Fabrice Brunet, MD M.I.C.U-E.D Cochin, Paris C.C.D. St Michael’s, Toronto

1. Teamwork Training in Critical Care Fabrice Brunet, MD M.I.C.U-E.D Cochin, Paris C.C.D. St Michael’s, Toronto

2. Training in Critical Care • Education system in nursing and medicine give clinical skills to individuals • Superb individual skills do not guarantee effective team performance in care delivery • Effective teamwork does not arise spontaneously and needs behavior changes • Teaching of teamwork as integral in critical care is uncommon

3. Teamwork Training is: • A novel education model derived from aviation organisations • Designed to train professionals • Behavior-based teamwork course • Using Problem-based learning • Multidisciplinary groups • Formal training program

4. Teamwork training is not • An individual education system • Focused on clinical skills • Designed to teach students • A transdisciplinary training

5. Teamwork training: Rationale • C.C.Ds are at risk environments • Patients conditions are complex • Technologies are always evolving • Care needs multidisciplinary interactions • Consequences of errors are severe • Burn-out Syndrome is common

6. Teamwork training: Goals • Enhance department performance • Improve Quality of Patient Care • Reduce errors and litigation risks • Improve patients/relatives comfort • Develop multidisciplinary approach • Increase staff satisfaction and as a result retention and recruitment of staff

7. Teamwork system: a standardized program • Teaching teamwork behavior and skills • Designed for a « core team » • Group animation concept • Multidisciplinary teaching approach • Interactive teaching method • Topics selected on team needs

8. Organisation of seminars • Same team during the whole duration • A coordinator following the team • Multidisciplinary teachers • Location: outside/inside the I.C.U • Three kind of topics: medical, ethics, organisation • Methods of training: lectures, simulation, clinical situation

9. Methods of training • Expert lecture: state-of-the art adapted for a multidisciplinary audience: Evidence-based • Simulation: Workshop allowing to adjust recommendations to real practice and to define local protocols: Experience-based • Clinical situation: confrontation with current practice: Real life

10. Factors of success • Involvement of the Head of the C.C.D • Steering committee • Motivation of the team • Training of the teachers • Choice of appropriate topics • Financial support by the institution • Frequent reports of results

11. Evaluation • Evaluation of training itself • Questionnaire of satisfaction • Assessment of team performance • Evaluation of its results on practice • Implementation of new advances • Quality indicators • Analysis of adverse events

12. Performance assessment • Team and not individual performance • Measurement of performance indicators during repeated simulations S.O.C.E. • Assessment of team performance in clinical situations and novel techniques • Decrease of adverse events • Quality indicators: Audits and M.I.T

13. Protocol of bedside surgery in ARDS • Preparation before operation • Patient stabilization and information • Equipment verification • Team organization • Surgical procedure • Incision and Dissection of pleural adhesion • Insertion of chest tube • Pulmonary, pleural and cutaneous repair • Postoperative detection of surgical complications

14. Bedside surgery: Results 1. • Surgical procedure • Dissection of pleural adhesions 11 pts • Insertion of chest tube 3.4 ± 1.2 /BT (1-7) • Pulmonary repair 11 pts • Pulmonary biopsy 3 pts • Postoperative complications • Hemothorax 7 pts • Hemodynamic instability 2 pts • Septic shock 3 pts • Re-operation • Postoperative bleeding 4 pts • Persisting air leak / bleeding 8 pts

15. Bedside surgery: Results 2. • 66 bedside thoracotomies in 33 patients • Elective / emergency 45 / 21 • Indication • Pneumothorax / BPF 39 (59 %) • Hemothorax 27 (41 %) • Ventilatory support during thoracotomy • CMV 16 BT • ECCO2R 36 BT • HFO 12 BT • Partial liquid ventilation 2 BT • Intervention outcome • Resolution of PTX /HTX 41 (62 %) • Failure 25 (38 %) • Survival 15 (46.8 %)

16. Quality of care markers • Previously identified indicators • Time between admission and treatment • Patients or relatives satisfaction • Global cost of a care for given diseases • Followed in a C.Q.I approach • Evidence based protocols • Medical Information Technology • Case and disease management

17. Research Quality Education Care Communication

18. Continuous Quality Improvement Evidence- based Experience- based Continuing Measurements of indicators Protocols Corrections Dysfunctioning

19. Reduction of errors • Number of adverse events • Spontaneous report of human errors • Design of multidisciplinary protocols • Analysis of critical situation • Benchmarking with other C.C.Ds

20. Teamwork in restructuring E.Ds • Tested in Cochin ED with teamwork training • 4 seminars of 1 week each • Repeated for 4 teams (140 h / team / yr) • Evaluated by C.Q.I with M.I.T • Same program used in 3 other E.Ds • 1 pediatrician with adapted topics to children • 2 adults with adapted topics to environment

21. Teamwork in E.Ds: results • Successful introduction of a new organisation • Triage, Observation units • Electronic patient chart • Increased department and team performance • Reducing waiting time for each step of the circuit • Designing Fast tracks for severely patients • Improving patient and team satisfaction • Decrease in patient complaints • Increased attractiveness of the E.Ds

22. Perspectives • Develop multicenter international studies on teamwork training sytems in C.C.Ds • Implement teamwork training early in the course of medical and nursing education • Design new systems of training to improve transdisciplinary teams performance

23. A few references • Brennan TA et al: The nature of adverse events in hospitalized patients. N Engl J Med 1991;324:370-376. • Brennan TA et al: Hospital characteristics associated with adverse events and substandard care. JAMA 1991;264:3265-3269. • Classen DC et al: Computerized surveillance of adverse drug events in hospital patients. JAMA 1991;266:2847-2851. • Helmreich R: Managing human error in aviation. Sci Am 1997;5:62-67. • Leape L. Error in medicine. JAMA 1994;272:1851-1857. • Phillips K: The Power of Health Care Teams: Strategies for Success. Oakbrook, IL: Joint Commission on Accreditation of Health Care Organizations, 1997. • Risser DTet al: The potential for improved teamwork to reduce errors in the emergency department. Ann Emerg Med 1999;34:373-383.