Journal of Pediatric Surgery (2008) 43, 1065–1071
www.elsevier.com/locate/jpedsurg
Multidisciplinary pediatric trauma team training
using high-fidelity trauma simulation
Richard A. Falcone Jr ⁎, Margot Daugherty, Lynn Schweer, Mary Patterson,
Rebeccah L. Brown, Victor F. Garcia
Division of Pediatric and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA
Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
Received 30 January 2008; accepted 9 February 2008
Key words:
Trauma;
Teamwork;
Simulation;
Crew resource
management;
Performance improvement
Abstract
Background: Trauma resuscitations require a high level of team performance. This study evaluated the
impact of a comprehensive effort to improve trauma care through multidisciplinary education and the
use of simulation training to reinforce training and evaluate performance.
Methods: For a 1-year period, expanded trauma education including monthly trauma simulation
sessions using high-fidelity simulators was implemented. All members of the multidisciplinary trauma
resuscitation team participated in education, including simulations. Each simulation session included
2 trauma scenarios that were videotaped for debriefing as well as subsequent analysis of team
performance. Scored simulations were divided into early (initial 4 months) and late (final 4 months)
for comparison.
Results: For the first year of the program, 160 members of our multidisciplinary team participated in the
simulation. In the early group, the mean percentage of appropriately completed tasks was 65%, whereas
in the late group, this increased to 75% (P b .05). Improvements were also observed in initial
assessment, airway management, management of pelvic fractures, and cervical spine care.
Conclusions: Training of a multidisciplinary team in the care of pediatric trauma patients can be
enhanced and evaluated through the use of high-fidelity simulation. Improvements in team performance
using innovative technology can translate into more efficient care with fewer errors.
© 2008 Elsevier Inc. All rights reserved.
Injury is the leading cause of pediatric mortality and its
optimal management requires a highly functioning multidisciplinary team. Clear and efficient team function is
essential to improve patient safety and reduce errors in the
Presented at the 59th Annual Meeting of the Section on Surgery,
American Academy of Pediatrics, San Francisco, CA, October 25-27, 2007.
⁎ Corresponding author. Division of Pediatric and Thoracic Surgery,
Cincinnati Children's Hospital Medical Center, Cincinnati, OH 452293039, USA. Tel.: +1 513 636 4371; fax: +1 513 636 7657.
E-mail address: [email protected] (R.A. Falcone Jr).
0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2008.02.033
high-paced and high-stress environment of a trauma
resuscitation [1-3]. Crew resource management (CRM)
training has been shown to be an effective method to
improve team function, originally in aviation and more
recently in health care [4-6]. In aviation, improved communication among all team members as a result of CRM training
has contributed significantly to the observed reduction in
accidents [7,8]. Key aspects of team function contributing to
improvements have been situation awareness shared by all
members, problem identification with input from all team
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R.A. Falcone Jr et al.
Fig. 1
Sample trauma multidisciplinary team simulation evaluation tool.
High-fidelity trauma simulation
1067
Fig. 1 (continued).
members, shared decision making, workload distribution
with assigned tasks, time management, and conflict resolution among team members [9]. Achieving a high level of
team function requires both education of team members as
well as a commitment to a culture change within an
institution [6,10-12].
High-fidelity simulators have been extensively used in
aviation and the military to improve performance [13,14]. As
a consequence of improving technology, high-fidelity human
patient simulators are playing an increasing role in training
health care professionals [15-17]. Training health care
providers to manage trauma resuscitations using simulation
has been demonstrated to be feasible for individuals as well
as for evaluating specific teams before and after a training
period [18-23].
In an effort to continually improve the functioning of the
teams caring for our pediatric trauma patients, we have
emphasized the importance of team organization and
communication during all trauma orientations and educational activities, as well as developed a core trauma nursing
team. To complement these efforts, we have implemented a
2-hour trauma simulation training program that emphasizes
CRM training techniques to improve team performance. This
training is the first that we are aware of to simultaneously
train and evaluate a multidisciplinary team of providers in the
care of injured children. The current study was therefore
designed to evaluate the effectiveness of our multidisciplinary trauma training program on team performance for the
first year of its implementation.
Fig. 2 Overall team performance comparing early (first 4
months) with late (last 4 months) of simulations.
and mortality conference, monthly videotape review, and
quarterly pediatric trauma grand rounds. In addition, a core
group of nurses received increased training and education in
pediatric trauma. This trauma core nursing team participated
in a web-based core curriculum and monthly trauma lectures.
To complement all of these activities, 2-hour trauma
simulation sessions were developed to reinforce education,
provide a safe environment to practice the care of an injured
child, and a consistent environment in which to evaluate
team performance and provide feedback.
For these simulation sessions, trauma scenarios were
developed based upon actual cases previously evaluated and
treated at our level I pediatric trauma center. The 3 standard
scenarios used for the 1-year time frame of this study
included an infant with head injury, a child with a penetrating
wound to the back, and an adolescent with multitrauma
including an unstable pelvic fracture. All 3 scenarios were
developed to evaluate team performance in recognizing and
achieving specific goals of the resuscitation. Particular
1. Methods
For a 1-year study period, an emphasis on team function
and communication was incorporated into all trauma
education activities including resident orientation, morbidity
Table 1 Multidisciplinary team members participating in
simulated trauma sessions
No. of participants
Pediatric surgery faculty
Emergency medicine faculty
Surgical/pediatric residents
Nurses (23 trauma core nurses)
Critical care fellows
Paramedics
Respiratory therapists
Total
11
7
72
60
4
2
4
160
Fig. 3 Comparison of task achievements in specific domains
between the early (first 4 months) and late (final 4 months) of the study.
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Fig. 4 Comparison of overall performance in early and late
simulation sessions and team performance on the first or second
trauma patient scenario of the session.
attention was paid to the initial assessment, airway management, cervical spine precautions, and the identification and
management of injuries such as pelvic fracture and increased
intracranial pressure. All simulations were performed on
high-fidelity human patient simulators, SimBaby, Pedia-Sim,
and SimMan (Medical Educational Technologies Incorporated, Sarasota, Fla), in a dedicated simulation suite with
complete video recording capabilities. Although key aspects
of each scenario were kept consistent to ensure reliability of
ongoing assessments, minor variations were added to reduce
familiarity with the scenarios by participants.
Before each 2-hour simulation session, participants were
provided with an online education module emphasizing the
core concepts of crew resource management and teamwork.
Each team then participated in 2 of the 3 trauma scenarios.
Each scenario lasted for approximately 20 minutes and
included initial assessment through disposition from the
trauma bay. After each scenario, formal debriefing with
video review was performed, generally lasting 30 minutes.
Debriefing emphasized team performance and communication and also reinforced appropriate care principles for the
management of the injured child.
All pediatric and surgical house staff rotating on
the pediatric surgical service were required to participate in
a 2-hour simulation session at the beginning of their rotation.
In addition, all pediatric surgical faculty participating in
trauma call responsibilities were required to participate in at
least one session annually. To create a realistic multidisciplinary team composition, emergency medicine faculty
and fellows, critical care fellows, trauma core nurses,
paramedics, and respiratory therapists all participated in
these trauma simulation sessions. This training was in
addition to Advanced Trauma Life Support and Trauma
Nurse Core Course that all surgical staff and trauma core
nurses, respectively, had completed before the start of the
study period. Members of these multiple disciplines made up
the teams of 4 to 7 individuals for each trauma scenario.
For evaluation of trauma teams for the 1-year period, team
performance during simulation was compared during the first
4 months of the study, the early group, with those from the last
R.A. Falcone Jr et al.
4 months of the study, the late group. Videos from the
simulated scenarios were reviewed and scored by 2 expert
reviewers. Reviewers were blinded as to whether the videos
came from the early or late group. Each scenario was scored
using a scoring sheet based on a previously published scoring
method [19] and adapted with input from a multidisciplinary
team specifically for our scenarios (Fig. 1). The analysis tool
placed an emphasis on objective measurements to improve
reliability. Intraclass correlation between the 2 reviewers was
0.7 that demonstrates a high level of reliability. To allow
comparison between specific scenarios, scoring for each
scenario was scaled up so that the best obtained score was
100% for each scenario.
Initial analysis evaluated the overall team score comparing
the early group with the late group using paired t tests with P
b .05 considered significant. Subsequent analyses were
performed to further understand the differences between the
2 time frames. Tasks were grouped into categories based on
specific portions of the trauma evaluation. An initial
assessment score was developed based on 7 individual scored
elements, and an airway management score was developed
comprising 9 individual-scored elements. In addition, management of cervical spine and pelvic fracture were looked at to
evaluate specific injury assessments. Achievement of 80% or
more of possible points for each of these areas was considered
satisfactory achievement. Finally, to evaluate changes
between the team performance during the first and second
scenario of a simulation session, overall scores were stratified
by both scenario timing and early vs late session. Comparisons of these groups were made using analysis of variance
with Bonferroni correction. All statistical analyses were
performed using SAS v9.1 (SAS Institute Inc, Cary, NC).
This study was approved by the institutional review
board (IRB) at Cincinnati Children's Hospital Medical
Center (Cincinatti, Ohio) (IRB no. 04-08-26x). The current
study was stimulated by an ongoing teamwork training
curriculum in the emergency department funded by Agency
for Healthcare Research and Quality (AHRQ) grant (U18
HS15841 01).
2. Results
For the 12-month period, a total of 23 two-hour multidisciplinary trauma simulation sessions were conducted in
addition to didactic trauma education. These sessions
involved 160 individuals from multiple domains of the
trauma care team (Table 1). The average team consisted of
6 members. Teams were led by a surgical faculty, emergency
medicine faculty, or senior surgical resident. The distribution
of team leaders was consistent throughout the study period.
The trauma core nurses were the only individuals to
participate in greater than one session, with an average
of nearly 3 sessions per participant. During the initial
12 months, a total of 46 individual-simulated trauma scenarios were performed.
High-fidelity trauma simulation
Comparing the early (first 4 months) to the late (last 4
months), there was a significant improvement in overall
performance as determined by the percentage of possible
appropriate and timely care measures achieved (Fig. 2). To
understand the underlying improvements leading to the
overall team performance improvement, specific phases of
the resuscitations were compared between the early and late
groups (Fig. 3). Criteria assessing skills related to airway
management, initial trauma assessment, cervical spine
precautions, and pelvic fracture recognition and management all showed evidence of improvement over the time of
the study.
During the individual 2-hour trauma simulation session,
each team managed 2 trauma patient scenarios. By looking at
overall performance stratified by both early and late session
group as well as team score for their first or second scenario,
we saw the expected sequential improvement (Fig. 4). Not
only did we observe improvements for individual teams
progressing from their first simulated scenario to their second
scenario in both the early and late groups, but we also saw an
improvement in the first scenario of the late group compared
to performance on either scenario in the early group. These
results demonstrated not only immediate improvement as a
result of feedback during the initial debriefing but also
improvement over time as a consequence of the multifaceted
educational initiatives and culture change.
3. Discussion
As a consequence of a hospital-wide commitment to
quality and improving safety, we have expanded our trauma
education initiatives including the addition of multidisciplinary trauma simulation training and evaluation. Previous
reports of simulation training have demonstrated improvements of individuals, teams of surgeons only, and previously
established military teams [18-21,23]. In most trauma centers
however, resuscitations are managed by a complex team
made up of trauma surgeons, emergency medicine physicians, residents, nurses, respiratory therapists, and possibly
others throughout the hospital. This interdisciplinary team,
often unfamiliar with each other, must function efficiently
within a highly dynamic and stressful trauma situation. This
study demonstrates improvement of trauma performance
among a complex and varied team through a combination of
traditional teaching techniques and the use of high-fidelity
simulation training of complex teams to reinforce and
evaluate improvements.
For a 1-year period, emphasis has been placed on team
performance and communication during all aspects of trauma
education among a multidisciplinary audience. High-fidelity
simulated trauma team training was used to complement
these activities as well as measure team performance. As a
consequence of this approach, we have observed both
subjective and objective improvements in team performance.
Data from evaluation of team performance during standar-
1069
dized trauma simulation scenarios reveal that teams are
performing more efficiently and appropriately during
sequential simulated trauma scenarios as well as demonstrating overall improvement during the 1-year evaluation period.
The improvements are apparent not only for overall
performance but also when specific domains of the
resuscitation are examined.
Although the overall commitment to education played an
important role in measured improved performance, the role of
simulation training cannot be underestimated. First, simulator
training has previously been demonstrated to improve an
individual's confidence in managing specific medical or
surgical problems [4,10,11,24]. Although specific evaluation
of team member confidence was not directly measured in the
current study, participants including residents and faculty
routinely provided positive feedback after participation in
simulated scenarios. Second, improved team communication
has been demonstrated to improve overall team performance
in many previous reports [12,17,25]. As reported in the
Institute of Medicine (Washington, DC) report on patient
safety, communication among health care providers is a key
aspect in improving safety [1,3]. Similar to other institutions,
our medical center has made a hospital-wide commitment to
improving safety and communication. Through all of our
educational endeavors, team communication skills were
emphasized. Important aspects that were emphasized for
trauma resuscitations included the importance of a defined
team leader, a shared mental model by all participants, and the
ability of any team member to question the plan or raise
concerns during the resuscitation. Emphasis on these topics
was a result of not only their demonstrated importance in
crew resource management training [9] but also the result of
our own review of multiple previous trauma resuscitations at
our institution. Simulated scenarios provided a safe environment for team members to practice these skills.
An important aspect of the observed improvements in
performance is related to our trauma core nursing team. At
least one member of this group of 23 nurses responds to
trauma resuscitations 24 hours a day. In addition to their
increased training, these nurses have been empowered to
increase their leadership role in the care of the injured child.
The importance of such specially trained nurses in the care of
injured patients has been previously demonstrated in both the
resuscitation bay [26] and throughout the hospital stay
[27,28]. Their consistent presence in the trauma bay was
replicated by their increased participation during simulated
scenarios and likely contributed to the observed improved
team performance.
Although this study has demonstrated a measurable
improvement in trauma team performance during simulated
scenarios, there are several limitations that require further
investigation. The current study was not designed to
concentrate on the impact of simulation alone as there
were several simultaneous changes that may have resulted in
the measured improvements. There have, however, been
multiple previous studies that have demonstrated the impact
1070
of simulation training in isolation[15,18,29,30]. The simulated environment provided a safe environment to practice
and reinforce effective communication and care of the
injured child by team members and was therefore likely a key
factor in improving overall team performance. An additional,
though unmeasured, benefit of the simulation training was to
allow rotating residents to be fully introduced to our trauma
system and culture of safety and communication in a
consistent and nonthreatening manner.
A further limitation of the current study is that the impact
of the demonstrated improvements during simulations has
not yet been studied and evaluated during actual trauma
resuscitations. Although demonstrating improvements in the
care of real children is the ultimate goal, the variability and
inconsistency of actual trauma scenarios make it quite
challenging to demonstrate measurable improvements in
overall performance for short periods. It is reasonable,
however, to predict that measured improvement in the
simulated environment will convert to improvements in the
real environment as has been observed in aviation.
In addition to continuing our current trauma education
program, expansion of our simulation team training to
include management of multiple simultaneous resuscitations,
operating room resuscitations, and mass casualty events is
necessary. Furthermore, use of simulation in the actual
trauma bay not only to improve team function but also to
help identify real-life safety threats has already begun at our
institution. The current study not only supports the use of
high-fidelity human patient simulation as a key component
of trauma team education but also demonstrates for the first
time, the importance and feasibility of training a complex
multidisciplinary team to improve performance in the care of
the injured child.
Acknowledgment
The authors would like to thank the simulator staff at
Cincinnati Children's Hospital (Cincinatti, Ohio), in
particular Mike Moyer, Brian Pio, and Tom Lemaster for
their expertise and dedication to trauma simulation. We
would also like to thank all of the participants throughout
the hospital who continue to improve for the benefit of
injured children.
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Discussion
Michael Hirsch, MD (Worcester, MA): I think this was a great
study; and very interesting to see team training done this
way. I have 2 questions for you: the high-fidelity
mannequin that you've been using, do you think that it
could be substituted with something potentially less
costly? Could a volunteer patient do the job? Or do you
think that the mannequin itself is critical to the study? Also,
have you ever used videotaping of live resuscitations?
Rebeccah Brown, MD (response): Those are very good
questions. I think the trauma simulators that we use
indeed are quite expensive; and in certain situations where
perhaps places can't afford such simulators, I think
probably using a live person in order to do those
resuscitations would probably be very good. I think it's
really the communication and teamwork that we're really
trying to achieve in improving our trauma resuscitations.
Yes, we videotape all of our trauma resuscitations in our
trauma bay. We review those trauma resuscitations and
our hope is that with incorporating the trauma simulator
sessions and that transmits to improved performance on
our actual trauma resuscitations in the trauma bay. And
we'll evaluate that.
Max Langham, MD (Memphis, TN): I would like to applaud
both your group and the program committee for putting
this paper on the program. I think it provides us a look at
1071
technology that may in fact be very important in the
100,000 live campaigns to reduce medical errors and
improve all of our performance.
One of the things that I wanted to ask about, which
is a little bit subtle, is that you intermingle the terms
team and crew. I think that, in fact, the idea of crew
resource management in the aviation industry, is exactly
what we deal with on a day-to-day basis when we show
up for trauma resuscitation or when we go to the OR, in
that we have a group of people who all have assigned
roles. But it is not a team like my son's soccer team that
practices together day after day after day with a single
team working. When we make our call schedules, we
don't look at nursing call schedules; we don't look at
RT call schedules. We don't look at anesthesia call
schedules. So the specific question is during your
training, do you work on the initial step in crew
resource management that the aviation guys talk about,
is a specific crew assignment and crew brief/debrief for
the group that will be in the batter's box on that day for
that resuscitation? And how would you advise us to
organize our crews, since I think that very few of us
will have a team that's consistent day in and day out
within our organizations?
Rebeccah Brown, MD (response): I appreciate your
comments. I think that indeed in our own trauma
resuscitations, that one of the problems is consistency of
trauma team members. One of the most important
things that we've implemented recently is the development of a trauma core nursing team. It's hard to have a
trauma core anesthesiologist and respiratory therapist
and all of those. But at each trauma resuscitation, there
is a trauma core nurse that has been highly trained in
trauma and has a commitment to trauma. That has
helped to improve consistency.
Certainly during our simulator sessions, we have
debriefing before and after the sessions in which we talk
about roles and assign roles during that time. I think that,
although you're not going to have the same team for every
trauma resuscitation, by carrying out the simulator
sessions, you become more familiar with those roles. I
think it helps improve team function.