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Paediatric out-of-hospital cardiac arrests — epidemiology and outcome

Resuscitation highlights in 2011

IntroductionEffective teamwork plays a critical role in achieving high-performance outcomes in healthcare. Consequently, conducting a comprehensive assessment of team performance is essential for providing meaningful feedback during team trainings and enabling comparisons in scientific studies. However, traditional methods like self-reports or behavior observations have limitations such as susceptibility to bias or being resource consuming. To overcome these limitations and gain a more comprehensive understanding of team processes and performance, the assessment of objective measures, such as physiological parameters, can be valuable. These objective measures can complement traditional methods and provide a more holistic view of team performance. The aim of this study was to explore the potential of the use of objective measures for evaluating team performance for research and training purposes. For this, experts in the field of research and medical simulation training were interviewed to gather their opinions, ideas, and concerns regarding this novel approach.MethodsA total of 34 medical and research experts participated in this exploratory qualitative study, engaging in semi-structured interviews. During the interview, experts were asked for (a) their opinion on measuring team performance with objective measures, (b) their ideas concerning potential objective measures suitable for measuring team performance of healthcare teams, and (c) their concerns regarding the use of objective measures for evaluating team performance. During data analysis responses were categorized per question.ResultsThe findings from the 34 interviews revealed a predominantly positive reception of the idea of utilizing objective measures for evaluating team performance. However, the experts reported limited experience in actively incorporating objective measures into their training and research. Nevertheless, they identified various potential objective measures, including acoustical, visual, physiological, and endocrinological measures and a time layer. Concerns were raised regarding feasibility, complexity, cost, and privacy issues associated with the use of objective measures.DiscussionThe study highlights the opportunities and challenges associated with employing objective measures to assess healthcare team performance. It particularly emphasizes the concerns expressed by medical simulation experts and team researchers, providing valuable insights for developers, trainers, researchers, and healthcare professionals involved in the design, planning or utilization of objective measures in team training or research.

Training teams and leaders to reduce resuscitation errors and improve patient outcome

Organizations increasingly set up multiteam projects for the development of highly complex products. While team research has emphasized the importance of team-internal processes for smaller scale projects, we know little about collaborative processes (especially between teams) in such large-scale projects. This study utilizes a multi-informant longitudinal research design on a product development project (39 teams, 36 months) in the European automotive industry investigating collaboration between and within teams. The results of the study demonstrate that interteam coordination, project commitment, and teamwork quality as rated by the team members at Time 1 (Month 12; end of concept phase) are significantly correlated to project managers’ ratings of overall team performance at Time 3 (Month 36; end of project). The process variables measured at Time 2 (Month 24; end of design phase) display generally weaker correlations with team performance at Time 3. Multiple regression analyses further detail the effects of collaborative processes within and between teams on different measures of team performance (i.e., overall performance, quality, budget, schedule). The results show that collaborative processes during the project have predictive properties in regard to later team performance and can serve as early warning indicators. Furthermore, the results of this study provide support for our hypotheses predicting positive relationships between interteam coordination, project commitment, and teamwork quality. Theoretical and practical implications of this study are discussed.

This thesis hypothesizes that providing task specific information to individual team members will improve coordination and decision-making, and therefore team performance, at time critical tasks. Major themes addressed in this research include teams and team processes, mental models, team mental models, work domain analysis, and hierarchical task analysis. Furthermore, the theory behind the development of complementary models is introduced. A unique method to identify the information sources and requirements in a complex team environment is first discussed in general and then specifically applied in two domains. The findings are presented of two experiments examining the effects of imposing different information distribution strategies that range from no complementariness to full complementariness of information. Team communication, team and individual task performance, workload, and timeliness and effectiveness of team decision making were assessed in nominal and off-nominal conditions. The first experiment used an automobile simulator and examined team navigation while driving. A second experiment was designed to incorporate additional measures to more specifically investigate individual performance, team workload, and clarity of information requirements using a UH-60 Black Hawk helicopter simulator. The procedures used for both experiments provided for dynamic yet controlled environments through which critical factors that influence team process and performance could be evaluated accurately. Results of these experiments provide empirical evidence that providing task relevant information to individual team members in a time critical environment, while limiting their access to non-relevant information, improves individual and team performance. Furthermore, there is evidence of increased individual performance that indicates this method of distributing information among team members may provide individual crewmembers with a more accurate “task relevant” mental model of their own environment. This research provides new insight into how the distribution of information among team members effects the development of mental models, information requirements, team and individual performance, and communications, and highlights several directions for future research. The information distribution design principles presented in this thesis address the heterogeneity of teams; teams cannot be thought of as groups of identical individuals. The results concerning the communication, workload, performance and team of mental models were consistent across the domains in this research.

To describe a large cohort of children with out-of-hospital cardiac arrest with return of circulation and to identify factors in the early postarrest period associated with survival. These objectives were for planning an interventional trial of therapeutic hypothermia after pediatric cardiac arrest. A retrospective cohort study was conducted at 15 Pediatric Emergency Care Applied Research Network clinical sites over an 18-month study period. All children from 1 day (24 hrs) to 18 yrs of age with out-of-hospital cardiac arrest and a history of at least 1 min of chest compressions with return of circulation for at least 20 mins were eligible. One hundred thirty-eight cases met study entry criteria; the overall mortality was 62% (85 of 138 cases). The event characteristics associated with increased survival were as follows: weekend arrests, cardiopulmonary resuscitation not ongoing at hospital arrival, arrest rhythm not asystole, no atropine or NaHCO3, fewer epinephrine doses, shorter duration of cardiopulmonary resuscitation, and drowning or asphyxial arrest event. For the 0- to 12-hr postarrest return-of-circulation period, absence of any vasopressor or inotropic agent (dopamine, epinephrine) use, higher lowest temperature recorded, greater lowest pH, lower lactate, lower maximum glucose, and normal pupillary responses were all associated with survival. A multivariate logistic model of variables available at the time of arrest, which controlled for gender, age, race, and asystole or ventricular fibrillation/ventricular tachycardia anytime during the arrest, found the administration of atropine and epinephrine to be associated with mortality. A second model using additional information available up to 12 hrs after return of circulation found 1) preexisting lung or airway disease; 2) an etiology of arrest drowning or asphyxia; 3) higher pH, and 4) bilateral reactive pupils to be associated with lower mortality. Receiving more than three doses of epinephrine was associated with poor outcome in 96% (44 of 46) of cases. Multiple factors were identified as associated with survival after out-of-hospital pediatric cardiac arrest with the return of circulation. Additional information available within a few hours after the return of circulation may diminish outcome associations of factors available at earlier times in regression models. These factors should be considered in the design of future interventional trials aimed to improve outcome after pediatric cardiac arrest.

As exploration of new frontiers continues, the need for team training in extreme environments grows. Operating in isolated, confined, and extreme environments (ICE) demands novel approaches to team performance measurement, as well as new strategies and methods for ensuring teams members are (1) equipped with the knowledge, skills, and attitudes critical for effective team performance over time, and (2) are supported by just-in-time training or other resources when breakdowns in performance inevitably occur. This panel brings together a range of experts in human performance in extreme environments to provide a comprehensive overview and discussion of the most current approaches and trends regarding team training and performance measurement in ICE environments.

Effective teamwork is not only essential for teams themselves, but also for organizations and our society. To facilitate team processes and enhance team performance, feedback interventions are a widely used means. However, different types of feedback (i.e., individual vs. team-level feedback, performance vs. process feedback) can have various effects leaving the question of their effectiveness unanswered. This is especially important when team members’ attitudes (namely collective orientation) are considered. Thus, understanding the interplay between types of feedback and team members’ attitudes would reveal new opportunities for fostering reliable teamwork. The methodology of the present study is based on a laboratory approach. Teams (N = 142) of two worked together over four scenarios to extinguish forest fires in a microworld. We examined the effects of collective orientation on team coordination and team performance. To understand the interplay between feedback and attitudes we examined the effect of different feedback interventions on team performance and on a change in collective orientation. For analyzing multilevel mediation and changes over time, Bayesian multilevel models were applied. Results show a positive relationship between collective orientation and team performance mediated by coordination. Additionally, team-level process and performance feedback seem to be slightly more beneficial for maintaining performance over time with increasing difficulty of the task compared to individual-level process feedback. Feedback can lead to an increase in collective orientation if these values are low at the beginning. Our research highlights the importance of collective orientation and feedback interventions on team processes and performance for interdependently working teams.

Although survival after in-hospital cardiac arrest is likely to vary among hospitals caring for children,validated methods to risk-standardize pediatric survival rates across sites do not currently exist. From 2006 to 2010, within the American Heart Association's Get With the Guidelines-Resuscitation registry for in-hospital cardiac arrest, we identified 1551 cardiac arrests in children (<18 years). Using multivariable hierarchical logistic regression, we developed and validated a model to predict survival to hospital discharge and calculated risk-standardized rates of cardiac arrest survival for hospitals with a minimum of 10 pediatric cardiac arrest cases. A total of 13 patient-level predictors were identified: age, sex, cardiac arrest rhythm, location of arrest, mechanical ventilation, acute nonstroke neurological event, major trauma, hypotension, metabolic or electrolyte abnormalities, renal insufficiency, sepsis, illness category, and need for intravenous vasoactive agents prior to the arrest. The model had good discrimination (C-statistic of 0.71), confirmed by bootstrap validation (validation C-statistic of 0.69). Among 30 hospitals with ≥10 cardiac arrests, unadjusted hospital survival rates varied considerably (median, 37%; interquartile range, 24-42%; range, 0-61%). After risk-standardization, the range of hospital survival rates narrowed (median, 37%; interquartile range, 33-38%; range, 29-48%), but variation in survival persisted. Using a national registry, we developed and validated a model to predict survival after in-hospital cardiac arrest in children. After risk-standardization, significant variation in survival rates across hospitals remained. Leveraging these models, future studies can identify best practices at high-performing hospitals to improve survival outcomes for pediatric cardiac arrest. (

List of contributors. Introduction (M.M. Beyerlein et al.). Foreword (L. Broedling). Acknowledgments. Empowering work teams with knowledge: enhancing performance in service and information oriented industries (V. Anand et al.). Cognitive engineering in team performance measurement (R.J. Stout et al.). Helping team members help themselves: propositions for facilitating guided team self-correction (K.A. Smith-Jentsch et al.). Influence in self-managing teams: a conceptual examination of the effects of content and context factors on training enrollment decisions (W.J. Smith et al.). Evaluating the capability formation potential of integrated project teams (P.F. Skilton, V. Smith-Daniels). Applying behavior modification to the management of team performance: a systems perspective (M.T. Barriere et al.). Organizational considerations in the evaluation and compensation of work team performance (D. Windsor). An integrative theoretical framework for understanding team reward allocation preferences (A.G. Parisi, L.T. Eby). Performance management in a fourth wave society: systemic measurement, evaluation, and incentives for developing a holonic performance management system (R.E. Debold, Jr.). Complex systems and sensemaking teams: conflict, connectedness, and leadership (D. Duchon et al.). About the editors.

Project Overview Team Situation Awareness (TSA), which is a part of team cognition, is a critical factor that influences team effectiveness. It can be defined as getting the right information from the right person within the right amount of time, in order to overcome an unexpected event (Gorman, Cooke, Pederson, Connor, &amp; DeJoode, 2005). TSA is developed and maintained through team interactions, allowing for the measurement of TSA based on team interaction (Cooke &amp; Gorman, 2009). In the current study, a specific measure, Coordinated Awareness of Situation by Teams (CAST) is used (Cooke &amp; Gorman, 2009). CAST evaluates the effectiveness and efficiency of team interaction under “roadblock” scenarios (Gorman, Cooke, &amp; Winner, 2006). These roadblocks represent novel situations in the task and require effective team communication and coordination. Team members must assess the situation according to their own specialized role and/or resources and coordinate with other team members to overcome each separate roadblock. In this task, effective communication refers to team anticipation. That is, each team member needs to anticipate each other’s needs by pushing information rather than pulling information during the task (Demir, McNeese, &amp; Cooke, 2017). In this study, we examined how pushing and pulling information, and CAST were associated with Team Situation Awareness (TSA) in both Human-Autonomy (HAT) and all-human teams in simulated Remotely Piloted Aircraft System (RPAS) task environment. In this research, we integrated the synthetic agent to the Cognitive Engineering Research on Team Tasks Remotely Piloted Aircraft Systems - Synthetic Task Environment (CERTT-RPAS-STE) which was designed to be both a flexible research platform and a realistic task environment with a view to researching team performance and interaction-based measures of team cognition. In the simulated CERTT testbed, there are three heterogeneous teammates who need to take good photos of each target waypoint by communicating via text-chat: (1) the navigator who creates a dynamic flight plan and provides information about the waypoints, the RPA’s airspeed, and altitude restrictions to the pilot; (2) the pilot, who controls the RPA’s heading, altitude, and airspeed, and negotiates with the photographer in order to take a good photo; and (3) the photographer, who monitors sensor equipment in order to take photographs of target waypoints and sends feedback to the other team members about the quality of the photo. This project aimed to understand how team behaviors and team performance differed between HATs and all-human teams in RPAS operations: (1) the synthetic condition—the pilot role was given to the synthetic teammate, which was an ACT-R based cognitive model (which had a limited interaction ability, see Ball et al., 2010; Demir et al., 2015); (2) the control condition—the pilot was a randomly selected human participant, just like the other two participants; and (3) the experimenter condition—one of the experimenters served as an expert pilot. Experimenter condition utilized a Wizard of Oz paradigm in which a trained experimenter (located in a separate room) used a script to imitate a synthetic teammate and communicated with participants in limited communication behaviors but pushing and pulling information in a timely manner (robust coordination). Method There were 30 teams (10 for each condition): control teams consisted of three participants randomly assigned to each role; synthetic and experimenter teams included two participants randomly assigned to the navigator and photographer roles. The experiment took place over five 40-minute missions, and the goal was to take as many “good” photos of ground targets as possible while avoiding alarms and rule violations. During each mission, teams were presented with “roadblocks” by the introduction of a new, ad hoc target waypoint. We collected several measures, but we focused on: the proportion of roadblocks overcome per mission as an outcome measure of TSA; the CAST which is a coordination sequence of team interaction across the team members (i.e. which team members share with team members their experience during the roadblock); and verbal behaviors such as pushing and pulling information. Results and discussion In this team task, effective teamwork involves anticipating the needs of teammates, which in turn means pushing information before it is requested. However, in addition to anticipation, effective coordination is also needed during roadblocks. HATs demonstrated significantly lower levels of CAST than all-human teams. These results indicate that HATs’ lack of anticipation and coordination resulted in poorer TSA performance. These findings help HATs to grow its coordination and communication methodologies. Finally, future studies might examine the relationships highlighted in this study via nonlinear measures in terms of team stability and flexibility based on their communication and coordination patterns during the novel events. HAT is here to stay but improvements to human-machine interactions must continue if we are to improve team effectiveness.

To evaluate the viability and effectiveness of a simulation-based pediatric mock code program on patient outcomes, as well as residents' confidence in performing resuscitations. A resident's leadership ability is integral to accurate and efficient clinical response in the successful management of cardiopulmonary arrest (CPA). Direct experience is a contributing factor to a resident's code team leadership ability; however, opportunities to gain experience are limited by relative infrequency of pediatric arrests and code occurrences when residents are on service. Longitudinal, mixed-methods research design. Children's hospital at an tertiary care academic medical center. Pediatric. Clinicians responsible for pediatric resuscitations responded to mock codes randomly called at increasing rates over a 48-month period, just as they would an actual CPA event. Events were recorded and used for immediate debriefing facilitated by clinical faculty to provide residents feedback about their performance. Self-assessment data were collected from all team members. Hospital records for pediatric CPA survival rates were examined for the study duration. Survival rates increased to approximately 50% (p = .000), correlating with the increased number of mock codes (r = .87). These results are significantly above the average national pediatric CPA survival rates and held steady for 3 consecutive years, demonstrating the stability of the program's outcomes. This study suggests that a simulation-based mock code program may significantly benefit pediatric patient CPA outcomes-applied clinical outcomes-not simply learner perceived value, increased confidence, or simulation-based outcomes. The use of mock codes as an integral part of residency programs could provide residents with the resuscitation training they require to become proficient in their practice. Future programs that incorporate transport scenarios, ambulatory care, and other outpatient settings could further benefit pediatric patients in prehospital contexts.

I adopt a leadership as a networks approach to propose ethical leadership can emerge and be shared among team members. Therefore, I introduce the construct of shared ethical leadership and I begin to build the construct's nomological network by first examining ethical leadership training and shared leadership training as factors which, when additively combined, promote the density of shared ethical leadership in teams. Further, I examine these antecedents by predicting their effects will be optimized when power differentials between team members and their nominal leader are minimized. Moving to the consequences of shared ethical leadership, I propose a four-path model of social learning and social-exchange effects on proximal and distal team outcomes. First, I suggest that shared ethical leadership promotes the emergence of the team moral potency needed to make ethical choices when confronted with opportunities to ethically transgress. I then predict that the team's moral potency mediates the positive relationship between shared ethical leadership and team ethical behavior. Additionally, I argue that shared ethical leadership promotes goal concessions among team members and those goal concessions mediate the positive relationship between shared ethical leadership and team performance. I then suggest that shared ethical leadership promotes team information elaboration, which in turn mediates positive relationships with the team's ethical behavior and performance. I examine the hypotheses in a 2x2x2, between-subjects experiment using a simulated team activity with a sample of 56, 5-person teams (n=280). While the findings indicate a lack of support for most of my hypothesized relationships, the density of team's shared ethical leadership network was found to be positively related to team ethical behaviors. In addition, team information elaboration was positively related to team performance. Based on my findings, the theoretical and practical implications of this research are discussed.

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