1. LDI SUMR Symposium
August 11th, 2011
Characteristics of an ad hoc LIVE eye Video Review:
trauma resuscitation team An analysis of
and patient outcomes clinician involvement
Mentor: Dr. Maureen McCunn Mentors: Dr. Jose Pascual-Lopez;
Anesthesiology and Critical Care Dr. Joseph Sakran
Traumatology, Surgical Critical Care,
and Emergency Surgery
Emmanuel Martinez Alcaraz
The College of New Jersey

2. Agenda
I. LIVE eye: SICU Study Overview
II. Characterization of ad hoc team:
Trauma Bay Study Overview
III.Lessons Learned

3. LIVE eye Video Review: An analysis
of clinician involvement
Mentors:
Dr. Jose Pascual-Lopez;
Dr. Joseph Sakran
HUP Department of Traumatology,
Surgical Critical Care,
and Emergency Surgery

4. LIVE eye: SICU Study
Overview
Using video in SICU rooms to evaluate
the extent of clinician’s interaction with
nurses, patients, and family members

5. Too many TLAs*
ICU
*Dr. Rob Burns
Intensive Care Unit
Other
SICU MICU NICU specialties
Surgical Medical Neurosurgical Neonatal

6. Surgical
What is a SICU? Intensive
 Area where patients who need constant attention for Care
life threatening conditions are cared for
Unit
 SICU pre- and post-operative recovery for critical
patients
 Multi-disciplinary team
 Beginnings stem from advancements in critical care:
 Patient triage, infection-control
 Artificial ventilation & its automation
 Resuscitation, anesthesiology

7. Research Process*
*Simplified

8. Aims of Study
 Video record events (procedures/emergent) when a Nurse
Practitioner or Physician is needed: e.g. central line
 Part of other observational studies — use same video
 Analyze extent of clinician interaction
 Based on latest research literature, determine if factors that could
affect the following are present:
 Links between communication and patient outcomes & satisfaction2,3
 Links between nurses’ and other co-workers’ job satisfaction,
collaboration, and decision-making inclusion; hospital hierarchies4,5,6
2. Baggs, JG, et.al., 1999. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine, 27, pp. 1991-1998.
3. Wheelan, Susan A., et.al., 2003. The Link Between Teamwork and Patient’s Outcomes in Intensive Care Units. American Journal of Critical Care, 12, pp. 527-534.
4. Baggs, JG, et.al., 1997. Nurse-physician collaboration and satisfaction with the decision-making process in three critical care units. American Journal of Critical Care, 6, pp. 393-399.
5. Larson, Elaine, et.al., 1999. The Impact of Physician-Nurse Interaction on Patient Care. Holistic Nursing Practice, 13, pp. 38-46.
6. Manthous, C.A., et.al., 2011. Team Science and Critical Care. American Journal of Respiratory and Critical Care Medicine, 184, pp.17-25.

9. Study Population &
Data Collection Methods
 HUP Rhodes 5 SICU care providers and patients
 All are consented to participate
 Use existing eICU system with real-time patient
monitoring
 Bedside nurse hits eICU button in room
 UPHS eICU team receives request
 Receive phone call from eICU to commence
 Record live-video through eICU room cameras and
real-time patient vital signs w/ secure computer

10. Methodology
 Checklist to evaluate the extent of clinician’s interaction:
 Reason for clinician request: e.g. respiratory issues
 Did eICU team intervene?
 If and how the clinician speaks w/ nurse, patient, & visitors
 What the clinician does: e.g. performs physical examination
 If patient has specific intervention, does the clinician evaluate it:
e.g. patient has a central line, clinician does not evaluate it
 Whether and to whom does the clinician verbalizes a plan of action?

11. What does it look like?

12. Significance
Methodology Topic
 New use of video analysis  Provide insight on the extent
in ICU patient rooms clinicians interaction with nurses,
patients, and family members —
 Previous studies focus on
interactions outside of real behaviors
 Patient/family satisfaction;
patient rooms7, non-
Patient/family anxiety10
emergent activities (ICU
 Other observations while study is in
rounds)8, or in the trauma
progress
bay9
7. Carroll, Katherine, 2009. Outsider, insider, alongsider: Examining reflexivity in hospital-based video research. International Journal of Multiple Research Approaches, 3, pp.
246-263.
8. Carroll, Katherine, et.al., 2008. Reshaping ICU Ward Round Practices Using Video-Reflexive Ethnography. Qualitative Health Research, 18, pp. 380-390.
9. Lubbert, Pieter H.W., et.al., 2009. Video Registration of Trauma Tram Performance in the Emergency Department: The Results of a 2-Year Analysis in a Level 1 Trauma
Center. The Journal of Trauma, 67, pp. 1412-1420.
10. Azoulay, Elie, et.al., 2000. Half the families of intensive care unit patients experience inadequate communication with physicians. Critical Care Medicine, 28, pp. 3044-3049.

13. Characteristics of an ad hoc trauma
resuscitation team and patient outcomes
Mentor:
Dr. Maureen McCunn
HUP Department of
Anesthesiology and Critical Care

14. Trauma Bay Research
Overview
Identify characteristics and qualities of high
functioning teams in the trauma bay
Then, whether they affect patient outcome
Using two instrument-questionnaires

15. What is unique about
work in the trauma bay?

16. Characteristics of Trauma Bay
 Part of a Trauma Network
 PENNStar Flight program
 In-house trauma surgeons & ED
physicians, trauma nurses, & others
 Most seriously injured patients
 Wide range: from car crashes to assaults
 High intensity environment
 Access to multi-disciplinary teams
 e.g. Anesthesia, orthopedics, neurosurgery

17. Research Process*
*Simplified

18. Aims of Study
 Determine how ad hoc team functioning and team
dynamics affect patient outcome
 Pilot Study: Identify characteristics of high functioning
teams in the trauma bay
 Subgroup analyses of responses of different team member
positions: nurse, resident, fellow, attending
 Long-term: Develop a training model for physician,
nurse, and student trauma team members
 To foster collaboration and teamwork6,11,12,13, and to improve
patient outcomes2,3
2. Baggs, JG, et.al., 1999. Association beteen nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine, 27, pp. 1991-1998.
3. Wheelan, Susan A., et.al., 2003. The Link Between Teamwork and Patient’s Outcomes in Intensive Care Units. American Journal of Critical Care, 12, pp. 527-534.
6. Manthous, C.A., et.al., 2011. Team Science and Critical Care. American Journal of Respiratory and Critical Care Medicine, 184, pp.17-25.
11. Keenan, G.M., et.al., 1998. Management of Conflicts: Keys to Understanding Nurse-Physician Collaboration. Research in Nursing & Health, 21, pp. 59-72.
12. Bergs, E.A.G., et.al., 2005. Communication during trauma resuscitation: do we know what is happening?. International Journal of the Care of the Injured, 36, pp. 905-911.
13. Maxson, Pamela M., et.al., 2011. Enhancing Nurse and Physician Collaboration in Clinical Decision Making Through High-fidelity Interdisciplinary Simulation Training.
Mayo Clinic Proceedings, 86, 31-36.

19. Model for Study
 An ad hoc crisis group:
 Team comes together for this one time, interacts in a high-
intensity environment, then disperses
 Seek to determine the characteristics of this group that
are not part of a fixed team
 Trauma evaluation is measurable since:
 Everyone should know their role and everyone else’s role.

20. Specific Aim #1 & Background
 To assess the views of collaboration of trauma team
members
 Better patient outcome has been associated with better
nurse-physician collaboration2,3
 Pilot Study showed a disparity between team members
(nurses, attendings, fellows, residents) in perceived
composition of the trauma team (McCunn)
 The role a team hierarchy6 plays in the functioning of a
trauma team and patient outcome
2. Baggs, JG, et.al., 1999. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine, 27, pp.
1991-1998.
3. Wheelan, Susan A., et.al., 2003. The Link Between Teamwork and Patient’s Outcomes in Intensive Care Units. American Journal of Critical Care, 12, pp. 527-
534.
6. Manthous, C.A., et.al., 2011. Team Science and Critical Care. American Journal of Respiratory and Critical Care Medicine, 184, pp.17-25.

21. Methods to Evaluate Aim #1
Assessment Tool: Collaboration and Satisfaction
About Care Decisions Instrument (CSACD)
Has been used to measures physician-nurse
collaboration and satisfaction
Originally used in the ICU  has been adapted for
use in the trauma bay
Validity and reliability metrics have been
established13,14
13. Maxson, Pamela M., et.al., 2011. Enhancing Nurse and Physician Collaboration in Clinical Decision Making Through High-fidelity Interdisciplinary Simulation Training.
Mayo Clinic Proceedings, 86, 31-36.
14. Baggs, Judith Gedney, 1994. Development of an instrument to measure collaboration and satisfaction about care decisions. Journal of Advanced Nursing, 20, 176-182.

22. Wheelan’s Integrated Model of
Group Development
 Implies a team has been working together for an
extended period of time
 Gradual linear development through 4 stages
 Stage 1: Dependency and inclusion
 Stage 2: Counterdependency and fight
 Stage 3: Trust and structure
 Stage 4: Work

23. Specific Aim #2 & Background
 To determine if ad hoc trauma teams exhibit the four
stages of group development
 If teams exhibit the same developmental characteristics of fixed
groups
 One marker of a high-functioning group  common goal
 Groups at last stage of development experience a time of
intense team productivity and effectiveness
 Focus its energy on goal achievement and task accomplishment

24. Methods to Evaluate Aim #2
Group Development Questionnaire (GDQ)
Integrated Model: Groups move through stages of
development as they continue to work together
Measures members’ perceptions of clarity of group
goals, individual goals, effectiveness of conflict-
resolution, and other quantifiable small group
characteristics
Extensively tested for both validity and reliability;
used in many industries including healthcare7
7. Wheelan, Susan A., et.al., 2003. The Link Between Teamwork and Patient’s Outcomes in Intensive Care Units. American Journal
of Critical Care, 12, pp. 527-534.

25. Subject Population — Recruitment
 Population: Trauma team members
 Nurses, attendings, fellows, residents, and ED techs
 Site: Hospital of the University of Pennsylvania trauma
bay
 By completing survey, a member consents to participate
in this research protocol
 Team member and group demographics will be collected
along with each instrument

26. Methods of Data Collection
 Team members are asked to fill questionnaire
following a resuscitation
 Responses are collected with the other team members
in the group for the respective resuscitation
 Subjects may participate in more than one survey if
they are a member of multiple resuscitation teams
 Each member will be given a Participant Information
Sheet
 By completing survey, a member consents to participate in
this research protocol

28. Significance
Methodology Patient Care
 1st time either  High stakes environment:
Collaboration and team leadership,
communication, and
Group Development
collaboration  vital
Questionnaires are used
 Characteristics of team with
in Trauma Bay teams
better outcomes
 Develop training model for
future care givers

29. Trauma Bay Study—Summary
 The composition and high-intensity characteristics of
trauma teams create a unique environment for group
dynamics & development.
 Using two separate instruments to:
 1) Assess views of collaboration of trauma team members
 2) Determine if ad hoc team exhibit the four stages of group development
 Studies will elucidate the characteristics of trauma
resuscitation teams and patient outcomes
 Help develop a research-based training model for trauma bay nurses,
physicians, technicians, and students

30. Lessons Learned
 Role of camera: empowering or disempowering for
participants
 Importance of the way video is incorporated in a hospital setting
 Video: capture actual behavior rather than simplified behavior
 Fine line between video use as a surveillance and objectification
method, and use as quality improvement
 Difficulty of administering questionnaires in trauma bay
 Difficulties of their repeated use
 Patience with the research process

31. Acknowledgements
Mentors UPenn LDI TCNJ, Friends & Family
 Dr. Maureen McCunn,  Joanne Levy, Lissy  My mom, dad, and
Dr. Jose Pascual-Lopez, Madden, Megan brother Luis
Dr. Joseph Sakran Pellegrino, Hoag  Krupa Jani
HUP
Levins, and rest of LDI  Christine Scaduto
 Dr. Chris Burchill, Emily
 All the SUMR Scholars!  TCNJ Mentors:
Bohm, Mary Hammond,
Totem Poles! Dr. Michelle Bunagan
Carole McMonagle and
rest of Anesthesiology &  All orientation & and Dr. Rachel Adler
CC Department, Trauma luncheon academic  All my other
Center teams presenters supportive friends
 Trauma fellows and the
 Other supporters of the  My Lions’ EMS Squad
rest of the LIVE eye Team,
LDI SUMR program
the entire Rhodes 5 SICU

32. References
1. Studdert, David M., et.al., 2003. Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors. Intensive
Care Medicine, 29, pp. 1489-1497.
2. Carroll, Katherine, 2009. Outsider, insider, alongsider: Examining reflexivity in hospital-based video research. International Journal of
Multiple Research Approaches, 3, pp. 246-263.
3. Carroll, Katherine, et.al., 2008. Reshaping ICU Ward Round Practices Using Video-Reflexive Ethnography. Qualitative Health Research,
18, pp. 380-390.
4. Lubbert, Pieter H.W., et.al., 2009. Video Registration of Trauma Tram Performance in the Emergency Department: The Results of a 2-
Year Analysis in a Level 1 Trauma Center. The Journal of Trauma, 67, pp. 1412-1420.
5. Azoulay, Elie, et.al., 2000. Half the families of intensive care unit patients experience inadequate communication with physicians.
Critical Care Medicine, 28, pp. 3044-3049.
6. Baggs, JG, et.al., 1999. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical
Care Medicine, 27, pp. 1991-1998.
7. Wheelan, Susan A., et.al., 2003. The Link Between Teamwork and Patient’s Outcomes in Intensive Care Units. American Journal of
Critical Care, 12, pp. 527-534.
8. Baggs, JG, et.al., 1997. Nurse-physician collaboration and satisfaction with the decision-making process in three critical care units.
American Journal of Critical Care, 6, pp. 393-399.
9. Larson, Elaine, et.al., 1999. The Impact of Physician-Nurse Interaction on Patient Care. Holistic Nursing Practice, 13, pp. 38-46.
10. Manthous, C.A., et.al., 2011. Team Science and Critical Care. American Journal of Respiratory and Critical Care Medicine, 184, pp.17-25.
11. Keenan, G.M., et.al., 1998. Management of Conflicts: Keys to Understanding Nurse-Physician Collaboration. Research in Nursing &
Health, 21, pp. 59-72.
12. Bergs, E.A.G., et.al., 2005. Communication during trauma resuscitation: do we know what is happening?. International Journal of the
Care of the Injured, 36, pp. 905-911.
13. Maxson, Pamela M., et.al., 2011. Enhancing Nurse and Physician Collaboration in Clinical Decision Making Through High-fidelity
Interdisciplinary Simulation Training. Mayo Clinic Proceedings, 86, 31-36.
14. Baggs, Judith Gedney, 1994. Development of an instrument to measure collaboration and satisfaction about care decisions. Journal of
Advanced Nursing, 20, 176-182.