Building Resilience in Trauma Care at a Sub-Saharan African Tertiary Center: A Longitudinal Assessment of Multidisciplinary Trauma and Disaster Team Response Training Impact

BackgroundIn the Netherlands, each year a three-day international multidisciplinary trauma masterclass is organized to provide the knowledge and skills needed to care for critically injured trauma patients. This study was designed to longitudinally evaluate the effect of the course on participant’s self-assessment of their own ability and confidence to perform general and specific skills.MethodsBetween 2013 and 2016, all participants were invited to complete a questionnaire before and during follow-up. Participants were asked to self-assess their level of confidence to perform general skills (communication, teamwork, leadership) and specific skills. Mean scores were calculated, and mixed models were used to evaluate correlation.ResultsWe asked 265 participants to participate. Response rate was 64% for the pre-questionnaire, 63% for the post-questionnaire and for 3 months, 1 year and 2 years, respectively, 40%, 30%, 20%. The surgical group showed a statistically significant increase in self-assessed confidence for general skills (3.82–4.20) and specific technical skills (3.01–3.83; p < 0.001). In the anesthetic group, self-assessed confidence increased significantly in general skills (3.72–4.26) and specific technical skills (3.33–4.08; p < 0.001). For both groups statistical significance remained during follow-up.ConclusionsThis study demonstrated a sustained positive effect of a dedicated multidisciplinary trauma training curriculum on participant’s self-assessed confidence to perform both general and specific technical skills necessary for the care of injured patients. Given the known association between confidence and competence, these findings provide evidence that dedicated trauma training curricula can provide positive lasting results.Level of evidenceThis is a basic science paper and therefore does not require a level of evidence.

Delay in the provision of definitive care for critically injured children may adversely effect outcome. We sought to speed care in the emergency department (ED) for trauma victims by organizing a formal trauma response system. A case-control study of severely injured children, comparing those who received treatment before and after the creation of a formal trauma response team. A tertiary pediatric referral hospital that is a locally designated pediatric trauma center, and also receives trauma victims from a geographically large area of the Western United States. Pediatric trauma victims identified as critically injured (designated as "trauma one") and treated by a hospital trauma response team during the first year of its existence. Control patients were matched with subjects by probability of survival scores, and were chosen from pediatric trauma victims treated at the same hospital during the year preceding the creation of the trauma team. A trauma response team was organized to respond to pediatric trauma victims seen in the ED. The decision to activate the trauma team (designation of patient as "trauma one") is made by the pediatric emergency medicine (PEM) physician before patient arrival in the ED, based on data received from prehospital care providers. Activation results in the notification and immediate travel to the ED of a pediatric surgeon, neurosurgeon, emergency physician, intensivist, pharmacist, radiology technician, phlebotomist, and intensive care unit nurse, and mobilization of an operating room team. Most trauma one patients arrived by helicopter directly from accident scenes. Data recorded included identifying information, diagnosis, time to head computerized tomography, time required for ED treatment, admission Revised Trauma Score, discharge Injury Severity Score, surgical procedures performed, and mortality outcome. Trauma Injury Severity Score methodology was used to calculate the probability of survival and mortality compared with the reference patients of the Major Trauma Outcome Study, by calculation of z score. Patients treated in the ED after trauma team initiation had statistically shorter times from arrival to computerized tomography scanning (27 +/- 2 vs 21 +/- 4 minutes), operating room (63 +/- 16 vs 623 +/- 27 minutes) and total time in the ED (85 +/- 8 vs 821 +/- 9 minutes). Calculation of z score showed that survival for the control group was not different from the reference population (z = -0.8068), although survival for trauma-one patients was significantly better than the reference population (z = 2.102). Before creation of the trauma team, relevant specialists were individually called to the ED for patient evaluation. When a formal trauma response team was organized, time required for ED treatment of severe trauma was decreased, and survival was better than predicted compared with the reference Major Trauma Outcome Study population.

Background/Introduction:The Republic of Moldova needs a proactive approach in building their trauma and emergency care capacity given the neighboring conflict in Ukraine and inflow of refugees. The World Health Organization, in collaboration with local and international experts, has implemented a series of training programs to address the identified need for improved emergency and trauma care. These programs are critical for future EMT development.Objectives:Objectives of the training programs include:1.Strengthening emergency medicine and trauma expertise amongst interdisciplinary healthcare providers2.Improving trauma care through the development and implementation of a novel trauma team program3.Increasing capacity for mass casualty managementMethod/Description:Emergency Care Systems Assessment and Hospital Emergency Unit Assessment Tool were used to identify gaps. Initial training focused on Basic Emergency Care, Advanced Trauma Life Support, and ultrasound courses led by WHO instructors in partnership with a local simulation center. A team of international experts, in partnership with local physicians, introduced trauma simulation sessions in the emergency department for multi-specialty teams to enhance their team communication and resuscitation skills. A training video was produced to improve dissemination of trauma care knowledge and instruction of an evidence-based pre-hospital handover tool. Finally, a table-top mass casualty simulation exercise was completed led by Emergo Train System instructors.Results/Outcomes:The Institutul de Medicină Urgentă launched the country’s first trauma team program on July 1, 2024 and neighboring regions will be replicating this approach.Conclusion:A multi-faceted training approach allows for proactive strengthening of emergency and trauma care to improve local response capacity.

Given the burden of rheumatic disease in our society and the anticipated future shortage of rheumatologists, all internal medicine (IM) residencies need to train internists who are capable of caring for patients with rheumatic diseases. The objective of this study was to perform a targeted needs assessment of the self-confidence of IM residents in the evaluation and care of patients with rheumatologic diseases. A 16-item, web-based, self-assessed confidence survey tool was administered to participating post graduate year (PGY)1 (N = 83) and PGY3 (N = 37) residents. The categories of questions included self-confidence in performing a rheumatologic history and exam, performing common rheumatologic procedures, ordering and interpreting rheumatologic laboratory tests, and caring for patients with common rheumatologic diseases. Resident demographics, prior rheumatology exposure, and career plans were also queried. PGY3 residents had higher self-assessed confidence than PGY1 residents in all categories. Self-assessed confidence in joint procedures was consistently low in both groups and when compared to other categories. Prior exposure to a rheumatology course or elective was not consistently associated with higher self-assessed confidence ratings across all categories. PGY3 residents showed less interest in rheumatology as a career than PGY1 residents, although the interest in the topic of rheumatology was not statistically different. Our needs assessment shows a low level of self-assessed confidence in rheumatology knowledge and skills among IM residents. Despite improvement with PGY year of training, self-assessed confidence remains low. To improve resident's skills and self-confidence in rheumatology, more curricular innovations are needed. Such innovations should be assessed for overall effectiveness.

Trauma care in India: A review of the literature

Management of acutely injured trauma patients is one of the most advanced clinical competencies required by a trauma care team physician. In the United States, the majority of multispecialty trauma care training of anesthesiology residents occurs at level 1 trauma centers. These are primarily academic teaching hospitals with a high trauma case volume, that admits severely injured patients, and who provides 24-hour in-house coverage of anesthesiology services. The anesthesiology service plays an integral role in the management of severely injured patients.1 In contrast to the training, according to the National Anesthesia Clinical Outcome Registry (NACOR) from the Anesthesia Quality Institute (AQI), most trauma and emergency patients are cared for at nonacademic, medium-sized community hospitals.2 All anesthesiologists should acquire the basics of resuscitation for a patient after traumatic injury because even those clinicians who do not practice at level 1 trauma centers may still care for patients with traumatic injuries after residency.2 Trauma anesthesiology (TA) education during residency has been under-recognized and underemphasized. Currently, anesthesiology residency programs offer rotations in a variety of anesthesia subspecialties including ambulatory, transplant, neurosurgery, cardiothoracic, vascular, pediatric, regional, pain management, critical care, and even bariatric surgery. However, a trauma rotation is typically not offered. The Residency Review Committee (RRC) of the American Board of Anesthesiology (ABA) has established that residents must achieve competence in the delivery of anesthetic care for a minimum 20 patients “undergoing procedures for complex, immediate life-threatening pathology,” which may include trauma. The RRC, however, does not specify a minimum number of trauma cases nor the trauma knowledge or skills to be acquired. The mission statement of the ABA declares: “Because of the nature of anesthesiology, the ABA diplomate must be able to manage emergent life-threatening situations in an independent and timely fashion.”3 Nevertheless, the content outline of the (ABA/American Society of Anesthesiologists [ASA]) Joint Council on In-Training Examinations does not offer guidance on a trauma curriculum for anesthesiology training programs to be followed. As a result, many anesthesiology residents graduate with a lack of experience, confidence, and the ability to resuscitate patients with life-threatening or multiorgan trauma. Given the high number of graduating residents who may provide care for trauma patients in the private and community practice, adequate trauma and acute care education should be offered to equip them with the skills and knowledge to care for polytrauma patients. Committee on Trauma and Emergency Preparedness (COTEP) believes that there is an insufficient emphasis on trauma training in anesthesiology residency programs and that the knowledge and skills of graduating residents for managing trauma patients are inadequate and below international standards. For example, TA training has been described in detail in the Royal College of Anesthetists advanced level training manual since 2010.4 We believe that there is a need for focused training and education on managing trauma patients during residency training. To explore the attitudes of anesthesiologists regarding the need for training in TA, we solicited opinions of anesthesiology residents, residency program directors (PDs) and practicing anesthesiologists. Additionally, we invited trauma surgeons to share their views of anesthesiologists’ performance in trauma cases and their thoughts on implementing a dedicated TA curriculum. METHODS Four different online survey questionnaires were sent via SurveyMonkey (Palo Alto, California) to 4 groups of participants. Responses for all participants were anonymous. Anesthesiology residents: Chief residents from 133 US anesthesiology residency programs were contacted and asked to distribute the resident survey to the categorical residents (CA-1, CA-2, and CA-3) at their programs. Anesthesiology residency PDs: The PD survey was distributed to 133 PDs via e-mail. Practicing anesthesiologists: We asked presidents and/or secretaries of all the anesthesiology state component societies to distribute the survey to their members. Trauma surgeons: The survey was e-mailed to all members of Western Trauma Association (WTA) and active, senior, and associate members of the Eastern Association for Surgery of Trauma (EAST). Survey questions for all groups were designed by the ASA COTEP. The questions related to the following: Demographics (year of residency training) Availability and duration of residency training at a level 1 trauma center Availability of a formal TA rotation and curriculum Participants’ exposure to trauma during their residency and perceived benefit of a TA rotation for their education and practice Trauma surgeons were also asked to comment on the importance of the anesthesiologist’s role as part of the trauma team, as well as their opinion on anesthesiologists’ adequacy of training when managing trauma patients. The surgeons were also asked to comment on anesthesiologists’ skills and knowledge in trauma care. The surveys were designed to take <5 minutes to complete and consisted of 6 to 8 questions. All responses were anonymous. Completion of survey was voluntary and without remuneration. We applied descriptive statistics to evaluate our result. Results are expressed as number (%) and the lower and upper limits of 95% confidence intervals were calculated. The qualitative data collected as free-text comments were analyzed for thematic content. Institutional review board exemption status was requested by the EAST Research and Scholarship Section; therefore, the survey was reviewed by the Medical College of Wisconsin institutional review board and was deemed exempt from further review. RESULTS The response rates for the surveyed groups were as follows: Residents: Of the total 4652 US categorical residents (2014–2015 Accreditation Council for Graduate Medical Education [ACGME] data book), 212 residents completed the survey (4.5% response rate). Among the respondents, 28% identified themselves as CA-1, 37% as CA-2, and 34% as CA-3 residents. Program directors: We received 35 responses from 133 PDs (26.3% response rate). Practicing anesthesiologists: Of the 49 anesthesiology state societies (Alaskan state society’s email was invalid), which consisted of 31 389 active members, 433 practicing anesthesiologists responded (1.4% response rate). Trauma surgeons: Of the 1937 WTA and EAST members, 455 responded (23.5% response rate); 95% (430/454) were surgeons, 0.9% (4/454) emergency medicine physicians, 1.5% (7/454) anesthesiologists, 2.2% (10/454) nonphysicians, and 0.66% (3/454) other. The results of the surveys are presented in the Tables 1, 2, 3, and 4 and Supplementary survey result charts for residents, PDs, anesthesiologists, and surgeons (Supplemental Digital Content 1–4, Figures 1–4, https://links.lww.com/AA/B901, https://links.lww.com/AA/B902, https://links.lww.com/AA/B903, https://links.lww.com/AA/B904).Table 1.: Survey Results: ResidentsTable 2.: Survey Results: Program DirectorsTable 3.: Survey Results: Practicing AnesthesiologistsTable 4.: Survey Results: Trauma Surgeons Residents: A clear majority of residents (98.6%) reported having their training at a level 1 trauma center and 81.5% felt they had sufficient exposure to emergency surgery for life-threatening or multiorgan trauma; 40.5% of them had a formal rotation in TA. The majority of the residents saw a benefit of trauma rotation for their education (87%) and for their future practice (76.5%). Program directors: Most of the PDs (94.3%) reported their training occurring at the level 1 trauma center and 81.3% believed that their residents had sufficient exposure to emergency surgery for life-threatening or multiorgan trauma; 41.9% offered a formal TA curriculum but only 20% offered a formal TA rotation. Only 32.1% of PDs saw a benefit of TA rotation for their residents’ education and less than half (46.9%) believed that it would be helpful to track ACGME case logs regarding their residents’ exposure to emergency surgery for life-threatening or multiorgan trauma. Practicing anesthesiologists: A majority of anesthesiologists (88.9%) recalled that their residency training occurred at a level 1 trauma center and 85% felt that they had sufficient exposure to the emergency surgery for life-threatening or multiorgan trauma. Forty one percent recalled that their residency program had focused training in TA and 78.2% believed that it was beneficial to have had such training in their current practice. Whereas only 43.1% of them felt that anesthesiologists employed at level 1 trauma centers should have dedicated training in trauma, and the majority (91.2%) felt that it was important to have the necessary skills and knowledge to perform anesthesia for life-threatening or multiorgan trauma in their current practice. Trauma Surgeons: Most of the surgeons practiced at level 1 (75.6%) and level 2 (20.6%) trauma centers. Ninety-eight percent of the surgeons believed that an anesthesiologist is an essential partner in a multidisciplinary trauma team. Ninety-six percent agreed that anesthesiologists should receive dedicated training for life-threatening or multiorgan trauma during their anesthesiology residency, but only 68.6% of them felt that anesthesiologists are adequately trained to manage these cases in their centers. The survey responders (total of 1.135) submitted 417 free-text comments. The most common topics were duration and kinds of trauma training provided in anesthesia residency, sufficiency of exposure to emergency surgery for life-threatening or multiorgan trauma, opinion on a benefit of trauma anesthesia rotation for anesthesiologist’s education and practice, and skills missing with anesthesiologists working in trauma centers. To present data more completely, we calculated the lower and upper limits of the 95% confidence interval. This, along with percentages, should help readers understand the strengths and weaknesses of the data. Since the responses did not contain a numerical range (eg, 1–5), we could not evaluate them based on a Likert scale. DISCUSSION We present the large spectrum of opinions appraising the current state of TA education during anesthesiology residency training, its challenges, and the need for this training among 4 groups of physicians—the key participants in the current US trauma care systems—anesthesiology residents, anesthesiology residency PDs, practicing anesthesiologists, and trauma surgeons. Our study was subject to several limitations; the main limitation is a low response rate in 2 surveyed groups (the anesthesia residents and practicing anesthesiologists). This low response rate was expected as the survey links had to be distributed to large target audiences (4652 US anesthesiology residents and 31, 389 anesthesiologists who were active members of anesthesiology state societies) via intermediaries (chief residents and state society presidents/secretaries). The cooperation of the intermediaries was unpredictable; therefore, the response rates in these 2 groups could not be accurately calculated. Additionally, there was potential for recall bias in the responses of the practicing anesthesiologists, as there was variability in the time since their graduation from residency. Most of the anesthesiologists surveyed (residents, practicing anesthesiologists, and PDs) confirmed being trained at level 1 trauma centers and felt they had adequate exposure to emergency surgery for life-threatening or multiorgan trauma during their training. However, less than half recalled being offered a formal TA rotation or curriculum. Interestingly, while residents and practicing anesthesiologists saw a benefit in having a dedicated rotation in TA, PDs did not. Although most of the residents, PDs, and practicing anesthesiologists agreed that, overall, level 1 trauma centers provide residents with sufficient exposure to a variety trauma cases, they also commented on several barriers to TA training including insufficient volume of penetrating trauma and the sporadic nature and unpredictable timing of trauma, making it interspersed throughout their training. Furthermore, a majority of practicing anesthesiologists felt they could apply principles of managing other complex cases requiring resuscitation of shock and coagulopathies to trauma management (eg, liver transplants, ruptured abdominal aortic aneurysm, and major cardiac and spine cases). We specifically queried the practicing anesthesiologists on benefits of a TA fellowship.5 The majority of them were critical toward the idea of this fellowship. They felt that creating another anesthesiology subspecialty would “not be feasible,” was “not practical,” was “too restrictive,” and “would create new barriers.” At the same time, some responders saw the value of employing fellowship-trained faculty to provide high-quality TA education. Members of the ASA COTEP believe that providing the anesthesiology residents with structured training by a well-designed TA rotation with a focused curriculum is the best method to educate and prepare them for taking care of trauma patients. To address this concern, COTEP developed a model TA curriculum, which identified the ACGME core competencies and outlined the goals and objectives for junior residents (categorical anesthesia CA-1 and -2) and another for senior residents.6–8 Many anesthesiologists surveyed favored the implementation of required documentation of high trauma caseload during residency and competency training for trauma anesthesiologists to practice at a level 1 trauma center. However, the latest version of the ACGME resident case logs no longer lists trauma as one of the data entry items. More than half of the surveyed PDs felt that trauma cases should not be tracked in the ACGME resident case logs. The reasons provided by PDs for not tracking trauma cases included insufficient case numbers and confusion with the definition of “trauma cases.” Additionally, PDs believed that the ACGME case log is already tracking life-threatening pathology, providing experiences similar to trauma (eg, liver transplant, emergency major vascular surgery, and obstetric hemorrhagic complications), which require massive transfusion. Nevertheless, to ensure the success of a TA education, COTEP strongly believes that the number of trauma cases should be documented and the definition of trauma cases should be classified as “life-threatening or multiple-organ trauma.” Without these data, it would be impossible to assess the residents’ trauma experience. Although there are conflicting views among anesthesiologists, residents, and PDs with respect to TA education and training, both COTEP members and trauma surgeons share the belief that a dedicated TA curriculum is warranted and needed. The vast majority of surgeons believe in required TA education for those anesthesiologists providing care to trauma patients at level 1 trauma centers. However, less than half of the anesthesiologists saw the need for this training. Many of the anesthesiologists believed that the TA skills “could be learned on the job” and that a practicing anesthesiologist “should be able to get up to speed with focused additional training, such as continued medical education (CME).” Moreover, the trauma surgeons emphasized the importance of the rotation on trauma and critical care service for anesthesiologists providing care for trauma patients. They felt this rotation should take longer than what is currently offered at anesthesiology training programs and include 3 months of intensive care unit training during CA-3 year. The surgeons also stressed the value of both high-fidelity (mannequin-based) and low-fidelity simulation (case discussion) training. Additional skills suggested to be incorporated into training included fostering leadership and team-building skills in trauma patient resuscitation. Both anesthesiologists and trauma surgeons agreed on the importance of the Advanced Trauma Life Support course, interdisciplinary conferences (including morbidity and mortality) with the anesthesiology, surgical, and emergency medicine departments, and hands-on practice sessions to master techniques (eg, cricothyrotomy, intraosseous line placement). There is a concerning disconnect between the trauma surgeons and the anesthesiologists around the latter’s knowledge and skill level to manage patients with life-threatening or multiorgan trauma. While 91% of practicing anesthesiologists believed that they had the necessary skill level, only 69% of the trauma surgeons felt that the anesthesiologists at their institutions had been adequately trained to manage these types of cases. Of the 450 trauma surgeons who responded to the survey, 135 (30%) reported skills that were deficient in anesthesiologists providing trauma care, including poor teamwork and coordination of care, as illustrated by the representative statement: “anesthesiologists need to be daily members of the trauma team, not every once in a while”; reluctance in responding to trauma alerts; an inability to expedite access for emergent procedures and to coordinate aggressive trauma resuscitation; the overuse of nurse anesthetists; and lack of communication with the surgeon regarding hemodynamics during intraoperative resuscitation were also concerns expressed by the surgeons. Trauma surgeons felt anesthesiologists lacked understanding of modern concepts of shock and trauma and evidence-based resuscitation strategies, such as damage control resuscitation, permissive hypotension, and hemostatic resuscitation.9,10 They felt that in general, anesthesiologists were slow to implement massive transfusion protocols and goal-directed management of acute traumatic coagulopathy based on viscoelastic methods, such as thromboelastography and rotational thromboelastometry.11 This is in agreement with data that anesthesiologists have gathered from their own practices.12 The surgeons also felt that anesthesiologists have not been adequately trained in intravascular volume assessment, minimizing the use of crystalloid solutions and avoiding the use of colloids in trauma scenarios. Other comments included statements such as, “anesthesiologists fail to recognize that ‘normal’ hemoglobin in an actively hemorrhaging patient is meaningless”; “unwilling to transfuse blood based on abnormal base deficit”; “use pressers without communication with surgeon.” Other respondents suggested more focused education on resuscitative endovascular balloon occlusion of the aorta, emergency thoracotomy, and emergency cricothyrotomy. A very critical point made by the trauma surgeons was that anesthesiologists may treat trauma patients just like elective patients with hemorrhage and hemodynamic instability. They made concerning comments regarding the common assumption apparently made by anesthesiologists that trauma required the same resuscitation as open heart, liver transplant, aortic surgery, and other cases with intraoperative hemorrhage, believing themselves to be equipped to care for trauma patients “because they deal with sick patients every day,” without any specific knowledge of current concepts in trauma resuscitation. Therefore, although most of the residency program training is performed at level 1 trauma hospitals and most surveyed anesthesiologists do not perceive a benefit in focused TA education, trauma surgeons disagreed. Trauma surgeons felt that practicing anesthesiologists lacked the knowledge and skills to appropriately manage trauma patients. These beliefs are shared by the authors and members of ASA COTEP, who realize the value of and support the implementation of a TA curriculum. CONCLUSIONS Our survey results revealed that a majority of anesthesiology residency programs conduct their training at the level 1 trauma hospitals, which ensures an adequate exposure of their residents to emergency surgery for life-threatening or multiorgan trauma. However, less than half of the programs that responded to our survey augment the exposure with a regimented education, such as didactic curriculum or formal rotation in TA. Furthermore, most of the residency PDs do not see the benefits of such education, unlike their current trainees and graduated anesthesiologists in various stages of their practice. Such a disconnect and a lack of formal education in TA could explain serious gaps in knowledge of unique physiology of shock and trauma and in understanding the principles of resuscitation. These deficiencies were stressed in numerous comments of the trauma surgeons, the largest group of responders and with one of the highest response rates. Our survey revealed substantial differences in perception of abilities of the anesthesiologists employed by the level 1 trauma centers—while practicing anesthesiologists were confident they were more than adequately trained to provide anesthesia to the trauma patients, the surgeons felt that they were inept to do this job. Thus, the vast majority of trauma surgeons supported the need of dedicated training in anesthesiology for life-threatening or multiorgan trauma during anesthesiology residency. These concerns raised by trauma surgeons highlight the premise that perhaps our current TA training is inadequate and support the COTEP’s viewpoint that implementing a dedicated TA curriculum in all anesthesiology training programs would be a stepping stone toward improving the knowledge and skill sets needed to care for trauma patients. TA is not just a mere practice of massive blood transfusion and coagulation management, but it requires a certain aptitude and mastery to efficiently deliver safe and effective multidisciplinary acute and trauma care in and out of the operating room environment, as well as national and international disaster preparedness. Dedicated training will give the authority to anesthesiologists to become academic and administrative leaders in an ever-growing acute and trauma care specialty. DISCLOSURES Name: Olga Kaslow, MD, PhD. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Dr Kaslow has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files. Conflicts of Interest: None. Name: Catherine M. Kuza, MD. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Maureen McCunn, MD, MIPP, FCCM. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Armagan Dagal, MD, FRCA. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Carin A. Hagberg, MD. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: Dr Carin A. Hagberg has a financial relationship with Ambu, Cadence Pharmaceuticals, Karl Storz Endoscopy, and MedCom Flow in the form of funded research and is an unpaid consultant for Ambu, Covidien, and SonarMed. Name: Joseph H. McIsaac, III, MD, MS. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Venkat R. Mangunta, MD. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Richard D. Urman, MD, MBA. Contribution: This author helped analyze the data and prepare the manuscript. Conflicts of Interest: None. Name: Chris A. Fox, PhD. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Albert J. Varon, MD, MHPE, FCCM. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. This manuscript was handled by: Richard P. Dutton, MD.

In Tanzania, inadequate infrastructures and shortages of trauma-response training exacerbate trauma-related fatalities. McGill University's Centre for Global Surgery introduced the Trauma and Disaster Team Response course (TDTR) to address these challenges. This study assesses the impact of simulation-based TDTR training on care providers' knowledge/skills and healthcare processes to enhance patient outcomes. The study used a pre-post-interventional design. TDTR, led by Tanzanian instructors at Muhimbili Orthopedic Institute from August 16-18, 2023, involved 22 participants in blended online and in-person approaches with simulated skills sessions. Validated tools assessed participants' knowledge/skills and teamwork pre/post-interventions, alongside feedback surveys. Outcome measures included evaluating 24-h emergency department patient arrival-to-care time pre-/post-TDTR interventions, analyzed using parametric and non-parametric tests based on data distributions. Participants' self-assessment skills significantly improved (median increase from 34 to 58, p<0.001), along with teamwork (median increase from 44.5 to 87.5, p<0.003). While 99% of participants expressed satisfaction with TDTR meeting their expectations, 97% were interested in teaching future sessions. The six-month post-intervention arrival-to-care time significantly decreased from 29 to 13min, indicating a 55.17% improvement (p<0.004). The intervention led to fewer ward admissions (35.26% from 51.67%) and more directed to operating theaters (29.83% from 16.85%), suggesting improved patient management (p<0.018). The study confirmed surgical skills training effectiveness in Tanzanian settings, highlighting TDTR's role in improving teamwork and healthcare processes that enhanced patient outcomes. To sustain progress and empower independent trauma educators, ongoing refresher sessions and expanding TDTR across low- and middle-income countries are recommended to align with global surgery goals.

Neuropalliative care is an emerging interprofessional field that aims to improve communication and quality of life for all people affected by serious neurologic disease. Teaching neuropalliative care skills is a key objective for neurology residencies, and the Accreditation Council for Graduate Medical Education requires proficiency in palliative care. The objective of this study was to describe a novel longitudinal multimodal curriculum in neuropalliative care communication and evaluate its feasibility and outcomes. We designed a multimodal curriculum focused on neuropalliative care communication skills using as our theoretical foundation transformative learning theory. We implemented this program for neurology residents at a single academic institution over the course of their 3-year training. Residents underwent (1) 3 communication workshops using VitalTalk modules and simulated patient encounters, (2) 3 or more observed clinical encounters with structured faculty feedback, and (3) at least 3 annual neuropalliative care lectures. We evaluated the effect on learners' self-assessed confidence in neuropalliative care skills with preworkshop and postworkshop questionnaires. In 2021, 14 of 20 eligible residents attended our workshops and completed the preworkshop questionnaire, and 12 of those completed the postworkshop questionnaire. After the workshop, a larger proportion of residents (75%, 9/12) agreed or strongly agreed that they felt confident leading family meetings compared with before the workshop (57%, 8/14). While more than 90% of residents felt confident recognizing patient and family emotions both before and after the workshop, the workshop improved their confidence in responding to such emotions. Still, some residents neither agreed nor disagreed (42%, 5/12) about feeling confident in responding to emotions after the workshop, and many commented on wanting more training in this area. The successful implementation and high attendance among eligible participants demonstrate the feasibility of our longitudinal multimodal neuropalliative care curriculum. The evaluation of intervention outcomes suggests that residents' confidence in neuropalliative communication skills improved. Our study shows that VitalTalk is a tool that can be adapted to teach neuropalliative communication skills for neurology residents, and this program can be easily adopted by other neurology training programs.

ABSTRACTBackground: Evidence-based antenatal care is one cornerstone in Safe Motherhood and educated and confident midwives remain to be optimal caregivers in Africa. Confidence in antenatal midwifery skills is important and could differ depending on the provision of education among the training institutions across Africa.Objective: The aim of the study was to describe and compare midwifery students’ confidence in basic antenatal skills, in relation to age, sex, program type and level of program.Methods: A survey in seven sub-Saharan African countries was conducted. Enrolled midwifery students from selected midwifery institutions in each country presented selfreported data on confidence to provide antenatal care. Data were collected using a selfadministered questionnaire. The questionnaire consisted of 22 antenatal skills based on the competency framework from the International Confederation of Midwives. The skills were grouped into three domains; Identify fetal and maternal risk factors and educate parents; Manage and document emergent complications and Physical assessment and nutrition.Results: In total, 1407 midwifery students from seven Sub-Saharan countries responded. Almost one third (25-32%) of the students reported high levels of confidence in all three domains. Direct entry programs were associated with higher levels of confidence in all three domains, compared to post-nursing and double degree programs. Students enrolled at education with diploma level presented with high levels of confidence in two out of three domains.Conclusions: A significant proportion of student midwives rated themselves low on confidence to provide ANC. Midwifery students enrolled in direct entry programs reported higher levels of confidence in all domains. It is important that local governments develop education standards, based on recommendations from the International Confederation of midwives. Further research is needed for the evaluation of actual competence.

Self-assessment promotes reflective practice, helps students identify gaps in their learning and is used in curricular evaluations. Currently, there is a dearth of validated self-assessment tools in rheumatology. We present a new musculoskeletal self-assessment tool (MSAT) that allows students to assess their confidence in their skills in and knowledge of knee and shoulder examination. We aimed to validate the 15-item MSAT, addressing its construct validity, internal consistency, responsiveness, repeatability and relationship with competence. Participants were 241 Year 3 students in Newcastle upon Tyne and 113 Year 3 students at University College London, who were starting their musculoskeletal skills placement. Factor analysis explored the construct validity of the MSAT; Cronbach's alpha assessed its internal consistency; standardised response mean (SRM) evaluated its responsiveness, and test-retest, before and after a pathology lecture, assessed its repeatability. Its relationship with competence was explored by evaluating its correlation with shoulder and knee objective structured clinical examinations (OSCEs). Results The MSAT was valid in distinguishing the 5 domains it intended to measure: clinical examination of the knee; clinical examination of the shoulder; clinical anatomy of the knee and shoulder; history taking, and generic musculoskeletal anatomical and clinical terms. It was internally consistent (alpha = 0.93), responsive (SRM 0.6 in Newcastle and 2.2 in London) and repeatable (intraclass correlation coefficient 0.97). Correlations between MSAT scores and OSCE scores were weak (r < 0.2). The MSAT has strong psychometric properties, thereby offering a valid approach to evaluating the self-assessment of confidence in examination skills by students. Confidence does not necessarily reflect competence; future research should clarify what underpins confidence.

This thesis reports on an environmentally-friendly pultrusion technique for the production of fibre-reinforced composites, termed as “clean pultrusion”. In this new manufacturing technique, the resin bath used in the conventional pultrusion was replaced with a custom-built resin impregnator. The resin impregnator was designed and built to impregnate the rovings using a combination of pin, injection and capillary-based impregnation. An integral aspect of the clean pultrusion process was spreading of the filaments in the rovings, via mechanical means, prior to impregnation. An automated fibre spreading rig was designed and built based on “tension-release” process. The rig-design was optimised using Taguchi method. &#13;\nThe physical, mechanical and thermo-mechanical properties of the composites pultruded using the clean and conventional techniques were compared. It was found that the composites manufactured using the clean pultrusion exhibited lower void and better mechanical properties. A life cycle assessment (LCA) was also performed to compare the environmental impact of the clean and conventional pultrusion processes. The LCA demonstrated conclusively that the clean pultrusion technique offers several environmental advantages over the conventional resin-bath pultrusion. The new pultrusion technique was demonstrated as being a viable method to pultrude composites without using a resin bath.&#13;\n

Simulation is frequently used to recreate many of the crises encountered in patient care settings. Teams learn to manage these crises in an environment that maximizes their learning experiences and eliminates the potential for patient harm. By designing simulation scenarios that include conditions associated with diagnostic errors, teams can experience how their decisions can lead to errors. The purpose of this study was to assess how trauma teams (TrT) and pediatric rapid response teams (RRT) managed scenarios that included a diagnostic error. We developed four scenarios that would require TrT and pediatric RRT to manage an error in diagnosis. The two trauma scenarios (spinal cord injury and tracheobronchial tear) were designed to not respond to the heuristic management approach frequently used in trauma settings. The two pediatric scenarios (foreign body aspiration and coarctation of the aorta) had an incorrect diagnosis on admission. Two raters independently scored the scenarios using a rating system based on how teams managed the diagnostic process (search, establish and confirm a new diagnosis and initiate therapy based on the new diagnosis). Twenty-one TrT and 17 pediatric rapid response managed 51 scenarios. All of the teams questioned the initial diagnosis. The teams were able to establish and confirm a new diagnosis in 49% of the scenarios (25 of 51). Only 23 (45%) teams changed their management of the patient based on the new diagnosis. Simulation can be used to recreate conditions that engage teams in the diagnostic process. In contrast to most instruction about diagnostic error, teams learn through realistic experiences and receive timely feedback about their decision-making skills. Based on the findings in this pilot study, the majority of teams would benefit from an education intervention designed to improve their diagnostic skills.

INTRODUCTION The timely and aggressive resuscitation of seriously injured trauma patients requires rapid assessment and efficient management of the injuries. Over the past thirty years, fatalities from trauma have decreased markedly due to the increased awareness of simple trauma care principles, such as those of the American College of Physicians Advanced Trauma Life Support [ATLS] (1). However, the ATLS approach is designed so that tasks are performed in sequence, one after the other, resulting in a ‘vertical organization’. A trauma team employing a ‘horizontal organization’ has been shown to lead to significant reductions in resuscitation times (2). Trauma and injury still remain the most common causes of death under the age of 44 years worldwide and the fourth leading cause of death in the western part of the world (1, 3, 4). The Pan American Health Organization reports that trauma is among the five leading causes of hospitalization, and is estimated to represent approximately 20% of hospital admissions in Jamaica (5). In 2000, the Royal College of Surgeons in England published a report emphasizing the insufficiencies in the management of the trauma patient (6). The report recommended the organization and institution of a trauma system and most importantly “the hospital trauma team” (6). Seven years later the United Kingdom (UK) National Confidential Enquiry into Patient Outcomes and Death reported that only 20% of hospitals in the UK had established trauma teams available, and of these trauma teams, only 59.7% of patients with an injury severity score (ISS) greater than 16 had a “documented trauma team response” (4). Studies have shown that even when a trauma team works in isolation outside a designated trauma system, it is still very effective in decreasing overall patient morbidity and mortality (7–11). The main objective of any trauma care system is to “assure optimal and equitable care for all trauma victims, prevent unnecessary death and disability from trauma, contain cost and assure quality of trauma care throughout the system” (12). The establishment of a trauma team is central to the fulfillment of this objective. This team should be able to i) resuscitate and stabilize patients, ii) determine the nature and extent of injuries in order to prioritize them, and iii) prepare and transport trauma patients for definitive care, whether to an operating theatre, intensive care unit or to another hospital (13, 14). The University Hospital of the West Indies sees approximately 56 000 patients annually (15). Trauma accounts for approximately 40% of the workload in both the Accident and Emergency Unit and the surgical wards (16). Between January 2001 and December 2005, penetrating trauma accounted for almost 50% of cases seen (17). These figures are a direct reflection on the probable societal burden and cost of trauma care in Jamaica. One study showed that only approximately 15% of the total cost for each trauma patient is recovered from the patient, making the care of these patients mainly state funded (17). A more efficient trauma care delivery system will therefore lessen the burden injuries place on the health service (16). The aim of a trauma team is to provide a safe and competent evaluation of a trauma patient within the shortest possible time (2). The following is a proposal to create a functioning trauma team that intends to further decrease preventable deaths utilizing a ‘horizontal organization’ to enhance significant reductions in resuscitation times and survival.

The objective of this study was to survey Trauma Center (TC) members of the National Foundation for Trauma Care/Trauma Center Association of America to determine usage and consistency of trauma team response charge codes and critical care accommodation charges for severely injured patients. Potential over- and underutilization of these enhanced reimbursements was assessed. All TC members of the National Foundation for Trauma Care/Trauma Center Association of America were surveyed (2007) on usage of codes Universal Billing (UB) 68x; Field Locator (FL) 19 (now FL 14) patient type 5 "TC," UB 208 and Centers for Medicare and Medicaid Services codes G0390 and Ancillary Procedure Codes 0618. Data were collected on the use of 68x "Trauma Response" in combination with emergency room UB 450 Healthcare Common Procedure Coding System Critical Care E/M Level of Service 99291, as well as the daily accommodation (bed) charge code 208 for trauma critical care. We received 57 responses of 217 requests (response rate, 26.3%). Most responding TCs are charging for either full (86%) or partial (79%) trauma activation. Fewer are charging for trauma team evaluation fees (51%) and UB 208, trauma critical care accommodation code (33%). Charges are extremely variable between and across TC levels and among regions. Full trauma activation fees ranged from $837 to $24,964 with level II TCs charging more on average than level I TCs. As many as 63% of TCs failed to use or did not recognize combining codes 68x with ED 450 Healthcare Common Procedure Coding System 99291. Significant underused opportunities exist for enhanced revenue by improved implementation of trauma response codes. Wide ranges in charges and the low frequency of full implementation suggest that education and coordination are needed among hospital departments involved, as well as among the trauma care community at large, to realize optimal reimbursement for trauma care services.

African midwifery students’ self-assessed confidence in postnatal and newborn care: A multi-country survey