Dallas 2015 Team and leadership training EI T 631 TFQO: Koen Monsieurs EVREV 1: Koen Monsieurs COI 246 EVREV 2: Elaine Gilfoyle COI xxx Taskforce: EIT TF 1
Dallas 2015 COI Disclosure (specific to this systematic review) Commercial/industry KM: none EG: none Potential intellectual conflicts KM: Editor, ERC Guidelines 2015 EG: • First author of one of the articles in this review • Funded by Heart and Stroke Foundation of Canada 2
Dallas 2015 2010 CoSTR Consensus on science Four studies (LOE 168,69; LOE 270,71) of advanced life support in simulated in-hospital cardiac arrest and seven LOE 5 studies72–78 of actual and simulated arrest demonstrated improved resuscitation team performance when specific team and/or leadership training was added to advanced life support courses. Treatment recommendation Specific teamwork training, including leadership skills, should be included in advanced life support courses. 3
Dallas 2015 C2015 PI CO Population : Among students who are taking advanced life support courses in an educational setting I ntervention : does inclusion of specific leadership or team training Comparison : compared with no such specific training Outcomes: improve patient outcomes, bystander CPR performance, skill performance in actual resuscitations, skill performance at 1 year, skill performance at course conclusion, cognitive knowledge 4
Dallas 2015 I nclusion/ Exclusion & Articles Found Inclusion criteria: - An abstract is available during the initial Pubmed search - Both manikin and human studies - Both pre- and in-hospital - Both adult/paediatric/neonatal - Resuscitation and trauma (there are relevant trauma studies) - All years Exclusion criteria: - Studies evaluating scoring systems (no relevant outcome) - studies with self-assessment as the only outcome - reviews - Abstracts without full article Search results: • Pubmed: 438 studies • Embase: 363 studies • Cochrane library: 30 studies • Total: 831 studies • Retained for review: 19 studies (10 RCTs, 9 non RCTs) 5
Dallas 2015 2015 Proposed Treatment Recommendations We suggest to include team and leadership training as part of advanced life support training for health care providers with a duty to perform CPR on neonates, children and adults (weak recommendation based on low quality evidence). We acknowledge that the quality of evidence supporting this recommendation is low. However, we have also considered that no harm has been demonstrated with team or leadership training, that we expect that the intervention will be well accepted, and that aside from the training, there is no additional cost. 6
Dallas 2015 Risk of Bias in in RCTs RCT bias assessment Allocation: Concealment Allocation: Generation Blinding: Participants Outcome: Complete Blinding: Assessors Outcome: Selective Other Bias Study Year Chung 2011 High Low High Low Low Low Low Cooper 2001 High High High Low Low Low Low Fernandez 2011 Low Low High Low High Low Low Fernandez 2013 Low Low High Low Low Low Low Hunziker 2009 High Low High High Low Low Low Hunziker 2010 Low Low High Low High Low Low Jankouskas 2011 High High High Low High Low Low Thomas 2007 Low High High Low High Low Low Thomas 2010 Low High High Low High Low Low Weidman 2010 Low Low High Low High Low High 7
Dallas 2015 Risk of Bias in in nonRCTs 8
Dallas 2015 Key ey dat a from key ey st st udies es Weidman 2010 (RCT) 9
Dallas 2015 Key ey dat a from key ey st st udies es Andreatta, 2010 (non RCT) 10
Dallas 2015 Key ey dat a from key ey st st udies es Neily, 2010 (non RCT) 11
Dallas 2015 Eviden ence e profile e t able e RCTs ( crit ic ical l out com es) 12
Dallas 2015 Evidence p profile t ab able R RCTs (im port ant nt out ut com es) 13
Dallas 2015 Evidence p profile t ab able n nonRCTs (crit ical al out com es) 14
Dallas 2015 Evidence p profile t ab able n nonRCTs (im port ant nt out ut com es) 15
Dallas 2015 Proposed Consensus on Science statements (1/ 4) For the critical outcome “patient survival”, we found no randomized clinical trials but found very low quality evidence from 2 observational studies [Andreatta, 2010, 33; Neily, 2010, 1693]. Andreatta reported hospital survival from pediatric cardiac arrest over a period of 4 years after implementation of a hospital-wide mock code program, which included team training. These authors found an increase in survival from pediatric cardiac arrest at their hospital during the study period. Neily reported hospital mortality in surgical patients at 74 hospitals in the United States that had implemented a surgical team training program. The severity-adjusted surgical mortality was found to be lower at the hospitals that had implemented the program compared with 34 hospitals which had not. The quality of these studies was downgraded for risk of bias and indirectness. 16
Dallas 2015 Proposed Consensus on Science statements (2/ 4) For the critical outcome “skill performance in actual resuscitation” we found very low quality evidence from a single randomized controlled trial [Weidman, 2010, 1556], downgraded for risk of bias, indirectness and imprecision. The study randomized 32 internal medicine residents to receive simulation training with a focus on the role of the resuscitation team leader versus no additional training but did not find an effect on CPR quality during actual resuscitation of patients. We also found very low quality evidence from 2 observational studies [Nadler 2011, 163; Su, 2014, 856], downgraded for risk of bias, inconsistency, indirectess and imprecision. For the important outcome “skill performance at 4 months-1 year (patient tasks)”, we found very low quality evidence from two randomized trials [Hunziker, 2010, 1086; Thomas, 2010, 539], downgraded for risk of bias, inconsistency and imprecision. For the important outcome “skill performance at 4 months-1 year (teamwork performance)” we found low quality evidence from a single randomized trial [Thomas, 2010, 539], downgraded for bias and imprecision, as well as very low quality evidence from a single observational study [Garbee, 2013, 340]. The quality of this observational study was downgraded for risk of bias. 17
Dallas 2015 Proposed Consensus on Science statements 3/ 4 For the important outcome “skill performance at 4 months-1 year (leader performance)”, we found moderate quality evidence from a single randomized trial [Hunziker, 2010, 1086], downgraded for risk of bias. We also found very low quality evidence from a single observational study [Gilfoyle, 2007, e276] downgraded for risk of bias and imprecision. For the important outcome “skill performance at course conclusion (patient tasks)” (assessed with: time to completion of various patient tasks), we found low quality evidence from seven randomized trials [Chung, 2011, 690; Fernandez, 2011, 1338; Fernandez, 2013, 2551; Hunziker, 2009, X; Hunziker, 2010, 1086; Jankouskas, 2011, 316; Thomas, 2010, 539], downgraded for risk of bias and imprecision. We also found very low quality evidence from three observational studies [DeVita, 2005, 326; Makinen, 2007, 264; Yeung, 2012, 2617], downgraded for risk of bias and indirectness. A dose response gradient was found. 18
Dallas 2015 Proposed Consensus on Science statements 4/ 4 For the important outcome “skill performance at course conclusion (teamwork performance)” (assessed with: teamwork score), we found low quality evidence from six randomized studies [Chung, 2011, 690; Fernandez, 2011, 1338; Fernandez, 2013, 2551; Jankouskas, 2011, 316; Thomas, 2007, 409; Thomas, 2010, 539], downgraded for risk of bias and imprecision. We also found very low quality evidence from two observational studies [Gargee, 2013, 340; Makinen, 2007, 264], downgraded for risk of bias, inconsistency and imprecision. For the important outcome “skill performance at course conclusion (leader performance)” we found low quality evidence from three randomized studies [Cooper, 2001, 33; Hunziker, 2009, X; Hunziker, 2010, 1086] downgraded for risk of bias and imprecision. We also found very low quality evidence from two observational studies [Gilfoyle, 2007, e276; Yeung, 2012, 2617] downgraded for indirectness and imprecision. For the important outcome “cognitive knowledge”, we found no evidence. 19
Draft Dallas 2015 Treatment Recommendation We suggest to include team and leadership training as part of advanced life support training for health care providers with a duty to perform CPR on neonates, children and adults (weak recommendation based on low quality evidence). Values and preferences statement We acknowledge that the quality of evidence supporting this recommendation is low. However, we have also considered that no harm has been demonstrated with team or leadership training, that we expect that the intervention will be well accepted, and that aside from the training, there is no additional cost. 20
Dallas 2015 Knowledge Gaps The current PICO was restricted to ALS courses. A wider search outside the medical field (e.g. training of pilots,…) may generate additional information, although indirect. Studies relating team and leadership training to patient outcome are lacking. 21
Dallas 2015 Next Steps This slide will be completed during Task Force Discussion (not EvRev) and should include: Consideration of interim statement Person responsible Due date 22
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