randomised, controlled trials was not possible because of the lack of randomisation of all studies and to the heterogeneity in both their design and outcome. This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses criteria.16
Results The search yielded 514 reports eligible for screening of title and abstract, which was done independently by all three authors. Before the final selection, we had a consensus meeting where we compared our individual selection of articles and discussed any discrepancies according to the inclusion criteria, searching for answers in the full articles in question. A consensus list of 18 reports was drawn up, and they were read through once more, again with the application of the inclusion and exclusion criteria, which resulted in the final inclusion of 13 reports in total.17–29 Below, the results of these studies can be
Simulation in trauma team training of NTS
EMBASE: 281 reports
PubMed: 233 reports
Cochrane: 0 reports
514 reports eligible for screening
114 duplicates removed
1st screening (title and abstract) (3 authors): 400 reports
384 reports excluded
2nd screening (read through): 18 reports
5 reports excluded
13 reports
Fig. 2. Flowchart of search strategy.
seen in two tables. Table 1 shows the characteristics of the educational intervention, and Table 2 presents the characteristics of the evaluation of effect.
Study design None of the studies was randomised. Two were retrospective,21,26 and the remaining studies were prospective, of which, two were controlled.24,29 Two had
blinded assessors.20,24 The learners were the actual trauma teams in nine of the reports,19,20,22,24–29 whereas the remaining four reports looked at pseudo teams being trained.17,18,21,23 The objective in all studies was to evaluate whether training of NTS using simulation had any effect. Their duration varied from half an hour to a couple of days, although in one study, the training was conducted
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778
The actual trauma team, in total 160 doctors, nurses, paramedics and others, OH, USA.
A pseudo team, in total 35 military healthcare personnel, Vancouver, Canada. All were later deployed to Afghanistan.
McLaughlin et al.21
The actual trauma team, To assess if team training improves team in total 16 nurses, 28 behaviours in the trauma residents and 6 faculty resuscitation bay? If so, surgeons, VA, USA. does it lead to more efficiency in the trauma bay and/or improved clinical outcomes?
Capella et al.19
Falcone et al.20
Pseudo trauma teams of three, in total 97doctors, nurses and medical students, CT, USA.
Brautigam et al.18
4 h.
5 times 3 h, if the participants attended all five sessions.
3 days.
Content
Trauma scenarios including introduction to objectives, the mannequin and the trauma room. Lecture on each injury and possible management strategies of the five simulation scenarios. Reviewing Carilion Clinic Trauma Room Roles and Responsibilities Policy and chosen parts of TeamSTEPPS Essentials* (Briefing, STEP†, CUS‡, Call outs, Check Backs) and three trauma scenarios. Two trauma scenarios with emphasis on team communication skills, importance of a defined team leader, SMM and ability to question the plan or raise concerns. Online module on CRM and teamwork. Didactic sessions, case Multi-disciplinary team skills (assertive communication, studies, surgical skills leadership, closed-loop laboratories communication, (animal/cadaver adaptability, workload models), mechanical management, situational human patient awareness, role clarity, simulators and clinical debriefing) and clinical shadowing of civilian basics of battlefield staff. trauma.
Simulations followed by video-enabled debriefings. Online education module before each 2 h session.
Didactic session and simulation scenarios followed by video-enabled debriefing.
Simulations with a didactic session afterwards.
Trauma-related topics. Didactic sessions, skill stations, team-training sessions including team exercises and simulations.
Duration of course Methods
2 h simulation, Prospective, To evaluate the preceded by an pre-test–post-test effectiveness of online module. interventional, multi-disciplinary uncontrolled, blinded. paediatric trauma training programme on team performance, emphasising team function and communication during the first year of implementation. 10–14 days. To measure the participants’ Retrospective, uncontrolled, not confidence in applying blinded. teamwork and clinical skills after finishing a tour in Afghanistan to determine which parts of the ITTTC were useful and applicable to the operational setting (long-term impact).
Prospective, pre-test–post-test interventional, uncontrolled, not blinded.
Prospective, To assess the impact of pre-test–post-test trauma team-training interventional, programme on trauma uncontrolled, not knowledge and blinded. performance of physicians and nurses. To provide an evaluation of Prospective, pre-test–post-test students’ self-efficacy and interventional, knowledge in the uncontrolled, not management of blunt blinded. trauma. To train how to function as team leader or team member.
Pseudo trauma teams of four, in total 7 physicians and 13 nurses, Tanzania.
Bergman et al.17
Design
Objective
Learners and setting (programme)
Source
Characteristics of the educational intervention.
Table 1
K. Gjeraa et al.
Pseudo teams, in total 26 doctors and nurses from hospitals in India and Sri Lanka, in cooperation with the Alfred Hospital, Melbourne, Australia.
Four actual trauma teams of a total of 8 doctors and 12 nurses already trained with the ETCC from a level I trauma centre, RI, USA.
The actual trauma team, in total 137 multi-disciplinary health-care providers, HI, USA.
27 actual trauma teams, in total 139 health-care providers from hospitals in the BEST programme, Norway.
O’Reilly et al.23
Shapiro et al.24
Steinemann et al.25
Westli et al.26
Miller et al.22 The actual trauma team at the ED in a level I trauma centre, New Mexico, USA. n = unknown.
To evaluate the impact of team training curriculum on team communication, coordination and clinical efficiency of trauma resuscitation. To study whether a higher frequency of good teamwork skills gives more favourable medical management outcomes and if teams with higher frequency of behavioural markers indicating SMM display superior outcomes.
To determine whether an ISTS programme could be feasibly instituted in the ED and to determine if such a programme could improve teamwork and communication during the care of trauma patients. To deliver the Trauma Team Training programme to a selection of emergency clinicians and thereby enhance Indian and Sri Lankan emergency clinicians’ understanding and skills in the reception and resuscitation of critically injured patients. To study whether high-fidelity simulation team training can enhance didactic training to achieve improved teamwork behaviour in the ED.
Retrospective, uncontrolled, not blinded.
Prospective, pre-test–post-test interventional, uncontrolled, not blinded.
Prospective, pre-test–post-test interventional, controlled, blinded.
Prospective, pre-test–post-test interventional, uncontrolled, not blinded.
Prospective, pre-test–post-test interventional, uncontrolled, not blinded.
The two experimental teams: didactic session, simulation scenarios followed by video-enabled debriefing and a survey at the end of the day. The two comparison teams: one normal workday together. Web-based didactic session and simulations followed by video-enabled debriefing.
Pre-reading handbook, didactic sessions, tutorials, skill stations and team-based scenarios and for 8 selected participants, a ‘train the trainer’ programme.
Didactic sessions, simulations including debriefings.
The BEST Analysis of video programme, see recordings of trauma 28 Wisborg et al. team training by simulation in local 2008. hospitals using the same patient case. Selected based on audio and video quality.
4 h.
8 h.
3 weeks followed later by 1 week.
Simulations and debriefings lasted 30–50 min. Unknown duration of didactic-only phase.
See Wisborg,28 2008.
Team training curriculum followed by three trauma resuscitation scenarios.
An overview of CRM, three patient care scenarios of increasing complexity followed by debriefing focusing on team dimensions and behaviour.
Integrated team-based trauma resuscitation scenarios and communication.
Teamwork and communication in trauma care. Trauma simulations with increasing difficulty, once weekly for 8 weeks, debriefings focusing primarily on teamwork and communication.
Simulation in trauma team training of NTS
779
780 1 day.
1 day.
Didactic sessions, case-based discussions and simulations with video-enabled debriefing.
Didactic sessions, case-based discussions and simulations with video-enabled debriefing.
Team skills such as communication, cooperation and leadership. Two trauma resuscitation simulations: one with a mannequin and one with a standardised patient. Allocated randomly to have either of the training modalities first and then vice versa.
Team skills such as communication, cooperation and leadership. Trauma resuscitation simulations using a simple mannequin.
Emphasis on the agreed upon principles of treatment of trauma patients, communication and team cooperation. Trauma resuscitation using a simple mannequin.
1 day.
Didactic sessions and simulations followed by video-enabled debriefing.
Content
Duration of course Methods
*TeamSTEPPS Essentials – strategies and tools to enhance performance and patient safety. †STEP – a situation monitoring acronym tool. ‡CUS – a mutual support acronym tool. CRM, crisis resource management; ITTTC, intensive trauma team-training course; ED, emergency department; ISTS, in situ trauma simulation; ETCC, emergency team coordination course; BEST, better and systematic trauma care; SMM, shared mental models.
Wisborg et al.29
Wisborg et al.28
Prospective, To train trauma team pre-test–post-test members in a familiar interventional, environment with uncontrolled, not emphasis on teamwork, blinded. communication, leadership and cooperation and to obtain evaluation from participants and assess the feasibility of the training. Prospective, To study whether a 1 day pre-test–post-test course in a complex and interventional, multi-professional setting uncontrolled, not in the ED can improve blinded. trauma team performance and increase knowledge and confidence among health-care providers and to assess the long-term effects. To examine the participants’ Prospective, interventional, assessment of their controlled, not educational outcome after blinded. simulation training with either a standardised patient or a simple resuscitation mannequin.
Actual trauma teams, including physicians, nurses and others from 28 hospitals in the BEST programme, Norway. 2860 participated in the theoretical part, of these 1237 participated in simulations. Actual trauma teams with health-care providers from 44 hospitals in the BEST programme, Norway. 4203 participated in the theoretical part, of these 1767 participated in simulations. Actual trauma teams, a total of 104 doctors, nurses, radiographers, lab technicians, etc., from five hospitals in the BEST programme, Norway.
Wisborg et al.27
Design
Objective
Learners and setting (programme)
Source
Table 1 Continued
K. Gjeraa et al.
Satisfaction questionnaire. MCQ. Trauma simulation assessment tool.
Self-efficacy test. MCQ (only technical knowledge).
Trauma Team Performance Observation Tool (leadership, situation monitoring, mutual support, communication) and a range of demographic factors and outcome parameters from the trauma registry. Videos of the simulated scenarios were reviewed and scored using a trauma team performance scoring sheet measuring procedural tasks.
MCQ including sections on Team Dynamics (rating confidence in applying the teamwork skills learned at ITTTC, Trauma Knowledge and Skills and Training Modalities.
Bergman et al.17
Brautigam et al.18
Capella et al.19
McLaughlin et al.21
Falcone et al.20
Type of evaluation
Source
On average 3.1 years after taking the ITTTC.
The first 4 months were compared with the last 4 months of a 1 year period.
Before and 0–3 months after the training period, actual trauma resuscitations were assessed.
Validated.
None.
Experts, not trained. Blinded.
Trained. Not blinded.
Validated (preliminary).
Validated.
None.
Not validated.
Overall satisfaction with the course. Significantly more passed (60% correct answers) the post-test compared with the pre-test. Scores between 84% and 96% on the simulation assessment. Significant increase of self-efficacy from pre-testing to post-testing in all scenarios. Significant increase of technical knowledge in three of five scenarios. Team performance scores improved significantly. Some (times from arrival to computed tomography scanner, endotracheal intubation and operating room), but not all clinical parameters improved significantly after training. Comparing early vs. late, significant improvement in overall performance. Also comparing either of the two scenarios in early group to the first in the late group showed long-term improvements. In the Team Dynamics section, the participants indicated a high level of confidence applying learned teamwork skills (mean score 4.1 on response range 1–5, 84.3% of responses were ≥ 4). Human Patient Simulator training was considered significantly more valuable than clinical shadowing.
Not trained. Not blinded.
MCQ also tested on senior general surgery residents. Trauma simulation assessment tool not validated.
MCQs done pre- and post-training. Assessment and satisfaction test done post-training.
Before and after each scenario.
Outcome
Assessors
Quality of evaluation
Time of evaluation
Characteristics of the evaluation of effect, including the four Kirkpatrick levels.
Table 2
1 2 (only as individuals)
1. Retrospective, uncontrolled. 2. 72.5% loss of participants. 3. Validated. 4. None. 5. None. Overall: high.
1. Prospective, uncontrolled. 2. None. 3. Validated. 4. None. 5. Blinded. Overall: moderate–high.
1. Prospective, uncontrolled. 2. None. 3. Validated. 4. Trained. 5. None. Overall: moderate–high.
3 4
1 2b
1. Prospective, uncontrolled. 2. None. 3. Not validated. 4. None. 5. None. Overall: high.
1. Prospective, uncontrolled. 2. None. 3. Not validated. 4. None. 5. None. Overall: high.
1 2a 2b
1
Risk of bias†
Kirkpatrick level*
Simulation in trauma team training of NTS
781
782
Steinemann et al.25
Survey: post-simulation. Teamwork observations: twice pre- and post-training, evaluating real patient care at the ED.
Shapiro et al.24
Survey regarding the simulation experience. Teamwork observations using BARS, evaluating five different team dimensions (maintain team structure and climate, apply problem-solving strategies, support team with information, execute plans and manage workload and improve team skills). Clinical process parameters and teamwork assessment performed with a T-NOTECHS.
Self-reporting questionnaires, Pre- and twice post-course MCQs including short (immediately after the answer questions and formal training and after team-based scenario the second phase). observation. Not possible to see whether the MCQs and the team-based scenario observations measured NTS or technical skills.
O’Reilly et al.23
Quality of evaluation
61⁄2 months’ pre- and post-simulation and post-training, evaluating real-life trauma resuscitations.
NOTECHS: validated.
Survey: not validated. BARS: validated.
Not validated.
Validated. Pre-interventional, didactic-only, ISTS and potential decay phases (beginning 1 week after ISTS had ended, lasting 4 weeks). 39 real trauma activations were evaluated.
The Clinical Teamwork Scale measuring 14 items of teamwork, including communication, situational awareness, decision-making, role responsibility and patient friendliness.
Miller et al.22
Time of evaluation
Type of evaluation
Source
Table 2 Continued
Trained. Not blinded.
No training. Blinded.
Not trained. Not blinded.
Trained. Not blinded.
Assessors
Significant improvements in teamwork scores (T-NOTECHS), speed and task completion post-simulation and post-training. Significant decrease in overall ED resuscitation time of 18%. No significant effect on mortality rate, duration of stay in intensive care unit or hospital.
11 of 14 scores improved (1 significantly) from baseline to didactic phase. 12 of 14 scores improved significantly from baseline to ISTS. In the decay phase, all scores were similar to baseline scores across all measures. Only overall communication appeared significantly different when tested for differences across all phases. Improvement on both the MCQ and short-answer questionnaires as well as on the team-based scenarios shown by completion of five out of six of the planned outcomes: increase in knowledge and skills in initial assessment and resuscitation of trauma patients and demonstration of application of these as organised, multi-disciplinary teams. The experimental group showed a trend towards improvement (not significant) in teamwork behaviour ratings after the simulation-based intervention. The 10 participants in the simulator training experienced very good or excellent both overall experience and quality of debriefing.
Outcome
1. Prospective, uncontrolled. 2. None. 3. Validated. 4. Trained. 5. None. Overall: moderate–high.
1. Prospective, controlled. 2. None. 3. Validated. 4. None. 5. Blinded. Overall: moderate.
1 3
2b 3 4
1. Prospective, uncontrolled. 2. None. 3. Not validated. 4. None. 5. None. Overall: high.
1. Prospective, uncontrolled. 2. None. 3. Validated. 4. Trained. 5. None. Overall: moderate–high.
Risk of bias†
1 2a 2b
1 3
Kirkpatrick level*
K. Gjeraa et al.
Anonymous, written questionnaire on self-reported changes in knowledge and confidence, evaluation of team performance in the last real trauma resuscitation and the respondents’ evaluation of changes at their institutions. Anonymous questionnaires. Focus group interviews.
Wisborg et al.28
Questionnaires: after each scenario. Group interview: after the entire course.
Not validated.
Not validated.
Not validated.
ANTS and ATOM: validated. Performance scores and medical management: not validated.
Questionnaire: none. Group interview: not trained, not blinded.
None.
None.
Medical management experts were trained. Psychologists evaluating teamwork skills and SMM were also trained. Not blinded.
Assessment of educational outcome was high. No differences in personal educational outcome, assessed realism or embarrassment was found comparing the two modalities.
Higher performing teams were more effective in information exchange and communication and used less supporting behaviours than the lower performing teams. Behavioural markers of SMM predicted effective medical management better than teamwork skills. Pre-training: high need for improvement of leadership and communication. Respondents who took part in both the didactic sessions and in the simulation/debriefing rated the learning higher. Significant increase in self-reported knowledge of order of procedures, confidence in their own role and perceived quality of care (evaluation of team performance) after the course.
1. Prospective, controlled. 2. None. 3. Not validated. 4. None. 5. None. Overall: high.
1. Prospective, uncontrolled. 2. Participants lost. 3. Not validated. 4. None. 5. None. Overall: high.
1 2
1
1. Prospective, uncontrolled. 2. None. 3. Not validated. 4. None. 5. None. Overall: high.
1. Retrospective, uncontrolled. 2. None. 3. Validated. 4. Trained. 5. None. Overall: moderate–high.
1
2b
*Kirkpatrick levels: (1) reaction and (2) learning (a. knowledge, b. skills) including attitudes (3) behaviour (clinical setting) and (4) patient outcome. †Risk of bias: (1) study design (as none of the studies were randomised, this is not stated in the table), (2) loss of participants to follow-up, (3) evaluation tool (validated/not validated), (4) training of assessors and (5) blinding of assessors. MCQ, multiple-choice questionnaire; ITTTC, intensive trauma team-training course; ISTS, in situ trauma simulation; BARS, behavioural anchored rating scales; ED, emergency department; NOTECHS, non-technical skills scale; T-NOTECHS, a modified NOTECHS scale for trauma; ANTS, anaesthetists’ non-technical skills behavioural marker system; SMM, shared mental models; ATOM, anti-air teamwork observation measure; VAS, visual analogue scale.
Wisborg et al.29
Pre- and post-course.
Questionnaire including the need for improvement at their hospital and an evaluation of the course on a VAS scale.
Wisborg et al.27
Pre- and post-training, and 6 months post-training.
Unknown.
Westli et al.26 Teamwork skills measured by a revised ANTS. Behaviours indicating SMM using ATOM. Medical management measured by performance scores and a global technical score named Medical Management.
Simulation in trauma team training of NTS
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K. Gjeraa et al.
over a period of 10–14 days including both technical and NTS,21 and in another study, the training was conducted over three to four weeks.23 The number of scenarios varied from one to eight; only one study did not specify the number of simulations. Methods included pre-reading of handbook, didactic sessions, case-based discussions, online training, skill stations and team-training sessions including team exercises and simulations followed by videoenabled debriefings. In addition to simulation, a ‘train-the-trainer’ concept was described by O’Reilly et al.23 and shadowing of civilian staff was mentioned as a method by McLaughlin et al.21 Overall, the studies presented courses with very varied structures as seen in Table 1.
Evaluation of effect In Table 2, the different evaluation types used are shown. In many of the studies, evaluation was done on several Kirkpatrick levels. Ten studies performed evaluation before intervention, eight immediately post-training, seven within the first 6 months after the intervention, one report more than 3 years later and one unknown. Four reports evaluated twice after the intervention. Seven of the evaluations were validated, nine were not. None of the papers evaluated the effect of training on all four levels. Ten studies evaluated the effect of training on the reaction level, and nine of these reported positive reactions to the training.17,18,20–24,27,28 The last study compared two modalities of simulation without finding any significant difference.29 Seven papers evaluated the effect of training on the learning level.17,20,21,23,25,26,28 Two papers evaluated the participants’ confidence in applying learned teamwork skills and in their own role, and both reported high levels of confidence.21,28 Two reports evaluated both knowledge and skills: Bergman et al.17 found that significantly, more participants passed the multiple choice questionnaire (MCQ) knowledge test after training than before. An assessment tool used during the simulations to evaluate skills found teamwork scores to be high (84–96%). O’Reilly et al.23 showed an increase in knowledge and skills in the initial assessment and resuscitation of trauma patients as well as in the demonstration of the multi-professional teams’ application of these skills. Three reports evaluated skills of which two20,25 reported significantly higher NTS performance scores after the simulationbased training than before, whereas the last report stated that higher-performing teams used more NTS.26
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Four reports19,22,24,25 evaluated the effect of training on the behaviour level, of which, two reported significantly improved team performance scores after training evaluated at real trauma resuscitations,19,25 whereas one found a trend towards improvement in teamwork scores.24 The fourth report found significant improvement of 12 of 14 scores after training compared with before, but no significant lasting improvements 1–4 weeks later. However, a significant improvement in communication was found across all phases.22 Two reports19,25 evaluated the effect of training on the result level. One report showed a significant decrease in the times from arrival to computed tomography scanner, endotracheal intubation and operating room (OR) after training; however, there were no effects on the duration of the stay in an intensive care unit or in hospital or on the complication or mortality rates, and no effect on the times from arrival to focused assessment with sonography in trauma examination nor on the time in emergency department. The number of participants was, however, small.19 The other report25 found a significant 76% increase in frequency of near-perfect task completion (≤ 1 unreported task) and a significant decrease in the mean overall emergency department resuscitation time of 18%. No significant effects on mortality rate or duration of stay in an intensive care unit or hospital were evident.
Discussion Overall, the multi-professional trauma teams had positive reactions to simulation-based training of NTS. Their knowledge and skills improved after training compared with before in all the studies evaluating the effect of training on learning. Team performance improved in three of the four studies looking at the ability to transfer learning to a clinical setting, although one found difficulties in maintaining these improvements. Significant improvements in task completion and in task performance times were found in the two studies evaluating patient outcome. No study, however, was able to show improvements on mortality rate, complication rate or duration of stay in an intensive care unit or hospital. None of the included studies was randomised, controlled and blinded at the same time, which indicates a moderate to high risk of bias. It is, however, positive that two of the studies aimed at evaluating the effect of simulation-based training on patient outcome.19,25 The training of the assessors and the validity of the ratings are described in more or less
Simulation in trauma team training of NTS
detail in the different papers. The duration of the training, the combination of methods used to prepare the participants and the number of participants vary in the studies. This makes it difficult to compare the results. The positive reactions to the simulation-based training and improvements in knowledge and skills are also seen following other team-training interventions such as cardiac resuscitation team training.30,31 This is in concordance with a review of simulation-based training activities.32 The attitude and the understanding of the importance of using NTS are easy to achieve, but the ability of the multiprofessional team to apply these skills can be difficult to obtain after short training interventions.33 In four of the studies,17,18,21,23 it was not the actual trauma team being trained, but a pseudo team. None of these studies evaluated at higher levels than the learning level. When the effect in the clinical setting, on the whole organisation and on patient outcome is evaluated, it shows that training of the actual trauma team is needed. This is consistent with Robertson et al.’s, Maslovitz et al.’s and Ellis et al.’s findings after obstetric team training.34–36 Overall, solid preparation of the participants consisting of a combination of introduction to the training methods and access to material about NTS before the training makes it easier for the participants to benefit from the simulation-based training.37 The conduct of several scenarios each followed by a debriefing of the team makes it possible to train based on lessons learned from the previous scenario. The intervention in several of the included studies is based on this concept, and it might to some extent explain the significant effects on learning. This is in agreement with a review describing the factors that lead to effective learning.32 The most important factors identified were feedback and repetitive practice. One study in our review indicates a challenge in maintaining the skills after successful training. This is well known from patient safety interventions.38 Two of the studies aimed at demonstrating an effect on patient outcome. No differences in mortality rate or duration of stay were found.19,25 One explanation might be the modest number of participants included. Large-scale studies are often needed to show an effect of training on patient outcome. In a study including almost 20,000 neonates, the perinatal outcome (Apgar score) was shown to increase after simulation-based obstetric team training in a region.39 A systematic review has found multiprofessional obstetric team training to be potentially effective.40
Training the multi-professional trauma team in NTS is essential for increased patient safety and high quality of the trauma patient treatment. Based on existing scientific literature, simulation-based training has high potential as a training method as it provides an opportunity to train without endangering the patient. Furthermore, simulation-based training provides an excellent opportunity for providing feedback to the individual team members.14,32 This is seldom done in the clinical setting. Acquiring NTS is often associated with change in attitudes and behaviours as well as learning of new skills and de-learning of former habits. Change is necessary at the individual, team and organisational levels. The challenges for individuals in applying the learned competences after Advanced Life Support courses have been identified in an interview study.33 The studies included in this review focus on the training of multi-professional teams, which might make it easier to apply the learning as indicated by the positive findings in four of the studies in this review.19,22,24,25 However, training of organisations might be necessary to achieve and maintain a difference in performance in the clinical setting and in patient outcome.41,42 The main obstacles for conducting multiprofessional trauma team training are the costs of the actual training and of pulling staff from their clinical tasks. Furthermore, close cooperation in between departments is necessary in order to plan the training.6 Important factors for successful implementation of trauma team training are leadership involvement and support at the administrative level as well as trained facilitators who can align the training objectives with the organisational goals. Other factors for successful team-training implementation are the facilitation of application of the trained skills on the job and the impact measurement of the teamtraining programme.41,43 Training of large organisations in briefing/debriefing and teamwork in the OR have demonstrated a marked decrease in mortality rates at 64 sites compared with a more moderate decrease at the 34 control sites.42 Such interventions, however, are highly dependent on leadership involvement and support to training and to maintaining focus on the topics.44 Although simulation is widely recognised as an effective tool in training NTS,13,45 literature supporting the effectiveness of multi-professional trauma team training in improving teamwork is still in its early stages and has not yet been linked firmly to improved clinical outcomes and patient safety.7,45,46 However, large studies on simulation-based train-
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ing of obstetric teams have shown to improve the clinical outcome.39 Continued educational research will be necessary to validate long-term learning, to evaluate methods of teaching effectiveness and, most importantly, to demonstrate progressive improvement in the overall quality of patient care.7,10,12–14 This implies initiating high-quality, randomised, controlled studies with a low risk of bias and a detailed description of the methods used in the reports.32,47 The development of appropriate checklists/rating scales needs to be validated in context, and trained, blinded assessors should be used.
Limitations We conducted the literature search based on a predefined search strategy and applied a broad approach to the search, but there may be a risk of studies not appearing due to missing relevant key terms in the search. As we did not search unpublished studies, there might be a risk of publication bias. The risk is considered small as no effect on ‘true’ end-points of outcome (patient outcome such as duration of stay in hospital/intensive care unit, complication rate or mortality) was found.
Conclusion In conclusion, a significant effect on learning after simulation-based training of the multi-professional trauma team in NTS has been found. A significant increase in team performance has been demonstrated in three of the four studies indicating that the learning can be transferred to the clinical setting. No effect on patient outcome was found. All studies found in this systematic review had a moderate to high risk of bias. The results indicate that the literature supporting the effectiveness of simulationbased training of NTS on behaviour and patient outcome is in its early stages. More extensive randomised studies of high quality are needed. Training of organisations and not only teams might be necessary to show any effect on patient outcome. Conflicts of interest: Authors declare no conflicts of interest. Funding: Departmental funding only.
References 1. Nishisaki A, Keren R, Nadkarni V. Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. Anesthesiol Clin 2007; 25: 225– 36.
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2. Barach P, Weinger M. Trauma team performance, In: Wilson WC, Grande CM, Hoyt DB eds. Trauma: resuscitation, anesthesia and emergency surgery. New York: Taylor and Francis, 2007: 101–13. 3. Yun S, Faraj S, Xiao Y, Sims HP. Team leadership and coordination in trauma resuscitation, In: Beyerlein MM, Johnson DA, Beyerlein ST eds. Team-based organizing, Vol. 9. Amsterdam, The Netherlands: JAI Press Inc., 2003: 189–214. 4. Georgiou A, Lockey DJ. The performance and assessment of hospital trauma teams. Scand J Trauma Resusc Emerg Med 2010; 18: 66. 5. Bergs EAG, Rutten FLPA, Tadros T, Krijnen P, Schipper IB. Communication during trauma resuscitation: do we know what is happening? Injury 2005; 36: 905–11. 6. Wisborg T, Castren M, Lippert A, Valsson F, Wallin CJ, on behalf of the WSG (WISE). Training trauma teams in the Nordic countries: an overview and present status. Acta Anaesthesiol Scand 2005; 49: 1004–9. 7. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand 2009; 53: 143–51. 8. Künzle B, Kolbe M, Grote G. Ensuring patient safety through effective leadership behaviour: a literature review. Saf Sci 2010; 48: 1–17. 9. Kohn LT, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000. 10. Berkenstadt H, Erez D, Munz Y, Simon D, Ziv A. Training and assessment of trauma management: the role of simulation-based medical education. Anesthesiol Clin 2007; 25: 65–74. 11. Flin RH, O’Connor P, Crichton M. Safety at the sharp end: a guide to non-technical skills. Aldershot; Burlington, VT: Ashgate, 2008. 12. Cherry RA, Ali J. Current concepts in simulation-based trauma education. J Trauma Inj Infect Crit Care 2008; 65: 1186–93. 13. Østergaard D, Dieckmann P, Lippert A. Simulation and CRM. Best Pract Res Clin Anaesthesiol 2011; 25: 239–49. 14. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care 2004; 13: i2–10. 15. Kirkpatrick DL, Kirkpatrick JD. Evaluating training programs the four levels. San Francisco, CA: Berrett-Koehler, 2006. 16. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6: e1000100. doi: 10.1371/journal.pmed.1000100. 17. Bergman S, Deckelbaum D, Lett R, Haas B, Demyttenaere S, Munthali V, Mbembati N, Museru L, Razek T. Assessing the impact of the trauma team training program in Tanzania. J Trauma Inj Infect Crit Care 2008; 65: 879–83. 18. Brautigam RT, Schott E, Burns KJ. A simulation education course for the initial management of blunt trauma. Conn Med 2009; 73: 267–71. 19. Capella J, Smith S, Philp A, Putnam T, Gilbert C, Fry W, Harvey E, Wright A, Henderson K, Baker D, Ranson S, ReMine S. Teamwork Training Improves the Clinical Care of Trauma Patients. J Surg Educ 2010; 67: 439–43. 20. Falcone RA, Daugherty M, Schweer L, Patterson M, Brown RL, Garcia VF. Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation. J Pediatr Surg 2008; 43: 1065–71. 21. McLaughlin T, Hennecke P, Garraway NR, Evans DC, Hameed M, Simons RK, Doucet J, Hansen D, Annand S, Bell
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N, Brown DR. A predeployment trauma team training course creates confidence in teamwork and clinical skills: a post-Afghanistan deployment validation study of Canadian forces healthcare personnel. J Trauma Inj Infect Crit Care 2011; 71: S487–93. Miller D, Crandall C, Washington C, McLaughlin S. Improving teamwork and communication in trauma care through in situ simulations. Acad Emerg Med 2012; 19: 608– 12. O’Reilly GM, Fitzgerald M, Dewan Y, Chou K, Mathew J, Peters N. The Alfred Trauma Team training program in India and Sri Lanka. Emerg Med Australas 2011; 23: 632–9. Shapiro MJ, Morey JC, Small SD, Langford V, Kaylor CJ, Jagminas L, Suner S, Salisbury ML, Simon R, Jay GD. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care 2004; 13: 417–21. Steinemann S, Berg B, Skinner A, DiTulio A, Anzelon K, Terada K, Oliver C, Ho HC, Speck C. In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ 2011; 68: 472–7. Westli H, Johnsen B, Eid J, Rasten I, Brattebø G. Teamwork skills, shared mental models, and performance in simulated trauma teams: an independent group design. Scand J Trauma Resusc Emerg Med 2010; 18: 47. Wisborg T, Brattebø G, Brattebø J, Brinchmann-Hansen Å. Training multiprofessional trauma teams in Norwegian hospitals using simple and low cost local simulations. Educ Health 2006; 19: 85–95. Wisborg T, Brattebø G, Brinchmann-Hansen Å, Uggen PE, Hansen KS. Effects of nationwide training of multiprofessional trauma teams in Norwegian Hospitals. J Trauma Inj Infect Crit Care 2008; 64: 1613–8. Wisborg T, Brattebø G, Brinchmann-Hansen A, Hansen KS. Mannequin or standardized patient: participants’ assessment of two training modalities in trauma team simulation. Scand J Trauma Resusc Emerg Med 2009; 17: 59. Andersen PO, Maaløe R, Andersen HB. Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database. Resuscitation 2010; 81: 312–6. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest 2008; 133: 56–61. Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teacher 2005; 27: 10–28. Rasmussen MB, Dieckmann P, Issenberg SB, Østergaard D, Søreide E, Ringsted CV. Long-term intended and unintended experiences after Advanced Life Support training. Resuscitation 2013; 84: 373–7. Robertson B, Schumacher L, Gosman G, Kanfer R, Kelley M, DeVita M. Simulation-based crisis team training for multidisciplinary obstetric providers. Simul Healthc J Soc Simul Healthc 2009; 4: 77–83.
35. Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol 2007; 109: 1295–300. 36. Ellis D, Crofts JF, Hunt LP, Read M, Fox R, James M. Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial. Obstet Gynecol 2008; 111: 723–31. 37. Dieckmann P. Using simulations for education, training and research. Lengerich, Germany: Pabst Science Publishers, 2009. 38. Rabøl LI, Østergaard D, Mogensen T. Outcomes of classroom-based team training interventions for multiprofessional hospital staff. A systematic review. Qual Saf Health Care 2010; 19: 1–11. 39. Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S, Whitelaw A. Does training in obstetric emergencies improve neonatal outcome? BJOG Int J Obstet Gynaecol 2006; 113: 177–82. 40. Merién AER, van de Ven J, Mol BW, Houterman S, Oei SG. Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review. Obstet Gynecol 2010; 115: 1021–31. 41. Wisborg T, Brattebø G. Keeping the spirit high: why trauma team training is (sometimes) implemented. Acta Anaesthesiol Scand 2008; 52: 437–41. 42. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP. Association between implementation of a medical team training program and surgical mortality. JAMA J Am Med Assoc 2010; 304: 1693– 700. 43. Salas E, Almeida SA, Salisbury M, King H, Lazzara EH, Lyons R, Wilson KA, Almeida PA, McQuillan R. What are the critical success factors for team training in health care? Jt Comm J Qual Patient Saf 2009; 35: 398–405. 44. Edwards S, Siassakos D. Training teams and leaders to reduce resuscitation errors and improve patient outcome. Resuscitation 2012; 83: 13–5. 45. McCulloch P, Rathbone J, Catchpole K. Interventions to improve teamwork and communications among healthcare staff. Br J Surg 2011; 98: 469–79. 46. Hunt EA, Shilkofski NA, Stavroudis TA, Nelson KL. Simulation: translation to improved team performance. Anesthesiol Clin 2007; 25: 301–19. 47. Issenberg BS, Ringsted C, Østergaard D, Dieckmann P. Setting a research agenda for simulation-based healthcare education a synthesis of the outcome from an utstein style meeting. Sim Healthcare 2011; 6: 155–67.
Address: Kirsten Gjeraa Danish Institute for Medical Simulation Herlev Hospital 25th floor, Herlev Ringvej 75 2730 Herlev Denmark e-mail: [email protected]
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© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12336
Review Article
Efficacy of simulation-based trauma team training of non-technical skills. A systematic review K. Gjeraa, T. P. Møller and D. Østergaard Danish Institute for Medical Simulation, Herlev Hospital, Capital Region of Denmark and Copenhagen University, Copenhagen, Denmark
Trauma resuscitation is a complex situation, and most organisations have multi-professional trauma teams. Non-technical skills are challenged during trauma resuscitation, and they play an important role in the prevention of critical incidents. Simulationbased training of these is recommended. Our research question was: Does simulation-based trauma team training of nontechnical skills have effect on reaction, learning, behaviour or patient outcome? The authors searched PubMed, EMBASE and the Cochrane Library and found 13 studies eligible for analysis. We described and compared the educational interventions and the evaluations of effect according to the four Kirkpatrick levels: reaction, learning (knowledge, skills, attitudes), behaviour (in a clinical setting) and patient outcome. No studies were randomised, controlled and blinded, resulting in a moderate to high risk of bias. The multi-professional trauma teams had positive reactions to simulation-based training of non-technical skills. Knowledge and skills improved in all
T
rauma resuscitation and management are complex tasks, in which time is an important factor for survival. It is often characterised by uncertain or insufficient information flow as well as multiple and concurrent tasks. Most organisations have established multi-professional health-care teams to handle the critically ill patients, and they need to perform a broad range of different and urgent tasks and make many management decisions based on clinical evaluation.1–3 Coordination and rapid assessment of the trauma patients by a multi-professional trauma team have been shown to reduce mortality.4 The multi-professional trauma team is a so-called ‘action team’, with high intensity, velocity and risk, that only exists briefly as it often assembles ad hoc, which consists of different specialities affecting interpersonal relations. Communication during trauma resuscitation is therefore challenging, and one study found that communication errors occurred in 50% of these situations.4 Even with a
studies evaluating the effect on learning. Three studies found improvements in team performance (behaviour) in the clinical setting. One of these found difficulties in maintaining these skills. Two studies evaluated on patient outcome, of which none showed improvements in mortality, complication rate or duration of hospitalisation. A significant effect on learning was found after simulationbased training of the multi-professional trauma team in nontechnical skills. Three studies demonstrated significantly increased clinical team performance. No effect on patient outcome was found. All studies had a moderate to high risk of bias. More comprehensive randomised studies are needed to evaluate the effect on patient outcome. Accepted for publication 07 April 2014 © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
trauma surgeon present, knowledge transfer from team leader to other team members can be suboptimal.5 On top of these challenges, the frequency of severe trauma resuscitations is low in many countries resulting in a lack of routine and experience in handling the difficult trauma patient.6 Studies have shown that teamwork plays an important role in the prevention of critical incidents and errors.7,8 For years, it has been recommended to train health-care professionals in teamwork and other non-technical skills (NTS).9,10 NTS can be defined as ‘the cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance’.11 NTS include situational awareness, decisionmaking, communication, teamwork, leadership and management of stress, fatigue and disturbances.11 Simulation-based training has been proposed as a safe and effective learning method providing the opportunity to video record the simulations. After-
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4. Patient outcome (beneit for the patient)
3. Behaviour (translation of learning to clinical setting)
2. Learning (knowledge, skills, attitudes)
1. Reaction (participants satisfaction)
Fig. 1. Kirkpatrick’s model for evaluating effects of educational courses.
wards, in the debriefing session where the team’s handling of the patient is discussed, excerpts from the recordings are used to illustrate performance. This has been shown to promote reflection and thereby learning.12 In addition, adult learning theories support simulation-based training as adults prefer to learn through experience.10,13,14 Simulationbased training has the potential to facilitate communication, cooperation and leadership skills, which are all essential in trauma resuscitation.4 Multiprofessional team training allows for more natural team interactions and reinforces understanding However, although across disciplines.1,8,13,14 simulation-based training of the multi-professional trauma team is recommended, the question is whether the initiative has an effect. In medical education, Kirkpatrick’s four-level model is often used to evaluate learning.15 The levels are reaction (participant satisfaction), learning (knowledge, skills and attitudes), behaviour (translation of learning to clinical setting) and patient outcome. See Fig. 1. This systematic review was carried out based on the following research question: Does simulationbased trauma team training of NTS have an effect on reaction, learning, behaviour or patient outcome?
Methods In July 2013, we carried out a search of PubMed (including Medical Subject Headings terms), EMBASE and the Cochrane Library with no historic time limit and using these search words: trauma team, training, simulation, Crew Resource Management, Crisis Resource Management and teamwork. Only articles in English were considered. See Fig. 2. Unpublished studies were not included. A priori, a list of inclusion and exclusion criteria was established. Inclusion criteria: interventional studies,
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training of trauma teams, training using simulation and evaluation of NTS (e.g. communication, leadership, teamwork). Exclusion criteria: training of other teams (e.g. unspecified emergency teams, heart resuscitation teams), mono-disciplinary teams or individuals, no training intervention specified, only evaluation of technical skills or no evaluation at all and simulation used only as an evaluation (assessment) tool. We included both actual trauma teams and pseudo teams. The latter are teams of different health-care providers that, unlike the actual trauma teams, do not normally work together as teams and/or at the same department/institution. Data were extracted into a table according to the predetermined characteristics of the educational intervention, see Table 1, and into a second table according to characteristics concerning the evaluation of effect, including the four Kirkpatrick levels,15 see Table 2. In regard to the design of the studies, we differentiated between prospective/retrospective, randomised/not randomised, controlled/ uncontrolled and blinded/not blinded, but as none were randomised, this aspect does not appear in the table. We also considered whether there had been any assessors and whether they were trained and/or blinded. The risk of bias was evaluated based on study design, loss of participants to follow-up, evaluation tool (validated/not validated) and training and blinding of assessors, which allowed for a categorisation of each report’s risk of bias as high, moderate or low. A meta-analysis of randomised, controlled trials was not possible because of the lack of randomisation of all studies and to the heterogeneity in both their design and outcome. This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses criteria.16
Results The search yielded 514 reports eligible for screening of title and abstract, which was done independently by all three authors. Before the final selection, we had a consensus meeting where we compared our individual selection of articles and discussed any discrepancies according to the inclusion criteria, searching for answers in the full articles in question. A consensus list of 18 reports was drawn up, and they were read through once more, again with the application of the inclusion and exclusion criteria, which resulted in the final inclusion of 13 reports in total.17–29 Below, the results of these studies can be
Simulation in trauma team training of NTS
EMBASE: 281 reports
PubMed: 233 reports
Cochrane: 0 reports
514 reports eligible for screening
114 duplicates removed
1st screening (title and abstract) (3 authors): 400 reports
384 reports excluded
2nd screening (read through): 18 reports
5 reports excluded
13 reports
Fig. 2. Flowchart of search strategy.
seen in two tables. Table 1 shows the characteristics of the educational intervention, and Table 2 presents the characteristics of the evaluation of effect.
Study design None of the studies was randomised. Two were retrospective,21,26 and the remaining studies were prospective, of which, two were controlled.24,29 Two had
blinded assessors.20,24 The learners were the actual trauma teams in nine of the reports,19,20,22,24–29 whereas the remaining four reports looked at pseudo teams being trained.17,18,21,23 The objective in all studies was to evaluate whether training of NTS using simulation had any effect. Their duration varied from half an hour to a couple of days, although in one study, the training was conducted
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The actual trauma team, in total 160 doctors, nurses, paramedics and others, OH, USA.
A pseudo team, in total 35 military healthcare personnel, Vancouver, Canada. All were later deployed to Afghanistan.
McLaughlin et al.21
The actual trauma team, To assess if team training improves team in total 16 nurses, 28 behaviours in the trauma residents and 6 faculty resuscitation bay? If so, surgeons, VA, USA. does it lead to more efficiency in the trauma bay and/or improved clinical outcomes?
Capella et al.19
Falcone et al.20
Pseudo trauma teams of three, in total 97doctors, nurses and medical students, CT, USA.
Brautigam et al.18
4 h.
5 times 3 h, if the participants attended all five sessions.
3 days.
Content
Trauma scenarios including introduction to objectives, the mannequin and the trauma room. Lecture on each injury and possible management strategies of the five simulation scenarios. Reviewing Carilion Clinic Trauma Room Roles and Responsibilities Policy and chosen parts of TeamSTEPPS Essentials* (Briefing, STEP†, CUS‡, Call outs, Check Backs) and three trauma scenarios. Two trauma scenarios with emphasis on team communication skills, importance of a defined team leader, SMM and ability to question the plan or raise concerns. Online module on CRM and teamwork. Didactic sessions, case Multi-disciplinary team skills (assertive communication, studies, surgical skills leadership, closed-loop laboratories communication, (animal/cadaver adaptability, workload models), mechanical management, situational human patient awareness, role clarity, simulators and clinical debriefing) and clinical shadowing of civilian basics of battlefield staff. trauma.
Simulations followed by video-enabled debriefings. Online education module before each 2 h session.
Didactic session and simulation scenarios followed by video-enabled debriefing.
Simulations with a didactic session afterwards.
Trauma-related topics. Didactic sessions, skill stations, team-training sessions including team exercises and simulations.
Duration of course Methods
2 h simulation, Prospective, To evaluate the preceded by an pre-test–post-test effectiveness of online module. interventional, multi-disciplinary uncontrolled, blinded. paediatric trauma training programme on team performance, emphasising team function and communication during the first year of implementation. 10–14 days. To measure the participants’ Retrospective, uncontrolled, not confidence in applying blinded. teamwork and clinical skills after finishing a tour in Afghanistan to determine which parts of the ITTTC were useful and applicable to the operational setting (long-term impact).
Prospective, pre-test–post-test interventional, uncontrolled, not blinded.
Prospective, To assess the impact of pre-test–post-test trauma team-training interventional, programme on trauma uncontrolled, not knowledge and blinded. performance of physicians and nurses. To provide an evaluation of Prospective, pre-test–post-test students’ self-efficacy and interventional, knowledge in the uncontrolled, not management of blunt blinded. trauma. To train how to function as team leader or team member.
Pseudo trauma teams of four, in total 7 physicians and 13 nurses, Tanzania.
Bergman et al.17
Design
Objective
Learners and setting (programme)
Source
Characteristics of the educational intervention.
Table 1
K. Gjeraa et al.
Pseudo teams, in total 26 doctors and nurses from hospitals in India and Sri Lanka, in cooperation with the Alfred Hospital, Melbourne, Australia.
Four actual trauma teams of a total of 8 doctors and 12 nurses already trained with the ETCC from a level I trauma centre, RI, USA.
The actual trauma team, in total 137 multi-disciplinary health-care providers, HI, USA.
27 actual trauma teams, in total 139 health-care providers from hospitals in the BEST programme, Norway.
O’Reilly et al.23
Shapiro et al.24
Steinemann et al.25
Westli et al.26
Miller et al.22 The actual trauma team at the ED in a level I trauma centre, New Mexico, USA. n = unknown.
To evaluate the impact of team training curriculum on team communication, coordination and clinical efficiency of trauma resuscitation. To study whether a higher frequency of good teamwork skills gives more favourable medical management outcomes and if teams with higher frequency of behavioural markers indicating SMM display superior outcomes.
To determine whether an ISTS programme could be feasibly instituted in the ED and to determine if such a programme could improve teamwork and communication during the care of trauma patients. To deliver the Trauma Team Training programme to a selection of emergency clinicians and thereby enhance Indian and Sri Lankan emergency clinicians’ understanding and skills in the reception and resuscitation of critically injured patients. To study whether high-fidelity simulation team training can enhance didactic training to achieve improved teamwork behaviour in the ED.
Retrospective, uncontrolled, not blinded.
Prospective, pre-test–post-test interventional, uncontrolled, not blinded.
Prospective, pre-test–post-test interventional, controlled, blinded.
Prospective, pre-test–post-test interventional, uncontrolled, not blinded.
Prospective, pre-test–post-test interventional, uncontrolled, not blinded.
The two experimental teams: didactic session, simulation scenarios followed by video-enabled debriefing and a survey at the end of the day. The two comparison teams: one normal workday together. Web-based didactic session and simulations followed by video-enabled debriefing.
Pre-reading handbook, didactic sessions, tutorials, skill stations and team-based scenarios and for 8 selected participants, a ‘train the trainer’ programme.
Didactic sessions, simulations including debriefings.
The BEST Analysis of video programme, see recordings of trauma 28 Wisborg et al. team training by simulation in local 2008. hospitals using the same patient case. Selected based on audio and video quality.
4 h.
8 h.
3 weeks followed later by 1 week.
Simulations and debriefings lasted 30–50 min. Unknown duration of didactic-only phase.
See Wisborg,28 2008.
Team training curriculum followed by three trauma resuscitation scenarios.
An overview of CRM, three patient care scenarios of increasing complexity followed by debriefing focusing on team dimensions and behaviour.
Integrated team-based trauma resuscitation scenarios and communication.
Teamwork and communication in trauma care. Trauma simulations with increasing difficulty, once weekly for 8 weeks, debriefings focusing primarily on teamwork and communication.
Simulation in trauma team training of NTS
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780 1 day.
1 day.
Didactic sessions, case-based discussions and simulations with video-enabled debriefing.
Didactic sessions, case-based discussions and simulations with video-enabled debriefing.
Team skills such as communication, cooperation and leadership. Two trauma resuscitation simulations: one with a mannequin and one with a standardised patient. Allocated randomly to have either of the training modalities first and then vice versa.
Team skills such as communication, cooperation and leadership. Trauma resuscitation simulations using a simple mannequin.
Emphasis on the agreed upon principles of treatment of trauma patients, communication and team cooperation. Trauma resuscitation using a simple mannequin.
1 day.
Didactic sessions and simulations followed by video-enabled debriefing.
Content
Duration of course Methods
*TeamSTEPPS Essentials – strategies and tools to enhance performance and patient safety. †STEP – a situation monitoring acronym tool. ‡CUS – a mutual support acronym tool. CRM, crisis resource management; ITTTC, intensive trauma team-training course; ED, emergency department; ISTS, in situ trauma simulation; ETCC, emergency team coordination course; BEST, better and systematic trauma care; SMM, shared mental models.
Wisborg et al.29
Wisborg et al.28
Prospective, To train trauma team pre-test–post-test members in a familiar interventional, environment with uncontrolled, not emphasis on teamwork, blinded. communication, leadership and cooperation and to obtain evaluation from participants and assess the feasibility of the training. Prospective, To study whether a 1 day pre-test–post-test course in a complex and interventional, multi-professional setting uncontrolled, not in the ED can improve blinded. trauma team performance and increase knowledge and confidence among health-care providers and to assess the long-term effects. To examine the participants’ Prospective, interventional, assessment of their controlled, not educational outcome after blinded. simulation training with either a standardised patient or a simple resuscitation mannequin.
Actual trauma teams, including physicians, nurses and others from 28 hospitals in the BEST programme, Norway. 2860 participated in the theoretical part, of these 1237 participated in simulations. Actual trauma teams with health-care providers from 44 hospitals in the BEST programme, Norway. 4203 participated in the theoretical part, of these 1767 participated in simulations. Actual trauma teams, a total of 104 doctors, nurses, radiographers, lab technicians, etc., from five hospitals in the BEST programme, Norway.
Wisborg et al.27
Design
Objective
Learners and setting (programme)
Source
Table 1 Continued
K. Gjeraa et al.
Satisfaction questionnaire. MCQ. Trauma simulation assessment tool.
Self-efficacy test. MCQ (only technical knowledge).
Trauma Team Performance Observation Tool (leadership, situation monitoring, mutual support, communication) and a range of demographic factors and outcome parameters from the trauma registry. Videos of the simulated scenarios were reviewed and scored using a trauma team performance scoring sheet measuring procedural tasks.
MCQ including sections on Team Dynamics (rating confidence in applying the teamwork skills learned at ITTTC, Trauma Knowledge and Skills and Training Modalities.
Bergman et al.17
Brautigam et al.18
Capella et al.19
McLaughlin et al.21
Falcone et al.20
Type of evaluation
Source
On average 3.1 years after taking the ITTTC.
The first 4 months were compared with the last 4 months of a 1 year period.
Before and 0–3 months after the training period, actual trauma resuscitations were assessed.
Validated.
None.
Experts, not trained. Blinded.
Trained. Not blinded.
Validated (preliminary).
Validated.
None.
Not validated.
Overall satisfaction with the course. Significantly more passed (60% correct answers) the post-test compared with the pre-test. Scores between 84% and 96% on the simulation assessment. Significant increase of self-efficacy from pre-testing to post-testing in all scenarios. Significant increase of technical knowledge in three of five scenarios. Team performance scores improved significantly. Some (times from arrival to computed tomography scanner, endotracheal intubation and operating room), but not all clinical parameters improved significantly after training. Comparing early vs. late, significant improvement in overall performance. Also comparing either of the two scenarios in early group to the first in the late group showed long-term improvements. In the Team Dynamics section, the participants indicated a high level of confidence applying learned teamwork skills (mean score 4.1 on response range 1–5, 84.3% of responses were ≥ 4). Human Patient Simulator training was considered significantly more valuable than clinical shadowing.
Not trained. Not blinded.
MCQ also tested on senior general surgery residents. Trauma simulation assessment tool not validated.
MCQs done pre- and post-training. Assessment and satisfaction test done post-training.
Before and after each scenario.
Outcome
Assessors
Quality of evaluation
Time of evaluation
Characteristics of the evaluation of effect, including the four Kirkpatrick levels.
Table 2
1 2 (only as individuals)
1. Retrospective, uncontrolled. 2. 72.5% loss of participants. 3. Validated. 4. None. 5. None. Overall: high.
1. Prospective, uncontrolled. 2. None. 3. Validated. 4. None. 5. Blinded. Overall: moderate–high.
1. Prospective, uncontrolled. 2. None. 3. Validated. 4. Trained. 5. None. Overall: moderate–high.
3 4
1 2b
1. Prospective, uncontrolled. 2. None. 3. Not validated. 4. None. 5. None. Overall: high.
1. Prospective, uncontrolled. 2. None. 3. Not validated. 4. None. 5. None. Overall: high.
1 2a 2b
1
Risk of bias†
Kirkpatrick level*
Simulation in trauma team training of NTS
781
782
Steinemann et al.25
Survey: post-simulation. Teamwork observations: twice pre- and post-training, evaluating real patient care at the ED.
Shapiro et al.24
Survey regarding the simulation experience. Teamwork observations using BARS, evaluating five different team dimensions (maintain team structure and climate, apply problem-solving strategies, support team with information, execute plans and manage workload and improve team skills). Clinical process parameters and teamwork assessment performed with a T-NOTECHS.
Self-reporting questionnaires, Pre- and twice post-course MCQs including short (immediately after the answer questions and formal training and after team-based scenario the second phase). observation. Not possible to see whether the MCQs and the team-based scenario observations measured NTS or technical skills.
O’Reilly et al.23
Quality of evaluation
61⁄2 months’ pre- and post-simulation and post-training, evaluating real-life trauma resuscitations.
NOTECHS: validated.
Survey: not validated. BARS: validated.
Not validated.
Validated. Pre-interventional, didactic-only, ISTS and potential decay phases (beginning 1 week after ISTS had ended, lasting 4 weeks). 39 real trauma activations were evaluated.
The Clinical Teamwork Scale measuring 14 items of teamwork, including communication, situational awareness, decision-making, role responsibility and patient friendliness.
Miller et al.22
Time of evaluation
Type of evaluation
Source
Table 2 Continued
Trained. Not blinded.
No training. Blinded.
Not trained. Not blinded.
Trained. Not blinded.
Assessors
Significant improvements in teamwork scores (T-NOTECHS), speed and task completion post-simulation and post-training. Significant decrease in overall ED resuscitation time of 18%. No significant effect on mortality rate, duration of stay in intensive care unit or hospital.
11 of 14 scores improved (1 significantly) from baseline to didactic phase. 12 of 14 scores improved significantly from baseline to ISTS. In the decay phase, all scores were similar to baseline scores across all measures. Only overall communication appeared significantly different when tested for differences across all phases. Improvement on both the MCQ and short-answer questionnaires as well as on the team-based scenarios shown by completion of five out of six of the planned outcomes: increase in knowledge and skills in initial assessment and resuscitation of trauma patients and demonstration of application of these as organised, multi-disciplinary teams. The experimental group showed a trend towards improvement (not significant) in teamwork behaviour ratings after the simulation-based intervention. The 10 participants in the simulator training experienced very good or excellent both overall experience and quality of debriefing.
Outcome
1. Prospective, uncontrolled. 2. None. 3. Validated. 4. Trained. 5. None. Overall: moderate–high.
1. Prospective, controlled. 2. None. 3. Validated. 4. None. 5. Blinded. Overall: moderate.
1 3
2b 3 4
1. Prospective, uncontrolled. 2. None. 3. Not validated. 4. None. 5. None. Overall: high.
1. Prospective, uncontrolled. 2. None. 3. Validated. 4. Trained. 5. None. Overall: moderate–high.
Risk of bias†
1 2a 2b
1 3
Kirkpatrick level*
K. Gjeraa et al.
Anonymous, written questionnaire on self-reported changes in knowledge and confidence, evaluation of team performance in the last real trauma resuscitation and the respondents’ evaluation of changes at their institutions. Anonymous questionnaires. Focus group interviews.
Wisborg et al.28
Questionnaires: after each scenario. Group interview: after the entire course.
Not validated.
Not validated.
Not validated.
ANTS and ATOM: validated. Performance scores and medical management: not validated.
Questionnaire: none. Group interview: not trained, not blinded.
None.
None.
Medical management experts were trained. Psychologists evaluating teamwork skills and SMM were also trained. Not blinded.
Assessment of educational outcome was high. No differences in personal educational outcome, assessed realism or embarrassment was found comparing the two modalities.
Higher performing teams were more effective in information exchange and communication and used less supporting behaviours than the lower performing teams. Behavioural markers of SMM predicted effective medical management better than teamwork skills. Pre-training: high need for improvement of leadership and communication. Respondents who took part in both the didactic sessions and in the simulation/debriefing rated the learning higher. Significant increase in self-reported knowledge of order of procedures, confidence in their own role and perceived quality of care (evaluation of team performance) after the course.
1. Prospective, controlled. 2. None. 3. Not validated. 4. None. 5. None. Overall: high.
1. Prospective, uncontrolled. 2. Participants lost. 3. Not validated. 4. None. 5. None. Overall: high.
1 2
1
1. Prospective, uncontrolled. 2. None. 3. Not validated. 4. None. 5. None. Overall: high.
1. Retrospective, uncontrolled. 2. None. 3. Validated. 4. Trained. 5. None. Overall: moderate–high.
1
2b
*Kirkpatrick levels: (1) reaction and (2) learning (a. knowledge, b. skills) including attitudes (3) behaviour (clinical setting) and (4) patient outcome. †Risk of bias: (1) study design (as none of the studies were randomised, this is not stated in the table), (2) loss of participants to follow-up, (3) evaluation tool (validated/not validated), (4) training of assessors and (5) blinding of assessors. MCQ, multiple-choice questionnaire; ITTTC, intensive trauma team-training course; ISTS, in situ trauma simulation; BARS, behavioural anchored rating scales; ED, emergency department; NOTECHS, non-technical skills scale; T-NOTECHS, a modified NOTECHS scale for trauma; ANTS, anaesthetists’ non-technical skills behavioural marker system; SMM, shared mental models; ATOM, anti-air teamwork observation measure; VAS, visual analogue scale.
Wisborg et al.29
Pre- and post-course.
Questionnaire including the need for improvement at their hospital and an evaluation of the course on a VAS scale.
Wisborg et al.27
Pre- and post-training, and 6 months post-training.
Unknown.
Westli et al.26 Teamwork skills measured by a revised ANTS. Behaviours indicating SMM using ATOM. Medical management measured by performance scores and a global technical score named Medical Management.
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over a period of 10–14 days including both technical and NTS,21 and in another study, the training was conducted over three to four weeks.23 The number of scenarios varied from one to eight; only one study did not specify the number of simulations. Methods included pre-reading of handbook, didactic sessions, case-based discussions, online training, skill stations and team-training sessions including team exercises and simulations followed by videoenabled debriefings. In addition to simulation, a ‘train-the-trainer’ concept was described by O’Reilly et al.23 and shadowing of civilian staff was mentioned as a method by McLaughlin et al.21 Overall, the studies presented courses with very varied structures as seen in Table 1.
Evaluation of effect In Table 2, the different evaluation types used are shown. In many of the studies, evaluation was done on several Kirkpatrick levels. Ten studies performed evaluation before intervention, eight immediately post-training, seven within the first 6 months after the intervention, one report more than 3 years later and one unknown. Four reports evaluated twice after the intervention. Seven of the evaluations were validated, nine were not. None of the papers evaluated the effect of training on all four levels. Ten studies evaluated the effect of training on the reaction level, and nine of these reported positive reactions to the training.17,18,20–24,27,28 The last study compared two modalities of simulation without finding any significant difference.29 Seven papers evaluated the effect of training on the learning level.17,20,21,23,25,26,28 Two papers evaluated the participants’ confidence in applying learned teamwork skills and in their own role, and both reported high levels of confidence.21,28 Two reports evaluated both knowledge and skills: Bergman et al.17 found that significantly, more participants passed the multiple choice questionnaire (MCQ) knowledge test after training than before. An assessment tool used during the simulations to evaluate skills found teamwork scores to be high (84–96%). O’Reilly et al.23 showed an increase in knowledge and skills in the initial assessment and resuscitation of trauma patients as well as in the demonstration of the multi-professional teams’ application of these skills. Three reports evaluated skills of which two20,25 reported significantly higher NTS performance scores after the simulationbased training than before, whereas the last report stated that higher-performing teams used more NTS.26
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Four reports19,22,24,25 evaluated the effect of training on the behaviour level, of which, two reported significantly improved team performance scores after training evaluated at real trauma resuscitations,19,25 whereas one found a trend towards improvement in teamwork scores.24 The fourth report found significant improvement of 12 of 14 scores after training compared with before, but no significant lasting improvements 1–4 weeks later. However, a significant improvement in communication was found across all phases.22 Two reports19,25 evaluated the effect of training on the result level. One report showed a significant decrease in the times from arrival to computed tomography scanner, endotracheal intubation and operating room (OR) after training; however, there were no effects on the duration of the stay in an intensive care unit or in hospital or on the complication or mortality rates, and no effect on the times from arrival to focused assessment with sonography in trauma examination nor on the time in emergency department. The number of participants was, however, small.19 The other report25 found a significant 76% increase in frequency of near-perfect task completion (≤ 1 unreported task) and a significant decrease in the mean overall emergency department resuscitation time of 18%. No significant effects on mortality rate or duration of stay in an intensive care unit or hospital were evident.
Discussion Overall, the multi-professional trauma teams had positive reactions to simulation-based training of NTS. Their knowledge and skills improved after training compared with before in all the studies evaluating the effect of training on learning. Team performance improved in three of the four studies looking at the ability to transfer learning to a clinical setting, although one found difficulties in maintaining these improvements. Significant improvements in task completion and in task performance times were found in the two studies evaluating patient outcome. No study, however, was able to show improvements on mortality rate, complication rate or duration of stay in an intensive care unit or hospital. None of the included studies was randomised, controlled and blinded at the same time, which indicates a moderate to high risk of bias. It is, however, positive that two of the studies aimed at evaluating the effect of simulation-based training on patient outcome.19,25 The training of the assessors and the validity of the ratings are described in more or less
Simulation in trauma team training of NTS
detail in the different papers. The duration of the training, the combination of methods used to prepare the participants and the number of participants vary in the studies. This makes it difficult to compare the results. The positive reactions to the simulation-based training and improvements in knowledge and skills are also seen following other team-training interventions such as cardiac resuscitation team training.30,31 This is in concordance with a review of simulation-based training activities.32 The attitude and the understanding of the importance of using NTS are easy to achieve, but the ability of the multiprofessional team to apply these skills can be difficult to obtain after short training interventions.33 In four of the studies,17,18,21,23 it was not the actual trauma team being trained, but a pseudo team. None of these studies evaluated at higher levels than the learning level. When the effect in the clinical setting, on the whole organisation and on patient outcome is evaluated, it shows that training of the actual trauma team is needed. This is consistent with Robertson et al.’s, Maslovitz et al.’s and Ellis et al.’s findings after obstetric team training.34–36 Overall, solid preparation of the participants consisting of a combination of introduction to the training methods and access to material about NTS before the training makes it easier for the participants to benefit from the simulation-based training.37 The conduct of several scenarios each followed by a debriefing of the team makes it possible to train based on lessons learned from the previous scenario. The intervention in several of the included studies is based on this concept, and it might to some extent explain the significant effects on learning. This is in agreement with a review describing the factors that lead to effective learning.32 The most important factors identified were feedback and repetitive practice. One study in our review indicates a challenge in maintaining the skills after successful training. This is well known from patient safety interventions.38 Two of the studies aimed at demonstrating an effect on patient outcome. No differences in mortality rate or duration of stay were found.19,25 One explanation might be the modest number of participants included. Large-scale studies are often needed to show an effect of training on patient outcome. In a study including almost 20,000 neonates, the perinatal outcome (Apgar score) was shown to increase after simulation-based obstetric team training in a region.39 A systematic review has found multiprofessional obstetric team training to be potentially effective.40
Training the multi-professional trauma team in NTS is essential for increased patient safety and high quality of the trauma patient treatment. Based on existing scientific literature, simulation-based training has high potential as a training method as it provides an opportunity to train without endangering the patient. Furthermore, simulation-based training provides an excellent opportunity for providing feedback to the individual team members.14,32 This is seldom done in the clinical setting. Acquiring NTS is often associated with change in attitudes and behaviours as well as learning of new skills and de-learning of former habits. Change is necessary at the individual, team and organisational levels. The challenges for individuals in applying the learned competences after Advanced Life Support courses have been identified in an interview study.33 The studies included in this review focus on the training of multi-professional teams, which might make it easier to apply the learning as indicated by the positive findings in four of the studies in this review.19,22,24,25 However, training of organisations might be necessary to achieve and maintain a difference in performance in the clinical setting and in patient outcome.41,42 The main obstacles for conducting multiprofessional trauma team training are the costs of the actual training and of pulling staff from their clinical tasks. Furthermore, close cooperation in between departments is necessary in order to plan the training.6 Important factors for successful implementation of trauma team training are leadership involvement and support at the administrative level as well as trained facilitators who can align the training objectives with the organisational goals. Other factors for successful team-training implementation are the facilitation of application of the trained skills on the job and the impact measurement of the teamtraining programme.41,43 Training of large organisations in briefing/debriefing and teamwork in the OR have demonstrated a marked decrease in mortality rates at 64 sites compared with a more moderate decrease at the 34 control sites.42 Such interventions, however, are highly dependent on leadership involvement and support to training and to maintaining focus on the topics.44 Although simulation is widely recognised as an effective tool in training NTS,13,45 literature supporting the effectiveness of multi-professional trauma team training in improving teamwork is still in its early stages and has not yet been linked firmly to improved clinical outcomes and patient safety.7,45,46 However, large studies on simulation-based train-
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ing of obstetric teams have shown to improve the clinical outcome.39 Continued educational research will be necessary to validate long-term learning, to evaluate methods of teaching effectiveness and, most importantly, to demonstrate progressive improvement in the overall quality of patient care.7,10,12–14 This implies initiating high-quality, randomised, controlled studies with a low risk of bias and a detailed description of the methods used in the reports.32,47 The development of appropriate checklists/rating scales needs to be validated in context, and trained, blinded assessors should be used.
Limitations We conducted the literature search based on a predefined search strategy and applied a broad approach to the search, but there may be a risk of studies not appearing due to missing relevant key terms in the search. As we did not search unpublished studies, there might be a risk of publication bias. The risk is considered small as no effect on ‘true’ end-points of outcome (patient outcome such as duration of stay in hospital/intensive care unit, complication rate or mortality) was found.
Conclusion In conclusion, a significant effect on learning after simulation-based training of the multi-professional trauma team in NTS has been found. A significant increase in team performance has been demonstrated in three of the four studies indicating that the learning can be transferred to the clinical setting. No effect on patient outcome was found. All studies found in this systematic review had a moderate to high risk of bias. The results indicate that the literature supporting the effectiveness of simulationbased training of NTS on behaviour and patient outcome is in its early stages. More extensive randomised studies of high quality are needed. Training of organisations and not only teams might be necessary to show any effect on patient outcome. Conflicts of interest: Authors declare no conflicts of interest. Funding: Departmental funding only.
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Address: Kirsten Gjeraa Danish Institute for Medical Simulation Herlev Hospital 25th floor, Herlev Ringvej 75 2730 Herlev Denmark e-mail: [email protected]
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