Team Stress and Its Impact on Interprofessional Teams: A Narrative Review.

Phenomenon: Interprofessional healthcare team (IHT) collaboration can produce powerful clinical benefits for patients; however, these benefits are difficult to harness when IHTs work in stressful contexts. Research about stress in healthcare typically examines stress as an individual psychological phenomenon, but stress is not only a person-centered experience. Team stress also affects the team's performance. Unfortunately, research into team stress is limited and scattered across many disciplines. We cannot prepare future healthcare professionals to work as part of IHTs in high-stress environments (e.g., emergency medicine, disaster response) unless we review how this dispersed literature is relevant to medical education. Approach: The authors conducted a narrative review of the literature on team stress experienced by interprofessional teams. The team searched five databases between 1 Jan 1990 and 16 August 2021 using the search terms: teams AND stress AND performance. Guided by four research questions, the authors reviewed and abstracted data from the 22 relevant manuscripts. Findings: Challenging problems, time pressure, life threats, environmental distractors, and communication issues are the stressors that the literature reports that teams faced. Teams reacted to team stress with engagement/cohesion and communication/coordination. Stressors impact team stress by either hindering or improving team performance. Critical thinking/decision-making, team behaviors, and time for task completion were the areas of performance affected by team stress. High-quality communication, non-technical skills training, and shared mental models were identified as performance safeguards for teams experiencing team stress. Insights: The review findings adjust current models explaining drivers of efficient and effective teams within the context of interprofessional teams. By understanding how team stress impacts teams, we can better prepare healthcare professionals to work in IHTs to meet the demands placed on them by the ever-increasing rate of high-stress medical situations.

Hemodynamic events during en route critical care for patients with traumatic brain injury.

BACKGROUND: Exposure to stressors of flight may increase risk of secondary insults among critically injured combat casualties wounded with traumatic brain injury (TBI). The primary objective of this study was to describe the prevalence of hemodynamic events by phase of transport among patients with TBI transported by Critical Care Air Transport Teams (CCATT). METHODS: We performed a secondary analysis of a retrospective cohort of 477 adults with moderate to severe TBI, who required transport by CCATT to Germany from multiple hospitals in the Middle East between January 2007 and May 2014. We abstracted clinical data from handwritten CCATT medical records. Hemodynamic events included systolic blood pressure <100 mm Hg and cerebral perfusion pressure <60 mm Hg. We calculated the proportion of patients experiencing hemodynamic events for each phase of flight. RESULTS: We analyzed 404 subjects after exclusions for catastrophic brain injury (n = 39) and missing timestamps (n = 34). Subjects had high Injury Severity Scores (median, 29; interquartile range [IQR], 21-35) and a median flight time of 423 minutes (IQR, 392.5-442.5 minutes). The median of documented in-flight vital signs was 8 measurements (IQR, 6.5-8 measurements). Documented systolic blood pressure in-flight events occurred in 3% of subjects during ascent, 7.9% during early flight, 7.7% during late flight, and 2.2% during descent, with an overall in-flight prevalence of 13.9%. Among patients with intracranial pressure monitoring (n = 120), documented cerebral perfusion pressure events occurred in 5% of subjects during ascent, 23% during early flight, 17% during late flight, and 5.8% during descent, with an overall in-flight prevalence of 30.8%. CONCLUSION: Documented hemodynamic events occurred during each phase of flight in severely injured combat casualties wounded with TBI, and episodic documentation likely underestimated the actual in-flight frequency of secondary insults. LEVEL OF EVIDENCE: Prognostic and epidemiological; Level IV.

Association of Hypocalcemia With Mortality of Combat Casualties With Brain Injury and Polytrauma Transported by Critical Care Air Transport Teams.

INTRODUCTION: Hypocalcemia at hospital presentation is associated with increased mortality in trauma patients with hemorrhagic shock. The 2019 updates to the Joint Trauma System Damage Control Resuscitation (DCR) Clinical Practice Guideline recommend calcium supplementation for ionized calcium (iCa) measurements <1.2 mmol/L. Ionized calcium goals for en route critical care (ERCC) following DCR are less defined, and the impact of in-flight hypocalcemia events among critically injured combat wounded is unknown. This study aimed to describe the association between hypocalcemia and mortality for combat-wounded with brain injury and polytrauma requiring transport by Critical Care Air Transport Teams (CCATT). METHODS: We performed a secondary analysis of a retrospective cohort of patients with moderate-to-severe traumatic brain injury transported by CCATT out of combat theater between January 2007 and May 2014. Additional inclusion criteria included polytrauma and at least one documented in-flight iCa measurement. We categorized exposures based on the minimum in-flight iCa measurement as severe hypocalcemia (iCa <0.9 mmol/L), hypocalcemia (iCa 0.9-1.11 mmol/L), and never hypocalcemic (iCa ≥1.12 mmol/L). The primary outcome measure was mortality. We calculated descriptive statistics and performed multivariate logistic regression to assess the association between hypocalcemia and mortality. RESULTS: We analyzed 190 subjects, with a median age of 24 years (interquartile range [IQR] 21 to 29 years) and 97.7% male gender. Explosive injuries (82.1%) and gunshot wounds (6.3%) were the most common mechanisms of injury. The median injury severity score was 34 (IQR 27 to 43). During the flight, 11.6% of patients had severe hypocalcemia, and 39.5% had hypocalcemia. Among patients with any hypocalcemia measurement in-flight (n = 97), 41.2% had hypocalcemia on pre-flight iCa, 28.9% received blood products in-flight, and 23.7% received in-flight calcium supplementation. Only 32.4% of patients with hypocalcemia or severe hypocalcemia in the setting of vasopressor administration received in-flight calcium supplementation. There was no significant difference in mortality between severe hypocalcemia (9.1%), hypocalcemia (5.3%), and never hypocalcemic (3.2%) patients even after controlling for pre-flight variables. CONCLUSION: In-flight hypocalcemia events were common among critically ill combat-wounded polytrauma patients transported by CCATT but were not associated with differences in mortality. Future training should emphasize the need for calcium correction among ERCC patients requiring vasopressors. Future studies with larger sample sizes of patients receiving ERCC are needed to assess the association between in-flight calcium supplementation with clinical outcomes.

Risk factors for pneumonia following rib fractures.

INTRODUCTION: Pneumonia is a known complication following rib fractures. This study was undertaken to identify clinical and demographic factors associated with the development of pneumonia among trauma patients with rib fractures. METHODS: This retrospective study examined trauma patients with one or more rib fractures, who were admitted for inpatient management during the time period 2012 through 2017. Variables studied included age, gender, injury severity score (ISS), mechanism of injury, smoking status, alcohol use, administration of influenza and pneumococcal vaccine, number and side of rib fracture(s), pulmonary contusion, pneumothorax, flail chest, spirometer use, blood transfusion, and intravenous fluid administration. RESULTS: Among 78 cases and 74 controls (matched for age and ISS), patients who developed pneumonia were more likely to be male, have higher number of rib fractures, alcohol consumption of 1-5 drinks per day, and a higher initial volume of intravenous fluids during first 24 h. Patients with pneumonia were more likely to be treated with incentive spirometry. There were no difference in age, ISS, smoking status, side of rib fractures, pulmonary contusion, pneumothorax, flail chest, influenza vaccination, pneumonia vaccination, or mechanism of injury between the two groups. CONCLUSION: Risk factors for the development of pneumonia following rib fractures include male gender, higher number of rib fractures, alcohol consumption, and higher rates of intravenous fluid administration during the initial 24 h following trauma.