A Study to Evaluate the Effectiveness of Simulation on Anaesthetic Non-Technical Skills in the Management of Major Trauma Patients
Background: Dynamic, challenging instances during the management of major trauma patients requires optimal team intervention to ensure patient safety and effective crisis management. These factors highlight the importance of increased awareness in both technical and non-technical skills (NTS) training. Simulation based training (SBT) is an effective tool that replicates and teaches the required clinical skills, resulting in teamwork improvement, better patient safety, and care. Aims: This study investigates change in NTS, during the management of major trauma patients, using SBT. We also investigated the relationship between NTS performance and participation in previous NTS workshop (NTSW), years of experience, previous simulation (PS), previous exposure to major trauma patient management (MTPM) and group size. Methods: NTS behaviours were assessed by a single rater using previously validated framework for observing and rating Anaesthetists’ Non-Technical Skills (ANTS) for anaesthetists and Anaesthetic Non-Technical Skills for Anaesthetic Practitioners (ANTS-AP) for anaesthetic nurses during SBT. Two anaesthetists (one senior, one junior) together with one to four registered anaesthetic nurses formed 17 teams. The SBT consisted of 3 major trauma scenarios: 1) Major haemorrhage following multiple stab wounds to the torso, 2) Traumatic brain injury complicated by unanticipated difficult intubation, and 3) Penetrating neck injury with major haemorrhage, complicated by a failed intubation. The scores of each NTS category for each scenario are evaluated for significance in change and used to correlate whether NTS during the simulation were affected by previous NTSW, PS, previous exposure to MTPM and group size. Results: The resulting anaesthetists and anesthetic nurses’ p-values were < 0.05 indicating a significant improvement in all NTS resulting from score differences between scenarios 1 & 2 and 1 & 3. Anaesthetists’ NTS categories were not influenced by PS, previous NTSW, and exposure to MTPM. However, anaesthetic nurses NTS categories were influenced by PS, exposure to MTPM but not by NTSW. Conclusions: SBT has shown to be effective in improving the NTS for both anaesthetists and anaesthetic nurses. This enhances safety and team performance for MTPM. The impact of SBT in the clinical environment for patient management and safety warrants further research.
[1] Riem N, Boet S, Bould MD, Tavares W. Do technical skills correlate with non-technical skills in crisis resource management: a simulation study. British journal of anaesthesia: BJA.109(5):723-8.
[2] Boulet JR, Murray DJ. Simulation-based assessment in anesthesiology: requirements for practical implementation. Anesthesiology (Philadelphia). 112(4):1041-52.
[3] Lai A, Haligua A, Dylan Bould M, Everett T. Learning crisis resource management: Practicing versus an observational role in simulation training – a randomized controlled trial. Anaesthesia Critical Care & Pain Medicine. 35(4): 275-281.
[4] Bruppacher HR, Alam SK, LeBlanc VR, Latter D. Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery. Anesthesiology (Philadelphia). 112(4):985-92.
[5] Higham H, Baxendale B. To err is human: use of simulation to enhance training and patient safety in anaesthesia. British journal of anaesthesia: BJA.119:i106-i14.
[6] Gaba DM, Howard SK, Flanagan B, Smith BE. Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Anesthesiology (Philadelphia).89(1).
[7] Flin R, O'Connor P, Flin R. Safety at the Sharp End: A Guide to Non- Technical Skills. Farnham: CRC Press LLC; 2016.
[8] Flin R, Patey R, Glavin R, Maran N. Anaesthetists' non-technical skills. British journal of anaesthesia: BJA.105(1):38-44.
[9] Doumouras AG, Hamidi M, Lung K, Tarola CL. Non-technical skills of surgeons and anaesthetists in simulated operating theatre crises. British journal of surgery.104(8):1028-36.
[10] University of Aberdeen. Non technical skills. (internet). 2012 (cited 2018 Nov 25); (18 pages) Available from: https://research.abdn.ac.uk/wpcontent/uploads/sites/14/2019/03/ANTS- Handbook-2012-1.pdf
[11] 11. University of Aberdeen. Non technical skills. (internet). 2012 (cited 2018 Nov 25); (18 pages) Available from: https://www.abdn.ac.uk/iprc/ants-ap/
[12] Blood transfusion working group. Guidelines to the management of massive blood loss. Mater Dei Hospital, Malta. 2012. Guideline number v01.0.
[13] World health organisation. Emergency and trauma care. (internet). 2016 (cited 2018 Nov 1); (2 screens). Available from: https://www.who.int/emergencycare/publications/trauma-care- checklist.pdf
[14] Difficult airway society. Difficult intubation guidelines. (internet). 2015 (cited 2018 Nov 1); (3 screens). Available from: https://das.uk.com/guidelines/das_intubation_guidelines
[15] Tobin JM, Grabinsky A, McCunn M, Pittet J. A Checklist for Trauma and Emergency Anesthesia. Anesthesia & Analgesia. 117(5):1178-84.
[16] DeVita MA, Schaefer J, Lutz J, Dongilli T. Improving medical crisis team performance. Critical Care Medicine.32(2): 61-65.
[17] Savoldelli GL, Naik VN, Hamstra SJ, Morgan PJ. Barriers to use of simulation-based education. Canadian journal of anesthesia.52(9):944- 50.
[18] DeCarlo D, Collingridge DS, Grant C, Ventre KM. Factors Influencing Nurses’ Attitudes toward Simulation-Based Education. Simulation in healthcare: Journal of the Society for Medical Simulation.3(2):90-6.
[19] Larsson J. Monitoring the anaesthetist in the operating theatre – professional competence and patient safety. Anaesthesia. 72(S1):76-83.
[20] Checketts MR, Alladi R, Ferguson K, Gemmell L. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 71(1):85-93.
[21] Frerk C, Mitchell VS, McNarry AF, Mendonca C. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British journal of anaesthesia: BJA.115(6):827-48.
[22] Guastello SJ. Nonlinear Dynamics of Team Performance and Adaptability in Emergency Response. Human Factors.52(2): 162–172.
[23] Zander AF. Making groups effective 2nd ed. San Francisco, CA, US: Jossey-Bass. 1994.
[24] Booth AWG, Vidhani K. Human factors can't intubate can't oxygenate
V. LIMITATIONS
The main limitations of this study were:
the small number of participants,
the study's geographical location, and
the participants’ exclusivity to the anaesthetic specialty.
The studied sample was representative of the local population of anaesthetists and nurses, currently employed at MDH. The small sample size and the fact that participants were working colleagues reduce the power of the study. Moreover, both the geographical location and the exclusion of other medical specialties may be misrepresentative of the ongoing practices in international hospitals. Further studies using larger participant numbers, diverse specialties, and varied medical facilities, would produce a broader picture of operating theatre practices during major trauma management.
The conducted study was not designed to gauge the long- term impact of NTS effectiveness. Although the NTS rater of the study received training in NTS facilitation and assessment, it is thought that 2 behavioural performance raters would have improved performance assessment; however this was considered unfeasible [6]. Furthermore, the NTS rater was not blinded and video recording was not used to re-evaluate NTS performances. Major trauma management is highly variable by nature. Due to time limitations, the 3 scenarios were simulated on the same day. Yet, the simulations conducted did mimic potential scenarios and provided an adequate platform for skill-set assessment. Conducting the study during real-life cases, in an actual operating theatre was not feasible.
VI. CONCLUSION
In conclusion, SBT exhibited NTS improvement in both anaesthetists’ and nurses’ performances. Additionally, SBT facilitated communication, leadership, cooperation and TW, improved safety during MTPM, which is fundamental to trauma resuscitation. The cumulative effect of multidisciplinary simulation training provided an environment to rehearse uncommon crises and reinforced understanding across disciplines. Yet more studies are required to evaluate time frames between simulations and skill retention. Further research is warranted to ascertain the usefulness of NTS simulation training in the clinical environment and its impact on patient management.
ACKNOWLEDGMENTS
The author wishes to thank the Department of Anaesthesia, Anaesthetic Nurses department and Simulation Centre, at Mater Dei Hospital. The author would also like to
(CICO) bundle is more important than needle versus scalpel debate.
British journal of anaesthesia: BJA.118(3):466-8.
[25] Koh RYI, Park T, Wickens CD. An investigation of differing levels of
experience and indices of task management in relation to scrub nurses’ performance in the operating theatre: Analysis of video-taped caesarean section surgeries. International Journal of Nursing Studies. 51(9):1230- 40.
[26] Gjerra K, Moller TP, Østergaard D. Efficacy of simulation-based trauma team training of non-technical skills. A systematic review. Acta Anaesthesiologica Scandinavica. 58(7):775-87.
[27] Georgiou A, Lockey DJ. The performance and assessment of hospital trauma teams. Scandinavian journal of trauma, resuscitation and emergency medicine.18(1):66-66.
[28] Draycott T, Sibanda T, Owen L, Akande V, Winter C. Does training in obstetric emergencies improve neonatal outcome? BJOG: An International Journal of Obstetrics & Gynaecology. 113(2):177-82.
[29] Rabøl LI, Østergaard D, Mogensen T. Outcomes of classroom-based team training interventions for multiprofessional hospital staff. A systematic review. Quality.19(6):e27-e.
[30] Gaba DM. Crisis resource management and teamwork training in anaesthesia. British journal of anaesthesia: BJA.105(1):3-6.
[31] Wisborg T, Castren M, Lippert A, Valsson F. Training trauma teams in the Nordic countries: an overview and present status. Acta anaesthesiologica Scandinavica. 2005;49(7).
[32] Holcomb JB, Dumire RD, Crommett JW, Stamateris CE. Evaluation of Trauma Team Performance Using an Advanced Human Patient Simulator for Resuscitation Training. The Journal of Trauma: Injury, Infection, and Critical Care. 52(6):1078-86.
[33] Marshall RL, Smith JS, Gorman PJ, Krummel TM. Use of a human patient simulator in the development of resident trauma management skills. The Journal of trauma. 51(1):17.
[1] Riem N, Boet S, Bould MD, Tavares W. Do technical skills correlate with non-technical skills in crisis resource management: a simulation study. British journal of anaesthesia: BJA.109(5):723-8.
[2] Boulet JR, Murray DJ. Simulation-based assessment in anesthesiology: requirements for practical implementation. Anesthesiology (Philadelphia). 112(4):1041-52.
[3] Lai A, Haligua A, Dylan Bould M, Everett T. Learning crisis resource management: Practicing versus an observational role in simulation training – a randomized controlled trial. Anaesthesia Critical Care & Pain Medicine. 35(4): 275-281.
[4] Bruppacher HR, Alam SK, LeBlanc VR, Latter D. Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery. Anesthesiology (Philadelphia). 112(4):985-92.
[5] Higham H, Baxendale B. To err is human: use of simulation to enhance training and patient safety in anaesthesia. British journal of anaesthesia: BJA.119:i106-i14.
[6] Gaba DM, Howard SK, Flanagan B, Smith BE. Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Anesthesiology (Philadelphia).89(1).
[7] Flin R, O'Connor P, Flin R. Safety at the Sharp End: A Guide to Non- Technical Skills. Farnham: CRC Press LLC; 2016.
[8] Flin R, Patey R, Glavin R, Maran N. Anaesthetists' non-technical skills. British journal of anaesthesia: BJA.105(1):38-44.
[9] Doumouras AG, Hamidi M, Lung K, Tarola CL. Non-technical skills of surgeons and anaesthetists in simulated operating theatre crises. British journal of surgery.104(8):1028-36.
[10] University of Aberdeen. Non technical skills. (internet). 2012 (cited 2018 Nov 25); (18 pages) Available from: https://research.abdn.ac.uk/wpcontent/uploads/sites/14/2019/03/ANTS- Handbook-2012-1.pdf
[11] 11. University of Aberdeen. Non technical skills. (internet). 2012 (cited 2018 Nov 25); (18 pages) Available from: https://www.abdn.ac.uk/iprc/ants-ap/
[12] Blood transfusion working group. Guidelines to the management of massive blood loss. Mater Dei Hospital, Malta. 2012. Guideline number v01.0.
[13] World health organisation. Emergency and trauma care. (internet). 2016 (cited 2018 Nov 1); (2 screens). Available from: https://www.who.int/emergencycare/publications/trauma-care- checklist.pdf
[14] Difficult airway society. Difficult intubation guidelines. (internet). 2015 (cited 2018 Nov 1); (3 screens). Available from: https://das.uk.com/guidelines/das_intubation_guidelines
[15] Tobin JM, Grabinsky A, McCunn M, Pittet J. A Checklist for Trauma and Emergency Anesthesia. Anesthesia & Analgesia. 117(5):1178-84.
[16] DeVita MA, Schaefer J, Lutz J, Dongilli T. Improving medical crisis team performance. Critical Care Medicine.32(2): 61-65.
[17] Savoldelli GL, Naik VN, Hamstra SJ, Morgan PJ. Barriers to use of simulation-based education. Canadian journal of anesthesia.52(9):944- 50.
[18] DeCarlo D, Collingridge DS, Grant C, Ventre KM. Factors Influencing Nurses’ Attitudes toward Simulation-Based Education. Simulation in healthcare: Journal of the Society for Medical Simulation.3(2):90-6.
[19] Larsson J. Monitoring the anaesthetist in the operating theatre – professional competence and patient safety. Anaesthesia. 72(S1):76-83.
[20] Checketts MR, Alladi R, Ferguson K, Gemmell L. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 71(1):85-93.
[21] Frerk C, Mitchell VS, McNarry AF, Mendonca C. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British journal of anaesthesia: BJA.115(6):827-48.
[22] Guastello SJ. Nonlinear Dynamics of Team Performance and Adaptability in Emergency Response. Human Factors.52(2): 162–172.
[23] Zander AF. Making groups effective 2nd ed. San Francisco, CA, US: Jossey-Bass. 1994.
[24] Booth AWG, Vidhani K. Human factors can't intubate can't oxygenate
V. LIMITATIONS
The main limitations of this study were:
the small number of participants,
the study's geographical location, and
the participants’ exclusivity to the anaesthetic specialty.
The studied sample was representative of the local population of anaesthetists and nurses, currently employed at MDH. The small sample size and the fact that participants were working colleagues reduce the power of the study. Moreover, both the geographical location and the exclusion of other medical specialties may be misrepresentative of the ongoing practices in international hospitals. Further studies using larger participant numbers, diverse specialties, and varied medical facilities, would produce a broader picture of operating theatre practices during major trauma management.
The conducted study was not designed to gauge the long- term impact of NTS effectiveness. Although the NTS rater of the study received training in NTS facilitation and assessment, it is thought that 2 behavioural performance raters would have improved performance assessment; however this was considered unfeasible [6]. Furthermore, the NTS rater was not blinded and video recording was not used to re-evaluate NTS performances. Major trauma management is highly variable by nature. Due to time limitations, the 3 scenarios were simulated on the same day. Yet, the simulations conducted did mimic potential scenarios and provided an adequate platform for skill-set assessment. Conducting the study during real-life cases, in an actual operating theatre was not feasible.
VI. CONCLUSION
In conclusion, SBT exhibited NTS improvement in both anaesthetists’ and nurses’ performances. Additionally, SBT facilitated communication, leadership, cooperation and TW, improved safety during MTPM, which is fundamental to trauma resuscitation. The cumulative effect of multidisciplinary simulation training provided an environment to rehearse uncommon crises and reinforced understanding across disciplines. Yet more studies are required to evaluate time frames between simulations and skill retention. Further research is warranted to ascertain the usefulness of NTS simulation training in the clinical environment and its impact on patient management.
ACKNOWLEDGMENTS
The author wishes to thank the Department of Anaesthesia, Anaesthetic Nurses department and Simulation Centre, at Mater Dei Hospital. The author would also like to
(CICO) bundle is more important than needle versus scalpel debate.
British journal of anaesthesia: BJA.118(3):466-8.
[25] Koh RYI, Park T, Wickens CD. An investigation of differing levels of
experience and indices of task management in relation to scrub nurses’ performance in the operating theatre: Analysis of video-taped caesarean section surgeries. International Journal of Nursing Studies. 51(9):1230- 40.
[26] Gjerra K, Moller TP, Østergaard D. Efficacy of simulation-based trauma team training of non-technical skills. A systematic review. Acta Anaesthesiologica Scandinavica. 58(7):775-87.
[27] Georgiou A, Lockey DJ. The performance and assessment of hospital trauma teams. Scandinavian journal of trauma, resuscitation and emergency medicine.18(1):66-66.
[28] Draycott T, Sibanda T, Owen L, Akande V, Winter C. Does training in obstetric emergencies improve neonatal outcome? BJOG: An International Journal of Obstetrics & Gynaecology. 113(2):177-82.
[29] Rabøl LI, Østergaard D, Mogensen T. Outcomes of classroom-based team training interventions for multiprofessional hospital staff. A systematic review. Quality.19(6):e27-e.
[30] Gaba DM. Crisis resource management and teamwork training in anaesthesia. British journal of anaesthesia: BJA.105(1):3-6.
[31] Wisborg T, Castren M, Lippert A, Valsson F. Training trauma teams in the Nordic countries: an overview and present status. Acta anaesthesiologica Scandinavica. 2005;49(7).
[32] Holcomb JB, Dumire RD, Crommett JW, Stamateris CE. Evaluation of Trauma Team Performance Using an Advanced Human Patient Simulator for Resuscitation Training. The Journal of Trauma: Injury, Infection, and Critical Care. 52(6):1078-86.
[33] Marshall RL, Smith JS, Gorman PJ, Krummel TM. Use of a human patient simulator in the development of resident trauma management skills. The Journal of trauma. 51(1):17.
@article{"International Journal of Medical, Medicine and Health Sciences:79558", author = "Velitchka Schembri Agius and Fiona Sammut and Tanya Esposito and Stephen Sciberras and John Mckenna", title = "A Study to Evaluate the Effectiveness of Simulation on Anaesthetic Non-Technical Skills in the Management of Major Trauma Patients", abstract = "Background: Dynamic, challenging instances during the management of major trauma patients requires optimal team intervention to ensure patient safety and effective crisis management. These factors highlight the importance of increased awareness in both technical and non-technical skills (NTS) training. Simulation based training (SBT) is an effective tool that replicates and teaches the required clinical skills, resulting in teamwork improvement, better patient safety, and care. Aims: This study investigates change in NTS, during the management of major trauma patients, using SBT. We also investigated the relationship between NTS performance and participation in previous NTS workshop (NTSW), years of experience, previous simulation (PS), previous exposure to major trauma patient management (MTPM) and group size. Methods: NTS behaviours were assessed by a single rater using previously validated framework for observing and rating Anaesthetists’ Non-Technical Skills (ANTS) for anaesthetists and Anaesthetic Non-Technical Skills for Anaesthetic Practitioners (ANTS-AP) for anaesthetic nurses during SBT. Two anaesthetists (one senior, one junior) together with one to four registered anaesthetic nurses formed 17 teams. The SBT consisted of 3 major trauma scenarios: 1) Major haemorrhage following multiple stab wounds to the torso, 2) Traumatic brain injury complicated by unanticipated difficult intubation, and 3) Penetrating neck injury with major haemorrhage, complicated by a failed intubation. The scores of each NTS category for each scenario are evaluated for significance in change and used to correlate whether NTS during the simulation were affected by previous NTSW, PS, previous exposure to MTPM and group size. Results: The resulting anaesthetists and anesthetic nurses’ p-values were < 0.05 indicating a significant improvement in all NTS resulting from score differences between scenarios 1 & 2 and 1 & 3. Anaesthetists’ NTS categories were not influenced by PS, previous NTSW, and exposure to MTPM. However, anaesthetic nurses NTS categories were influenced by PS, exposure to MTPM but not by NTSW. Conclusions: SBT has shown to be effective in improving the NTS for both anaesthetists and anaesthetic nurses. This enhances safety and team performance for MTPM. The impact of SBT in the clinical environment for patient management and safety warrants further research.", keywords = "simulation, major trauma, non technical skills, crisis management, teamwork", volume = "14", number = "4", pages = "109-7", }
