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There’s No “I” in Code: Team Dynamics in Resuscitation
Cory Miller RN, BSN, CCRN
(ExpoED Class Code: EXED140)
Overview and Learning Objectives
Content
This session will explore the different human factors that affect team leadership behavior and performance of the resuscitation team. Training options and strategies for nurses and multidisciplinary healthcare team members to improve communication, team dynamics, role identification and task delegation will be discussed.
Learning Objectives
This session will enable the attendee to: • Identify 3 human factors shown to affect team performance during
cardiopulmonary resuscitation.
• Discuss 3 ways to enhance multidirectional communication among team members during a cardiac resuscitation.
Survival from Cardiopulmonary Arrest…..
Growing interest in the effects of
human factors and team dynamics on
the performance of resuscitation teams
Minimal improvement in
survival for in-hospital cardiac arrest over the last
several decades
Survival outcomes vary widely among
institutions
We train individuals but perform as a
team
Edelson, DP, et al (2014). J Hosp Med, 9(6), 353-357.
Trajectories of a Code
Time
Ch
aos
Time
Ch
aos
Time
Ch
aos
Time
Ch
aos
“Good” or “Bad” Code?
• Qualities of a “Bad” Resuscitation Event: – Chaos
– No defined leader
– Conflict among leaders or over leadership
– Confusing and/or inaccurate communication
– Deviation from standard guidelines
– Loud
– Crowded
– Safety issues
Mahramus, T., et al (2013) CNS, (27)6, 291-7.
Human Factors: Definition
“All things that make us different from logical, completely predictable machines”
“How we think and relate to other people, equipment and the environment.”
“The things that affect our personal performance.”
Clinical Human Factors Group. www.chfg.org Accessed 5-12-16
Human Factors Affecting Code Teams
Leadership
• Identification of leader
• Communication
• Task Distribution
• Situation Monitoring
Teamwork
• Leadership
• Communication
• Task Management
• Mutual Performance Monitoring
Anderson, P, et al. (2010). Resuscitation, 81(6), 703-11. Norris, E, et al. (2012). Resuscitation, 83(4), 423-7.
Leadership D
efin
itio
n
The ability to influence, motivate and enable others to contribute towards the common goals of the team
Trai
nin
g Leadership skills can be taught
Pra
ctic
e Leadership training has sustained effect
Clinical Human Factors Group. www.chfg.org Accessed 5-12-16 Yeung, J., et al (2012). Crit Care Med, 40(9), 2617-21. Hunziker, S., et al (2010). Crit Care Med, 38(4), 1086-91. Marsch, S., et al (2004). Resuscitation, 60(1), 51-6.
Leadership and Teamwork on Outcomes Su
rviv
al f
rom
IHC
A
Impacted by:
• Quality of CPR
• Compression rate
• Compressions depth
• Compression fraction
• Time to defibrillation
• Adherence to guidelines
Effe
ct
Leadership and Teamwork have been shown to improve the quality of CPR and adherence to guidelines.
Ou
tco
mes
??
Proposed: Better Leadership and Teamwork will improve survival from IHCA
Hunziker, S. et al (2011), JACC, 57(24), 2381-8. Talikowska, M, et al (2015). Resuscitation, 96, 66-77. Yeung, J., et al (2012). Crit Care Med, 40(9), 2617-21.
Leadership: Team Leader
• Identification
– Code Team Leader should be easily identified • Visually: Sticker, badge, vest etc.
• Verbally: Confident verbalization
Communication
• Definition: “Transmission of information between one person to another person or group.”
• Purpose: 1. Build and uphold team structure 2. Coordinate team processes 3. Information intake and exchange
• Associated with: 1. Treatment errors 2. Overall CPR performance 3. Algorithm adherence
Castelao, E, et al (2013). J Crit Care, 28(4), 504-21.
Communication
Leadership
• Use of Closed-Loop Communication
• Use of short, clear statements (“Less is more”)
• Think out loud
• Give orders to a person
• Invite feedback and input from the team
Teamwork
• Confirm receipt of orders
• Confirm completion of tasks
• Voice critical findings “Call Out”
• Communicate specific findings and avoid stating diagnosis
TeamSTEPPS™ www.ahrq.gov Accessed on 5-12-16
Task Completion During A Code
Leadership: Task Distribution
• Roles: – Assign
– Assess
– Set expectations
• Avoid task information overload
• Remain Hands Off
Teamwork: Task Management
• Communicate task completion
• Assist each other
• Coordinate within team the distribution of tasks
Anderson, P, et al (2010). Resuscitation, 81(6), 695-702 Mahramus, T., et al (2013) CNS, (27)6, 291-7.
Monitoring of Code
Leadership:
Situation Monitoring
• Maintain overview of situation
• Identify, process and grasp critical elements (patient, team, environment, progress)
• Avoid fixation on select details
• Perform periodic reviews of situation
Teamwork:
Mutual Performance Monitoring
• Monitor each other’s performance “Have each other’s back” – Task assistance
– Anticipate needs
• Flexibility
• Mutual respect
Anderson, P, et al (2010). Resuscitation, 81(6), 695-702 TeamSTEPPS™ www.ahrq.gov Accessed on 5-12-16 .
Barriers to Leadership and Teamwork
• Hierarchies
– Status characteristics performance expectations hierarchies
– Creates barrier to sharing of information
• Stress Causes:
– Impaired memory
– Reduced concentration
– Difficulties in decision making
Muller, MP, et al (2009). Resuscitation, (80) 8, 919-24. Hunziker, S, et al (2011). JACC, 57(24), 2381-8.
Barriers to Leadership and Teamwork
Conflict Three Degrees:
1. Discussion
2. Disagreement
3. Dispute
Response to Conflict:
1. Acknowledge
2. Assess value
3. Add to plan
or
4 Assertive and take action
Norris, E, et al (2012), Resuscitation, 83(4), 423-427.
Recommendations
• Leadership training for Code Team leader and Code Team members – Increases confidence – Decreases stress – Improves quality of leadership communication and
overall leadership skills
• Practice with inter-professional team – With simulation
• Debrief after every code – Entire group that participated in code – Code Team
Norris, E, et al (2012), Resuscitation, 83(4), 423-427.
Code Blue Team Leader Tips Upon Arrival:
• Announce arrival and receive handoff: – “I am the CCU resident and will be running this
code.”
– “Please confirm code status.”
– “Who has been running the code and can give me a handoff?”
• Assess for high quality CPR and defibrillate if indicated
First 2 minutes: • Assigns/assesses roles and give expectations
• Debride room
• Ask for primary team to be contacted
• Early interventions: – Assess patient
– Review or send labs
– Review medications
– Give volume (if appropriate)
– Review recent events and H&P
General Tips: 1. Remain calm.
2. Give orders to a person.
• Get confirmation of order and completion.
3. Ask for feedback from the room.
4. To order drugs:
“Give ______ now and Prepare ______ for the next cycle.”
5. Think out loud.
6. Periodically summarize the key information and situation.
Cardiopulmonary Arrest: The Perfect Storm • High Stakes
• High Complexity
• High Variability
• High Stress
• Time Sensitive
• Low Frequency
• Unplanned
Conclusion
Improving the quality of team building and team dynamics are key factors for increasing the quality of the resuscitation and survival outcomes.
AHA 2015 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: “…..The inclusion of team and leadership training as part of ACLS training is reasonable.”
(Class IIa, LOE C-LD)
References: 1. Andersen PO, Jensen MK, Lippert A, Ostergaard D. Identifying non-technical skills and barriers for improvement of teamwork in cardiac arrest teams. Resuscitation. 2010;81(6):695-702. 2. Fernandez Castelao E, Russo SG, Riethmuller M, Boos M. Effects of team coordination during cardiopulmonary resuscitation: a systematic review of the literature. Journal of critical care. 2013;28(4):504-21. 3. Hunziker S, Buhlmann C, Tschan F, Balestra G, Legeret C, Schumacher C, et al. Brief leadership instructions improve cardiopulmonary resuscitation in a high-fidelity simulation: a randomized controlled trial. Critical care medicine. 2010;38(4):1086-91. 4. Hunziker S, Johansson AC, Tschan F, Semmer NK, Rock L, Howell MD, et al. Teamwork and leadership in cardiopulmonary resuscitation. Journal of the American College of Cardiology. 2011;57(24):2381-8. 5. Mahramus T, Frewin S, Penoyer DA, Sole ML. Perceptions of teamwork among code team members. Clinical nurse specialist CNS. 2013;27(6):291-7. 6. Norris EM, Lockey AS. Human factors in resuscitation teaching. Resuscitation. 2012;83(4):423-7. 7. Talikowska M, Tohira H, Finn J. Cardiopulmonary resuscitation quality and patient survival outcome in cardiac arrest: A systematic review and meta-analysis. Resuscitation. 2015;96:66-77. 8. Yeung JH, Ong GJ, Davies RP, Gao F, Perkins GD. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Critical care medicine. 2012;40(9):2617-21.
