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Effects of team coordination during cardiopulmonary
resuscitation: A systematic review of the literature
Ezequiel Fernandez Castelao
a,
⁎
, Sebastian G. Russo
b
,
Martin Riethmüller
a
, Margarete Boos
a
a
Department of Social and Communication Psychology, Georg-August-University Göttingen, Germany
b
Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Centre Göttingen, Germany
Keywords:
Cardiopulmonary
resuscitation;
Advanced life support;
Coordination;
Communication;
Leadership;
Planning;
Teamwork
Abstract
Purpose: The purpose of this study is to identify and evaluate to what extent the literature on team
coordination during cardiopulmonary resuscitation (CPR) empirically confirms its positive effect on
clinically relevant medical outcome.
Material and Methods: A systematic literature search in PubMed, MEDLINE, PsycINFO and
CENTRAL databases was performed for articles published in the last 30 years.
Results: A total of 63 articles were included in the review. Planning, leadership, and communication as
the three main interlinked coordination mechanisms were found to have effect on several CPR
performance markers. A psychological theory–based integrative model was expanded upon to explain
linkages between the three coordination mechanisms.
Conclusions: Planning is an essential element of leadership behavior and is primarily accomplished by a
designated team leader. Communication affects medical performance, serving as the vehicle for the
transmission of information and directions between team members. Our findings also suggest teams
providing CPR must continuously verbalize their coordination plan in order to effectively structure
allocation of subtasks and optimize success.
© 2013 Elsevier Inc. All rights reserved.
1. Introduction
Every 5 years, international resusc itat ion orga niza-
tions (eg, such as the European Resuscitation Council)
publish updated guidelines based on the latest medical
research on ca rd iopulmo nary resuscitation (CPR) [1].
The Advanced Life Suppor t (ALS) Guidelines provide
an algorithm for how C PR subtasks should be optimally
organized and synchronized during the resuscitation
process. Tas k synchronization requires assignment and
coordination of responsibilities among r escue team
members, which can be an additional challenge yet
essential for efficie ncy of CPR as well as patients’ and
team members’ safety [2,3].
During CPR, the team of health care providers typically
functions in a setting characterized by high levels of stress
[4], time pressure, and impending danger to the patient [5].It
is because of these inherent characteristics of CPR—high-
stakes, complex, team-administered, and clarity of shared
goal—that we conduct a systematic literature review of team
⁎
Corresponding author. Tel.: +49 551 397954; fax: +49 551 3912496.
E-mail address: e.fernandezcastelao@uni-goettingen.de
(E. Fernandez Castelao).
0883-9441/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcrc.2013.01.005
Journal of Critical Care (2013) 28, 504–521
Author's Personal Copy
coordination in CPR to establish how team coordination
contributes to the quality of CPR.
Team coordination is defined as the management of
interdependencies of subtasks by regulated ac tion and
information flow in order to achieve a common goal, that
is, the performance of high quality CPR [6]. This comprises
task management, leadership, and communication as essen-
tial prerequisites of effective teamwork and, thu s, the
resulting quality of CPR and patient safety [7]. Faulty team
coordination has been widely recognized as a factor
contributing to medical errors [8], and the positive relation-
ship between effective teamwork and patient outcome is
supported in other dynamic domains of healthcare [9].
The coordination requirements of CPR are well described
by Tschan et al [10], who provide a hierarchical task analysis
(HTA) on the basis of the aforementioned ALS Guidelines.
Their HTA identifies the goal dependencies which emergency
teams have to manage during CPR and what types of
coordination mechanisms are suitable to successfully accom-
plish these goal dependencies. The core goals outlined are (1)
diagnosing the cardiac arrest, (2) oxygenating the brain, and
(3) attempting to re-establish spontaneous blood circulation,
which are further broken down into hierarchies of subgoals.
The benefits of effective team coordination in CPR are
substantive. For example, Fernandez Castelao et al [11]
showed a positive relationship between well phrased
leadership utterances, functioning as a coordination mech-
anism, and no-flow time. The provision of less or poorly
articulated leadership utterances was found to be related to
treatment delays, which in turn correlate with morbidity [12].
International guidelines [1,13] all focus on describing the
optimal sequence of medical actions during a CPR but
without specific reference to coordination as the facilitator
for seamless transition between completions and beginnings
of each subgoal to avoid time loss and thereby increase
survival rate [14]. Based on task analysis [10] and related
empirical findings [9,15], team coordination and CPR
performance seem to be closely linked. The literature also
contains a rich body of research regarding team coordina-
tion methods in emergency medical teams, how the nature
of a task defines whether explicit or implicit methods are
optimal, and how these 2 general methods interact to
achieve team goals [16–18].
This review examines whether and to what extent team
coordination in CPR is empirically confirmed as affecting
clinically relevant outcome, with particular focus on findings
that contribute to improvement of current ALS Guidelines.
Furthermore, the quality of the included articles will be
assessed by defi ning level of e vidence (LOE)—which
indicates risk of bias—and level of concreteness (LOC)—
which indicates lucidity of the reckoning coordination
behavior. Finally, we aim to organize the findings into
meaningful patterns by deducing a coordination mechanism
model based on Hacker's (2003) action regulation theory
(ART) [19]. As the ART perceives thought and action of
individuals as an interlinked process it was widely used as a
theoretical approach for structuring and designing work
processes [20]. Thus, the ART provides the necessary
background for creating a model to reflect and analyze
goal-oriented interpersonal action processes like CPR in
order to improve effectiveness [19].
2. Methods
2.1. Search strategy for identification of relevant
papers
The procedure to identify publications relevant for this
review is based on the Cochrane guidelines for designing
systematic reviews [21].
2.1.1. Step 1
A computerized literature search of electronic databases
PubMed, MEDLINE, PsycINFO, and CENTRAL was per-
formed in September 2011, limited to the last 30 years. The
search focus was journal articles on potential impact of
coordination behavior regarding CPR, using all meaningful
combinations of two groups of search terms (Fig. 1). Keyword
combinations within each of the 2 groups were not applied.
Duplicates were excluded from the sample resulting from Step 1.
2.1.2. Step 2
All study titles were screened by the lead author (EFC) for
relevance to this review. To assure selection reliability, a
second author (MR) independently reviewed a random 20%
subset of the titles (n = 1008). The inter-rater agreement was
almost perfect (κ = 0.91) [22].
2.1.3. Step 3
The abstracts of the remaining publications were further
screened for relevance. Inter-rater agreement between EFC and
MR—based on the decision whether to include or discard each
of the remaining articles (n = 462)—at this step was also almost
perfect (κ =0.81)[22]. The references of the end-selected
articles were perused to identify further appropriate literature,
which were then added to the starting pool of this same step.
2.1.4. Step 4
The remaining articles were screened according to our
two criteria: (1) the main findings offer empirical evidence of
team coordination in CPR or related medical emergencies
(eg, trauma resuscitation) concerning a link between
coordination efforts and performance effectiveness; and (2)
the article was published in a peer reviewed journal. Once
again, inter-rater reliability between EFC and MR was
calculated based on the decision whether to include or
discard the remaining articles (n= 191) (κ = 0.81) [22].
2.1.5. Step 5
The selected articles were sorted into topic categories and
assessed for quality, with p articular attention to the
505Effects of team coordination during CPR
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development of coordination behavior classes influencing
CPR performance. The categories were inductively generat-
ed out of the focal contents of the studies in order to create a
comprehensible overview of the findings, simultaneously
providing an expandable basis for the allocation of future
empirical results.
2.2. Article quality assessment
The LOE scales we applied are a unified version of the
International Liaison Committee on Resuscitation (ILCOR) LOE
scales: scale for studies of therapeutic interventions, scale for
prognostic studies and scale for diagnostic studies [23].The
ILCOR LOE scales are used as part of a standard approach to
create systematic reviews in order to support the development and
update of guidelines for the management of several cardiovas-
cular emergencies, including cardiac arrest. ILCOR experts
developed the LOE scales after a detailed review of comparable
classifications in common use aiming to ensure external validity
[24]. Each of the reviewed cla ssification s—for example, GRADE
[25]—wasdesignedbyexperttaskforceswhointurnconsulted
at that time existing rating systems used for the generation of
several treatment recommendations for different medical fields
[26]. Thus, the quality of the studies included in this review can be
assessed with confidence by applying a rating procedure based on
the ILCOR scales. For our purpose we generalized the ILCOR
LOE scales to their common quality criteria—the potential for
bias—into one single scale to make the assessment easier to
apply. Based on our LOE scale (lower number, less potential of
bias), studies rated LOE 1 (highest score) were those that (a)
provide qualitative, quantitative, and temporal aspects of the
impact of coordination on CPR outcome, and ( b) minimize risk of
Fig. 1 Selection flowchart. *In step 5, several of the 63 articles were categorized into more than one topic.
506 E. Fernandez Castelao et al.
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bias (eg, randomized controlled studies). Studies rated LOE 2
were those without true randomization (eg, alphabetical
randomization). If information included in a study was archival
(eg, analysis of medical records), we rated it LOE 3. Case studies
were rated LOE 4. Studies not directly related to specific context
of CPR were rated LOE 5, including reviews in which no
comparable evidence criteria were defined.
The LOC, defined as “clarity of the described/measured
coordination behavior,” was rated using a 5-point Likert scale
developed by the authors. LOC score (1) was awarded if the
description of the investigated, discussed, and/or recom-
mended coordination behavior was so clearly depicted that the
reader would be able to exactly reconstruct the behavior,
including the appropriate moment of its initialization. The
initial inter-rater agreement for the LOE and LOC rating was
κ =0.84andκ = 0.74, respectively; all disagreement s were
discussed afterwards by the authors to reach full agreement.
Table 1 describes the LOE and LOC scales in detail.
3. Results
3.1. LOE and LOC assessments
The flow diagram (Fig. 1) shows the selection procedure
of the papers included in our review, which produced 63
papers for thematic categorization as well as LOE and LOC
ratings. Of these 63 papers, 4 (6.34%) were rated LOE 1; 5
(7.93%), LOE 2; 2 (3.17%), LOE 3; 18 (28.57%), LOE 4; and
34 (53.96%), LOE 5. Regarding LOC, 12 papers (19.04%)
were rated LOC 1; 10 (15.87%), LOC 2; 11 (17.46%), LOC
3; 14 (22.22%), LOC 4; and 16 (25.39%), LOC 5. The
median LOE and LOC were 5 and 3, respectively. Table 2
presents the characteristics of the included studies.
3.2. Categorization by topic
Empirical evidence of the papers included in this review
rendered three interlinked team coordination mechanisms
within CPR treatment: (1) planning, (2) leadership, and (3)
communication. Because these mechanisms are associated with
each other and in some cases were included within the same
article, some papers were classified into more than one topic
category. All papers were thematically allocated into at least
one of the above 3 categories.
3.3. Integrative model of team coordination
mechanisms affecting CPR performance
Our integrative coordination mechanism model (Fig. 2)
summarizes the literature findings. This model is a
combination of a deductive and inductive reasoning process,
Table 1 Definitions, numbers and percentages of LOE and LOC allocations
No. of allocated studies (%)
LOE
LOE 1: Randomized controlled studies, meta-analyzes and systematic
reviews of randomized controlled studies which are directly related
to our research question: identifying and quantifying the link between
team coordination and clinically relevant medical outcomes.
4 (6.34%)
LOE 2: Studies using concurrent controls without true randomization,
meta-analyses or systematic reviews of these type of studies
(eg, non-controlled pre-post studies).
5 (7.93%)
LOE 3: Retrospective studies (eg, studies based on past reports). 2 (3.17%)
LOE 4: Studies with no control group (eg, case studies). 18 (28.57%)
LOE 5: Studies are not directly related to the research question
(eg, trauma resuscitation) but they provide information to be
included in this review.
34 (53.96%)
LOC
LOC 1: Coordination behavior is depicted in detail. (eg, content
of verbalization is documented word by word). On the
basis of these descriptions an accurate reconstruction of effective
coordination is easily possible.
12 (19.04%)
LOC 2: Coordination behavior is depicted in detail but some of these
behaviors remain intangible to some extent.
10 (15.87%)
LOC 3: Coordination behavior is depicted partly in detail but to some
extent these behaviors cannot be simply reconstructed.
11 (17.46%)
LOC 4: Coordination behavior is partly depicted on a very
perfunctory level.
14 (22.22%)
LOC 5: Coordination behavior is mainly depicted on a very perfunctory
level. A concrete reconstruction of these behaviors turns out to be
difficult, due to missing details (eg, “good” communication).
16 (25.39%)
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resulting in a dynamic organization and a linkage between the
three main coordination mechanisms revealed in this review:
planning, leadership, and communication. The inductive part
of our reasoning process consisted in the definition of our
three topic categories—planning, leadership, and communi-
cation—based on the coordination mechanism(s) mainly
focused by the authors of each study included in this review.
The deductive part in the screening consisted of pertinent
teamwork frameworks—eg, ‘Big Five’ of Teamwork [27],
the Structure of Teamwork Behaviors [28], or the FEMP
IPO
model of group coordination [16]—in order to confirm our
defined topic categories as coordination mechanisms affect-
ing team performance. In fact, planning, leadership and
communication are interrelated coordination mechanisms
empirically confirmed as performance influencing mecha-
nisms in all types of team tasks. As planning, leadership and
communication are coordination mechanisms which cannot
be completely regarded as disjunct, we postulated a partial
interrelation between them. The interrelation is based to the
facts that, effective communication is needed for transmitting
plans, planning is defined as a function of leadership and in
turn communication is needed to be an effective leader. In our
model the interrelations of planning, leadership and commu-
nication are represented by the overlapping of the inner
circles (Fig. 2, inner core). Excerpts from articles included in
this review, which are highlighted in the next paragraphs,
clarify these interrelations.
The structure of our integrated model is based on a
theoretical reasoning. Adaptive application of the three
coordination mechanisms affects team members’ action
regulation to obtain an ideal result [19]. According to the
structure of the action process [29], our model exposes the
requirement for CPR teams to first orientate themselves
within the clinical situation (eg, by monitoring the patient),
conceptualize a treatment procedure (eg, plan whether to
attempt defibrillation depending on the assessment of the
initial rhythm), orchestrate and execute the appropriate
actions (eg, first defibrillation and then check breathing), and
evaluate and modify strategy (eg, heart rate check) (Fig. 2,
four elements of outer ring).
The model is a meaningful complement of Tschan's HTA
of the CPR task [10] as it merges empirical findings related to
coordination demands with a theoretical background (Hack-
er's ART) [19] . Furthermore, on the basis of the ART— the
frame of our model—it becomes apparent which steps teams
have to run through to accomplish each subgoal.
In sum, by inter-connecting the coordination mechanisms
and each of the ART phases and explicitly stating that the
four phases of the CPR action cycle are iterative, we
underline that, depending on the subtask at hand, teams
providing CPR repeatedly run through these action phases.
In order to accomplish these phases, teams constantly have
the aforementioned 3 interrelated coordination mechanisms
at their disposal: planning, leadership and communication.
These 3 coordination mechanisms are equally important to
succeed in CPR, but according to the ART, each phase is
characterized by particular coordination demands. Thus, our
model depicts the interrelated coordination mechanisms
(Fig. 2, inner core) and the iterative CPR coordination
demands (Fig. 2, outer ring) to accomplish each subtask.
Evidence for each mechanism of the model and their
interrelations are depicted in the following 3 paragraphs.
3.4. Planning as a CPR coordination mechanism
influencing medical performance
Our analysis of the empir ical evidence identified
“planning” as a ke y performance mechanism affecting
coordination requirements in CPR situations. A total of 26
papers were categorized into this topic.
We al so detected in ten studies that leadership tasks of
prioritization and distributionofsubtasksamongtheteam
members—before the CPR begins (pre-process) as well as
during the CPR treatment (in-process)—is stat istically
related to a va rie ty of outcome: reduced hands-off time
[30], faster treatment completion [31–33], higher algorithm
adherence [2,34–37], and prevention of in ter ruptio ns [38].
Pre-process planning in three studies was positively
associated with return of spontaneous circulation (ROSC)
[39], and initiation of crucial treatments (eg, time to first
defibrillation) [40,41].
Simulation training as a means to improve planning
behavior of CPR teams was successfully evaluated in six
studies; improvementsof medical outcomes werereportedafter
multidisciplinary resuscitation trainings [42,43].Inonestudy,
the impact of the training on treatment times was rescinded by
the integration of new team members into concomitant plans
[44]. Two other team trainings evoked augmented planning
activities by team members [45,46]. Both training concepts
aimed to enhance CPR performance by teaching CPR planning
skills, although CPR performance quality as a potential result
of improved planning was not quantified. Students reported to
be aware of the importance of planning within CPR after
completing a crisis resource management (CRM) training
including planning recommendations [47].
Planning behavior is empirically proven to directly affect
the improvement of chest compressions (CC)—an essential
CPR performance marker—by ensuring the minute-by-
minute rotation of CC providers [48,49].
Planning is closely related to leadership behavior.
Participants of 2 interview studies underline that an effective
in-process task distribution can be hindered by “hands-on”
acting of the team leader (TL), which in turn reduces the
leader's capacity to overview the process [50], and that the
early establishment of a plan should be clearly transmitted to
the team by the TL [51]. One literature review focused on
teamwork behavior in dynamic domains of healthcare,
including CPR teams, and reported that task distribution
(mostly performed by the TL) is one important aspect
relevant to the quality of patient care [9].
In summa ry, pre- and in-proce ss planning, i. e. task
distribution, role assignment, and timing of tasks, are crucial
508 E. Fernandez Castelao et al.
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Table 2 Main characteristics of the studies included in this review
Authors, year of
publication [Ref.]
Aim of the paper LOE LOC Topic category Setting Major findings
PL LDS COM
Adams et al
(2005) [67]
Determination of which physician-
staffing model ― emergency medicine
residents or staff hospitalist physicians
― is best for cardiac arrest teams.
4 5 x Code blue
activation
Teams led by emergency medicine
residents reestablished ROSC faster.
No differences in survival rates.
Andersen et al
(2010) [50]
Identificatio n of non-technical skills
suitable for improving CPR team
performance and
description of barriers to the
use and implementation of
such skills.
5 1 x x x Undefined List of recommended
non-technical behavior with regard to
the improvement
of resuscitation training.
Arshid et al
(2009) [56]
Determination of CPR quality during
pediatric resuscitation training sessions
and to assess the awareness of the team
leaders on the CPR quality and their
team members.
5 5 x Simulation Suboptimal CPR performance. Team
leaders failed to address
poor CPR performance.
Bergs et al
(2005) [84]
Evaluation of communication
during multidisciplinary trauma
resuscitation.
5 3 x Emergency
room
Knowledge transfer is not optimal.
Trend towards better
communication during the exposure of
severely injured patients. Higher
diversity in major teams (12 persons) in
comparison to minor
teams (b 12).
Bernhard et al
(2007) [41]
Investigation of whether
the intervals between admission,
diagnosis, and treatment can be
reduced and if mortality can be
improved by employing treatment
algorithms.
4 3 x Emergency
room
Significant reduction of intervals and
mortality
after algorithm introduction.
Blum et al
(2005) [87]
Evaluation of information sharing
during critical event simulation
training.
5 5 x Simulation Significant difference in
information sharing from the 1st
scenario to the final scenario. Training
was reported as useful.
Bogenstätter et al
(2009) [85]
Examination of factors
influencing the accuracy
of information transmitted to nurses
and physicians
joining a medical
emergency situation.
4 4 x Simulation Information transmitted to team
members who join a CPR process is
only partly reliable.
(continued on next page)
509Effects of team coordination during CPR
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Table 2 (continued)
Authors, year of
publication [Ref.]
Aim of the paper LOE LOC Topic category Setting Major findings
PL LDS COM
Bradley et al
(2009) [43]
Identification of effects of
interprofessional
resuscitation skills
training―including attitudes,
leadership, teamwork, and
BLS skills―on medical and
nursing students.
4 4 x Simulation Training improved leadership,
coordination behavior and BLS skills.
Capella et al
(2010) [60]
Evaluation of formal team
training with regard to
improvement of teamwork
in the trauma resuscitation
bay and its link to clinical
outcome.
4 5 x x Simulation Improvement of teamwork
and medical performance after
intervention.
Cole & Crichton
(2006) [51]
Ethnographic exploration of
the culture of a trauma team
in relation to human factors.
5 4 x x Emergency
room
Leadership performance and
experience influence team
performance. Leadership has to be
trained specifically. Role awareness
and consideration of the others’ skills
have positive influence on team
behavior. Conflict is detrimental.
Communication affects cohesion.
Cooper (2001) [76] Evaluation of the
effectiveness of a leadership
development seminar.
2 2 x Simulation Training improves leadership
performance. Training was widely
accepted.
Cooper & Wakelam
(1999) [58]
Determination of the
linkages between leadership
behavior, team
communication, and CPR
performance.
5 1 x Resuscitation
t+eam call
Correlations between structuring
behavior by the team leader and
adequate CPR performance. Team
leader structuring behavior is
negatively affected by hands-on
participation.
De Vita et al
(2005) [42]
Experience report of a crisis team
simulation training that is focused on
team organization.
4 3 x Simulation Role allocation seems to lead to better
performance when combined with team
skills training.
Driscoll & Vincent
(1992) [40]
Determination of to what extent time
differences within trauma resuscitation
are affected by the structure of the
trauma team.
4 4 x Emergency
room
The fastest teams are those where tasks
have been allocated before the patient
arrives. The risk of personnel listening
or reporting to the team leader
moderated by the number of team
members.
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Dwyer & Williams
(2002) [88]
Exploration of factors that
may be associated with nurses
participatin g in resuscitation.
5 5 x Undefined Delays caused by nurses occur due to
insecurity during CPR. Their team
members might influence this level of
insecurity.
Fernandez Castelao
et al (2011) [1 1]
Evaluation of the impact of video-based
interactive CRM training on NFT and on
proportions of team member
verbalizations during simulated CPR.
Further, to investigate the link between
team leader verbalization accuracy and
NFT.
1 1 x x Simulation CRM training reduces NFT and
improves team leader verbalization
proportions.
Flanagan et al
(2004) [47]
Exploration of the role of simulation in
providing CRM trainings to manage
evolving critical situations.
5 3 x x x Simulation Importance of CRM documented by
statements of course participants.
Coordination requirements in critical
situations are listed.
Gaba et al
(1998) [37]
Evaluation of ratings of performance
through the assessment of clinical and
teamwork performance during
simulated crises.
5 4 x x x Simulation Correlations exist between team
behavior and technical score.
Behavioral rating system can be
improved.
Gilfoyle et al
(2007) [75]
Presentation and evaluation of an
educational intervention with regard to
long term increase of leadership skills.
2 4 x x Simulation Educational intervention does improve
leadership skills. Skills were retained
after 6 months.
Hayes et al
(2007) [73]
Determination of internal
medicine residents’
perceptions of the adequacy of their
training to serve as in-hospital cardiac
arrest team leaders.
5 5 x Undefined Perceived deficits in the training of
residents ― lack of feedback and
supervision ― to adequately function
as CPR team leaders.
Henderson &
Ballesteros
(2001) [39]
Assessment of the impact of a formal,
structured resuscitation team for
in-hospital cardiopulmonary
resuscitation over the year following its
creation.
4 5 x Code blue Formation of formalized, well trained
CPR team was associated with better
ROSC rates.
Hoff et al
(1997) [66]
Evaluation of the effect of an identified
command–physician on resuscitation
performance.
4 4 x Emergency
room
Adherence to ALS algorithm
significantly higher in teams in which a
command-physician was identified.
Holcomb et al
(2002) [46]
Validation of a simulator as an
evaluation tool of trauma team
resuscitation skills.
4 2 x x Simulation Significant improvement in team
performance after 28-day trauma
refresher course.
Høyer et al
(2009) [36]
Description of physician behavior as
team leaders in a simulated cardiac
arrest during inter-hospital transfer.
5 5 x Simulation Junior physicians performed CPR well.
Deficiencies in task delegation were
found in junior physicians.
(continued
on next page)
511Effects of team coordination during CPR
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Table 2 (continued)
Authors, year of
publication [Ref.]
Aim of the paper LOE LOC Topic category Setting Major findings
PL LDS COM
Hunt et al
(2008) [62]
Characterization of the quality of
resuscitation efforts and identification
of targets for educational interventions.
5 3 x x Simulation Low adherence to algorithms, lack of
leadership, and communication
misdiagnoses were identified during
CPR.
Hunziker et al
(2011) [52]
Description of the state of the science
linking team interactions to the
performance of CPR.
1 2 x Misc. A prolonged process of team building
and poor leadership are associated with
significant shortcomings in CPR.
Hunziker et al
(2010) [12]
Impact comparison between leadership
instruction and general technical
instruction on simulated CPR scenario
performance.
2 2 x Simulation Both interventions improve CPR
performance. Leadership instruction
was rated superior.
Hunziker et al
(2009) [30]
Exploration of effects of ad hoc team-
building on the adherence to the
algorithms of CPR among general
practitioners and hospital physicians.
2 1 x x Simulation Ad hoc formed teams had less hands-
on time during early phase of CPR and
made less leadership statements.
Husebø et al
(2011) [96]
Exploration and description of verbal
and non-verbal coordination
mechanisms employed by students
during a simulated CPR.
5 1 x Simulation Coordination implies a combination of
bodily conduct and gestures and
verbalizations.
Huseyin et al
(2002) [49]
Establishment of the length of time
over which an individual can maintain
effective chest compressions.
4 5 x Simulation Best performance is maintained if CC
roles changes every minute.
Hynes et al
(2006) [64]
Specification of leadership challenges
during resuscitations.
5 3 x Undefined To manage team member aggressive
behavior, effective task delegation and
communication were identified as team
leader challenges.
Khetarpal et al
(1999) [68]
Investigation of how the presence of an
attending trauma surgeon during
trauma team activation affects
treatment times.
4 3 x Trauma team
activations
Presence of trauma surgeon (leading
person) leads to reduce treatment times.
Klein et al
(2006) [54]
Gaining new theoretical insights into
team leadership in trauma resuscitation
units.
5 1 x Emergency
room
Recommendation of dynamic
delegation (shared leadership).
Kozer et al
(2004) [82]
Examination of the incidence and
nature of medication errors during
simulated pediatric resuscitations.
5 2 x Simulation Physicians and nurses made errors,
even lethal errors; errors sometimes
due to incomplete orders.
Künzle et al
(2010) [53]
Systematic review of effective
leadership
strategies in critical care
teams.
5 3 x Misc. Effective leaders play a pivotal role in
promoting team performance.
512 E. Fernandez Castelao et al.
Author's Personal Copy
Lo et al
(2009) [44]
Description and evaluation of
effectiveness of weekly pediatric
resuscitation training.
4 4 x Simulation Weekly training improves skills, and
the introduction of new leading and
non-leading team members leads to
increased treatment times.
Lubbert et al
(2009) [61]
Analysis of trauma team functioning
with respect to adherence to
recommended guidelines.
5 5 x Emergency
room
Inadequate leadership was related to a
higher number of algorithm violations.
Mäkinen et al
(2007) [57]
Development of a method to assess
CPR skills of nurses and to contribute
to the construction of an educational
program.
3 5 x Simulation Defining and teaching leadership
seems to improve CPR performance.
Mann & Heyworth
(1996) [59]
Impact evaluation of ALS and ACLS
team leader training on resuscitation
team performance.
4 5 x Resuscitation
room
Teams led by ALS or ACLS trained
leaders showed reduced defibrillation
and drug administration times.
Manser (2009)
[9]
Identification of aspects of teamwork
affecting quality and safety of
healthcare.
5 2 x x x Misc. Quality of collaboration, shared mental
models, coordination, communication,
and leadership are relevant to the
quality of healthcare.
Marsch et al
(2004) [32]
Determination of whether and how
human factors affect the quality of
CPR.
5 2 x x Simulation Failure was associated with absence of
leadership and explicit task
distribution.
Marsch et al
(2005) [70]
Determination of first responders’
adherence to CPR algorithms CPR in
simulated cardiac arrests in intensive
care.
5 4 x x Simulation First responders failed to build a team
structure that ensured effective
monitored and ongoing team activity.
Marsch et al
(2004) [33]
Testing hypothesis that the process of
teambuilding affects the quality of CPR
during its early phase.
3 5 x Simulation Teams that were able to plan before the
CPR treatment showed faster treatment
times. The teambuilding process (incl.
planning) leads to treatment delays.
Meerabeau &
Page (1999) [3]
Reflection upon aspects of teamwork
within CPR treatment.
5 2 x Cardiology
ward
CPR teams do not have time for a
teambuilding process. Leadership is
important.
Niemi-Murola
et al (2007) [77]
Examination of medical and nursing
students’ beliefs and attitudes toward
CPR and current guidelines.
4 4 x Undefined Only 42% of medical students and 20%
of nursing students felt confident about
their ability to work as a CPR team
leader.
Nishiyama et al
(2010) [48]
Comparison of time-dependent
deterioration of CC between two types
of CPR (CC-only vs conventional).
2 4 x Simulation CC quality rapidly declined.
Recommendation of changing CC roles
after
1 min to maintain quality of CC.
O´Brien (2001)
[74]
Examination of interns' perceptions of
own performance; confidence in
managing and/or participating in
simulated and real CPR.
5 4 x x Simulation/
undefined
Importance of leadership, team
communication, and role assignment
during CPR was reported. Simulation
training increases confidence and
decreases individual stress level.
(continued on next page)
513Effects of team coordination during CPR
Author's Personal Copy
Table 2 (continued)
Authors, year of
publication [Ref.]
Aim of the paper LOE LOC Topic category Setting Major findings
PL LDS COM
Oakley et al
(2006) [97]
Comparison of two methods (video
recording vs. medical reports) to
identify management errors in trauma
resuscitations.
5 5 Pediatric
emergency
room
Video recording is more effective for
detecting errors (drug administration,
coordination, communication). 40% of
the recorded teams showed lack in
leadership and team functioning.
Østergaard et al
(2004) [86]
Description of connections between
multiprofessional team training and
patient safety.
4 4 x Simulation Training participants report that poor
performance is based on lack of
communication and coordination skills.
After the training, self-evaluation
showed NTS improvements.
Pittman et al
(2001) [83]
Determination of CPR team
communication before and after
treatment. Examination of team
composition and team leader selection
during the treatment.
5 1 x Undefined Poor communication between team
members before and after CPR. Team
leader selection is not always based on
their CPR experience.
Quintana Riera
et al (2007) [98]
Evaluation of health professionals
tolerance providing uninterrupted CC.
5 5 x Simulation Two minutes of uninterrupted CC is
well tolerated physically by health
professionals.
Ritchie & Cameron
(1999) [72]
Analysis of trauma team leader
performance using video recordings.
5 4 x Emergency
room
Reticence of team leaders to verbalize
their thoughts and clear instructions
was observed. Video recording is a
feasible method to measure team leader
performance.
Streiff et al
(2011) [69]
Determination of predictors of
leadership behavior in CPR.
4 2 x x Simulation Amount of leadership statements is
determined by gender and personality
and not by knowledge or experience.
Sugrue et al
(1995) [71]
Assessment of the performance of
trauma team leaders and definition of
scope for improvement.
5 5 x Emergency
room
High scores for medical performance.
Deficiencies in communication and
delegation were found.
Thomas et al
(2006) [34]
Measurement of teamwork behaviors
during delivery room care and its link
to the quality of care.
5 2 x x x Emergency
room
Teamwork behaviors significantly
correlated with resuscitation
compliance.
Thomas et al
(2010) [31]
Evaluation of two team trainings (high-
fidelity and low-fidelity) and its impact
on neonatal CPR quality.
1 1 x Simulation Teamwork behaviors significantly
correlated with medical quality.
514 E. Fernandez Castelao et al.
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Thomas et al
(2007) [45]
Evaluation of the impact of a 1-day
neonatal CPR training.
1 1 x x Resuscitation
room
Training led to increased amount of
teamwork components (eg, information
sharing, Inquiry, assertion). Link to
medical quality was not investigated.
Tschan et al
(2011) [99]
Determination of CPR team member
activities and their attention focus
during unnecessary interruptions.
4 3 x Simulation Team members mainly observed the
monitor or dealt with the defibrillator
during unnecessary interruptions and
their attention was focused on these
activities.
Tschan et al
(2006) [2]
Evaluation of the impact of leadership
mechanisms on CPR performance.
5 1 x x x Simulation Leadership and structuring partly
explain differences in CPR
performance.
Weinstock et al
(2008) [78]
Specification of the concept of
teamwork during trauma resuscitation.
5 3 Undefined Emphasis of importance of teamwork
in emergencies. Appeal for more useful
learning methods, assessment tools,
and qualitative scientific approaches.
Wright et al
(2009) [35]
Examination of the link between
observed teamwork behavior and
objective measures of medical
performance.
5 1 x x x Simulation Positive relationship between
teamwork skills and clinical skills in a
simulation scenario.
Xiao et al
(2004) [100]
Exploratory analysis of team leader
functions relative to situational
demands.
5 1 x Emergency
room
Identification of six leadership
functions depending on the situation.
Yun et al
(2005) [63]
Investigation of leadership and
effectiveness of teams performing
trauma resuscitation.
5 3 x Emergency
room
Linkage of leadership to team
effectiveness, as moderated by
relatively specific situational
contingencies.
LDS, Leadership; PL, Planning; COM, Communication.
515Effects of team coordination during CPR
Author's Personal Copy
toattain adherence to the ALSalgorithms.Theresults from our
reviewrevealthatthedesignationofaTLisameanstomaintain
the required in-process planning (i.e. task coordination).
3.5. Leadership behavior as a factor contributing to
effective CPR performance
The literature d ocuments leadership as a substantial
behavior in managing CPR task complexity and positively
influencing CPR performance outcomes. A total of 38 papers
were categorized into this topic.
The pivotal role of leadership within CPR is supported by
five review articles regarding CPR situations [52], as well as
related medical fields (eg, trauma resuscitation) [9,51,53,54].
Hunziker et al [52] deduce five principles for effective CPR
leadership: (1) consider situational demands, (2) facilitate
contributions of the non-leading team members, (3) ask
problem related questions, (4) keep hands-off, and (5)
promote exchange of information. As a meaningful addition
to these principles, St Pierre [55] defines further relevant
leadership tasks that stipulate (6) to deduce a treatment plan
based on medical knowledge and (7) to communicate and
distribute tasks of this plan by assigning tasks according to
individual skills and knowledge.
The TL role has an impact on various CPR performance
markers as reported in 16 studies: provision of CC (rate,
depth, discharge) [30,56–58], reduction of no-flow time
(NFT) [2,11,12,30,56], improvement of ventilation quality
[30,56–58], medication conformity [58,59], quality of
defib rillation [58,59], and the adherence to algorithms
(overall medical performance) [2,32,34,35,37,57,60–63].
Several core leadership behaviors, partly overlapping
with the above-mentioned principles, were considered to be
required to manage challenging CPR situations effectively.
First of all, it is important to be easily identifiable as a TL and
to keep hands-off during the treatment in order to maintain a
procedural overview [50]. Secondly, the TL should be
capable of building a team structure by distributing tasks and
communicating using comprehensible commands and re-
sponses [3,50,64]. Finally, the leading team member should
radiate calmness and positively reinforce the other team
members on desirable actions at every occasion [50,65].
The presence of a designated TL leads to reduced
treatment times and optimized results [66]. Teams led by
experienced TLs re-establish ROSC faster but show no
differences regarding survival rates [67]. The presence of a
board-certified surgeon who is considered by the team to be
an expert for the case at hand reduces treatment decision times
during straightforward as well as intrusive trauma resuscita-
tions [68]. Interestingly, TL experience does not predict the
amount of leadership statements (neither increases nor
decreases) of students performing simulated CPR [69].
Failures in leadership—structuring failures, poor moni-
toring of the ongoing process [70], delegation deficiencies
[71], and verbal reticence [72]—are also empirically
documented. These deficits are observed in real-life settings
as well as in ALS training scenarios of medical residents
[73]. On the other hand, leadership trainings are found to be
effective by increasing participants’ confidence and by
decreasing individual stress level while performing simulat-
ed CPR as a TL [74] by elevating the quality of TL
statements [11,12] and by improving overall leadership skills
[75,76]. Some of these studies focus on leadership behavior
and do not empirically take into consideration the impact of
leadership behavior on CPR performance [69,73–76].
Residents as well as students report to be unprepared to
lead
a CPR team [73,77] and underline the importance of
taking part in leadership trainings [47]. The result of two
exploration studies is the appeal to set a wider focus on the
training of leadership skills after their examinations revealed
that leadership behavior—as an essential element of
teamwork—positively influences treatment quality [51,78].
In summary, the literature indicates trainable key functions
(task distribution, monitoring, and comprehensible communi-
cation) of leadership behavior. Furthermore, there is empirical
evidence that the designation of a TL and his/her experience
level is related to shorter treatment times. Accordingly, the
influence of communication properties (eg, common speech,
verbalization) on the quality of leadership and results deserves
to be especially focused upon, as was repeatedly reported in
the literature [11,30,50,53,55,74,79].
3.6. Effective communication as a factor
contributing to effective CPR performance
The re sul ts reveal the influence of the process of
communication as a medium for information-sharing and
leadership statements on the medical success of CPR. A total
of 23 papers were categorized into this topic.
In medical emergencies, communication (defined as the
transmission of information between one person to another
person or group) [80] fulfils four functions: (1) building and
maintaining team structure, (2) coordination of team
processes, (3) information exchange, and (4) facilitation of
interpersonal relationships [55,79].
A direct link between different elements of communica-
tion and CPR performance markers are reported in several
articles: the accuracy level of TL verbalizations are found to
be negatively related to NFT [11], failures of information
sharing (eg, confirmation of drug administration) are linked
to treatment errors [81,82], information sharing and inquiry
are positively related to overall CPR performance [34],
provision of directions for immediate action and inquiry
correlate with cardiovascular support (provision of CC and
defibrillation) [2], and teamwork skills (including communi-
cation defined as repetition of messages, usage of accurate
terminology, establishment of a conventional speech, and
unsolicited provision of information) are found to be
positively linked to CPR performance algorithm adherence
[35,37] and clinical care of trauma patients [60].
Communication is the vehicle for information sharing, as
pointed out by ALS instructors [50]. We found evidence of
516 E. Fernandez Castelao et al.
Author's Personal Copy
inadequate communication regarding different aspects:
insufficient communication about individual team member
skills, no or unclear designation of seniority or leadership
roles before CPR treatment, and infrequent post-process team
reflection of CPR performance (eg, no formal debriefing)
[83]. At least one third of the trauma team communication
was neither comprehensible nor audible [84]. Furthermore,
the detail rate of verbalizations was found to positively
correlate with the accuracy of ongoing tasks: the lack of detail
in verbalizations can lead to inaccurate information trans-
mission during treatment [85]; sparse communication
between interns, nurses, and senior staff members was
perceived by interns after performing simulated CPR, and
also in real-world CPR situations [74]. A lack of clear
messages was reported by nearly two-thirds of ALS course
participants after performing a simulated CPR [86].
Recommendations of how to communicate effectively—
that is, to coordinate teams—comprise the application of
closed-loop communication (ie, to express orders explicitly
and to confirm the receipt of orders verbally), avoidance of
information overload, and use of terms known and shared by
all team members [9,50].
Communication skill improvements were attained after
different types of interventions as reported in several studies:
a video-based CRM lecture that leads to self-reporte d
improvements of trainees’ communication skills [87]; a 90-
minute CRM seminar that increases the quality of TL
verbalizations [11]; and a 2-hour didactic session, a half-day
workshop, and a 28-day trauma course tha t includes
suggestions for effective team communication [46,60,75].
Additionally, simulated CPR scenarios followed by debrief-
ing sessions are perceived as useful for improving commu-
nication by interns and students [47]. A mixed methods
intervention—including role play, video examples illustrat-
ing desired behaviors and group discussio ns—leads to
higher rates of inquiry and information sharing as compared
to a standard training [45].
The literature also documents that communication
behavior of medical students and nurses during CPR
treatment is predicted by gender: female students make
fewer leadership statements and tend to verbalize more
emotional expressions [69]. In addition, personality traits
like extraversion and negative agreeableness [69] and
subjective attitudes towards own CPR skills [88] are reported
to be related to the amount of communication behavior.
4. Discussion
This systematic literature review is focused on articles
reporting the impact of effective team coordination for high
quality medical performance during CPR. Aside from differ-
ences in the coordination and performance measurement
methods, all selected papers at least support by trend that team
coordination is essential for managing CPR situations success-
fully. Based on our general understanding of the assessed
literature, we deduce the following: (1) Pre- and in-process
planning, i.e. situation assessment and task distribution/role
assignment, can compensate for the lack of team coordination
depicted in the ALS algorithms. (2) The designation of a TL is a
potential means for adequate in-process CPR planning activities.
(3) How far coordination, ideally provided by the TL, leads to
the desired results is affected by the quality of interpersonal
communication as the vehicle for the transmission of informa-
tion between team members.
Our integrative model of team coordination of the CPR
action cycle was created based on a screening and reviewing
process of pertinent literature. In the model we deduced three
interrelated team coordination components: planning, lead-
ership, and communication. Planning represents a coordina-
tion mechanism essential before CPR treatment begins.
According to the Coordination Mechanism Circumplex
Model [89], the ALS algorithms can be considered as
explicit pre-process planning mechanisms. Such documented
guidelines were developed with the intention to inform
health care team members about the exact sequence of CPR
actions to be administered. However, CPR teams must
compensate for the lack of outlined team coordination advice
given in these algorithms with situation-specific in-process
planning, that is, team coordination during clinic adminis-
tering of CPR treatment, in order for CPR treatment to be
effective. Planning, including pre-process and in-process
planning, can be equated with the assessment orientation and
conceptualization phases within the action regulation theory
[19] because it implies upcoming action.
The designation of a leading team member is repeatedly
identified in the literature to be a necessary and efficient
means to manage the transition from the planning phase into
the execution phase in CPR treatments. The benefits are clear:
because inherent time pressure makes a collective decision
about the course of action ineffective, role allocation and task
assignment are ideally performed by an experienced and
suitably qualified person available—the TL. By the organi-
zation of subtasks and the monitoring of the CPR treatment
without distraction of constant hands-on administering of
process tasks, the TL is able to maintain and convey a shared
plan of procedures. Further responsibilities of the TL are to
gather relevant information, to provide feedback regarding
the performance of the team members, and to make decisions
about further treatments. This compilation of responsibilities
of the TL reveals the complexity of leadership as a necessary
coordination mechanism.
The reported empirical relationship between non-optimal
communication and treatment failures requires a closer
consideration of linguistic factors and their influence on
task performance. As mentioned before, verbal communi-
cation se rves as the bes t medium for coordination
mechanisms. For example, directive leading via assign-
ments can be optimized if the receiver verbally acknowl-
edges the assignment and a corresponding feedback of the
person that initiated the assignment follows. Such commu-
nication that obeys closed loop principles is found to be
517Effects of team coordination during CPR
Author's Personal Copy
positively related to performance quality [90]. Each closed
loop represents the completion of a subtask, which in turn
reduces the level of workload if the corresponding subtask
was accomplished in a desired manner. Furthermore, the
non–directly involved team members remain updated about
the current status of the process and are therefore able to
adjust their own behavior to the given circumstances.
According to the action regulation theory [19] and our
integrative model, this function represents the evaluation
and adjustment phase.
The rec ommendation to express short and accurate
utterances can be explained on the basis of the results of
experimental approaches in the investigation of task load
effects on langu age processing [91]. It is empirically
confirmed that the communication process becomes vulner-
able to both time delays and errors when the task load
increases. In simulated CPR scenarios, the accuracy level of
TL coordination demands is related to better NFT rates [11].
Thus, clear and comprehensible communication should be
further focused on as a key coordination mechanism in CPR
and emergency room settings.
This review has some limitations. It does not focus
primarily on the quality of methods for measurement of
teamwork. The rules that we apply for the LOE rating are
based on the assessment of the psychometric characteristics
as long as they are included in the article in question. Thus,
we purposely dismiss rep orts of solely psychometric,
thematically focused data in order to not lose our current
study focus on coordination requirements. Regarding the
methodical quality of the modified LOE scale, we suggest
conducting a comprehensive validation in order to increase
the validity of this measurement tool. A systematic validity
test would enable a more veridical interpretation of the
results of this review. Nevertheless, our generalized LOE
scale can be regarded as having a certain degree of content
validity. According to Moosbrugger and Kelava (2012)
[101], content validity relies on experts’ logical and
functional thoughts related to the research question at hand.
Despite the validity limitation, it is eye-catching that only
a small percentage of the articles were comprehensive enough
to be rated LOE 1. This sheds light on the general state-of-the-
art of empirical research in the field. Thus, to expand existent
Fig. 2 Integrative model of team coordination in CPR action cycle.
518 E. Fernandez Castelao et al.
Author's Personal Copy
knowledge about the impact of coordination behavior on
medical performance, ra ndomized experimental studies
should be applied more widely, allowing the controlled
elimination of confounding variables (eg, medical knowl-
edge, status). Beside experimental approaches, it is also
crucial to obtain more detailed information about t he
processes of actual interaction in the real clinical world in
order to assess ecological validity. We also suggest applying
methods to study temporal dynamics, for example, effects of
changes in staff, institutional values and/or functional
backgrounds on CPR team coordination over time [92].
However, it will remain difficult to apply experimental
designs and to assess process and outcome of CPR in the field
because of security and other access problems to data. Hence,
high fidelity simulators are likely to provide the best available
context to organize experimental designs by creating a
realistic situation [93–95].
5. Conclusion
In summary, the results of our literature review confirm that
team coordination—planning, leadership and communication
—are well studied and highly relevant factors predicting CPR
performance quality. Our findings also served as the basis for
the development of an integrative model based on the ART
elements of emergency procedure planning—role allocation
and task distribution—through effective leadership applied via
clear and comprehensible verbal communication as crucial
coordination requirements in CPR treatments. Furthermore,
we list the resources needed to meet those requirements: CPR
skills training, communication workshops, simulated CPR
scenarios and debriefing sessions. It is now clear that although
the ALS Guidelines provide a detailed description of the
sequence of medical actions, the accomplishment of situation-
specific clinical treatment requires substantial additional
coordination efforts to optimize the success of applied CPR.
With inclusion of the above resources, we expect that the ALS
Guidelines and, in turn, success rates of applied, clinical CPR
can be improved in a significant way. The implementation of
coordination advice into ALS guidelines will help rescuers to
round out a more detailed representation of CPR task and team
demands. This includes well-reputed medical demands—for
example, chest compression, defibrillation, etc—and also
knowledge about how to coordinate to effectively adhere to the
CPR algorithm, which in turn will free more time for
completing CPR subtasks. The advantage of saving time is
especially beneficial to CPR teams who, by virtue of tending to
medical emergencies, work under time pressure.
Acknowledgments
This research was partly financed by the Courant
Research Centre “Evolution of Social Behavior”, University
of Göttingen, Germany. Special thanks to Margarita Neff-
Heinrich for her English-for-the-sciences proofreading.
References
[1] Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE,
Kronick SL, et al. Part 8: advanced life support. 2010 International
Consensus on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science with Treatment Recommendations.
Resuscitation 2010;81:e93.
[2] Tschan F, Semmer NK, Gautschi D, Hunziker P, Spychiger M,
Marsch SU. Leading to recovery: group performance and coordinative
activities in medical emergency driven groups. Hum Perform
2006;19:277-304.
[3] Meerabeau L, Page S. I'm sorry if I panicked you: nurses' accounts of
teamwork in cardiopulmonary resuscitation. J Interprofessional Care
1999;13:29-40.
[4] Hunziker S, Laschinger L, Portmann-Schwarz S, Semmer NK,
Tschan F, Marsch S. Perceived stress and team performance during a
simulated resuscitation. Intens Care Med 2011;37:1473-9.
[5] Rosen MA, Salas E, Wilson KA, King HB, Salisbury M, Augenstein
JS, et al. Measuring team performance in simulation-based training:
adopting best practices for healthcare. Simul Healthc 2008;3:33-41.
[6] Boos M, Kolbe M, Kappeler P, Ellwart T, editors. Coordination in
human and primate groups. Berlin: Springer; 2011.
[7] Soar J, Monsieurs KG, Ballance JH, Barelli A, Biarent D, Greif R,
et al. European Resuscitation Council Guidelines for Resuscitation
2010 Section 9. Principles of education in resuscitation. Resuscitation
2010;81:1434-44.
[8] Kohn LT, editor. To err is human: Building a safer health system.
7th ed. Washington, DC: National Academy Press; 1999.
[9] Manser T. Teamwork and patient safety in dynamic domains of
healthcare: a review of the literature. Acta Anaesth Scand 2009;53:
143-51.
[10] Tschan F, Semmer NK, Vetterli M, Gurtner A, Hunziker S, Marsch
SU. Developing observational categories for group process research
based on task and coordination requirement analysis: examples from
research on medical emergency-driven teams. In: Boos M, Kolbe M,
Kappeler P, Ellwart T, editors. Coordination in human and primate
groups. Berlin: Springer; 2011. p. 93-118.
[11] Fernandez Castelao E, Russo SG, Cremer S, Strack M, Kaminski L,
Eich C, et al. Positive impact of crisis resource management training on
no-flow time during simulated cardiopulmonary resuscitation: a closer
look at verbal coordination behaviour. Resuscitation 2011;82:1338-43.
[12] 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. Crit Care Med 2010;38:1-6.
[13] Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway
CW, et al. Part 8: adult advanced cardiovascular life support: 2010
American Heart Association guidelines for cardiopulmonary resuscita-
tion and emergency cardiovascular care. Circulation 2010;122:S729.
[14] Christenson J, Andrusiek D, Everson-Stewart S, Kudenchuk P,
Hostler D, Powell J, et al. Chest compression fraction determines
survival in patients with out-of-hospital ventricular fibrillation.
Circulation 2009;120:1241-7.
[15] Semmer NK, Tschan F, Hunziker S, Marsch S. Leadership and
minimally invasive training enhance performance in medical
emergency driven teams: simulator studies. In: Duffy VG, editor.
Advances in Human Factors and Ergonomics in Healthcare. Boca
Raton: Taylor & Francis; 2011. p. 180-90.
[16] Boos M, Kolbe M, Strack M. An inclusive model of group coordination.
In: Boos M, Kolbe M, Kappeler P, Ellwart T, editors. Coordination in
human and primate groups. Berlin: Springer; 2011. p. 11-35.
[17] Riethmüller M, Fernandez Castelao E, Eberhardt I, Timmermann A,
Boos M. Adaptive coordination development in anaesthesia teams: a
longitudinal study. Ergonomics 2012;55:55-68.
[18] Kolbe M, Burtscher M, Manser T, Künzle B, Grote G. The role of
coordination in preventing harm in healthcare groups: research examples
from anaesthesia and an integrated model of coordination for action
519Effects of team coordination during CPR
Author's Personal Copy
teams in health care: coordination in human and primate groups. In:
Boos M, Kolbe M, Kappeler P, Ellwart T, editors. Coordination in
human and primate groups. Berlin: Springer; 2011. p. 75-92.
[19] Action Hacker W, Theory Regulation. A practical tool for the design of
modern work processes? Eur J Work Organ Psychol 2003;12:105-30.
[20] Oesterreich R, Volpert W. Task analysis for work design on the basis
of action regulation theory. Economic and Industrial Democracy
1986;7:503-27.
[21] Higgins JPT, Green S, editors. Cochrane handbook for systematic
reviews of interventions. Chichester, England. Hoboken, NJ: Wiley-
Blackwell; 2008.
[22] Landis JR, Koch GG. The measurement of observer agreement for
categorical data. Biometrics 1977;33:159-74.
[23] Morley PT. Evidence evaluation worksheets: the systematic reviews
for the evidence evaluation process for the 2010 International
Consensus on Resuscitation Science. Resuscitation 2009;80:719-21.
[24] International Liaison Committee On Resuscitation. Defining levels of
evidence. Available from:http://mc.manuscriptcentral.com:80/
societyimages/ilcor/Defining%20Levels%20of%20Evidence.doc.
[Accessed June 13, 2012].
[25] Working Group GRADE. Grading quality of evidence and strength of
recommendations. Brit Med J 2004;328:1490.
[26] Atkins D, Eccles M, Flottorp S, Guyatt GH, Henry D, Hill S, et al.
Systems for grading the quality of evidence and the strength of
recommendations I: Critical appraisal of existing approaches. BMC
Health Serv Res 2004;4:38.
[27] Salas E, Sims DE, Burke CS. Is there a "Big Five" in teamwork?
Small Group Research 2005;36:555-99.
[28] Rousseau V, Aubé C, Savoie A. Teamwork behaviors. Small Group
Research 2006;37:540-70.
[29] Frese M, Zapf D. Action as the core of work psychology: a German
approach. In: Triandis HC, Dunnette MD, Hough LM, editors.
Handbook of Industrial and Organizational Psychology. Second edition.
Palo Alto, California: Consulting Psychologists Press; 1994. p. 271-340.
[30] Hunziker S, Tschan F, Semmer NK, Zobrist R, Spychiger M, Breuer
M, et al. Hands-on time during cardiopulmonary resuscitation is
affected by the process of teambuilding: a prospective randomised
simulator-based trial. BMC Emerg Med 2009;9:3.
[31] Thomas EJ, Willia ms AL, Reichman EF, Lasky RE, Crandell S,
Taggart WR. Team trainin g in the neonatal resuscitatio n
program for interns: teamwork and quality of resuscitat ions.
Pediatri cs 2010;125:5 39-46.
[32] Marsch S, Muller C, Marquardt K, Conrad G, Tschan F, Hunziker
PR. Human factors affect the quality of cardiopulmonary resuscita-
tion in simulated cardiac arrests. Resuscitation 2004;60:51-6.
[33] Marsch S, Hunziker P, Mueller C, Spychiger M, Breuer M, Semmer
N, et al. The process of teambuilding delays cardiopulmonary
resuscitation. Crit Care 2004;8:297.
[34] Thomas EJ, Sexton JB, Lasky RE, Helmreich RL, Crandell DS,
Tyson J. Teamwork and quality during neonatal care in the delivery
room. J Perinatol 2006;26:163-9.
[35] Wright MC, Phillips-bute BG, Petrusa ER, Griffin KL, Hobbs GW,
Taekman JM. Assessing teamwork in medical education and practice:
relating behavioural teamwork ratings and clinical performance. Med
Teach 2009;31:30-8.
[36] Høyer CB, Christensen EF, Eika B. Junior physician skill and behav-
iour in resuscitation: a simulation study. Resuscitation 2009;80:244-8.
[37] Gaba DM, Howard SK, Flanagan B, Smith BE, Fish KJ, Botney R.
Assessment of clinical performance during simulated crises using
both technical and behavioral ratings. Anesthesiology 1998;89:
8-18.
[38] Marsch SCU, Tschan F, Semmer N, Spychiger M, Breuer M,
Hunziker PR. Unnecessary interruptions of cardiac massage during
simulated cardiac arrests. Eur J Anaesthiol 2005;22:831-3.
[39] Henderson MD. Psychological distance and group judgments: the
effect of physical distance on beliefs about common goals. Person
Soc Psychol Bull 2009;35:1330-41.
[40] Driscoll PA, Vincent CA. Organizing an efficient trauma team. Injury
1992;23:107-10.
[41] Bernhard M, Becker TK, Nowe T, Mohorovicic M, Sikinger M,
Brenner T, et al. Introduction of a treatment algorithm can improve
the early management of emergency patients in the resuscitation
room. Resuscitation 2007;73:362-73.
[42] DeVita MA, Schaefer J, Lutz J, Wang H, Dongilli T. Improving
medical emergency team (MET) performance using a novel
curriculum and a computerized human patient simulator. Qual Saf
Health Care 2005;14:326-31.
[43] Bradley P, Cooper S, Duncan F. A mixed-methods study of
interprofessional learning of resuscitation skills. Med Educ 2009;
43:912-22.
[44] Lo TYM, Morrison R, Atkins K, Reynolds F. Effective performance
of a new post-operative cardiac resuscitation simulation training
scheme in the paediatric intensive care unit. Intensive Care Med
2009;35:725-9.
[45] Thomas EJ, Taggart B, Crandell S, Lasky RE, Williams AL, Love LJ,
et al. Teaching teamwork during the neonatal resuscitation program:
A randomized trial. J Perinatol 2007;27:409-14.
[46] Holcomb JB, Dumire RD, Crommett JW, Stamateris CE, Fagert MA,
Cleveland JA, et al. Evaluation of trauma team performance using an
advanced human patient simulator for resuscitation tra ining. J
Trauma 2002;52:1078-86.
[47] Flanagan B, Nestel D, Joseph M. Making patient safety the focus:
Crisis resource management in the undergraduate curriculum. Med
Educ 2004;38:56-66.
[48] Nishiyama C, Iwami T, Kawamura T, Ando M, Yonemoto N, Hiraide
A, et al. Quality of chest compressions during continuous CPR;
comparison between chest compression-only CPR and conventional
CPR. Resuscitation 2010;81:1152-5.
[49] Huseyin TS, Matthews AJ, Wills P, O'Neill VM. Improving the
effectiveness of continuous closed chest compressions: an explor-
atory study. Resuscitation 2002;54:57-62.
[50] Andersen PO, Jensen MK, Lippert A, Ostergaard D. Identifying non-
technical skills and barriers for improvement of teamwork in cardiac
arrest teams. Resuscitation 2010;81:695-702.
[51] Cole E, Crichton N. The culture of a trauma team in relation to human
factors. J Clin Nurs 2006;15:1257-66.
[52] Hunziker S, Johansson AC, Tschan F, Semmer NK, Rock L, Howell
MD, et al. Teamwork and Leadership in Cardiopulmonary Resusci-
tation. J Am Coll Cardiol 2011;57:2381-8.
[53] Künzle B, Kolbe M, Grote G. Ensuring patient safety thr
ough
effecti
ve leadership behaviour: A literature review. Safety Sci 2010;
48:1-17.
[54] Klein KJ, Ziegert JC, Knight AP, Xiao Y. Dynamic delegation:
Shared, hierarchical, and deindividualized leadership in extreme
action teams. Admin Sci Quart 2006;51:590-621.
[55] St. Pierre M, Hofinger G, Buerschaper C. Crisis Management in
Acute Care Settings: Human Factors and Team Psychology in a High
Stakes Enviroment. 1st ed. Berlin, Heidelberg: Springer; 2008.
[56] Arshid M, Lo TM, Reynolds F. Quality of cardio-pulmonary
resuscitation (CPR) during paediatric resuscitation training:
Time to stop th e blind leadin g the blind. Res uscitation 200 9;80:
558-60.
[57] Mäkinen M, Aune S, Niemi-Murola L, Herlitz J, Varpula T, Nurmi J,
et al. Assessment of CPR-D skills of nurses in Goteborg, Sweden and
Espoo, Finland: Teaching leadership makes a difference. Resuscita-
tion 2007;72:264-9.
[58] Cooper S, Wakelam A. Leadership of resuscitation teams: ‘Light-
house Leadership’. Resuscitation 1999;42:27-45.
[59] Mann CJ, Heyworth J. Comparison of cardiopulmonary resuscitation
techniques using video camera recordings. J Accid Emerg Med
1996;13:198-9.
[60] Capella J, Smith S, Philp A, Putnam T, Gilbert C, Fry W, et al.
Teamwork training improves the clinical care of trauma patients. J
Surg Educ 2010;67:439-43.
520 E. Fernandez Castelao et al.
Author's Personal Copy
[61] Lubbert PHW, Kaasschieter EG, Hoorntje LE, Leenen LPH. Video
registration of trauma team performance in the emergency depart-
ment: the results of a 2-year analysis in a level 1 trauma center. J
Trauma 2009;67:1412-20.
[62] Hunt EA, Walker AR, Shaffner DH, Miller MR, Pronovost PJ.
Simulation of in-hospital pediatric medical emerge ncies and
cardiopulmonary arrests: highlighting the importance of the first 5
minutes. Pediatrics 2008;121:e34-43.
[63] Yun S, Faraj S, Sims HPJR. Contingent leadership and effectiveness
of trauma resuscitation teams. J Appl Psychol 2005;90:1288-96.
[64] Hynes P, Kissoon N, Hamielec CM, Greene AM, Simone C. Dealing
with aggressive behavior within the health care team: a leadership
challenge. J Crit Care 2006;21:224-8.
[65] Xiao Y, group tL. Understanding coordination in a dynamic medical
environment: methods and results. In: McNeese M, Salas E, Endsley
M, editors. New trends in cooperative activities: Understanding
system dynamics in complex environments. Santa Monica, CA:
Human Factors and Ergonomics Society; 2001. p. 242-58.
[66] Hoff WS, Reilly PM, Rotondo MF, DiGiacomo JC, Schwab CW. The
importance of the command-physician in trauma resuscitation. J
Trauma 1997;43:772-7.
[67] Adams BD, Zeiler K, Jackson WO, Hughes B. Emergency medicine
residents effectively direct inhospital cardiac arrest teams. Am J
Emerg Med 2005;23:304-10.
[68] KhetarpalS,SteinbrunnBS,McGonigalMD,StaffordR,NeyAL,KalbDC,
etal.Traumafacultyandtraumateamactivation:Impactontraumasystem
functionandpatientoutcome.JTrauma1999;47:576-81.
[69] Streiff S, Tschan F, Hunziker S, Buehlmann C, Semmer NK,
Hunziker P, et al. Leadership in medical emergencies depends on
gender and personality. Simul Healthc 2011;6:78-83.
[70] Marsch SCU, Tschan F, Semmer N, Spychiger M, Breuer M,
Hunziker PR. Performance of first responders in simulated cardiac
arrests. Crit Care Med 2005;33:963-7.
[71] Sugrue M, Seger M, Kerridge R, Sloane D, Deane S. A prospective
study of the performance of the trauma team leader. J Trauma
1995;38:79-82.
[72] Ritchie PD, Cameron PA. An evaluation of trauma team leader
performance by video recording. Aust N Z J Surg 1999;69:
183-6.
[73] Hayes CW, Rhee A, Detsky ME, Leblanc VR, Wax RS. Residents
feel unprepared and unsupervised as leaders of cardiac arrest teams in
teaching hospitals: A survey of internal medicine residents. Crit Care
Med 2007;35:1668-72.
[74] O'Brien G, Haughton A, Flanagan B. Interns' perceptio ns of
performance and confidence in partici pating in an d managing
simulated and real cardiac arrest situations. Med Teach 2001;23:
389-95.
[75] Gilfoyle E, Gottesman R, Razack S. Development of a leadership
skills workshop in paediatric advanced resuscitation. Med Teach
2007;29:e276-83.
[76] Cooper S. Developing leaders for advanced life support: evaluation of
a training programme. Resuscitation 2001;49:33-8.
[77] Niemi-Murola L, Mäkinen M, Castren M. Medical and nursing
students' attitudes toward cardiopulmonary resuscitation and current
practice guidelines. Resuscitation 2007;72:257-63.
[78] Weinstock P, Halamek LP. Teamwork during resuscitation. Pediatr
Clin North Am 2008;55:1011-24.
[79] Boos M, Mey D. Führung, Team und Kommunikation. In: Welk I,
Bauer M, editors. OP-Management—Von der Theorie zur Praxis. 1st
ed. Heidelberg, Berlin: Springer; 2011. p. 141-52.
[80] Riggio RE. Introduction to industrial/organizational psychology. . 5th
ed.Upper Saddle River, NJ: Prentice Hall; 2008.
[81] Hunt EA, Hohenhaus SM, Luo X, Frush KS. Simulation of pediatric
trauma stabilization in 35 North Carolina emergency departments:
Identification of targets for performance improvement. Pediatrics
2006;117:641-8.
[82] Kozer E, Seto W, Verjee Z, Parshuram C, Khattak S, Koren G, et al.
Prospective observational study on the incidence of medication errors
during simulated resuscitation in a paediatric emergency department.
Brit Med J 2004;329:1321-4.
[83] Pittman J, Turner B, Gabbott DA. Communication between
members of t he cardiac arrest team—a postal survey. Resusci-
tation 2001;49:175-7.
[84] Bergs EAG, Rutten FLPA, Tadros T, Krijnen P, Schipper IB.
Communication during trauma resuscitation: do we know what is
happening? Injury 2005;36:905-11.
[85] Bogenstätter Y, Tschan F, Semmer NK, Spychiger M, Breuer M,
Marsch S. How accurate is information transmitted to medical
professionals joining a medical emergency? A simulator study. Hum
Factors 2009;51:115-25.
[86] Østergaard HT, Østergaard D, Lippert A. Implementation of team
training in medical education in Denmark. Qual Saf Health Care
2004;13:i91-5.
[87] Blum RH, Raemer DB, Carroll JS, Dufresne RL, Cooper JB. A method
for measuring the effectiveness of simulation-based team training for
improving communication skills. Anesth Analg 2005;100:1375-80.
[88] Dwyer T, Williams LM. Nurses' behaviour regarding CPR and the
theories of reasoned action and planned behaviour. Resuscitation
2002;52:85-90.
[89] Strack M, Kolbe M, Boos M. Dimensions of group coordination:
applicability test of the coordination mechanism circumplex model.
In: Boos M, Kolbe M, Kappeler P, Ellwart T, editors. Coordination in
human and primate groups. Berlin: Springer; 2011. p. 57-73.
[90] Tschan F. Communication enhances small group performance if it
conforms to task requirements: The concept of ideal communication
cycles. Basic Applied Soc Psychol 1995;17:371-93.
[91] Hohlfeld A, Fukuda R, Neuper S, Sangals J, Sommer W, Sträter O.
Task load effects on language processing: experimental approaches.
In: Dietrich R, Childress TM, editors. Group Interaction in High Risk
Environments. Hampshire: Ashgate; 2004. p. 207-40.
[92] Roe RA. Time in applied psychology. Eur Psychol 2008;13:37-52.
[93] Müller MP, Hänsel M, Fichtner A, Hardt F, Weber S, Kirschbaum C,
et al. Excellence in performance and stress reduction during two
different full scale simulator t raining courses: a pilot study.
Resuscitation 2009;80:919-24.
[94] DeVita M. Organizational factors affect human resuscitation: the role of
simulation in resuscitation research. Crit Care Med 2005;33:1150-1.
[95] Hunziker S, Tschan F, Semmer NK, Howell MD, Marsch S. Human
factors in resuscitation: lessons learned from simulator studies. J
Emerg Trauma Shock 2010;3:389-94.
[96] Husebø SE, Rystedt H, Friberg F. Educating for teamwork
—nursing
students’ coordination
in simulated cardiac arrest situations. J Adv
Nurs 2011;67:2239-55.
[97] Oakley E, Stocker S, Staubli G, Young S. Using video recording to
identify management errors in pediatric trauma resuscitation.
Pediatrics 2006;117:658-64.
[98] Quintana Riera S, Sánchez González B, Trenado Álvarez J. del Mar
Fernández Fernández M, Mestre Saura J. The physiological effect on
rescuers of doing 2 min of uninterrupted chest compressions.
Resuscitation 2007;74:108-12.
[99] Tschan F, Vetterli M, Semmer NK, Hunziker S, Marsch SCU.
Activities during interruptions in cardiopulmonary resuscitation: a
simulator study. Resuscitation 2011;82:1419-23.
[100] Xiao Y, Seagull FJ, Mackenzie CF, Klein K. Adaptive
leadership in trauma res uscitation te ams: a grounde d theor y
approach to video analysis. Cognit Tech Work 2004;6:
158-64.
[101] Moosbrugger H, Kelava A. Qualitätsanforderungen an einen
psychologischen Test (Testgütekrite rien). I n: Moosbr ugger H,
Kelava A, e ditors. Testtheorie und Fragebogenkonstr uktion.
2nd ed. Berlin, Heidelberg, New York: Springer; 2012.
p. 7-25.
521Effects of team coordination during CPR
Author's Personal Copy
