Improving Ad Hoc Medical Team Performance with an Innovative "I START-END" Communication Tool.

Purpose: To study the effect of a communication tool entitled: "I START-END" (I-Identify; S-Story; T-Task; A-Accomplish/Adjust; R-Resources; T-Timely Updates; E-Exit; N-Next; D-Document and Debrief) in simulated urgent scenarios in non-operating room settings (referred to as "Ad Hoc") with anesthesia residents. The "I START-END" tool was created by incorporating Crisis Resource Management (CRM) principles into a practical and user-friendly format.

Methods: This was a mixed methods pre/post observational study with 47 anesthesia resident volunteers participating from July 2014 to June 2016. Each resident served as their own control, and participated in three simulated Ad Hoc scenarios. The first simulation served as a baseline. The second simulation occurred 1-2 weeks after training. The third simulation occurred 3-6 months later. Simulation performance was videotaped and reviewed by trained experts using technical skill checklists and Anesthesia Non-Technical Skills (ANTS) score. Residents filled out questionnaires, pre-simulation, 1-2 weeks after training and 3-6 months later. Concurrently, resident performance at actual Code Blue events was scored by trained observers using the Mayo High Performance Teamwork Scale.

Results: 80-90% of residents stated the tool provided an organized approach to Ad Hoc scenarios - specifically, information helpful to care of the patient was obtained more readily and better resource planning occurred as communication with the team improved. Residents stated they would continue to use the tool and apply it to other clinical settings. Resident video performance scores of technical skills showed significant improvement at the "late" session (3-6 months post exposure to the ). ANTS scores were satisfactory and remained unchanged throughout. There was no difference between residents with and without training as measured by the Mayo High Performance Teamwork Scale, however, debriefing at Code Blues occurred twice as often when residents had training.

Conclusion: Non-operating room settings are fraught with unfamiliarity that create many challenges. The tool operationalizes key CRM elements. The tool was well received by residents; it enabled them to speak up more readily, obtain vital information and continually update each other by anticipating, planning, and debriefing in an organized and collaborative way.