Design
A prospective, observational multicentric study of NTS in clinical pre-hospital emergencies was conducted. No randomisation was applied.
Locations
The study took place in three independent organisations in three Czech regions: EMS of Prague, EMS of the Karlovy Vary Region and EMS of the Pilsen Region. The total population of these three regions is approx. 2.2 million [4] with approx. 250,000 emergency cases per year [5]. The data from real clinical events was collected between October 2019 and August 2020.
Eligible criteria
All EMS cases in the Czech Republic in which pre-hospital care was provided by two or more crews (at least four crew members) and the field supervisor were available for observation. The EMS is organised by the regional government as a rendezvous system – advanced care ambulance with paramedic and emergency medical technician and rapid response vehicle with emergency medical technician (or paramedic) and physician on board. Those units can be supported by a field supervisor in all three regions.
Only those cases where two or more ambulance units/crews met with the presence of the field supervisor were observed and included in the study.
In all eligible events, the date and time, the number of crews working in the field (two, three or more), the type of event (CPR, Trauma and Medical, i.e. general medicine emergency events), the name of the field supervisor evaluating the event and the location of the EMS were recorded (Fig. 1).
Exclusion criteria
All emergency cases with only one crew or events without the presence of the field supervisor were excluded, as well as all cases without complete forms.
Outcome measures
Adaptation of the team emergency assessment measure
The modified and simplified Team Emergency Assessment Measure questionnaire (TEAM) was used in this study (Fig. 1). The creation and validation of this tool is described elsewhere and its validation was not part of this study [6,7,8,9,10,11]. The TEAM was modified for this study as follows: items one through six, i.e. (1) the team leader let the team know what was expected of them through direction and command, (2) the team leader maintained a global perspective, (3) the team communicated effectively, (4) the team worked together to complete tasks in a timely manner, (5) the team acted with composure and control and (6) team morale was positive, all remained unchanged. Item 7 (the team adapted to changing situations) and item 8 (the team monitored and reassessed the situation) were merged into one item, as were items 9 (the team anticipated potential actions) and 10 (the team prioritised tasks). Item 11 (the team followed approved standards/guidelines) was not used, nor was item 12 (the global score) to simplify the field evaluation in the pre-hospital setting. Moreover this modification has been used in the past to evaluate NTS in simulated scenarios [12], and was therefore well known to researchers and field supervisors.
Each of eight TEAM items were rated using a five-point scale (range 0–4; 0 never / hardly ever, 1 seldom, 2 about as often as not, 3 often, 4 always / nearly always) and covered three categories – leadership, teamwork and task management – the same way as the original TEAM [8]. The total score was calculated as the sum of the values of the eight items and used for further statistical interpretations.
Twenty field supervisors (EMS of Prague, n = 5; EMS of the Karlovy Vary Region, n = 6; EMS of the Pilsen Region, n = 9) underwent a standardised e-learning course on the use of the modified TEAM score before the study began. At the end of the e-learning course, each participating field supervisor had to evaluate video recordings of two simulated clinical scenarios (numbered one and two) with actors for further evaluation of inter-rater variability of field supervisors assessments.
Subgroup analysis
This study compared the results of observations between subgroups of cardiopulmonary resuscitation (CPR – defined by the occurrence of cardiac arrest with ongoing CPR on scene), traumatic (TRAUMA – defined by the occurrence of any injury) and general medical events (MEDICAL – defined by any other non-traumatic, non-CPR but general medical situations, including paediatric cases).
Statistical analysis
Baseline characteristics are reported as numbers and percentages. The results of individual items and the total score of modified TEAM questionnaires are presented as median and interquartile range. Internal reliability, consistency and validity were evaluated through inter-item correlation and Cronbach’s alpha coefficient and item to total correlation [13]. Inter-rater reliability was assessed with intraclass correlation coefficient (ICC) of evaluation of the two different simulated scenarios (video recordings) [14].
The nonparametric Kruskal–Wallis test was used to compare modified TEAM scores among three presented subgroups, with p < 0.05 considered as significant. The post hoc Mann-Whitney U test with Bonferroni correction was used for multiple comparisons.
The sample size was not calculated but was determined by researchers prior to the study to at least 100 evaluated events per each participating emergency medical services.
The data were collected and basic calculations performed in Excel (Microsoft, USA). Statistical software STATISTICA 7.0 (StatSoft, USA) was used for statistical analyses and calculation. The ICC calculation software Mangold, Pascal (2018), based on Wirtz & Caspar 2002, (Germany) was used to calculate the adjusted average scores, assuming no interaction effect was present.
Reliability, consistency and validity of testing of modified TEAM score
The inter-rater variability assessed by ICC was 0.958 for e-learning scenario number 1 and 0.701 for e-learning scenario number 2. Inter-item correlation for items 1–8 varied from 0.53 to 0.78, with average inter-item correlation 0.63. Cronbach’s alpha coefficient of the final dataset was 0.93 and item-total correlations varied from 0.79–0.87.