Testing a Novel Deliberate Practice Intervention to Improve Diagnostic Reasoning in Trauma Triage: A Pilot Randomized Clinical Trial
Type of article: Clinical Research Summary
MedED Catalogue Reference: MCECS0010
Category: Emergency Medicine | CPD
Category Tags: Triage, Critical Care, trauma, intervention, coaching, simulation
Source: JAMA Network Open
Key Take Aways
1. Undertriage remains common, despite standard triage guidelines
2. Goal-oriented training with a coach may improve diagnostic reasoning in trauma triage
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Overview | Objectives | Study Design,Method & Management | Findings | In Summary| Conclusion
This is a summary of an original research article, reproduced under CC-by-Licence
Overview
Undertriage due to diagnostic errors remains common despite efforts to standardize triage practices. Clinicians must evaluate and stabilize a patient's injuries and determine whether to transfer to a trauma centre. A timely and accurate explanation of injuries presented at the non-trauma centre shortens the duration of pain and reduces mortality by 10-25%.
Goal-oriented training with a coach who provides immediate, personalized performance feedback has not previously been used in trauma triage to improve diagnostic reasoning. This study aims to test this theory.
Objectives
"To test the practicability, delivery of tasks, palatability, intention to try behaviours, fitting the user’s goals and needs, and efficacy of a novel deliberate practice intervention in trauma triage."
Study Design, Methods & Measurements
Key Endpoints
Implementation outcome was defined as feasibility, fidelity, acceptability, adoption, and appropriateness, while service outcome (efficacy) was defined as compliance with clinical practice guidelines with assessment in a laboratory before real-world testing.
Participants
Seventy-two board-certified emergency physicians who treated adults in emergency departments of either a non-trauma centre or a Level III or IV trauma centre in the US were included in the study. Of the seventy-two, forty-four were men, and the mean age was 43.4 years of age.
Thirty physicians were assigned to the coaching intervention group, and twenty-six of these physicians used the virtual simulator
The coaches consisted of three members of the study team, who had expertise in trauma surgery and emergency medicine
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Study Design
The study was a pilot randomized clinical trial of a deliberate practice intervention to improve diagnostic reasoning in trauma triage between January 1 and March 31, 2022, without follow-up.
Primary outcome
Both implementation and service (efficacy and feasibility) outcomes were assessed using a simulation as a measurement of efficacy.
“The primary theory was that physicians in the intervention group would undertriage 25% fewer patients or more on the simulation than physicians in the control group who had not received coaching.”
Secondary implementation outcome
90% or more of participating physicians would receive three 30-minute coaching sessions.
Implementation outcome
- Percentage of targeted coach-physician sessions completed (feasibility)
- Percentage of session tasks delivered to participants (fidelity)
- Responses to user engagement forms and coaching rubric (acceptability)
- Summarized themes from semi-structured interviews (acceptability, appropriateness and adoption)
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Method
- Participants received a screening questionnaire and written instructions on how to complete tasks
- Participants in the intervention group were paired with a coach before completing the video game
- The passive control group completed the video game simulation without any prior coaching
- Following the final coaching sessions, debriefing interviews were used to discuss the acceptability, adoption and appropriateness of the intervention and evaluation of the video game and the quality of coaching
Interventions
The delivery of tasks for the intervention was standardized in the following ways for the coaches:
- Three 1-hour training sessions before the trial
- A coaching manual setting out the learning objectives and core tasks of the coaching sessions
- Instructional strategies that coaches should use
- During the trial, coaches met weekly with the full study team to debrief
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Coaching
Coaching (deliberate practice intervention) sessions consisted of 30-minute video-conference sessions three times a week. The physician would play a trauma triage video game while the coach observed the performance and discussed decision principles. Each session covered 1 to 3 decision principles and included 6 to 8 tasks.
The video game was a theory-based puzzle in which physicians “triaged 10 injured patients over 42 minutes, compared 2 cases to identify similarities or differences so that they could derive the rule for the level, received standardized feedback on their performance, reviewed the decision principle, and finally received a synthesis of the evidence supporting the decision principle”.
Physicians were encouraged to “think aloud” as they played, enabling the coaches to make observations during the triage process to provide tailored feedback to improve the diagnostic reasoning.
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Simulation to assess guidelines compliance
After exposure to the coaching intervention, participants were required to respond to 10 cases using a validated 2D simulation online. Patient symptoms, vital signs, a history and physical examination were included in the game.
The game involved new patients arriving at unpredictable intervals. The below patients were managed concurrently during the simulation:
- 4 severely injured patients,
- 2 minimally injured patients,
- 4 critically ill non-trauma patients (i.e., distractor patients)
Each case was concluded when the participant made a decision to admit, discharge or transfer the patient or the patient died.
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Findings
The results can be broadly summarised as follows:
- The intervention was delivered with high fidelity, with 28 of 30 physicians (93%) completing 3 coaching sessions (2 of 30 (7%) completed 2 sessions)
- The coaches delivered 95% of session tasks (642 of 674) with debriefing the most frequently missed due to time constraints.
- 93% of physicians in the intervention group described the sessions as entertaining and valuable for a useful refresher of guidelines.
- 80% of the participants said the length and number of sessions were appropriate.
- 87% would recommend the intervention and 64% would use the material in the future.
In Summary
The coaching intervention affected physicians’ adherence to trauma triage practice guidelines with the intervention group more likely to adhere to guidelines than those in the control group during the online simulation. By thinking aloud, the coaches were able to access the cognitive process of the participant, helping the coaches to suggest and convey potentially missed cues.
Conclusion
The authors conclude that their study shows a strong association between goal-oriented training with a coach who provides immediate, personalized performance feedback was feasible and acceptable and the effect on diagnostic reasoning in trauma triage decisions.
Based on their initial results, the authors plan for a phase 3 trial of a novel deliberate practice intervention
Access the original research
Mohan D, Elmer J, Arnold RM, et al. Testing a Novel Deliberate Practice Intervention to Improve Diagnostic Reasoning in Trauma Triage: A Pilot Randomized Clinical Trial. JAMA Netw Open. 2023;6(5):e2313569. doi:10.1001/jamanetworkopen.2023.13569.
Reproduced under CC-by-Licence
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