Publications by authors named "Sylvain Boet"

86 Publications

Peripheral Nerve Blocks and Potentially Attributable Adverse Events in Older People with Hip Fracture: A Retrospective Population-based Cohort Study.

Anesthesiology 2021 Jun 15. Epub 2021 Jun 15.

Background: Peripheral nerve blocks are being used with increasing frequency for management of hip fracture-related pain. Despite converging evidence that nerve blocks may be beneficial, safety data are lacking. This study hypothesized that peripheral nerve block receipt would not be associated with adverse events potentially attributable to nerve blocks, as well as overall patient safety incidents while in hospital.

Methods: This was a preregistered, retrospective population-based cohort study using linked administrative data. This study identified all hip fracture admissions in people 50 yr of age or older and identified all nerve blocks (although we were unable to ascertain the specific anatomic location or type of block), potentially attributable adverse events (composite of seizures, fall- related injuries, cardiac arrest, nerve injury), and any patient safety events using validated codes. The study also estimated the unadjusted and adjusted association of nerve blocks with adverse events; adjusted absolute risk differences were also calculated.

Results: In total, 91,563 hip fracture patients from 2009 to 2017 were identified; 15,631 (17.1%) received a nerve block, and 5,321 (5.8%; 95% CI, 5.7 to 6.0%) patients experienced a potentially nerve block-attributable adverse event: 866 (5.5%) in patients with a block and 4,455 (5.9%) without a block. Before and after adjustment, nerve blocks were not associated with potentially attributable adverse events (adjusted odds ratio, 1.05; 95% CI, 0.97 to 1.15; and adjusted risk difference, 0.3%, 95% CI, -0.1 to 0.8).

Conclusions: The data suggest that nerve blocks in hip fracture patients are not associated with higher rates of potentially nerve block-attributable adverse events, although these findings may be influenced by limitations in routinely collected administrative data.

Editor’s Perspective:
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http://dx.doi.org/10.1097/ALN.0000000000003863DOI Listing
June 2021

The Effectiveness and Safety of Hyperbaric Oxygen Therapy in Various Phenotypes of Inflammatory Bowel Disease: Systematic Review With Meta-analysis.

Inflamm Bowel Dis 2021 May 18. Epub 2021 May 18.

The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.

Background: Accumulating evidence suggests that hyperbaric oxygen therapy (HBOT) may be effective for inflammatory bowel disease (IBD). Our systematic review aimed to quantify the effectiveness and safety of HBOT in various IBD phenotypes.

Methods: We performed a proportional meta-analysis. Multiple databases were systematically searched from inception through November 2020 without language restriction. We included studies that reported effectiveness and/or safety of HBOT in IBD. Weighted summary estimates with 95% confidence intervals (Cis) were calculated for clinical outcomes for each IBD phenotype using random-effects models. Study quality was assessed using the Cochrane evaluation handbook and National Institute of Health criteria.

Results: Nineteen studies with 809 patients total were eligible: 3 randomized controlled trials and 16 case series. Rates of clinical remission included 87% (95% CI, 10-100) for ulcerative colitis (n = 42), 88% (95% CI, 46-98) for luminal Crohn's disease (CD, n = 8), 60% (95% CI, 40-76) for perianal CD (n = 102), 31% (95% CI, 16-50) for pouch disorders (n = 60), 92% (95% CI, 38-100) for pyoderma gangrenosum (n = 5), and 65% (95% CI, 10-97) for perianal sinus/metastatic CD (n = 7). Of the 12 studies that reported on safety, 15% of patients (n = 30) had minor adverse events. Study quality was low in the majority of studies due to an absence of comparator arms, inadequate description of concomitant interventions, and/or lack of objective outcomes.

Conclusions: Limited high-quality evidence suggests that HBOT is safe and associated with substantial rates of clinical remission for multiple IBD phenotypes. Well-designed randomized controlled trials are warranted to confirm the benefit of HBOT in IBD.
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http://dx.doi.org/10.1093/ibd/izab098DOI Listing
May 2021

Barriers and enablers to effective interprofessional teamwork in the operating room: A qualitative study using the Theoretical Domains Framework.

PLoS One 2021 22;16(4):e0249576. Epub 2021 Apr 22.

Department of Anaesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada.

Background: Effective teamwork is critical for safe, high-quality care in the operating room (OR); however, teamwork interventions have not consistently resulted in the expected gains for patient safety or surgical culture. In order to optimize OR teamwork in a targeted and evidence-based manner, it is first necessary to conduct a comprehensive, theory-informed assessment of barriers and enablers from an interprofessional perspective.

Methods: This qualitative study was informed by the Theoretical Domains Framework (TDF). Volunteer, purposive and snowball sampling were conducted primarily across four sites in Ontario, Canada and continued until saturation was reached. Interviews were recorded, transcribed, and de-identified. Directed content analysis was conducted in duplicate using the TDF as the initial coding framework. Codes were then refined whereby similar codes were grouped into larger categories of meaning within each TDF domain, resulting in a list of domain-specific barriers and enablers.

Results: A total of 66 OR healthcare professionals participated in the study (19 Registered Nurses, two Registered Practical Nurses, 17 anaesthesiologists, 26 surgeons, two perfusionists). The most frequently identified teamwork enablers included people management, shared definition of teamwork, communication strategies, positive emotions, familiarity with team members, and alignment of teamwork with professional role. The most frequently identified teamwork barriers included others' personalities, gender, hierarchies, resource issues, lack of knowledge of best practices for teamwork, negative emotions, conflicting norms and perceptions across professions, being unfamiliar with team members, and on-call/night shifts.

Conclusions: We identified key factors influencing OR teamwork from an interprofessional perspective using a theoretically informed and systematic approach. Our findings reveal important targets for future interventions and may ultimately increase their effectiveness. Specifically, achieving optimal teamwork in the OR may require a multi-level intervention that addresses individual, team and systems-level factors with particular attention to complex social and professional hierarchies.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249576PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061974PMC
April 2021

Implementation of the Operating Room Black Box Research Program at the Ottawa Hospital Through Patient, Clinical, and Organizational Engagement: Case Study.

J Med Internet Res 2021 Mar 16;23(3):e15443. Epub 2021 Mar 16.

Department of Obstetrics, Gynecology, and Newborn Care, University of Ottawa, Ottawa, ON, Canada.

Background: A large proportion of surgical patient harm is preventable; yet, our ability to systematically learn from these incidents and improve clinical practice remains limited. The Operating Room Black Box was developed to address the need for comprehensive assessments of clinical performance in the operating room. It captures synchronized audio, video, patient, and environmental clinical data in real time, which are subsequently analyzed by a combination of expert raters and software-based algorithms. Despite its significant potential to facilitate research and practice improvement, there are many potential implementation challenges at the institutional, clinician, and patient level. This paper summarizes our approach to implementation of the Operating Room Black Box at a large academic Canadian center.

Objective: We aimed to contribute to the development of evidence-based best practices for implementing innovative technology in the operating room for direct observation of the clinical performance by using the case of the Operating Room Black Box. Specifically, we outline the systematic approach to the Operating Room Black Box implementation undertaken at our center.

Methods: Our implementation approach included seeking support from hospital leadership; building frontline support and a team of champions among patients, nurses, anesthesiologists, and surgeons; accounting for stakeholder perceptions using theory-informed qualitative interviews; engaging patients; and documenting the implementation process, including barriers and facilitators, using the consolidated framework for implementation research.

Results: During the 12-month implementation period, we conducted 23 stakeholder engagement activities with over 200 participants. We recruited 10 clinician champions representing nursing, anesthesia, and surgery. We formally interviewed 15 patients and 17 perioperative clinicians and identified key themes to include in an information campaign run as part of the implementation process. Two patient partners were engaged and advised on communications as well as grant and protocol development. Many anticipated and unanticipated challenges were encountered at all levels. Implementation was ultimately successful, with the Operating Room Black Box installed in August 2018, and data collection beginning shortly thereafter.

Conclusions: This paper represents the first step toward evidence-guided implementation of technologies for direct observation of performance for research and quality improvement in surgery. With technology increasingly being used in health care settings, the health care community should aim to optimize implementation processes in the best interest of health care professionals and patients.
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http://dx.doi.org/10.2196/15443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8074833PMC
March 2021

Can we sooth the subconscious during general anaesthesia?

BMJ 2020 12 10;371:m4547. Epub 2020 Dec 10.

Departments of Anesthesiology & Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada.

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http://dx.doi.org/10.1136/bmj.m4547DOI Listing
December 2020

Editorial: is hyperbaric oxygen a therapeutic opportunity for refractory perianal Crohn's disease?

Aliment Pharmacol Ther 2021 03;53(5):667-668

Department of Gastroenterology, University of British Columbia, Vancouver, BC, Canada.

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http://dx.doi.org/10.1111/apt.16253DOI Listing
March 2021

Impact of physician's sex/gender on processes of care, and clinical outcomes in cardiac operative care: a systematic review.

BMJ Open 2020 09 29;10(9):e037139. Epub 2020 Sep 29.

Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

Objectives: This systematic review aimed to assess the role of physician's sex and gender in relation to processes of care and/or clinical outcomes within the context of cardiac operative care.

Design: A systematic review.

Data Sources: Searches were conducted in PsycINFO, Embase and Medline from inception to 6 September 2018. The reference lists of relevant systematic reviews and included studies were also searched.

Eligibility Criteria For Selecting Studies: Quantitative studies of any design were included if they were published in English or French, involved patients of any age undergoing a cardiac surgical procedure and specifically assessed differences in processes of care or clinical patient outcomes by physician's sex or gender. Studies were screened in duplicate by two pairs of independent reviewers.

Outcome Measures: Processes of care, patient morbidity and patient mortality.

Results: The search yielded 2095 publications after duplicate removal, of which two were ultimately included. These studies involved various types of surgery, including cardiac. One study found that patients treated by female surgeons compared with male surgeons had a lower 30-day mortality. The other study, however, found no differences in patient outcomes by surgeon's sex. There were no studies that investigated anaesthesiologist's sex/gender. There were also no studies investing physician's sex or gender exclusively in the cardiac operating room.

Conclusions: The limited data surrounding the impact of physician's sex/gender on the outcomes of cardiac surgery inhibits drawing a robust conclusion at this time. Results highlight the need for primary research to determine how these factors may influence cardiac operative practice, in order to optimise provider's performance and improve outcomes in this high-risk patient group.
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http://dx.doi.org/10.1136/bmjopen-2020-037139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526284PMC
September 2020

Nontechnical Skills (NTS) in the Undergraduate Surgical and Anesthesiology Curricula: Are We Adequately Preparing Medical Students?

J Surg Educ 2021 Mar-Apr;78(2):502-511. Epub 2020 Aug 21.

Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada. Electronic address:

Objectives: Nontechnical skills (NTS) encompass interpersonal, cognitive, and personal resource skills that can mitigate surgical errors and improve patient outcomes. However, inconsistencies in medical student awareness around NTS suggest limited exposure to these skills. This study aimed to determine the prevalence and content of NTS in medical school surgery and anesthesiology education.

Design And Setting: Learning objectives from clerkship core surgery and anesthesiology rotations were collected from Canadian anglophone medical schools. Two raters independently classified each objective under one of the Non-Technical Skills for Surgeons (NOTSS) or Anaesthetists' Non-Technical Skills (ANTS) "Categories" and "Elements" of NTS, or as a non-NTS objective. Rater disagreements were resolved by group consensus. Group discussion was also held to identify examples of objectives that could help develop future curricula. Descriptive statistics were used to determine the number of NTS objectives from each school and within each NOTSS and ANTS Categories and Elements.

Results: Learning objectives were obtained from 12 out of 14 Canadian medical schools. A total of 2116 surgery objectives and 571 anesthesiology objectives were reviewed. Of these, 16 (0.76%) and 26 (4.55%) were identified as NTS objectives in surgery and anesthesiology, respectively. Of the NOTSS and ANTS Categories, "Situation Awareness" and "Decision Making" were represented by only one objective each in both specialties. Approximately half of the NOTSS and ANTS Elements were not represented by a single objective. Group discussion yielded examples of NTS objectives that were excellent, could use improvement, or were too vague to be classified as NTS.

Conclusions: A paucity of objectives in the clerkship perioperative curricula involve NTS. These findings suggest that NTS are unlikely being adequately introduced as critical skillsets of surgeons and anesthesiologists in undergraduate perioperative education. Future curriculum development should involve greater medical student exposure to NTS as key components of their surgery and anesthesiology education.
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http://dx.doi.org/10.1016/j.jsurg.2020.08.001DOI Listing
June 2021

Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis.

Br J Anaesth 2020 10 16;125(4):605-613. Epub 2020 Jul 16.

Department of Anaesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada.

Background: Handover of anaesthesia patient care during surgery is common; however, its association with patient outcome is unclear. This systematic review aimed to assess the impact of anaesthesia handover during surgery on patient outcome.

Methods: All prospective and retrospective clinical studies specifically investigating the association of intraoperative transfer of anaesthesia care between anaesthesia providers in the operating room with patient morbidity and mortality were included. Searches were conducted from inception to April 24, 2019 in Medline, Medline in Process, CINAHL, and Embase. Reference lists of included studies were searched. Studies were assessed for eligibility and data were extracted by independent reviewers in duplicate with disagreements resolved by consensus or a third reviewer. Risk of bias was assessed in duplicate using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data were summarised narratively given substantial heterogeneity. An exploratory meta-analysis was conducted using a random-effects model for a subset of comparable studies.

Results: Eight studies met the inclusion criteria. Six studies focused on patients as the unit of analysis (n=605 678) and two focused on anaesthesia providers as the unit of analysis (n=307). Seven studies identified a relationship between anaesthesia handovers and adverse patient outcomes, whereas one suggested that handover may be beneficial to error detection or rectification. Included studies were of fair or good quality. Meta-analysis of four studies found a 40% increased risk of patients experiencing an adverse event when an anaesthesia handover occurs during the procedure (pooled risk ratio=1.40; 95% confidence interval, 1.19 to 1.65; P<0.001; I=98%).

Conclusions: Intraoperative anaesthesia handovers generally increase morbidity and mortality for surgical patients but could have the potential to improve safety in certain contexts. Future research should determine the specific handover characteristics that impact safety.
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http://dx.doi.org/10.1016/j.bja.2020.05.062DOI Listing
October 2020

Physical health risks during simulation-based COVID-19 pandemic readiness training.

Can J Anaesth 2020 11 25;67(11):1667-1669. Epub 2020 Jun 25.

Department of Anesthesiology and Pain Medicine, University of Ottawa, General Campus, 501 Smyth Rd, Critical Care Wing 1401, Ottawa, ON, K1H 8L6, Canada.

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http://dx.doi.org/10.1007/s12630-020-01744-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7316163PMC
November 2020

Cognitive aids with roles defined (CARD) for obstetrical crises: a multisite before-and-after cohort study.

Can J Anaesth 2020 08 15;67(8):970-980. Epub 2020 May 15.

Department of Innovation in Medical Education, University of Ottawa, Ottawa, ON, Canada.

Purpose: Patient outcome during an obstetrical emergency depends on prompt coordination of an interprofessional team. The cognitive aids with roles defined (CARD) is a cognitive aid that addresses the issue of teamwork in crisis management. This study evaluated the clinical impact of implementing the CARD cognitive aid during emergency Cesarean deliveries.

Methods: We conducted a prospective before-and-after cohort trial at the maternity units of two Canadian academic hospital campuses. Both sites received didactic online training regarding teamwork during crises, which involved training on using CARD for the "CARD" campus (intervention) and no mention of CARD at the "no CARD" campus (control). The primary outcome was the total time to delivery after the call for an emergency Cesarean delivery. Secondary outcomes included specific intervals of time within the time to delivery and clinical outcomes for both the babies and mothers.

Results: We analyzed data from 267 eligible emergency Cesarean deliveries that occurred between January 11 2014 and December 31 2017. The use of CARD did not significantly change the median [interquartile range] time to delivery of the baby during an emergency Cesarean delivery from the pre-intervention to the post-intervention time period (17 [12-28] vs 15 [13-20], respectively; median difference, 2; 95% confidence interval, -1 to 5; P = 0.36). The clinical outcomes for the baby or the mother and other secondary outcomes also did not change.

Conclusions: The CARD cognitive aid did not significantly improve time-based or clinical maternal and neonatal outcomes of emergency Cesarean delivery at our academic maternity unit.
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http://dx.doi.org/10.1007/s12630-020-01685-6DOI Listing
August 2020

La définition des moments critiques et non critiques en salle d'opération : une étude de consensus Delphi modifiée.

Can J Anaesth 2020 08 6;67(8):949-958. Epub 2020 May 6.

Department of Surgery, University of Toronto, Toronto, ON, Canada.

Background: While the operating room (OR) has significantly benefited from aviation strategies to improve safety, the rate of avoidable human errors remains relatively high. One key aviation strategy that has yet to be formally established in the OR is the "sterile cockpit" rule, which prohibits all non-essential behaviours during critical moments of a flight. Applying this rule to the OR may enhance patient safety, but the critical moments of surgery need to be defined first.

Methods: This study used a modified Delphi methodology to determine critical moments during surgery according to OR team members across institutions, professions, and specialties. Analysis occurred after each round. The stopping criterion was consensus on 80% of survey items or no change in the mean score for any individual item between two consecutive rounds.

Results: The first round included 304 respondents. Of these, 115 completed the second-round survey, and 75 completed all three rounds (27 nurses, 29 anesthesiologists, 19 surgeons). Critical moments obtained by consensus were: induction of anesthesia; emergence from anesthesia; preoperative briefing; final counts at the end of the procedure; anesthesiologist- or surgeon-relevant intraoperative event; handovers; procedure-specific high-risk surgical moments; crisis resource management situations; medication and equipment preparation; and key medication administration.

Conclusions: By defining the most critical moments of surgery, future research can determine the relative importance of behaviour and actions at each stage and target interventions to these stages.
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http://dx.doi.org/10.1007/s12630-020-01688-3DOI Listing
August 2020

Can preventive hyperbaric oxygen therapy optimise surgical outcome?: A systematic review of randomised controlled trials.

Eur J Anaesthesiol 2020 Aug;37(8):636-648

From the Department of Anaesthesiology and Pain Medicine, The Ottawa Hospital (SB), Clinical Epidemiology Program, The Ottawa Hospital Research Institute (SB, ME, NE), Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (LM, OCB), Department of Diving and Hyperbaric Medicine, Sainte Anne's Military Hospital, Toulon, France (PL), Diving and hyperbaric Unit, University hospitals of Geneva, Geneva, Switzerland (PL, RP, MP, MAM), Department of Anaesthesiology and Acute Medicine, University Hospitals of Geneva, Geneva, Switzerland (MP), Department of Diving and Hyperbaric Medicine, Prince of Wales Hospital and the University of New South Wales, Randwick, New South Wales, Australia (MB).

Background: A primary underlying cause of postoperative complications is related to the surgical stress response, which may be mitigated by hyperbaric oxygen therapy (HBOT), the intermittent administration of oxygen at a pressure higher than the atmospheric pressure at sea level. Promising clinical studies have emerged suggesting HBOT's efficacy for reducing some postoperative complications. Notwithstanding, the effectiveness (if any) of HBOT across a range of procedures and postoperative outcomes has yet to be clearly quantified.

Objective: This systematic review aimed to summarise the existing literature on peri-operative HBOT to investigate its potential to optimise surgical patient outcome.

Design: A systematic review of randomised controlled trials (RCTs) with narrative summary of results.

Data Sources: MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials were searched without language restrictions through to 19 June 2018.

Eligibility Criteria: Studies were included if they involved patients of any age undergoing any surgical procedure and provided with at least one HBOT session in the peri-operative period. Two independent reviewers screened the initial identified trials and determined those to be included. Risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs.

Results: The search retrieved 775 references, of which 13 RCTs were included (627 patients). Ten RCTs (546 patients) reported treatment was effective for improving at least one of the patient outcomes assessed, while two studies (55 patients) did not find any benefit and one study (26 patients) found a negative effect. A wide range of patient outcomes were reported, and several other methodological limitations were observed among the included studies, such as limited use of sham comparator and lack of blinding.

Conclusion: Peri-operative preventive HBOT may be a promising intervention to improve surgical patient outcome. However, future work should consider addressing the methodological weaknesses identified in this review.

Trial Registration: The protocol (CRD42018102737) was registered with the International ProspectiveRegister of Systematic Reviews (PROSPERO).
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http://dx.doi.org/10.1097/EJA.0000000000001219DOI Listing
August 2020

Sex/gender and additional equity characteristics of providers and patients in perioperative anesthesia trials: a cross-sectional analysis of the literature.

Korean J Anesthesiol 2021 02 13;74(1):6-14. Epub 2020 Mar 13.

Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.

Sex and gender, among other equity-related characteristics, influence the process of care and patients' outcomes. Currently, the extent to which these characteristics are considered in the anesthesia literature remains unknown. This study assesses their incorporation in randomized controlled trials (RCTs) on anesthesia-related interventions, for both patients and healthcare providers. This is a cross-sectional analysis using an existing dataset derived from the anesthesia literature. The dataset originated from a scoping review searching MEDLINE, Embase, CINAHL, CENTRAL, and the Cochrane Database of Systematic reviews. RCTs investigating the effect of anesthesia-related interventions on mortality for adults undergoing surgery were included. Equity outcome measures were recorded for both patients and providers and assessed for inclusion in the study design, reporting of results, and analysis of intervention effects. Three-hundred sixty-one RCTs (n = 144,674) were included. Most RCTs (91%) reported patient sex/gender, with 58% of patients identified as male. There were 139 studies (39%), where 70% or more of the sample was male, compared to just 14 studies (4%), where 70% or more of the sample was female. Only 10 studies (3%) analyzed results by patient sex/gender, with one reporting a significant effect. There was substantial variation in how age was reported, although nearly all studies (98%) reported some measure of age. For healthcare providers, equity-related information was never available. Better consideration of sex/gender and additional health equity parameters for both patients and providers in RCTs is needed to improve evidence quality, and ultimately, patient care and outcome.
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http://dx.doi.org/10.4097/kja.19484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7862933PMC
February 2021

Effect of combined individual-collective debriefing of participants in interprofessional simulation courses on crisis resource management: a randomized controlled multicenter trial.

Emergencias 2020 Abr;32(2):111-117

Toulouse Institute of Simulation Healthcare, University Hospital Toulouse, Toulouse, Francia. Department of Anesthesiology and Intensive Care Medicine, Toulouse University Hospital, Toulouse, Francia. University Toulouse III Paul Sabatier, Toulouse, Francia.

Objectives: Interprofessional simulation (IPS) training is an effective way to learn crisis resource management. The type of debriefing used in IPS training may affect participants' performance and their level of psychological safety. We aimed to assess and compare performance after standard collective debriefing versus a combination of individual and collective debriefing ("combined" approach).

Material And Methods: Randomized, controlled multicenter trial. IPS sessions were randomized to have either standard or combined debriefing. Each team's performance in the IPS session was assessed with the Team Emergency Assessment Measure. The participants assessed the debriefing quality with the Debriefing Assessment for Simulation in Healthcare.

Results: Forty IPS sessions were randomized, and 30 were analyzed, 15 using standard collective debriefing and 15 the combined individual-collective method. Teams' performance improved with both types of debriefing, based on pre-post testing (P<.01), and there were no significant differences in overall performance scores between the 2 types of debriefing (P=.64). However, the combined approach was associated with higher scores for leadership skills (P<.05) and psychological safety, and the participants' learning experience was better (P<.05).

Conclusion: During IPS courses on crisis resource management, debriefing improves participants' performance, but similar overall results can be obtained with both debriefing methods. Combined debriefing might be more effective for improving participants' leadership skills and psychological safety and also provide a better learning experience.
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March 2020

Measuring the teamwork performance of operating room teams: a systematic review of assessment tools and their measurement properties.

J Interprof Care 2021 Jan-Feb;35(1):37-45. Epub 2019 Dec 22.

Clinical Epidemiology Program, The Ottawa Hospital Research Institute.

Teamwork is fundamental to surgical patient safety but is inconsistently measured. While many tools have been developed for elective intraoperative situations, it is unclear which is the most robust. This systematic review aimed to identify tools to measure the teamwork of operating room teams. Studies were included if they examined the measurement properties of these tools. PsycINFO, Embase (via OVID), CINAHL, ERIC, Medline and Medline in Process (via OVID) were searched through to May 3, 2019, as were reference lists of included studies and previously published relevant reviews. Retrieved articles were screened and data extracted in duplicate by two independent reviewers. Quality was assessed using the COSMIN checklist. Of the 2121 references identified, 14 studies of six assessment tools were included. Tools were validated across various specialties, mostly in clinical rather than simulated settings. The Observational Teamwork Assessment for Surgery (OTAS) and Operating Theater Team Non-Technical Skills Assessment Tool (NOTECHS) were the most frequently investigated tools. Though acceptable for assessing teamwork, both NOTECHS and OTAS rely on the questionable assumption that the teamwork of a team is equivalent to the sum of individual performances. Future studies may investigate other assessment tools that assess the whole team as the unit of analysis along with the potential of these tools to provide healthcare providers with meaningful feedback in clinical practice.
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http://dx.doi.org/10.1080/13561820.2019.1702931DOI Listing
December 2019

Interventions for improving teamwork in intrapartem care: a systematic review of randomised controlled trials.

BMJ Qual Saf 2020 01 10;29(1):77-85. Epub 2019 Oct 10.

Department of Anesthesiology and Pain Medicine, Ottawa Hospital, Ottawa, Ontario, Canada

Background: The labour and delivery environment relies heavily on interdisciplinary collaboration from anaesthesiologists, obstetricians and nurses or midwives to deliver optimal patient care. A large number of adverse events in obstetrics are associated with failure in communication and teamwork among team members, with substantive consequences. The objective of this study is to perform a systematic review of interventions aimed at improving teamwork in obstetrics.

Methods: This systematic review identified and assessed randomised controlled trials (RCTs) of interventions aimed at improving teamwork among interdisciplinary teams in obstetrical care. Medline, CENTRAL, CINAHL and Embase were searched for studies evaluating one of: patient outcomes, team performance or processes of clinical efficiency. Identified citations were reviewed in duplicate for eligibility.

Results: Nine RCTs met the inclusion criteria; five of these RCTs were conducted under simulated clinical environments. Simulation-based teamwork training interventions were the most represented (n=7 studies, 3047 healthcare providers (HCPs), 107 782 births), followed by checklists (n=1 study, 136 HCPs) and an electronic-based decision support tool (n=1 study, 296 HCPs). Simulation-based teamwork training was found to improve team performance in 100% of relevant studies (3 of 3 studies assessing team performance) and patient morbidity in 75% of relevant studies (3 of 4 studies assessing patient morbidity). However, no direct mortality benefit was identified among all the studies reviewed. Studies were assessed to be of low-moderate quality and had significant limitations in their study designs.

Conclusion: While the evidence is still limited and from low to moderate quality RCTs, simulation-based teamwork interventions appear to improve team performance and patient morbidity in labour and delivery care.

Prospero Trial Registration Number: CRD42018090452.
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http://dx.doi.org/10.1136/bmjqs-2019-009689DOI Listing
January 2020

Evidence for simulation-based education in hyperbaric medicine: A systematic review.

Diving Hyperb Med 2019 Sep;49(3):209-215

Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.

Introduction: Evidence from many areas of healthcare suggests that skills learned during simulation transfer to clinical settings; however, this has not yet been investigated in hyperbaric medicine. This systematic review aimed to identify, summarize, and assess the impact of simulation-based education in hyperbaric medicine.

Methods: Eligible studies investigated the effect of simulation-based education for learning in hyperbaric medicine, used any design, and were published in English in a peer-reviewed journal. Learning outcomes across all Kirkpatrick levels were included. MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched. Pairs of independent reviewers assessed references for study eligibility.

Results: We found no article assessing the impact of simulation-based education in hyperbaric medicine published in English. Only one potentially relevant paper published in German was found.

Conclusions: More research is needed to determine how the hyperbaric medicine community and their patients may benefit from simulation-based education to optimize both practice and patient care.
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http://dx.doi.org/10.28920/dhm49.3.209-215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6884102PMC
September 2019

Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework.

BMJ Open Qual 2019 1;8(3):e000686. Epub 2019 Aug 1.

Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.

Background: Systematically observing clinical performance in the operating room (OR) to support patient safety initiatives faces numerous logistical and methodological challenges. These may be solved by new audio-video recording technologies like the OR Black Box, which is a tool similar to black boxes in aviation. This study aimed to identify barriers and enablers that may influence patients', clinicians' and senior leadership team members' support of the OR Black Box in order to guide its future implementation.

Methods: Patients, clinicians and senior leadership team members were recruited to participate in semistructured interviews informed by the theoretical domains framework (TDF) to identify factors relevant to planning OR Black Box implementation. Deidentified interview transcripts were analysed in duplicate following a TDF coding structure.

Results: Data saturation was achieved at 15 patients, 17 clinicians and 9 senior leadership team members. Seven domains were relevant for patients, nine for clinicians and four for senior leadership. Knowledge and Beliefs about consequences were barriers and enablers for all three groups. Memory, attention and decision processes and Social influences were enablers for both clinicians and senior leadership. Environmental context and resources, Emotion and Behavioural regulation were found to be barriers and enablers for both clinicians and patients. Social/professional role and identity and Reinforcement were enablers for patients only and Optimism and Intentions were barriers and enablers to clinicians.

Conclusions: While most stakeholders were supportive of the OR Black Box, we identified many key areas that need to be addressed during its implementation. It is critical to ensure all stakeholders have adequate and accurate information about the OR Black Box system and research goals, and that the OR Black Box is positioned as a patient safety initiative for learning from and improving practice.
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http://dx.doi.org/10.1136/bmjoq-2019-000686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683111PMC
August 2019

[Simulation-based interprofessional education for critical care teams: Concept, implementation and assessment].

Presse Med 2019 Jul - Aug;48(7-8 Pt 1):780-787. Epub 2019 Aug 2.

Institut Toulousain de Simulation en Santé, University Hospital of Toulouse, 31059 Toulouse, France; University Hospital of Toulouse, Department of Anaesthesia and Intensive Care, 31059 Toulouse, France.

Interprofessional simulation-based education is effective for learning non-technical critical care skills and strengthening interprofessional team collaboration to optimize quality of care and patient outcome. Implementation of interprofessional simulation sessions in initial and continuing education is facilitated by a team of "champions" from each discipline/profession to ensure educational quality and logistics. Interprofessional simulation training must be integrated into a broader interprofessional curriculum supported by managers, administrators and clinical colleagues from different professional programs. When conducting interprofessional simulation training, it is essential to account for sociological factors (hierarchy, power, authority, interprofessional conflicts, gender, access to information, professional identity) both in scenario design and debriefing. Teamwork assessment tools in interprofessional simulation training may be used to guide debriefing. The interprofessional simulation setting (in-situ or simulation centre) will be chosen according to the learning objectives and the logistics.
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http://dx.doi.org/10.1016/j.lpm.2019.07.001DOI Listing
September 2019

Personalized perioperative medicine: a scoping review of personalized assessment and communication of risk before surgery.

Can J Anaesth 2019 Sep 25;66(9):1026-1037. Epub 2019 Jun 25.

Departments of Anesthesiology & Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada.

Background: Personalized medicine aims to improve outcomes through application of therapy directed by individualized risk profiles. Whether personalized risk assessment is routinely applied in practice is unclear; the impact of personalized preoperative risk prediction and communication on outcomes has not been synthesized. Our objective was to perform a scoping review to examine the extent, range, and nature of studies where personalized risk was evaluated preoperatively and communicated to the patient and/or healthcare professional.

Methods: A systematic search was developed, peer-reviewed, and applied to Embase, Medline, CINAHL, and Cochrane databases to identify studies of individuals having or considering surgery, where a process to assess personalized risk was applied and where these estimates were communicated to a patient and/or healthcare professional. All stages of the review were completed in duplicate. We narratively synthesized and described identified themes.

Results: We identified 796 studies; 24 underwent full-text review. Seven studies were included; one communicated personalized risk to patients, four to a healthcare professional, and two to both. Cardiac (n = 2) and orthopedic surgery (n = 2) were the most common surgical specialties. Four studies used electronic risk calculators, and three used paper-based tools. Personalized preoperative risk assessment and communication may improve accuracy of information provided to patients, improve consent processes, and influence length of stay. Methodologic weaknesses in study design were common.

Conclusions: Personalized preoperative risk assessment and communication may improve patient and system outcomes. This evidence is limited, however, by weaknesses in study design. Appropriately powered, low risk of bias evaluation of personalized risk communication before surgery is needed.
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http://dx.doi.org/10.1007/s12630-019-01432-6DOI Listing
September 2019

Interprofessional communication in the operating room: a narrative review to advance research and practice.

Can J Anaesth 2019 Oct 28;66(10):1251-1260. Epub 2019 May 28.

Department of Anaesthesiology & Pain Medicine, The Ottawa Hospital, Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.

Purpose: Communication failures are often at the root of adverse events for surgical patients; however, evidence to inform best communication practice in the operating room is relatively limited. This narrative review outlines the importance of interprofessional communication for surgical patient safety, maps its barriers and facilitators, and highlights key strategies for enhancing communication quality in the operating room. Based on this review, a research agenda to inform best practices in interprofessional operating room communication is suggested.

Source: The non-systematic literature search included searches of relevant databases (Medline (via OVID), PubMed, Scopus, and EMBASE, PsycINFO, CINAHL), relevant grey literature sources (e.g., patient safety institute websites), and reference lists of selected articles.

Principal Findings: Effective interprofessional communication plays a critical role in the operating room, but faces many challenges at the individual, team, environmental, and organizational level. Factors that support effective communication are less documented than barriers, but include team integration, flattened hierarchies, and structure/standardization. Checklists, safety briefings, and teamwork/communication training are the most common techniques used to improve communication in the operating room. Of all communication techniques, closed-loop communication may be the most practical and inexpensive strategy.

Conclusion: The perioperative community should be encouraged to implement existing effective solutions to improve communication and investigate creative solutions to identified barriers. Improved methods of data collection are needed to enhance evidence quality, increase understanding of communication barriers and facilitators, and identify the best strategy to advance practice.
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http://dx.doi.org/10.1007/s12630-019-01413-9DOI Listing
October 2019

Reporting preclinical anesthesia study (REPEAT): Evaluating the quality of reporting in the preclinical anesthesiology literature.

PLoS One 2019 23;14(5):e0215221. Epub 2019 May 23.

Discipline of Anesthesia, Memorial University, St. John's, Newfoundland and Labrador, Canada.

Poor reporting quality may contribute to irreproducibility of results and failed 'bench-to-bedside' translation. Consequently, guidelines have been developed to improve the complete and transparent reporting of in vivo preclinical studies. To examine the impact of such guidelines on core methodological and analytical reporting items in the preclinical anesthesiology literature, we sampled a cohort of studies. Preclinical in vivo studies published in Anesthesiology, Anesthesia & Analgesia, Anaesthesia, and the British Journal of Anaesthesia (2008-2009, 2014-2016) were identified. Data was extracted independently and in duplicate. Reporting completeness was assessed using the National Institutes of Health Principles and Guidelines for Reporting Preclinical Research. Risk ratios were used for comparative analyses. Of 7615 screened articles, 604 met our inclusion criteria and included experiments reporting on 52 490 animals. The most common topic of investigation was pain and analgesia (30%), rodents were most frequently used (77%), and studies were most commonly conducted in the United States (36%). Use of preclinical reporting guidelines was listed in 10% of applicable articles. A minority of studies fully reported on replicates (0.3%), randomization (10%), blinding (12%), sample-size estimation (3%), and inclusion/exclusion criteria (5%). Statistics were well reported (81%). Comparative analysis demonstrated few differences in reporting rigor between journals, including those that endorsed reporting guidelines. Principal items of study design were infrequently reported, with few differences between journals. Methods to improve implementation and adherence to community-based reporting guidelines may be necessary to increase transparent and consistent reporting in the preclinical anesthesiology literature.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0215221PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6532843PMC
January 2020

Improving skills retention after advanced structured resuscitation training: A systematic review of randomized controlled trials.

Resuscitation 2019 05 27;138:284-296. Epub 2019 Mar 27.

Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.

Aims: To systematically evaluate the literature on interventions that improve skills retention following advanced structured resuscitation training programs designed for healthcare professionals.

Methods: A systematic review of MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO, ERIC, and Scopus was performed. Only randomized controlled trials investigating skills retention following advanced structured resuscitation training programs for healthcare professionals between inception to November 21, 2018 were included. Publications that assessed only knowledge acquisition were excluded. Relevant data from included studies were extracted and study quality was critically appraised, both independently and in duplicate by multiple reviewers. The risk of bias was assessed with the Cochrane Risk of Bias tool and the Medical Education Research Study Quality Instrument (MERSQI). Due to significant clinical heterogeneity in SRT training, study designs and interventions, a qualitative synthesis was used to summarize findings.

Main Results: Sixteen studies, with a combined total of 1192 participants, were included in the final analysis. The majority of studies were conducted in North America and involved trainees or novice learners. ACLS was the most extensively studied, followed by NRP, ALS, and ATLS. Skills retention at 6 months was the most commonly used primary endpoint assessed using a simulated resuscitation checklist with either an adopted or created assessment tool. Most studies demonstrated a positive impact on skills retention when an interactive intervention or simulation was used. However, merely having a high-fidelity mannequin alone for simulation was found to have minimal effect on skills retention in the absence of other changes in content delivery. Booster sessions were found to be minimally effective in reinforcing long-term skills retention; however, most studies examining this intervention had small sample sizes and were underpowered.

Conclusions: Simulation-based interventions, refresher courses and adjustments to the content delivery of advanced structured resuscitation training courses were found to have the greatest impact on skills retention. However, due to significant heterogeneity and methodological flaws in the available studies, no definitive conclusions can be made regarding other interventions. Overall, there is a paucity of skills retention research and further high-quality randomized controlled trials are needed to determine the optimal intervention and design for resuscitation training that would maximize skills retention.
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http://dx.doi.org/10.1016/j.resuscitation.2019.03.031DOI Listing
May 2019

Nontechnical Skill Assessment of the Collective Surgical Team Using the Non-Technical Skills for Surgeons (NOTSS) System.

Ann Surg 2020 12;272(6):1158-1163

International Centre for Surgical Safety, Keenan Centre for Biomedical Research, St. Michael's Hospital, Toronto, ON, Canada.

Objective: To validate the Non-Technical Skills for Surgeons (NOTSS) system for assessment of the collective surgical teams' nontechnical skills after observing recordings of actual OR environment.

Background: The NOTSS system is a widely accepted tool to measure nontechnical skills of individual surgeons, and has mostly been used in the simulated setting. Surgical procedures are rarely performed by a single surgeon, but by a surgical team of attending surgeons, surgical assistants, and surgical trainees. Therefore, assessment of nontechnical skills may benefit from holistic assessment of the collective surgical teams.

Methods: Five trained participants assessed surgical team and attending surgeon using the NOTSS system after watching ten 20-minute long videos obtained from live OR. A set of reference ratings was provided by a multidisciplinary expert committee. We performed analyses to assess system sensitivity; examine inter-rater reliability of ratings; investigate concurrent construct validity; and assess feasibility and acceptability of using the NOTSS system to measure surgical team performance.

Results: There was adequate system sensitivity when comparing participants' and reference ratings. Inter-rater reliability among the participants' ratings was good except for decision-making category. The level of inter-rater reliability was similar when rating teams and attending surgeons. There was strong positive correlation between teams' and attending surgeons' NOTSS ratings at category [Pearson coefficient 0.86, 95% confidence interval (CI) 0.82-0.89] and element levels (0.83, 95% CI 0.80-0.85), demonstrating evidence of concurrent construct validity. The participants felt that the use of NOTSS system to measure teams' nontechnical skills was acceptable and feasible to a fair extent.

Conclusion: The NOTSS system, although developed for assessment of individual surgeons, is a useful tool for observing and rating surgical teams.
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http://dx.doi.org/10.1097/SLA.0000000000003250DOI Listing
December 2020

The potential for anesthesiologist practice feedback to reduce postoperative vomiting in an academic centre.

Can J Anaesth 2019 05 23;66(5):609-610. Epub 2019 Jan 23.

Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.

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http://dx.doi.org/10.1007/s12630-019-01298-8DOI Listing
May 2019

Anesthesia interventions that alter perioperative mortality: a scoping review.

Syst Rev 2018 11 30;7(1):218. Epub 2018 Nov 30.

Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Rd, Critical Care Wing 1401, Ottawa, Ontario, K1H 8L6, Canada.

Background: With over 230 million surgical procedures performed annually worldwide, better application of evidence in anesthesia and perioperative medicine may reduce widespread variation in clinical practice and improve patient care. However, a comprehensive summary of the complete available evidence has yet to be conducted. This scoping review aims to map the existing literature investigating perioperative anesthesia interventions and their potential impact on patient mortality, to inform future knowledge translation and ultimately improve perioperative clinical practice.

Methods: Searches were conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library databases from inception to March 2015. Study inclusion criteria were adult patients, surgical procedures requiring anesthesia, perioperative intervention conducted/organized by a professional with training in anesthesia, randomized controlled trials (RCTs), and patient mortality as an outcome. Studies were screened for inclusion, and data was extracted in duplicate by pairs of independent reviewers. Data were extracted, tabulated, and reported thematically.

Results: Among the 10,505 publications identified, 369 RCTs (n = 147,326 patients) met the eligibility criteria. While 15 intervention themes were identified, only 7 themes (39 studies) had a significant impact on mortality: pharmacotherapy (n = 23), nutritional (n = 3), transfusion (n = 4), ventilation (n = 5), glucose control (n = 1), medical device (n = 2), and dialysis (n = 1).

Conclusions: By mapping intervention themes, this scoping review has identified areas requiring further systematic investigation given their potential value for reducing patient mortality as well as areas where continued investment may not be cost-effective given limited evidence for improving survival. This is a key starting point for future knowledge translation to optimize anesthesia practice.
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http://dx.doi.org/10.1186/s13643-018-0863-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6267894PMC
November 2018

Hydroxyethyl starch (HES) utilization before and after a regulatory safety warning.

Can J Anaesth 2019 01 25;66(1):113-114. Epub 2018 Oct 25.

Clinical Epidemiology Program, Department of Anesthesiology and Pain Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.

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http://dx.doi.org/10.1007/s12630-018-1244-6DOI Listing
January 2019

Measuring the teamwork performance of teams in crisis situations: a systematic review of assessment tools and their measurement properties.

BMJ Qual Saf 2019 04 11;28(4):327-337. Epub 2018 Oct 11.

Division of General Surgery, St Michael's Hospital, Toronto, Canada.

Background: Educational interventions to improve teamwork in crisis situations have proliferated in recent years with substantial variation in teamwork measurement. This systematic review aimed to synthesise available tools and their measurement properties in order to identify the most robust tool for measuring the teamwork performance of in crisis situations.

Methods: Searches were conducted in Embase (via OVID), PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Education Resources Information Center, Medline and Medline In-Process (via OVID) (through 12 January 2017). Studies evaluating the measurement properties of teamwork assessment tools for in clinical or simulated crisis situations were included. Two independent reviewers screened studies based on predetermined criteria and completed data extraction. Risk of bias was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

Results: The search yielded 1822 references. Twenty studies were included, representing 13 assessment tools. Tools were primarily assessed in simulated resuscitation scenarios for emergency department teams. The Team Emergency Assessment Measure (TEAM) had the most validation studies (n=5), which demonstrated three sources of validity (content, construct and concurrent) and three sources of reliability (internal consistency, inter-rater reliability and test-retest reliability). Most studies of TEAM's measurement properties were at no risk of bias.

Conclusions: A number of tools are available for assessing teamwork performance of teams in crisis situations. Although selection will ultimately depend on the user's context, TEAM may be the most promising tool given its measurement evidence. Currently, there is a lack of tools to assess teamwork performance during intraoperative crisis situations. Additional research is needed in this regard.
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http://dx.doi.org/10.1136/bmjqs-2018-008260DOI Listing
April 2019
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