Jamie Shandro

Alcohol and Risk of Mortality in Patients With Traumatic Brain Injury

BACKGROUND Laboratory and clinical studies demonstrate inconsistent findings on the effect of alcohol on traumatic brain injury (TBI) outcome. The purpose of this study is to use a comprehensive trauma database to determine whether blood alcohol concentration (BAC) is associated with mortality in patients with TBI. METHODS DESIGN Cohort study. SETTING Eighteen trauma centers and 51 nontrauma centers in the United States. PATIENTS A total of 1,529 patients aged 18 years to 84 years of age admitted to hospital with TBI between July 2001 and November 2002. EXPOSURE BAC assessed in the index hospital emergency department. OUTCOME Mortality in-hospital, 90 and 365 days after injury. RESULTS After adjusting for confounding variables, there was no significant difference for in-hospital, 90-day, and 365-day mortality by BAC. CONCLUSIONS When fully adjusted for injury severity, alcohol intoxication is not associated with significantly lower mortality after TBI. The trend toward lower mortality at higher BACs prompts questions about the complex interaction of alcohol and TBI, and warrants further investigation of the possible protective effect of alcohol.

Leadership training in health care action teams: a systematic review.

Purpose To identify and describe the design, implementation, and evidence of effectiveness of leadership training interventions for health care action (HCA) teams, defined as interdisciplinary teams whose members coordinate their actions in time-pressured, unstable situations. Method The authors conducted a systematic search of the PubMed/MEDLINE, CINAHL, ERIC, EMBASE, PsycINFO, and Web of Science databases, key journals, and review articles published through March 2012. They identified peer-reviewed English-language articles describing leadership training interventions targeting HCA teams, at all levels of training and across all health care professions. Reviewers, working in duplicate, abstracted training characteristics and outcome data. Methodological quality was evaluated using the Medical Education Research Study Quality Instrument (MERSQI). Results Of the 52 included studies, 5 (10%) focused primarily on leadership training, whereas the remainder included leadership training as part of a larger teamwork curriculum. Few studies reported using a team leadership model (2; 4%) or a theoretical framework (9; 17%) to support their curricular design. Only 15 studies (29%) specified the leadership behaviors targeted by training. Forty-five studies (87%) reported an assessment component; of those, 31 (69%) provided objective outcome measures including assessment of knowledge or skills (21; 47%), behavior change (8; 18%), and patient- or system-level metrics (8; 18%). The mean MERSQI score was 11.4 (SD 2.9). Conclusions Leadership training targeting HCA teams has become more prevalent. Determining best practices in leadership training is confounded by variability in leadership definitions, absence of supporting frameworks, and a paucity of robust assessments.

A Systematic Review of Tools Used to Assess Team Leadership in Health Care Action Teams.

Purpose To summarize the characteristics of tools used to assess leadership in health care action (HCA) teams. HCA teams are interdisciplinary teams performing complex, critical tasks under high-pressure conditions. Method The authors conducted a systematic review of the PubMed/MEDLINE, CINAHL, ERIC, EMBASE, PsycINFO, and Web of Science databases, key journals, and review articles published through March 2012 for English-language articles that applied leadership assessment tools to HCA teams in all specialties. Pairs of reviewers assessed identified articles for inclusion and exclusion criteria and abstracted data on study characteristics, tool characteristics, and validity evidence. Results Of the 9,913 abstracts screened, 83 studies were included. They described 61 team leadership assessment tools. Forty-nine tools (80%) provided behaviors, skills, or characteristics to define leadership. Forty-four tools (72%) assessed leadership as one component of a larger assessment, 13 tools (21%) identified leadership as the primary focus of the assessment, and 4 (7%) assessed leadership style. Fifty-three studies (64%) assessed leadership at the team level; 29 (35%) did so at the individual level. Assessments of simulated (n = 55) and live (n = 30) patient care events were performed. Validity evidence included content validity (n = 75), internal structure (n = 61), relationship to other variables (n = 44), and response process (n = 15). Conclusions Leadership assessment tools applied to HCA teams are heterogeneous in content and application. Comparisons between tools are limited by study variability. A systematic approach to team leadership tool development, evaluation, and implementation will strengthen understanding of this important competency.

Parental Injury and Psychological Health of Children

OBJECTIVE: To determine how parental injury affects the psychological health and functioning of injured as well as uninjured children. METHODS: We recruited 175 parent-child dyads treated at a regional trauma center in 4 groups: parent and child both injured in the same event, child-only injured, parent-only injured, and neither parent nor child met criteria for significant injury. The preinjury health and functioning of parents and children were assessed with follow-up at 5 and 12 months. RESULTS: Parents who were injured themselves showed higher levels of impairment in activities of daily living, quality of life, and depression at both follow-up assessments than parents who were not injured. Children in dyads with both parent and child injured had the highest proportion of posttraumatic stress disorder (PTSD) symptoms at both 5 and 12 months. In addition, children with an injured parent but who were not injured themselves were more likely to report PTSD symptoms at 5 months. CONCLUSIONS: There were bidirectional effects of parental and child injury on the outcomes of each other. Injuries to the parent negatively affected the health-related quality of life of the injured children, over and above the effect of the injury itself on the child. Of great concern is the effect of parental injury on risk of stress and PTSD among uninjured children in the home.

A Novel Approach to Medical Student Peer-assisted Learning Through Case-based Simulations

Introduction Peer-assisted learning (PAL) is the development of new knowledge and skills through active learning support from peers. Benefits of PAL include introduction of teaching skills for students, creation of a safe learning environment, and efficient use of faculty time. We present a novel approach to PAL in an emergency medicine (EM) clerkship curriculum using an inexpensive, tablet-based app for students to cooperatively present and perform low-fidelity, case-based simulations that promotes accountability for student learning, fosters teaching skills, and economizes faculty presence. Methods We developed five clinical cases in the style of EM oral boards. Fourth-year medical students were each assigned a unique case one week in advance. Students also received an instructional document and a video example detailing how to lead a case. During the 90-minute session, students were placed in small groups of 3–5 students and rotated between facilitating their assigned cases and participating as a team for the cases presented by their fellow students. Cases were supplemented with a half-mannequin that can be intubated, airway supplies, and a tablet-based app (SimMon,

Board 407 - Research Abstract Simulation-Based Healthcare Leadership Training: A Systematic Review (Submission #1186)

22.99) to remotely display and update vital signs. One faculty member rotated among groups to provide additional assistance and clarification. Three EM faculty members iteratively developed a survey, based on the literature and pilot tested it with fourth-year medical students, to evaluate the course. Results 135 medical students completed the course and course evaluation survey. Learner satisfaction was high with an overall score of 4.6 on a 5-point Likert scale. In written comments, students reported that small groups with minimal faculty involvement provided a safe learning environment and a unique opportunity to lead a group of peers. They felt that PAL was more effective than traditional simulations for learning. Faculty reported that students remained engaged and required minimal oversight. Conclusion Unlike other simulations, our combination of brief, student-assisted cases using low-fidelity simulation provides a cost-, resource- and time-effective way to implement a medical student clerkship educational experience.

Pilot case-control study of paediatric falls from windows.

Introduction/Background Effective team leadership is associated with improved healthcare team performance and patient care.1,2 Team science research supports training leaders in a setting that emulates the team and work environment.3 Immersive simulation can facilitate such training. The aim of this systematic review is to synthesize the leadership training literature, focusing on the following questions: 1) What simulation-based curricular interventions have been used to train team leadership in healthcare teams?; 2) What specific behaviors have been targeted by simulation-based healthcare team leadership curricula?; 4) What evidence exists to support the effectiveness of simulation-based team leadership training? Methods The authors conducted a systematic review, searching the following databases PubMed/MEDLINE, CINAHL, ERIC, EMBASE, PyscINFO and Web of Science as well as hand searching key journals and review articles. Original research articles were included if they utilized simulation to train team leadership in a healthcare action team. eviewers working independently, and in duplicate, abstracted data in four domains: 1) study characteristics, 2) participant demographics, 3) leadership definitions and 4) training curriculum characteristics. Three additional data domains were extracted for studies that contained an evaluation component: 1) assessment design, 2) evidence of validity and 3) outcomes measured.4 Results Forty two studies met inclusion criteria. The majority of studies were published after 2006 (n=36). The most common study design was a single group pre and post-test (n=15), followed by randomized control trials (n=11). The majority of studies trained physicians or medical students (n=40) from a wide range of medical specialties. Half of the studies trained nurses or nursing students (n=21). Most studies described interventions that included training intact teams (n=32). Four articles reported leadership training as the primary objective of their curricula, while the remainder trained general teamwork with a leadership component. Only one study cited a team leadership model. Discrete leadership behaviors were explicitly mentioned in 12 studies, including three of the four studies that focused on leadership. When reported, leadership behaviors were heterogeneous and included planning-related behaviors (e.g., task delegation, information gathering), action processes (e.g., monitoring progress, coordinating actions) and interpersonal skills (e.g., effective communication, conflict management). Most of the reviewed studies (n=21) reported using or modifying a training program previously reported in the literature. The most commonly referenced programs included Crisis Resource Management (n=15) a set of principles rather than a single curriculum and TeamSTEPPS (n=4). Among the entire cohort of 42 studies, only nine explicitly mentioned using a theoretical framework to direct the development of their curricular intervention. These frameworks included experiential learning, deliberate practice, reflective learning, self-efficacy theory, cognitive modeling and theory of probabilistic functionalism. The impact of the training was assessed in 35 of the 42 studies reviewed. One study assessed leadership as a primary outcome, while 19 assessed teamwork with a leadership component. Twenty one studies reported at least one objective measure of training effectiveness, most frequently the acquisition of knowledge or skills (n=17), which was assessed via written tests (n=6) and/or direct observation of simulation-based care (n=15). Transfer of behavioral change to the clinical setting was assessed via observation of live patient care in three studies. Patient or system level outcomes were reported in four studies. Conclusion This review highlights the role of simulation in leadership training and identifies gaps in healthcare team leadership research. There is a clear need for researchers to develop, test and adopt leadership frameworks and behavioral taxonomies that can support the development and assessment of leadership curricula. Concurrently, there is a need for training assessments that target multiple outcome levels. This work will promote the identification of leadership training characteristics that support transfer of learning, team effectiveness and ultimately, healthcare quality. References 1. Yeung JHY, Ong GJ, Davies RP, Gao F, Perkins GD. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Critical Care Medicine. 2012;40(9):2617-2621. 2. Hunziker S, Johansson AC, Tschan F, et al. Teamwork and Leadership in Cardiopulmonary Resuscitation. Journal of the American College of Cardiology. 2011;57(24):2381-2388. 3. Kozlowski SWJ, Gully SM, Salas E, Cannon-Bowers JA. Team leadership and development: Theory, principles, and guidelines for training leaders and teams. In: Beyerlein MM, Johnson DA, Beyerlein ST, eds. Advances in interdisciplinary studies of work teams: Team leadership. Vol 3. US: Elsevier Science/JAI Press; 1996:253-291. 4. Kirkpatrick DL. Evaluation of training. In: Craig RL, Bittel LR, eds. Training and Development Handbook. 2nd ed. New York: McGraw-Hill; 1967:87-112. Disclosures None.

Human trafficking: a guide to identification and approach for the emergency physician

Background Unintentional falls from windows are an important cause of paediatric morbidity. There have been no controlled studies to identify modifiable environmental risk factors for window falls in young children. The authors have piloted a case–control study to test procedures for case identification, subject enrolment, and environmental data collection. Methods Case windows were identified when a child 0–9 years old presented for care after a fall from that window. Control windows were identified (1) from the childs home and (2) from the home of an age- and gender-matched child seeking care for an injury diagnosis not related to a window fall. Study staff visited enrolled homes to collect window measurements and conduct window screen performance tests. Results The authors enrolled and collected data on 18 case windows, 18 in-home controls, and 14 matched community controls. Six potential community controls were contacted for every one enrolled. Families who completed the home visit viewed study procedures positively. Case windows were more likely than community controls to be horizontal sliders (100% vs 50%), to have deeper sills (6.28 vs 4.31 inches), to be higher above the exterior surface (183 vs 82 inches), and to have screens that failed below a threshold derived from the static pressure of a 3-year-old leaning against the mesh (60.0% vs 16.7%). Case windows varied very little from in-home controls. Discussion Case–control methodology can be used to study risk factors for paediatric falls from windows. Recruitment of community controls is challenging but essential, because in-home controls tend to be over-matched on important variables. A home visit allows direct measurement of window type, height, sill depth, and screen performance. These variables should all be investigated in subsequent, larger studies covering major housing markets.