The Trauma team is a multidisciplinary group of individuals drawn from the specialties of emergency medicine, intensive care, surgery, nursing, allied health and support staff, who work together as a team to assess and manage the trauma patient.

The purpose of the trauma team is to provide advanced simultaneous care from relevant specialists to the seriously injured trauma patient. When functioning well, the outcome of the trauma team performance should be greater than the sum of its parts. Trauma teams have been shown to reduce the time taken for resuscitation, as well as time to CT scan, to emergency department discharge and to the operating room. These benefits are demonstrated by improved survival rates, particularly for the most severely injured patients, both within and outside of dedicated trauma centres. In order to ensure the best possible performance of the team, the leadership skills of the trauma team leader are essential and their non-technical skills have been shown to be particularly important. Team performance can be enhanced through a process of audit and assessment of the workings of the team and the evidence currently available suggests that this is best facilitated through the process of video review of the trauma resuscitation.

The use of human patient simulators to train and assess trauma teams is becoming more commonplace and this technique offers a safe environment for the future education of trauma team staff.Trauma teams are a key component of most programmes which set out to improve trauma care. This article reviews the background of trauma teams, the evidence for benefit and potential techniques of performance assessment.

The review was written after a PubMed, Ovid, Athens, Cochrane and guideline literature review of English language articles on trauma teams and their performance and hand searching of references from the relevant searched articles. IntroductionTrauma is the leading cause of death in the 1-44 year old age group and the fourth leading cause of death in the western world. Despite the widespread recognition of simple principles of trauma care which have the potential to reduce mortality and the implementation of trauma education initiatives such as the American College of Surgeons Advanced Trauma Life Support courses (ATLS ®) , the uptake and implementation of many of these principles has been sporadic and variable. In the UK for example, The Royal College of Surgeons of England highlighted important deficiencies in the management of severely injured patients in a report in 1988. A second report in 2000 addressed the lack of ongoing improvement in the last six years of the twentieth century , recommending amongst other things, the introduction of a system of trauma audit and the establishment of hospital trauma teams. In 2007 a report by the UK National Confidential Enquiry into Patient Outcomes and Death found that trauma teams were only available in 20% of hospitals, and a trauma team response was documented for only 59.7% of patients with injury severity scores (ISS) 16.

The report strongly recommended that hospitals in the UK ensure that a trauma team is available twenty four hours a day, seven days a week. This problem is not confined to the UK. Data from Australia in 2003 show that only 56% of adult trauma hospitals and 75% of tertiary paediatric hospitals which receive trauma provided a trauma team reception.The trauma team usually comprises a multidisciplinary group of individuals drawn from the specialties of anaesthesia, emergency medicine, surgery, nursing and support staff, each of whom provide simultaneous inputs into the assessment and management of the trauma patient, their actions being coordinated by a team leader. The primary aims of the team are to rapidly resuscitate and stabilise the patient, prioritise and determine the nature and extent of the injuries and prepare the patient for transport to the site of definitive care, be that within or outside the receiving hospital.

This 'horizontal' approach to trauma care aims to provide rapid input to a critically injured patient without the need to contact and request the presence of individual team members. This aims to reduce the time from injury to critical interventions and surgery. The original aim of the trauma team was to reduce the second peak of the trimodal distribution of death following trauma, by appropriately managing correctable disturbances to the airway, breathing and circulation, which, if well implemented, was predicted to reduce preventable deaths by 42%. The validity of the trimodal concept has since been questioned , but the likely benefits of coordination and rapid assessment of the trauma victims by a trauma team are widely accepted. The Structure of the Trauma TeamA typical trauma team composition is shown in Figure. It is important not to over-staff the trauma team; excessive numbers of people in the core team can lead to fragmentation, with individuals failing to adhere to the directions of the team leader.

Additional team members do not necessarily improve team function. There are wide regional and national variations in the composition of hospital trauma teams and there has been much work in assessing the optimal makeup and performance dynamics of the trauma team. The presence of a surgeon on the trauma team is considered by some to be essential. The availability of an attending trauma surgeon on the trauma team twenty four hours a day has been demonstrated to reduce resuscitation time and time to incision for emergency operations, but has not been demonstrated to impact on mortality. Many centres now have a tiered trauma team response according to the severity of injury of the trauma patient.

The application of triggering systems attempts to ensure that the appropriate tier of trauma team response is activated. The triggering system usually depends on the reported mechanism of trauma, the assessed injuries or the derangement in physiology noted on examination -. Information from pre-hospital care providers is useful for guiding the appropriate tier of response and for assembly and preparation of the trauma team. Although these triggering systems serve as useful guide as to when the team should be activated, a considerable rate of over-triage, in the region of 30 to 50%, is deemed essential to prevent any under-triage and therefore delays in mobilising the team where it is deemed essential. The typical composition of a trauma team. (Adapted from ).The leader of the trauma team must be experienced in the diagnosis and management of trauma patients and the likely pitfalls associated with dealing with severely injured patients.

This individual must also be comfortable directing and being responsive to other team members. Non technical skills such as leadership are particularly important ; a good team leader will change his leadership style according to the experience of the team and the severity of the trauma. Commonly the leader is an emergency physician, a surgeon or an intensivist-anaesthetist. Data comparing surgeons with other trauma team leaders such as emergency physicians, show no difference in the length of stay in the emergency department or in the actual or predicted survival of patients ,. The seniority of the physician present has been linked to team performance and is a key feature of trauma system development.

The Benefits and Pitfalls of a Trauma TeamTrauma systems have been shown to reduce mortality amongst the victims of trauma -. The trauma system is a multifaceted approach to trauma care involving professionals of many disciplines acting both pre-and in-hospital, within an organised model of care.

The trauma team represents only one facet of the trauma system and separating the relative merits or drawbacks of the trauma team in isolation of the trauma system is not straightforward.Data from Canada identifies that the involvement of the trauma team for patients with injury severity scores (ISS) 12 results in significantly better outcomes than if patients are dealt with on a service-by-service basis. Not only was performance better than predicted, but there were more unexpected survivors in the group managed by the trauma team.

Patients managed by a trauma team had higher ISS scores, were older, with more motor vehicle collisions and received more secondary transfers from other (non-trauma centre) hospitals, all of which should adversely affect the outcomes from this group, making the impact of the trauma team perhaps even more noteworthy. The incorporation of several specialties into one team therefore appears to be more valuable in outcome terms than the sum of its parts.

The introduction of a trauma team in a level I trauma centre has been shown to reduce overall trauma mortality rates from 6.0% to 4.1% (absolute risk reduction 1.9%; 95% confidence interval 0.7%-3.0%), and in those severely injured patients with ISS scores 25, from 30.2 to 22.0% (absolute risk reduction 8.3%; 95% confidence interval 2.1%-14.4%). Data shows that the trauma team also improves survival in hospitals not recognised as trauma centres.Trauma teams also reduce times from emergency department arrival to CT scan, to the operating room and to emergency department discharge, manifesting as improved survival amongst critically injured paediatric patients.

The mortality benefit is however lost in paediatric patients who have less severe injuries. Conversely, those patients who meet well established trauma call criteria, but who are not treated by the trauma team (i.e. The team was not called) have a higher mortality; 28% of all trauma patients fell into this category in a study of 2539 consecutive patients from China. Part of the benefit of the trauma team may be related to a reduction in time to definitive care (often haemorrhage control). When well organised, the trauma team has been shown to reduce total resuscitation time from 122 to 56 minutes. The introduction of a trauma team and a trauma service led to a ten fold reduction (4.3% to 0.46%) in delayed injury diagnosis in the setting of paediatric trauma in Salt Lake City , but the exact contribution of the trauma team to this improvement is not clear.Despite the huge associated socioeconomic burden of increased morbidity no data on the impact of the trauma team on morbidity exist. It is clearly very difficult to separate the impact of a trauma team on morbidity and isolate it from the care received from scene to hospital discharge - a lengthy and variable pathway for many severely injured patients.The initial phase of hospital care in the emergency room has been identified as the area where most preventable problems in trauma care occur.

The trauma team is naturally implicated in many of these errors. Common problems include errors or delays in treatment, diagnosis, and intervention. Inadequate system capacity and poor processes are also frequently implicated. Data from Australia identify that 6.09 errors per fatal case occur in the emergency department with an alarming 3.47 errors directly contributing to patient death.In paediatric trauma resuscitation, 5.9 errors per case have been shown to occur but with no fatalities directly attributable to the resuscitation phase. Emergency room problems, errors or inadequacies are however less likely to occur in a trauma centre where 1.7 errors occurred per case as opposed to 5.1 per case in small regional hospitals (p. Assessment of Trauma Team PerformanceEvidence from the Scottish Trauma Audit Group has showed that the implementation of a trauma service audit programme can significantly improve survival in trauma patients.

Survival rates for seriously injured trauma patients increased from 65 to79% through the course of the audit process, during which 53,000 trauma patients were seen in emergency departments in Scotland. Assessment of the impact and performance of the trauma team as an isolated component of the trauma pathway is complex. Separation of the impact of multiple members of staff in a rapidly evolving environment with multiple variables is challenging and the optimal outcome measure that should be employed is open to debate.Recording of error rates is somewhat crude and correlation of rates to outcome is fraught with confounding factors including assessor subjectivity and casemix variation. Assessment of single interventions rarely addresses the performance of a coordinated resuscitation attempt by professionals from different backgrounds. Carefully selected key performance indicators (e.g. Time to CT scan) can be used to improve performance and set standards. Alternative outcomes may include compliance to local or published protocols , missed injury rates, improved outcomes and preventable deaths, all of which have benefits and drawbacks.The optimal method of data acquisition during trauma team assessment has yet to be established.

The options commonly employed are video review, observer review, medical notes review or the use of simulation. The remainder of this review will discuss the role for each. VideoVideo review of trauma team resuscitation has been shown to identify more errors than review of the medical notes. The retrospective review of medical notes has been shown to miss 80% of resuscitation errors identified through video review.

Video has been shown to be a more efficient use of review time which allows correction of conceptual as well as technical errors. Errors identified by video analysis are most commonly those relating to the airway, breathing, provision of oxygen and omissions in the secondary survey. In the analysis of tracheal intubation in trauma, video review was able to identify performance errors such as failure of team coordination; poor communication, and omission of key tasks by team members. Poor recovery from errors has also been identified. These findings have led to revised practices to improve the safety of tracheal intubation in trauma.Careful scrutiny of the video data may yield further details of the resuscitation attempt which may prove difficult to obtain by other means. For example, team leader performance , time to procedural intervention , compliance with ATLS guidelines and assessment of the use of universal precautions have all been examined by video review in the past.

Video has also allowed assessment of process errors and reasoning which were found to occur in every case, although they were only infrequently judged to result in adverse outcomes. However errors of omission were judged to be more severe ; these include failure to consider, observe or document, available relevant information in order to select appropriate care. This was found to occur at a frequency of 2.4 errors per case. Video review has identified that poor team organisation results in a significant increase in error, whereas adequate pre-hospital report, evident and efficient leadership, continued supervision of the patient, resuscitation in the correct order and working to defined protocols were each related to a lower total number of errors.Review of videotaped trauma scenarios allows an appropriate source of feedback, debrief and learning for those concerned.

In one study video review reduced the time to definitive care over a 3 month period by 13 minutes. It has also allowed a retrospective review of the assessment of priorities during the resuscitation, the cognitive and physical integration of the workup by the team leader, team member adherence to assigned responsibilities, resuscitation time, errors or breaks in technique and behaviour change over time. Through this process of performance review and retrospective learning, resuscitations have been shown to become more efficient and adherence to assigned responsibilities have improved. Video data collection can be used to provide a quality appraisal system, for example during out-of-hours care, where no supervisor is available on site. The process of video review of trauma resuscitations therefore has benefits of performance and error analysis, audit and education, which together may manifest as an increase in patient survival.There are potential disadvantages to the use of video in the assessment of trauma. Assessment of the vital signs from the video recording may be difficult and an appreciation of these signs is of course important for assessing the validity and timeliness of decisions made by the trauma team.

This may be overcome by a direct vital sign stream to the video or by review of the medical records. The audio quality may be poor and analysis of events outside the field of view may be difficult. Errors which are better identified through medical record review include errors such as drug or fluid dosing errors (particularly important in paediatric trauma) or changes to vital signs that fail to trigger an appropriate response from the team.Confidentiality issues can exist in taking and storing data about patients from whom consent is often difficult to obtain. The use of retrospective consent may be difficult, given that the patient may be sedated for some time, or moved to alternative wards no longer under the remit of the emergency department where the video was recorded. However, multiple prestigious centres across the world have employed video review as a useful, educational, quality assurance tool with the approval of legal representatives, and so long as the data is erased in a timely fashion, this should pose few problems from a legal standpoint. The assessment of video data is usually performed by an expert panel with the assistance of published guidelines; this system is time consuming and may involve subjective bias.Furthermore, delays in analysis may lessen the potential benefits of immediate feedback.

It is also costly to establish and maintain and requires routine staff participation. A high school story. SimulatorTrauma team performance may be assessed using a simulator. Mannequins and simulators are increasingly being used in the assessment and education of critical care residents , and a similar approach may be appropriate in the assessment of trauma team performance.Simulators have been used to facilitate educational goals such as communication, cooperation and leadership , which have already been identified as crucial qualities in trauma resuscitation.

A study of the use of an advanced human patient simulator (HPS) showed it to be a useful and reproducible tool for assessment of the trauma team , with the necessary use of video within the simulator to review team performance. Similarly, HPS has been used to demonstrate improvement in team performance following educational interventions such as an ATLS provider course or a rotation to a trauma centre. Significant improvements in critical treatment decisions, a reduced potential for adverse outcomes and improved team behaviour, function and efficiency have been observed following such interventions ,. Simulators have also been used to facilitate educational on-site intervention of simulated paediatric trauma, to good effect.

HPS has been used to trial team behaviour assessment tools for application in trauma scenarios which are thought to be important in team dynamics.A learning curve exists in the use of simulation; the ability to interact with the simulator, 'role play' and verbalise requests for information requires some experience and this explanation may in part explain some of the improvements in team performance over time when simulation is used as the measurement tool. However, it allows exposure of the team to scenarios infrequently encountered in real life and provides a controlled, safe environment to learn from errors. Observation by Third PartyObservation by a third party may yield selective or biased data. It is useful if just one variable or individual is being examined, for example in assessment of the performance of the team leader , but one or two individuals cannot be expected to review overall performance where a horizontal rather than vertical model of care is applied. The observer requires a knowledge and understanding of the processes of trauma care and needs to be available at the time of trauma calls. Although this is a resource intensive approach a 'shadow' trauma team leader is a common training technique. Medical Notes ReviewReview of the medical notes is a slow and laborious process.

Key information is often excluded from the notes leading to a false negative error rate when assessing the performance of the trauma team. Essential elements of care such as the timeline, processes, communication, leadership, organisation, omissions and errors are difficult if not impossible to discern from medical record review. The contribution of professionals who do not usually enter information into the notes cannot be assessed and alternative considered diagnoses may not be recorded.

For this reason the review of medical notes identifies only 20% of the errors seen on video review. Furthermore, the ability to debrief, teach and learn is limited were the medical records alone are used. ConclusionsThe rapid development of trauma services has not been universal despite the high mortality rates in the young and the repeated reporting of suboptimal outcomes. Mortality reduction requires a comprehensive performance improvement programme and an effectively performing trauma team is one contributing feature of good system performance.

As a component of the trauma service, the trauma team has been independently shown to reduce time in the resuscitation room, time to key investigations and to definitive care and reduce the rate of missed injury, all of which contribute to mortality reduction. If well audited, further reductions in mortality should be anticipated by education and by the introduction of processes to improve the workings of the team.

Based on the limited evidence available the most effective method of trauma team audit and education appears to be by video review which can only be performed with careful consideration of consent and medicolegal issues. The use of human patient simulators may also provide a useful tool for the education of trauma team members.

Simulation, MysterySix doctors, six specialties, one goal: To save lives.Trauma Team, released in Japan as Hospital.: 6 Doctors (HOSPITAL.: 6人の医師), is a game published by Atlus for the Wii. Despite many similarities and to the Trauma Center series, including the appearance of previously established characters, Atlus state that it is a separate project. Announced at E3 2009, it was subsequently released in 2010 in America and Japan. Similarly to, it was never released in Europe.The events of the game are told in the style of a, with character art in the style of.The game features six episodic storylines focusing on six doctors specialising in varying medical fields:; a paramedic,; a diagnostician, returns as a forensics expert,; a general surgeon,; an endoscopic surgeon, and; an orthopedic surgeon. Contents StoryThe setting of this game presumably takes place in 2020 at, a large hospital in Portland, Maine. The main story progresses without many complications, as seemingly ordinary procedures are carried out, regular diseases are discovered, and ordinary cases are solved. 6 characters representing 6 different professions make up the game;, a prison inmate performing to save lives in exchange for a reduced sentence;, an EMT who gives to victims of incidents;, an;, the member of a family of honored doctors;, a gaining deductions from a; and, a now forensic doctor with a.Over the course of the game's first half, unusual cases are found, like strange foci and moving bruises appearing in the patient.

At the same time, Naomi's cases get more and more complex as the killers and victims become associated with the name 'Rosalia'. Once each profession's levels are completed, the second half of the game, 'Patient Zero' is unlocked.The chaos begins one day with a woman coming out of a subway train, who suddenly collapses. This is when the begins to strike. Maria begins stabilizing patients at the stop. Gabriel is ordered to diagnose a patient by a government official, and finds it to be a form of viral hemorrhagic fever.Resurgam is soon flooded with patients, with operations already going underway, and almost nearly every place quarantined, including the prison where CR-S01 is. The prison was going to move the people to a new place, but CR-S01's guard collapses in front of him and he realizes that the virus has already spread to the prison.

When he tells another guard nearby that the prison has already been infected, the panicking guard instead thinks that CR-S01 infected the guard with the disease. CR-S01 then escapes and goes to a nearby hospital to see how bad the situation is. While he was there, a man collapses. Maria later makes it to the hospital where she supports CR-S01 in the man's operation.

After completing the operation, CR-S01 passes out. When he wakes up, he said that he regained his memories and remembers everything.As it turns out, his adoptive father and professor at the Cumberland College, was behind the incident.

Albert was researching the virus that was supposed to wipe out illnesses but turned out to be too aggressive. According to CR-S01, they should be able to find a cure by cultivating blood from the host, his adopted sister and Maria's friend,.Meanwhile, Tomoe notes that Chloe, Alyssa's cat, had some inflammations in her mouth, and began operating to extract the foreign objects.

However, under the foreign objects, she discovers virus colonies that explode and form the same bruise caused by the Rosalia Virus. Then, Gabriel was ordered to deliver bones that the government thinks is connected to the virus to the hospital for Naomi to reconstruct, but when the officials say his landing will be 'safe', he is dropped unexpectedly into a garbage container. When Naomi reassembles the bones, according to her, the victim died of the Rosalia Virus and the skeleton matches Albert's.With Rosalia's blood being the only hope to cure the Rosalia Virus, Maria and Naomi head to Mexico to find Rosalia's body, while the rest stay behind at Resurgam to treat the Rosalia victims flowing in.

There, Naomi determined Rosalia's cause of death, and discovered that while her blood could not be used, the flowers around her had absorbed her blood and can be used to develop an antiserum. Also as it turns out, the truth of the virus is that Monarch Butterflies stored the absorbed blood in the flowers with the virus and during their migration pattern, their shedding scales spread the virus, which is why the quarantine didn't work.Back at Resurgam, Tomoe struggles to treat a patient infected with the Rosalia Virus, using a makeshift method to extract the virus colonies without causing them to burst. However, after treating the virus colony, several other unseen ones begin bursting and spreading the Rosalia bruise. Then, Maria arrives back at Resurgam with the newly developed antiserum, allowing for Tomoe to successfully treat the Rosalia Virus.Just when things seem to be fine, however, Naomi collapses. A diagnosis reveals that she too had been infected with the Rosalia Virus, and it mutated with her genetic disease to become the Twisted Rosalia.

With some advice from, the final battle begins as the Twisted Rosalia is treated within Naomi's heart by CR-S01.After a successful operation, Naomi regains consciousness, and Tomoe reveals that the genetic disease afflicting Naomi had also been cured with the Rosalia Virus, allowing for her to continue looking after Alyssa. The other doctors had returned to their previous lives - Maria continues to argue with the paramedics; Hank had become close friends with his former patient, Claire, along with resuming his superhero identity; Gabriel continues his work as usual with as much frustration from RONI; and CR-S01 was returned to prison, but still gets called upon to perform surgeries across the country, as his release requirements were changed.At the end of the credits, Gabriel is seen on the roof. He then thanks the player for their hard work across the entire game. The camera pans up to the sky and a message is shown, telling the player that they are, truly, the seventh member of the Trauma Team.FieldsTrauma Team offers six different medical fields, each offering it's own specific gameplay style:.: While the gameplay is mostly identical from the surgery in previous Trauma Center games, some tweaks have been made. As well as a larger variation in treatment procedures, the player is often given more indicators and guidance on how to proceed with treatment.: With the assistance of a radar, the player must navigate difficult-to-reach areas of the body with an endoscopic tube in order to treat affected areas. These operations feature many new tools exclusive to the endoscope.: Surgery focusing on the skeletal system, including the spine. The importance of precision is emphasised, with the player being allowed only a finite number of mistakes during the operation.: The player must collect evidence from a crime scene and pay attention to certain details in order to deduce a victim's cause of death.: Dealing with multiple casualties at the scene of an incident, the player must stabilise patients for transport while ensuring others remain in good condition.

The tools used differ greatly from other gameplay modes, due to the nature of the on-site location. The death of a patient will not end in immediate failure of the operation, however there is a limit to how many patients can die before the level ends.: Using a combination of an interview, an examination, observing behaviour, and analysis of a variety of test results, the player must reach a diagnosis of a patient by studying their symptoms.Characters Playable.: The general surgeon. A former death row inmate sent to prison for his involvement in a biological terror attack, he was offered a chance to decrease his sentence by performing surgery at Resurgam. Suffering from amnesia, he cannot recall his identity, nor the incident he was involved in, but still possesses keen medical skills.: The forensic medical examiner, and a returning character from. A brilliant surgeon whose successful career ended when she was diagnosed with an incurable genetic disease. Her mind remains sharp, so she was hired by the FBI to solve a series of murder cases while working at the Cumberland Institute of Forensic Medicine.: The first response doctor.

One known to react or overreact quickly in situations, she can lose her temper easily, but shows exceptional skills in handling emergency medical situations.: The orthopedic surgeon. A former member of the U.S. Army with a secret identity, who patrols the streets under the guise of Captain Eagle, when not working as a doctor.: The diagnostician. An intelligent but sarcastic doctor, he analyses symptoms in order to diagnose patients with the assistance of RONI, an artificial intelligent robot.: The endoscopic surgeon.

Daughter of the wealthy Tachibana clan, Tomoe left Japan after dishonoring and severing ties with her family, seeking independence and her own path of honor.Other. (also known as 'Little Guy'), Kimishima's assistant in the investigation of crimes. He and her share a that they both agreed to never speak of again. Naomi's neighbor, and by the end of the game, her adopted daughter.

She is a playful little girl, but her proximity to Naomi towards the end of her story. The butler and guard of Tomoe, always seen at her side. The adopter father of both and CR-S01. His over-ambition in the search of a highly curative drug had him create. The catalytic character of the game's story, Rosalia was the natural host of the. SurgeonGameplay and FeaturesA preview screenshot of Surgery multiplayer, with new tools for use.Unlike the previous games in the series, Trauma Team removes the timer for most of the operations, allowing for the player to concentrate mainly on the operation and the patient's vitals itself. However, some operations still reward the player if they complete it fast enough, and the operation clear time is also a major contributor to the final score and rank.Each doctor has their own chapter in the game, all of which run within the same timeline.

It would not be surprising to see some familiar patients or conditions between chapters. Once all 6 chapters are completed, the final chapter is unlocked, where the specialties of all 6 doctors are rolled together in the final scenario as they take on an unknown disease., and all use a vitals system, where a drop to 0 in them will fail the level (or in First Response, lose the patient, something that both negatively impacts the score and can cause a failure if done too many times). And use a heart system; every mistake costs half or all (respectively) of one of 5 hearts, and losing all 5 hearts ends the level (but since the levels are longer than the other professions, there are save points). Unique amongst the 4 surgical professions, uses a heart-based system; making a mistake costs half a heart (that which there are 5 of), so making 10 mistakes ends the level.levels are slightly different, too. The Easy and Normal difficulties are relabelled Intern and Resident respectively. After completing the game, a new difficulty - Specialist - is unlocked, and has a difficulty level corresponding to somewhere between the Hard and difficulty.

The XS is only obtainable on Specialist. The Intern difficulty level will allow the player to restart from where they failed if they fail, and the non-surgical professions (Diagnosis and Forensics) are not changable at all by difficulty.Scoring is not elaborated on. However, adding a degree of easiness to the game, the are revealed to the player regardless of whether they acquire them or not. Cools, Goods and Bads are all counted, and along with the Special bonuses acquired and clear time of the operation, they add up to determine the final score and the player's rank.After completing the game, the player also unlocks bonus audio scenarios for each character, along with the that can be gained by achieving several difficult tasks.Gallery.