Multimodal Team Performance Assessments in Simulated Military en Route Critical Care Missions

Large-scale combat operations in multi-domain environments are projected to result in patient care volumes and complexities that exceed historical en route critical care (ERCC) capabilities. Multimodal assessments in field environments are needed to evaluate and optimize ERCC team performance and identify solutions that assist teams in maintaining care standards in difficult operational environments. Recent advances in sensors enable audio-video data for detailed measures of technical performance, such as efficiency and accuracy, and nontechnical performance, such as cognitive load management and communication. These metrics enable insights into drivers of team effectiveness for optimizing care in challenging operational environments. Our primary aim was to evaluate the association between nontechnical team performance and time to critical action in simulated multi-provider, multi-patient usual care ERCC missions. This is a critical first step to exploring threats and protective factors toward teamworking and cognition in more stressful and/or resource-limited settings.

We conducted simulations with n = 14 ERCC teams comprising a physician, nurse, and respiratory therapist or a second nurse, each transporting 2 casualties in a static aircraft. The San Antonio Institutional Review Board approved the study procedures. Participants completed a NASA Task Load Index (NASA-TLX) after the simulation. Independent raters reviewed audio and video recordings to assess nontechnical team performance using the Assessment of Combat Casualty Non-Technical Skills (AC2ENTS) Rubric and technical performance by assessing time to critical action completion. We calculated Pearson's correlations and R2 values among the AC2ENTS scores and time to critical action.

We analyzed 14 teams. Higher team nontechnical skills scores were significantly associated with shorter time to critical actions. The median cumulative time to critical action for 2 events was 169.0 seconds (IQR 114.8-299.5 seconds). Mean global team nontechnical score (1-100 scale) was 56.3 (SD 12.7). Higher global nontechnical scores were associated with shorter time to critical action (r = -0.60, P = .0222). Higher situational awareness (r = -0.70, P = .0053) and decision making (r = -0.63, P = .0153) scores reflect the AC2ENTS domains that were most predictive of better technical performance. The median NASA-TLX reported workload (1-100 scale) was 32.6 (IQR 26.2-43.4). Reduced NASA-TLX workload was associated with improved gathering information (r = -0.54) and anticipating (r = -0.61) among AC2ENTS elements.

Improved nontechnical team performance was associated with superior technical performance in multi-provider, multi-casualty simulated ERCC missions. This provides important validity evidence for the impact of nontechnical skills on team performance in ERCC operations. These findings support further assessment and training optimization of casualty care in field environments.