253 - Team Reflexivity During Simulation in the Pediatric Emergency Department

Poster Number: 253
Publication Number: 253.418

Anisha Kshetrapal, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Mark D. Adler, Northwestern University The Feinberg School of Medicine, Chicago, IL, United States

Background: The pediatric emergency department (PED) is a complex clinical setting, characterized by high variability, complexity, and psychological demand. Emergency medicine teams must work together to provide high-quality, safe care. Ineffective teamwork contributes to error, perhaps more in high-demand, high-variability environments. Team reflexivity (TR) refers to the extent to which group members reflect on and communicate about the group's objectives, strategies, and processes, and has been suggested as a means to mitigate teamwork gaps. We piloted a simulation-based TR training intervention to investigate the effect of TR behaviors on performance.

Objective: To pilot a department-wide simulation program and evaluate how time spent in TR relates to outcome of simulated pediatric emergency cases.

Design/Methods: All pediatric emergency medicine faculty, nurses, and paramedics at a freestanding quaternary care children’s hospital were eligible to participate in a simulation program. The author observed and debriefed each simulation. Each simulation and debriefing was recorded and coded using the published team reflexivity behavioral observation (TuRBO) tool. Time dedicated to TR was measured across teams and simulation cases and was then compared to the time required to achieve the required case endpoint. Debriefings were coded using reflexive thematic analysis.

Results: Thirteen multidisciplinary teams participated in two simulated cases; one trauma and one cardiac arrest. Time in TR was highly variable, ranging from 2.1 to 8.3 minutes, with a median of 4.3 minutes. Time to clinical outcome varied from 3.3 to 5.9 minutes, with a median of 4.5 minutes. Increased time spent in TR reduced time to clinical outcome (r = 0.55) across teams and cases. This relationship was stronger in the cardiac arrest case (r = 0.63) than the trauma case (r = 0.44). 
Team members reported challenges and strengths experienced during these simulations. Strengths included overall clinical experience within the team, specifically that of the nurses, use of closed-loop communication, and camaraderie within the team. Challenges included noting the different resources that would be present in a clinical case rather than a simulated case, as well as participant experience in simulation or lack thereof. Conclusion(s): In this pilot, increased TR behaviors decreased time to clinical outcome. Limitations include that TR does not include information-sharing, and the small sample size of this study. Further study is required to understand the role of TR in team performance in acute patient care.
Relationship between time in TR and time to endpoint