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Abstract
Introduction: Trauma is the leading cause of under-45 mortality worldwide, and the leading cause of years of life lost. To manage the severe trauma patients, trauma teams require both improved technical and nontechnical skills, such as communication, leadership, teamwork, and team resource management. The objective of this study was to measure the impact of the identification of trauma team members on teamwork performance. The hypothesis was that wearing identification jackets was associated with better teamwork performance. Methods: The study was conducted from 2015 to 2019 at the Percy Army Training Hospital, a trauma center in the Ile-de-France region. In 2016, the protocol for receiving severe trauma patients was modified, including the obligation to wear identification jackets. Thus, each member of the trauma team wore a jacket identifying his or her function. This study was carried out by analyzing videos of medical simulation sessions during the reception of trauma patients in the trauma bay. The study compared the teamwork performance before 2016, a period with no identification jackets wearing, with the teamwork performance after 2016, a period with identification jackets wearing. The Team Emergency Assessment Measure (TEAM) Scale was used. This TEAM scale is a benchmark measure of teamwork performance, particularly adapted to the context of trauma. Results: A total of 48 participants were included in the study. Six videos of medical simulation sessions “arrival of severe trauma patients” were analyzed and divided into two groups. A first group of three videos with no identification jackets wearing was the GROUP ID(-). A second group of three videos with identification jackets wearing was the GROUP ID(+). An 11-item TEAM scale was used to rate each video for a total of 33 scores per group. The distribution of the median scores for the GROUP ID(+) was significantly different from the distribution of the median scores for the GROUP ID(-) (P = 0.001). These results were consistent with those of other single-center studies conducted in operating theaters and in emergency departments, where clearly identifying the roles of each member of the medical teams was associated with less communication errors. The main limits of this study were its single-center nature and a limited data sample. Conclusion: In this single-center simulation study, wearing identification jackets was associated with an improvement in the trauma team performance TEAM scores. Further studies are needed to confirm these results but they already encourage the consideration of nontechnical skills in the management of severe trauma patients.
Keywords: Communication, human factors organization, medical simulation, nontechnical skills, trauma
How to cite this article: Introduction 
Trauma is the leading cause of death among the under-45s in worldwide, and the leading cause of years of life lost.[1] The management of severe trauma patients is a major public health challenge.[2] Facing this issue, Davenport et al. showed that the management of severe trauma patients in a trauma center was associated with better outcomes, as compared to management in a nontrauma center multidisciplinary hospital.[3],[4] The Advanced Trauma Life Support (ATLS) has proposed a specific training course focused on the trauma team, as well as an algorithm for the initial management of severe trauma patients based on the Airway Breathing Circulation Disability Exposure (ABCDE) principle. In the ABCDE algorithm, management of severe trauma patients requires dedicated technical skills.[5] However, the efficacy of the trauma team requires also nontechnical skills. Thus, an effective communication, the use of checklists, the assertion of leadership, the quality of decision making by the trauma leader, and the quality of the feedback to this decision-making by followers are essential elements to improve patient safety.[6],[7] Among all the nontechnical skills required for the management of severe trauma patients, ATLS recommended that each team member be clearly identified. The ATLS recommended that the trauma leader introduce him/herself to the whole team: “Introduce yourself and make sure that all team members know that you are the team leader. Ask team members to introduce themselves when they arrive.”[8] Nontechnical skills have been already evaluated in several clinical situations. For example, in operating theater setting, communication errors were highlighted in 30% of the discussions between the surgical, anesthetic, and nurses teams.[9] Thus, poor quality communication is associated with an increased risk of medical error, with potentially serious consequences for the patient.[10] Using the names of colleagues would be associated with a decreased risk of communication errors and a better productivity and team cohesion.[11] In trauma setting, a study observed communication between members of the trauma team, during the initial management of severe trauma patients. Among 74 cases taken into care, verbal exchanges were deemed audible in only 39/74 of cases (56%), and clear in 31/74 of cases (44%).[12] Finally, in a review of 60 cases each resulting in harm to patients, ambiguity about responsabilities was a common associated factor (73%).[13] Regarding technical skills in trauma, dedicated simulation-based training of the trauma teams improves their performance.[14] Regarding nontechnical skills, some evidence exists but the effect on patient outcome remains unclear due to the lack of high-level studies.[15] Yet, nontechnical skills continue to account for the majority of medical errors.[16],[17] As far as we know, there is no study to date describing the data of communication and identification among trauma team members. The aim of this study was to measure the impact of identifying each trauma team member on teamwork performance. The hypothesis was that wearing identification jackets was associated with better trauma teamwork performance scores.
Methods The study was carried out from 2015 to 2019 at the Percy Army Training Hospital, Clamart, France. The Percy Army Training Hospital is a trauma center receiving around 300 civilian and military severe trauma patients per year. In 2016, the protocol for the reception of severe trauma patients at Percy Army Training Hospital was modified. The wearing of identification jackets was added. Thus, each member of the trauma team wears now an identification jacket, clearly identifying his or her function, medical and paramedical [Figure 1]. Twice a year, the Emergensim team organized in situ high-fidelity simulation sessions in the Percy Army Training Hospital's trauma bay. The aim of these high-fidelity simulation sessions is to train the local trauma teams to perform initial management of severe trauma patients. The in situ medical simulation in the trauma center makes it possible to train for the reception of severe trauma patients in conditions close to reality, in the same locations, with the same equipment, and according to the same procedures that in real-life experience. During these in situ simulation sessions, the trauma team would therefore receive a call from the Emergency Medical Services announcing the severe trauma patient's arrival and specifying his pre-hospital conditions. After a preparation time, the trauma team welcomed the patient in the trauma bay. Depending on the scenario concerned, surgeons and medical electro-radiology manipulators could also take part in the simulation session. A high-fidelity model (Laerdal USA® SIM MAN 3G®, USA, Wappingers Falls, NY, USA, LLEAP®, Laerdal Learning Application) was used in each medical simulation session.[18] The members of the different trauma teams were not aware of the scenario before participating. Video cameras, installed before the start of the scenario, filmed all the simulation sessions. Written consent was obtained prior to participation in the medical simulation session. At the end of each medical simulation session, the instructors realized a structured debriefing with all the participants.
Figure 1: Example of an identification jacket: The trauma leader identification jacketThe objective of the study was to compare the teamwork performance of trauma teams with no identification jackets wearing GROUP ID(-), before 2016; with the teamwork performance of trauma teams with identification jackets wearing, GROUP ID(+), after 2016.
Videos of high-fidelity in situ simulation sessions conducted between 2015 and 2019 were analyzed to compare the teamwork performance of GROUP ID(-), with that of GROUP ID(+). The Team Emergency Assessment Measure (TEAM) scale was used to assess the performance of teamwork.[19],[20] The TEAM scale is an observation and assessment tool designed to evaluate the nontechnical skills of trauma teams, when receiving severe trauma patients. The TEAM scale is a validated reference scale for measuring teamwork performance in a trauma context. A systematic review of assessment tools in resuscitation scenarios and trauma context, has validated the TEAM scale as being the most appropriate tool, associated with improved validity, reliability, and less risk of bias.[21] The TEAM scale consists of 11 assessment items with three subgroups: leadership (two items), teamwork (seven items) and task management (two items). Each item is scored between zero (never/almost never), one (rarely), two (about half the time), three (often), and four (always/almost always). The total TEAM score can vary from zero to 44. In addition to this total TEAM score, an overall score (item 12) of the trauma team nontechnical performance is given for each team, which may vary from 1 to 10.
Video analysis
First, two independent researchers analyzed the medical simulation videos and used the TEAM scale to assess the teamwork performance of the participants in each medical simulation session. The two independent researchers were anonymous. They did not have any knowledge of the trauma team members. An online training has allowed the researchers to use the TEAM scale. Incomplete medical simulation videos and/or those involving incomplete trauma teams were excluded from the analysis. A total of three simulation videos with identification jackets wearing and three simulation videos with no identification jackets wearing were analyzed [Figure 2]. Second, a panel of 13 students of the postgraduate diploma in anesthesia and intensive care were interviewed. These 13 participants did not previously know any of the members of the trauma teams involved in the medical simulation sessions videos. All of them analyzed the three medical simulation videos with no identification jackets wearing. The 13 participants had to note, for each of these three medical simulation videos, the length of time between the beginning of the medical simulation video and the time of identification of each member of the trauma team.
Figure 2: Flow chart: GROUP ID(−) with no identification jackets wearing; GROUP ID(+) with identification jackets wearingStatistical analyses
For the statistical analysis, the software R. version 3.6.2 (R foundation for Stastistical Computing, vienna, austria) was used. In the first part, the TEAM scale with 11 items was used to evaluate the six medical simulation videos. A second part described the identification times of the different trauma team members involved in the three medical simulation videos with no identification jacket wearing. Means and medians were used to describe the TEAM scores and the identification times. The Mann–Whitney test was used for comparison between the two groups. The Kruskal–Wallis test was used when there were three or more groups (such as items, participants, videos). The significance level was set at P ≤ 0.05. The nonparametric Mann–Whitney U-test was used to test the hypothesis that the data distribution was the same for both groups. Student's t-test was not used due to limited data.
Ethics
This study received approval from a Local Ethics Committee (Comité d'Ethique de la Recherche en Anesthésie et Réanimation; SFAR; Paris, France) under the number IRB 00010254-2019-194.
Results A total of 48 participants were included in the study. [Table 1] describes the six medical simulation videos analyzed. In each medical simulation video, the trauma team was complete, with a total of eight members: One senior anesthesiologist-intensivist, one anesthesia-intensive care unit (ICU) resident, one certified registered nurse anesthetist (CRNA), two registered nurses, one scribe, one surgical senior, and one surgical resident.
The median of the TEAM scale scores of both GROUP ID(-) and GROUP ID(+) was equal to 3. The mean TEAM scale score for GROUP ID(-) and GROUP ID(+) were 2.57 and 3.21 respectively. Even though the median TEAM score was equal in both groups, the distribution of the TEAM score in the GROUP ID(-) was between 2 and 3, compared between 3 and 4 in the GROUP ID(+), P < 0.001, [Figure 3]. [Figure 4] shows the results of the overall TEAM score, i.e., the sum of the 11 items for each medical simulation video. Of note, the TEAM scores of GROUP ID(+) were higher than those of GROUP ID(-). [Table 2] shows the minimum, maximum, mean, and median times (expressed in seconds) between the start of the medical simulation video and the identification of all trauma team members, for the three medical simulation videos in which identification jackets were not worn, i.e., GROUP ID(-). The mean time to identify the trauma leader was 70 s (min–max: 5–237 s). The mean time to identify the anesthesia-ICU resident was 193 s (min–max: 3–559 s).
Table 2: Duration (seconds) from the start of the simulation video until the identification of all the trauma team members in the Group ID (-) medical simulation videos
Figure 3: Distribution of the TEAM scores in GROUP ID(-) and GROUP ID(+): GROUP ID(−) with no identification jackets wearing; GROUP ID(+) with identification jackets wearing
Figure 4: Sum of the 11 TEAM scale items for each video analyzed: GROUP ID(−) with no identification jackets wearing (white); GROUP ID(+) with identification jackets wearing (black) Discussion This study suggests that the identification of trauma team members is associated with improved teamwork performance. The second part of the study, describing the times between the start of the medical simulation video and the identification of each trauma team member, showed that with no identification jackets wearing, i.e., GROUP ID(-), the time to identify some trauma team members, for example, the scribe, could be prolonged up to 16 min.
The time for identification of each trauma team member could be reduced by wearing an identification jacket where the function of each one is clearly displayed. Initial management of the severe trauma patient in the trauma bay is an emergency situation that can be associated with stress for the trauma team.[22],[23] Such emergency situations are associated with an increased risk of adverse events due to a lack of communication.[24] Besides the trauma setting, a study by Freund et al. showed an occurrence of 10% of medical errors in the emergency room. One of the main causes of these errors was related to poor information and communications. Hence, improving communication skills could reduce medical errors.[25] In the retrospective study by Risser et al., 54 cases of medical errors were reported in the emergency departments of eight hospitals in the United States, from 1985 to 1996. Experts analyzed all these 54 cases for teamwork actions, rating on a 1–32 scale. The actions that were not carried out or were carried out poorly, and in connection with medical errors, were rated as “failure.” An average of 8.8 teamwork failures occurred per case. More than 50% of serious side effects were considered preventable with a better teamwork.[26] These results are also comparable with those found in studies carried out in intensive care unit settings.[27] In a review of factors contributing to medical errors in intensive care units, nontechnical skills were at the forefront. The authors concluded that the improvement of these “soft” skills, which included teamwork performance, would reduce the risk of medical errors.[27] Lingard et al. conducted several studies showing the association between communication failures and the occurrence of medical errors in the operating room.[9],[28],[29],[30]
In operating theatres and emergency rooms, the identification of all the medical team members and their function is associated with improved prevention of medical errors, better involvement in the work, and increased confidence.[31]
To the best of our knowledge, the study described here is the first study to focus on the identification of medical team members in trauma settings. Therefore, a method for identifying medical team members seems indispensable for a better functioning of teamwork, especially in stressful situations. Thus, since 2017, several countries have participated in the Theatre Cap Challenge.[32] This is a simple method of identification in the operating theaters, with the wearing of an identification cap that clearly identifies the name and function of the wearer. There is no randomized study evaluating the value of the Theatre Cap Challenge, but some questionnaires have shown positive responses in several hospitals. For example, at the Newcastle Hospital, before the Theatre Cap Challenge, 40% of the staff interviewed in the operating theatre knew the names of their colleagues, compared to 80% afterward.[32] In the same hospital, a before–after survey showed that with the port of such an identification cap, team members presented themselves spontaneously more often (38% of cases before, vs. 90% after), and remembered their colleagues' names and functions more easily (42% of cases before, vs. 85% after).[32] At the Percy Army Training Hospital, the choice of the identification method for the different trauma team members is the identification jackets for function, and not for names. These identification jackets, with a dedicated color code, allow better immediate visual recognition compared to identification cap, where the written letters are smaller. Interestingly, a similar color code method has been proposed for the triage of casualties during mass casualties incidents.[33]
This study has several limitations. Firstly, the study involved a small sample size. Also, the median TEAM scores observed were the same in both ID(+) and ID(-) GROUPS. To balance the small sample size, nonparametric statistical tests were used to compare the distribution of medians in each group. The distribution of median TEAM scores was significantly different between the two ID(+) and ID(-) GROUPS. Had the number of participants in the study been larger, a significant difference between the medians of the TEAM scores could also have been observed. A multi-center study could allow for a larger sample size. Secondly, this is a retrospective study, involving medical simulation videos. A total of 14 medical simulation videos were excluded from the analysis because they were incomplete: either not all of the trauma team members were wearing identification jackets (10 medical simulation videos), or the trauma team was incomplete (4 medical simulation videos). Although this could represent conditions close to reality, only medical simulation videos fully complying with the systematic identification jackets wearing protocol were selected. Videos with incomplete jacket-wearing were excluded to improve the comparison between the two groups and reduce significative bias. Furthermore, the order of the videos was not randomized for the viewers. Thirdly, there was a significant disparity in terms of trauma experience within the panel of the 13 students of postgraduate diploma in anesthesia and intensive care. Students with little or no experience in trauma took longer to identify the trauma team members, compared to students with advanced trauma experience. Fourthly, it is a single-center study, with a local protocol dedicated for the management of the severe trauma patients; which can be found to be different from the protocols of other trauma centers. For example, airway management is generally carried out by a CRNA, whereas in other trauma centers it may be an anesthesiologist-intensivist, junior or senior. The very existence of different protocols between the trauma centers does, however, argue in favor of the generalization of identifying jackets wearing. This would be particularly useful during the transmission of medical data by the prehospital team. Finally, this single-center study involved a military trauma center. The military medical personnel of the Percy Army Training Hospital benefits from dedicated medical simulation training sessions, particularly before their projection in overseas military operations.[34],[35],[36] This is a possible selection bias, but which concerns the GROUP ID(+) as much as it concerns the GROUP ID(-). Furthermore, the military medical personnel at the Percy Army Training Hospital is used to work with each other but this study still shows a significant difference. One could imagine that with trauma team members that do not know each other at all, the benefit of identification jackets wearing would be even greater.
On the other hand, the identification of medical team members, using the identification jackets wearing or any other means of identification, could be useful during mass casualty incidents, terrorist attacks, or natural disasters.[37],[38]
Finally, wearing of identification jackets could be useful in situations where there is bound to be chaos at the resuscitation phase such as teaching hospitals with high junior attrition and frequent staff rotations.[39] It also is an economical and practical way to improve care organization in developing countries.[40]
Conclusion In this single-center simulation study, wearing identification jackets was associated with an improvement in the trauma team performance TEAM scores. Identification jackets appeared as a simple way to improve recognition of each trauma team member and thus to increase teamwork performance. Further larger, multi-center, prospective, randomized studies are still needed to confirm the results of this observational study and to determine the most effective identification method of trauma team members.
Research quality and ethics statement
This study was approved by the Institutional Review Board (IRB 00010254-2019-194). The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines during the conduct of this research project.
Acknowledgments
The authors would like to thank the Emergensim teams who performed the in situ medical simulation sessions, Mrs de Garambe who conducted the statistical analysis, and all medical teams of the Percy Army Training Hospital involved in the management of trauma patients (Dr. Hyrien, emergency department, Dr. de Rudnicki intensive care unit, Dr. Daban anesthesiology unit, Prof. Lahutte medical imaging unit, Prof Boddaert thoracic surgery unit, Prof. Hornez visceral surgery unit, Prof. Mathieu orthopedic surgery unit, Dr. Delmas neurosurgery unit, Dr. Dedome French Military Blood Institute).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jets.jets_168_21
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