ObjectivesThe goal of this study was to examine the relationship between measured teamwork and adverse safety events in the prehospital emergency care of children using high-fidelity simulation. We posit that non-technical skills such as leadership, teamwork, situation awareness and decision-making are associated with the clinical success of teams.DesignObservational study.SettingEmergency medical services (EMS) responders were recruited from public fire and private transport agencies in Oregon State to participate in four simulations of paediatric emergencies using high-fidelity patient simulators, scene design, and professional actors playing parents and bystanders.ParticipantsForty-four fire/transport teams consisting of 259 EMS professionals consented to participate and completed simulations.Primary and secondary outcome measuresTeams were assessed using the Clinical Teamwork Scale (CTS), a validated instrument that measures overall teamwork and 15 specific elements in five overarching domains: communication, decision-making, role responsibility (leadership and followership), situational awareness/resource management and patient-friendliness. We used generalised estimating equations to estimate the odds of error with increasing overall CTS teamwork score while adjusting for clinical scenario and potential clustering by team.ResultsAcross 176 simulations, the mean overall score on the CTS was 6.04 (SD 2.10; range 1=poor to 10=perfect) and was normally distributed. The distribution of scores was similar across the four clinical scenarios. At least one error was observed in 82% of the simulations. In simulations with at least one observed error, the mean CTS score was 5.76 (SD 2.04) compared with 7.16 (SD 1.95) in scenarios with no observed error. Logistic regression analysis accounting for clustering at the team level revealed that the odds of an error decreased 28% with each unit increase in CTS (OR 0.72, 95% CI 0.59 to 0.88).ConclusionsThis study found that overall teamwork among care delivery teams was strongly associated with the risk of serious adverse events in simulated scenarios of caring for critically ill and injured children.

BackgroundThe purpose of this study was to characterize implicit gender bias among residents in US Emergency Medicine and OB/GYN residencies.MethodsWe conducted a survey of all allopathic Emergency Medicine and OB/GYN residency programs including questions about leadership as well as an implicit association test (IAT) for unconscious gender bias. We used descriptive statistics to analyze the Likert-type survey responses and used standard IAT analysis methods. We conducted univariate and multivariate analyses to identify factors that were associated with implicit bias. We conducted a subgroup analysis of study sites involved in a multi-site intervention study to determine if responses were different in this group.ResultsOverall, 74% of the programs had at least one respondent. Out of 14,234 eligible, 1634 respondents completed the survey (11.5%). Of the five sites enrolled in the intervention study, 244 of 359 eligible residents completed the survey (68%). Male residents had a mean IAT score of 0.31 (SD 0.23) and females 0.14 (SD 0.24), both favoring males in leadership roles and the difference was statistically significant (p < 0.01). IAT scores did not differ by postgraduate year (PGY). Multivariable analysis of IAT score and participant demographics confirmed a significant association between female gender and lower IAT score. Explicit bias favoring males in leadership roles was associated with increased implicit bias favoring males in leadership roles (r = 0.1 p < 0.001).ConclusionsWe found that gender bias is present among US residents favoring men in leadership positions, this bias differs between male and female residents, and is associated with discipline. Implicit bias did not differ across training years, and is associated with explicit bias.

IntroductionEfforts to improve the quality of emergency medical services (EMS) care for adults with out-of-hospital cardiac arrest (OHCA) have led to improved survival over time. Similar improvements have not been observed for children with OHCA, who may be at increased risk for preventable adverse safety events during prehospital care. The purpose of this study is to identify patient and organisational factors that are associated with adverse safety events during the EMS care of paediatric OHCA.Methods and analysisThis is a large multisite EMS study in the USA consisting of chart reviews and agency surveys to measure, characterise and evaluate predictors of our primary outcome severe adverse safety events in paediatric OHCA. Using the previously validated Paediatric prehospital adverse Event Detection System tool, we will review EMS charts for 1500 children with OHCA from 2013 to 2019 to collect details of each case and identify severe adverse safety events (ASEs). Cases will be drawn from over 40 EMS agencies in at least five states in geographically diverse areas of the USA. EMS agencies providing charts will also be invited to complete an agency survey to capture organisational characteristics. We will describe the frequency and proportion of severe ASEs in paediatric OHCA across geographic regions and clinical domains, and identify patient and EMS organisational characteristics associated with severe ASEs using logistic regression.Ethics and disseminationThis study has been approved by the Oregon Health & Science University Institutional Review Board (IRB Approval# 00018748). Study results will be disseminated through scientific publications and presentations, and to EMS leaders and staff through local EMS medical directors, quality and training officers and community engagement activities.

Purpose To determine whether a brief leadership curriculum including high-fidelity simulation can improve leadership skills among resident physicians. Method This was a double-blind, randomized controlled trial among obstetrics–gynecology and emergency medicine (EM) residents across 5 academic medical centers from different geographic areas of the United States, 2015–2017. Participants were assigned to 1 of 3 study arms: the Leadership Education Advanced During Simulation (LEADS) curriculum, a shortened Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum, or as active controls (no leadership curriculum). Active controls were recruited from a separate site and not randomized to limit any unintentional introduction of materials from leadership curricula. The LEADS curriculum was developed in partnership with the Council on Resident Education in Obstetrics and Gynecology and Council of Residency Directors in Emergency Medicine as a novel way to provide a leadership toolkit. Both LEADS and the abbreviated TeamSTEPPS were designed as six 10-minute interactive web-based modules. The primary outcome of interest was the leadership performance score from the validated Clinical Teamwork Scale instrument measured during standardized high-fidelity simulation scenarios. Secondary outcomes were 9 key components of leadership from the detailed leadership evaluation measured on 5-point Likert scales. Both outcomes were rated by a blinded clinical video reviewer. Results One hundred ten obstetrics–gynecology and EM residents participated in this 2-year trial. Participants in both LEADS and TeamSTEPPS had statistically significant improvement in leadership scores from “average” to “good” ranges both immediately and at the 6-month follow-up, while controls remained unchanged in the “average” category throughout the study. There were no differences between LEADS and TeamSTEPPS curricula with respect to the primary outcome. Conclusions Residents who participated in a brief structured leadership training intervention had improved leadership skills that were maintained at 6-month follow-up.

ImportanceMortality from pediatric out-of-hospital cardiac arrest (OHCA) is high and has not improved in decades, unlike adult mortality. The low frequency of pediatric OHCA and weight-based medication and equipment needs may lead to lower quality of pediatric resuscitation compared with adults.ObjectiveTo compare the quality of pediatric and adult resuscitation from OHCA in a controlled simulation environment and to evaluate whether teamwork, knowledge, experience, and cognitive load are associated with resuscitation performance.Design, Setting, and ParticipantsThis cross-sectional in-situ simulation study was conducted between September 2020 and August 2021 in the metropolitan area of Portland, Oregon, and included engine companies from fire-based emergency services (EMS) agencies.ExposuresParticipating EMS crews completed 4 simulation scenarios presented in random order: (1) adult female with ventricular fibrillation; (2) adult female with pulseless electrical activity; (3) school-aged child with ventricular fibrillation; and (4) infant with pulseless electrical activity. All patients were pulseless on EMS arrival. Data were captured by the research team in real time during the scenarios.Main outcomes and measuresThe primary outcome was defect-free care, which included correct cardiopulmonary resuscitation depth, rate, and compression to ventilation ratio, time to bag-mask ventilation, and time to defibrillation, if applicable. Outcomes were determined by direct observation by an experienced physician. Secondary outcomes included additional time-based interventions and the use of correct medication doses and equipment size. We measured teamwork using the clinical teamwork scale, cognitive load with the National Aeronautics and Space Administration task load index (NASA-TLX), and knowledge using advanced life support resuscitation tests.ResultsAmong the 215 clinicians (39 crews) who participated in 156 simulations, 200 (93%) were male, and the mean (SD) age was 38.7 (0.6) years. No pediatric shockable scenario was defect free and only 5 pediatric nonshockable scenarios (12.8%) were defect free, while 11 (28.2%) adult shockable scenarios and 27 adult nonshockable scenarios (69.2%) were defect free. The mental demand subscale of the NASA-TLX was higher in the pediatric compared with the adult scenarios (mean [SD] pediatric score, 59.1 [20.7]; mean [SD] adult score, 51.4 [21.1]; P = .01). Teamwork scores were not associated with defect-free care.Conclusions and RelevanceIn this simulation study of OHCA, resuscitation quality was significantly lower for pediatric than adult resuscitation. Mental demand may have been a contributor.

Centered Research and Reviews (JPCRR) is a peer-reviewed scientific journal whose mission is to communicate clinical and bench research findings, with the goal of improving the quality of human health, the care of the individual patient, and the care of populations.

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Background The efficacy of pre-hospital emergency services is heavily dependent on the effective communication of care providers. This effective communication occurs between providers as part of a team, but also among providers interacting with family members and patients. The COVID-19 pandemic introduced a number of communication challenges to emergency care, which are primarily linked to the increased use of PPE. Methods We sought to analyze the impacts of the Covid-19 pandemic on Emergency Medical Service (EMS) workers and pre-hospital care delivery. We conducted focus groups and one-on-one interviews with fire-EMS first responders between Sept 2021 and 2022. Interviews included questions about job related stress, EMS skills, work experiences and changes during Covid-19. Interviews were recorded, independently dual coded, and analyzed for themes. Results 223 first responders participated in 40 focus groups and 40 lead paramedics participated in individual interviews. We found that additional use of personal protective-equipment (PPE) was reported to have significantly impaired efficiency and perceptions of quality of care—among EMS team members and also between EMS workers and patients. EMS personnel also experienced on scene hostility on arrival (from both families and other agencies). Use of extensive PPE muffles voices, obscures facial expressions, and can cause team members to have difficulty recognizing and communicating with one another and can be a barrier to showing empathy and connecting with patients. Creative solutions such as putting a hand on someone’s shoulder, wearing name tags on suits, and explaining rationale for perceived delays were mentioned as methods to transcend these barriers. The appearance of providers in heavy PPE can be unsettling and create barriers to human connection, particularly for pediatric patients. Conclusion Human connection is an important element of health care delivery and healing. These findings shed light on new skills that are needed to initiate and maintain human connection in these times of PPE use, especially full body PPE. Awareness of the communication and empathy barriers posed by PPE is the first step to improving provider-patient interactions in pre-hospital EMS. Additionally, ‘communication-friendly’ adaptations of PPE equipment may be an important area for future research and development in manufacturing and the healthcare industry.