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Resuscitation Team Organization for Emergency Departments: A Concep-tual Review and Discussion
Abstract and Figures
In this article we discuss code or resuscitation team organization. The goals of this article are to define the questions surrounding code team organization and structure, discuss how organization can make a difference, review re-suscitation systems and processes, and discuss aspects of team structure and performance. Issues of team performance in-clude teamwork, leadership, communication and safety.
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... 1,13,[15][16][17] Multiple studies have demonstrated that leader identification is especially important in large medical centers where resuscitations are dependent on the team members available and the numerous team members involved may have infrequent interactions with one another. 12,18,19 This challenge is further magnified during a pandemic, when personal protective equipment may further obscure appropriate team member identification. ...
... The CTLC also provided a secondary benefit of occupying the code team leader's hands during a CPR, thereby allowing that person to focus on overseeing the team rather than assisting with procedural tasks, an extremely beneficial aspect to this tool. 6,13,19 A vital aspect of being a successful leader includes evaluating the situation in its entirety, which is difficult to accomplish if the leader is focused on fragmented tasks. 6,13,19 With the use of the CTLC, leaders were able to fully concentrate on managing the code team, providing thorough and complete patient care. ...
... 6,13,19 A vital aspect of being a successful leader includes evaluating the situation in its entirety, which is difficult to accomplish if the leader is focused on fragmented tasks. 6,13,19 With the use of the CTLC, leaders were able to fully concentrate on managing the code team, providing thorough and complete patient care. ...
Prompt and clear code team leader identification is vital in effective cardiopulmonary resuscitation (CPR), and pediatric trainees often have limited experience in these scenarios. This project sought to develop a tangible object that provided clear leader identification and assisted in code team management and simulated team training. A Code Team Leader Card (CTLC) was designed to provide clear leader identification while simultaneously providing a cognitive aid via integration of pediatric advanced life support (PALS) algorithms. Additionally, CTLC served to occupy the leader’s hands to limit their ability to intervene on procedural tasks. The CTLC was incorporated into pediatric resident simulation training, and pre- and postintervention survey data were analyzed. Analysis particularly focused on whether “a leader was clearly identified by all team members.” The relationship between CTLC implementation and consistent leader recognition was evaluated using chi-squared test, and secondary qualitative data were obtained via debriefing sessions.
Pediatric residents completed 131 surveys prior to CTLC implementation and 41 surveys after implementation. Consistent code team leader recognition increased significantly from 61.8% (81 of 131) pre-CTLC to 80.5% (33 of 41) after introduction of CTLC (P = 0.027). Participants commented on the benefits of CTLC during debriefing sessions. Use of a CTLC significantly improved leader recognition during simulated CPR. Inclusion of PALS algorithms led to normalization and increased utilization of these adjunct materials. The CTLC provided a secondary benefit of occupying the leader’s hands, thereby allowing that person to focus on overseeing the team rather than assisting with procedural tasks.
... Beyond ROSC, successful CPR also indicates the restoration of quality of life and the functional health status of the individual to the baseline status from before CA (5). Teamwork, closed-loop communication, the responsibilities of the team leader, the provision of the minimum equipment for CPR and the nontechnical aspects of CPR training all have a significant effect on the success of CPR, and they have emerged as a separate area of research in recent years (1,6). Resuscitation teams and equipment, as well as the architectural design of the emergency department (ED), all have a direct effect on the CPR success rate, and these factors must be fully considered if CPR interventions are to be standardised and efficient. ...
... Effective CPR protocols can be managed when an immediate diagnosis of CA and effective CPR can be made and the team members act in harmony in all stages of the resuscitation. The development of concepts dictating the team makeup, team leadership and education of the team and leader is known to improve the outcomes of in-hospital CA cases (6,7,13,14). In a study by Mellick et al. (6) in which the organisation of the resuscitation team was discussed, a team composed of experienced nurses and physicians educated in resuscitation was reported to reduce the number of mistakes during resuscitation. ...
... The development of concepts dictating the team makeup, team leadership and education of the team and leader is known to improve the outcomes of in-hospital CA cases (6,7,13,14). In a study by Mellick et al. (6) in which the organisation of the resuscitation team was discussed, a team composed of experienced nurses and physicians educated in resuscitation was reported to reduce the number of mistakes during resuscitation. Efforts to establish Blue Code applications for in-hospital cases of arrest around the world are one of the most important indicators of such a need (15)(16)(17). ...
... Assim, logo na admissão do paciente, cada membro da equipe já sabe imediatamente qual tarefa deve executar, o que contribui para a agilidade e a adequada priorização das ações. [1][2][3] O uso de instrumentos para identificar as funções dos membros da equipe vem sendo estudado, porém ainda não existe um instrumento adequadamente estruturado e validado pela literatura médica atual. [4][5][6] Este estudo visa avaliar o impacto do uso de crachás de identificação das funções dos membros da equipe de reanimação nos tempos de execução das primeiras ações do atendimento à PCR quando comparado à não identificação. ...
... 9 Isso reduz a carga cognitiva dos profissionais envolvidos no atendimento, pois assegura pelo menos uma pessoa responsável para cada ação necessária, o que evita que alguma ação seja negligenciada, uma mesma tarefa seja executada mais de uma vez ou que alguns membros da equipe sejam sobrecarregados, garantindo a alocação adequada dos recursos humanos disponíveis. [1][2][3]9 Também diminui o estresse emocional de todos os membros da equipe que, ao admitir o paciente, já se encontra preparada para atuar e executar suas funções, de acordo com a designação predefinida. Assim, é possível ações imediatas e que contribuem diretamente para a qualidade do atendimento e o desfecho do paciente. ...
Objetivo: Avaliar se o uso de crachás de identificação das funções dos membros da equipe de reanimação reduz os tempos de execução das primeiras ações do atendimento à parada cardiorrespiratória. Métodos: Estudo experimental prospectivo randomizado realizado com médicos contratados e residentes de uma Secretaria Estadual de Saúde. Os participantes foram randomizados em grupo intervenção, recebendo crachás de identificação das funções dos membros da equipe (líder, desfibrilador e via aérea), e em grupo controle, sem crachás de identificação das funções dos membros da equipe, para a realização de um atendimento em simulação realística de uma parada cardíaca intra-hospitalar. Posteriormente, comparamos as médias de tempo, entre os grupos, para a primeira desfibrilação (desfecho primário), reconhecimento da parada cardiorrespiratória e obtenção de via aérea avançada por meio do teste t de Student. Além disso, avaliamos a autopercepção dos participantes sobre a qualidade do atendimento e da intervenção. Resultados: Participaram do estudo 42 pessoas. Não houve diferença estatisticamente significativa entre as médias de tempo dos grupos nas variáveis analisadas, porém os participantes consideraram que a intervenção teve impacto positivo no atendimento. Conclusão: A utilização de crachás de identificação é uma estratégia para a organização da equipe de reanimação cardiopulmonar, mas não parece ser uma variável independente para a formação de equipes de alto desempenho.
... Lack of communicating skills between team members would cause obstacles against success in CPR operation. Mellick and Adams proved that existence of communication skills in team members can affect the CPR quality (14). Hunziker et al. reported that ineffective communication between team members could cause failure in CPR (7). ...
Abstract
Background: Performing cardio pulmonary resuscitation at hospitals by clinic staffs requires skills, knowledge, precision, and speed for obtaining proper results. The main purpose of the present study was to identify mistakes and errors that occur during cardio pulmonary resuscitation by clinic staffs.
Methods: The present study was observational and was performed between years 2014 and 2016, in a way that the researchers, as presenting the resuscitation code, observed patients, who had cardiac arrest, and recorded all actions performed by the clinical staff. The sampling method of the study was convenient sampling and was performed for 48 cases of CPR. Collected data were analyzed without mentioning the patients’ and hospitals’ name.
Results: Most common and important errors or mistakes made during CPR included treating monitors instead of patients, problems in identifying proper equipment, ignoring clinical symptoms of the disease, such as agonal gasp, deciding to terminate the CPR, improper placement of the staffs’ palm for circulation, and increasing the speed and number of times for circulating. Over hyperventilation, inability in patients ventilation with bag valve mask, wasting time in difficult vein puncture, delay in circulation, inability in realizing actions priority during CPR, broken and out of service equipment, forgetting to check the pulse, rhythm and shock discharge without shock indication, lack of attention to device sync bottom status, device discharge without informing others, and over use and excessive fluid therapy.
Conclusions: The obtained results from the present study indicate that level and quality of presenting clinical care in the emergency section in studied hospitals was not at a desirable and acceptable level and indicates lack of proper education and training for clinical staffs and physicians. Educational needs assessment and optimizing human resource, and proper investment are key factors in developing clinical care and can increase efficiency and reduce casualties.
... B. "1 mg Adrenalin verabreicht") kann hier sehr hilfreich sein. Ebenfalls sollte, wenn genügend Personal verfügbar ist, ein Teammitglied zum Protokollanten designiert werden [35], der wichtige Details aufschreiben kann [36]. Überlegungen zur Fehlervermeidung sind in . ...
In der Notfallmedizin spielt die interdisziplinäre Teamarbeit eine zentrale Rolle und ist zur Bewältigung vieler Krisensituationen wie der Reanimation elementar. Eine funktionierende Teamarbeit wiederum bedingt eine umsichtige Teamleitung und Führung. Gerade in der Notfallmedizin sind Teamleiter durch eine besonders hohe Arbeitsbelastung gefordert. Um in diesen Situationen die notwendige Übersicht zu behalten, ist eine Leuchtturmführung wichtig. Die effiziente Teamleitung während einer Reanimation, aber auch in andren Notfallsituationen ist lernbar und sollte deshalb integraler Bestandteil von Notfall- sowie Reanimationskursen sein.
Effective teamwork in interprofessional healthcare teams requires expert performance by individuals in clearly defined roles. This focus on role clarity and role performance provides the basis of the ‘pit crew’ approach, now commonly utilized in resuscitation teams with demonstrated benefits in patient care. Maternity teams responding to emergencies may benefit from a similar approach to teamwork; however, little attention has been paid to team member roles within the maternity emergency context. In this qualitative case study of maternity teams responding to two simulated maternity emergencies in the context of a teamwork training course, we aimed to describe team member performance in roles and explore clinician perceptions of role allocation and performance within the team. Video analysis of role performance demonstrated team members performed actively and passively in multiple roles throughout the scenario, with some improvement in role consistency between Case 1 and Case 2. Workload distribution was uneven, with some clinicians performing tasks across several roles concurrently, while others did not appear to take on any role. Thematic analysis of debriefing conversations and post-scenario interviews and focus groups revealed four themes. Three themes related to the process of team member allocation to roles with participants describing the need to firstly gain an understanding of the situation, have knowledge of clinical requirements and priorities and consider their suitability for role in the clinical case. The fourth theme related to participants shift in conceptual understanding of how to work in roles facilitated by the simulations and debriefings. This study provides a preliminary understanding of how team members allocate roles in
Background:
Delivering high-quality cardiopulmonary resuscitation (CPR) requires teams to administer highly choreographed care. The American Heart Association recommends audiovisual feedback for real-time optimization of CPR performance. In our Emergency Department (ED) resuscitation bays, ZOLL cardiac resuscitation device visibility was limited.
Objective:
To optimize the physical layout of our resuscitation rooms to improve cardiac resuscitation device visibility for real-time CPR feedback.
Methods:
A simulated case of cardiac arrest with iterative ergonomic modifications was performed four times. Variables included the locations of the cardiac resuscitation device and of team members. Participants completed individual surveys and provided qualitative comments in a group debriefing. The primary outcome of interest was participants' perception of cardiac resuscitation device visibility.
Results:
The highest scoring layout placed the cardiac resuscitation device directly across from the compressor and mirrored the device screen to a television mounted at the head of the bed. Comparing this configuration to our standard configuration on a five-point Likert scale, cardiac resuscitation device visibility increased 46.7% for all team members, 150% for the team leader, and 179% for team members performing chest compressions.
Conclusion:
An iterative, multidisciplinary, simulation-based approach can improve team satisfaction with important clinical care factors when caring for patients suffering cardiac arrest in the ED.
There is an emerging body of literature on handover communication in civilian emergency care settings between paramedics and hospital receiving staff. However, little is known about how handover is conducted in the UK military and how this might differ from the NHS. The aim of this study was to explore the handover experiences of paramedics who have worked in both organisations in order to learn more about handover communication. The key objectives were to gain further insights into how these experiences changed paramedics’ expectations and knowledge of handover, and how they managed the transition between different emergency care settings.
The study was informed by a mixed methods approach. It used semi structured interviews with paramedics who have worked in the NHS and with the Medical Emergency Response Team (MERT). Data from interviews was recorded, transcribed, and organised using Computer Assisted Qualitative Data Analysis (CAQDA). The study was supplemented by reflexive diary entries of handover communication and includes contemporaneous notes, drawings and reflections on handover.
The study showed that there were differences between handover communication in the military and the NHS, and these were driven by organisational culture and mission, patient characteristics, training of health care professionals, and available resources. However, standardisation was a common feature in both emergency care settings. In the military, the ATMIST mnemonic was a key element of standardisation, whilst in the NHS this was driven by the Patient Report Form (PRF). It appeared that transition between different healthcare settings, especially from the military to the NHS, was challenging for paramedics. More research is needed into how paramedics manage these transitions and how they can be supported through this process.
The number of victims of sudden cardiac arrest is increasing. Some countries have developed strategies that allow optimizing the immediate response in the pre-hospital setting. However, the survival rate remains low. So it is important to study how we can improve the care of victims of cardiac arrest with spontaneous circulation recovery to improve the survival rate, and the quality of post-cardiac arrest care, central to the outcome of these people. The continuity of care of these patients, implies that in order to provide skilled nursing care, we have the knowledge and competence to act in the prevention and resolution of complications that compromise vital functions of the person, and are able to optimize the detection of problems, increase the satisfaction of the people, and improve their outcome. This theme was the core topic for the skills’ acquisition based on the Dreyfus model for the acquisition and development of skills, which brings us the importance of practical experience combined with the area of capabilities, in a dynamic perspective and evolutionary aiming at the quality of care (P. Benner, 2001). To this end, I developed my internship with the emergency stage path and intensive care, carrying out several activities that allowed me to achieve the master's course objectives in nursing in the area of expertise of the person in critical condition (Escola Superior de Enfermagem de Lisboa, 2010).
Keywords: Person in critical condition, cardiac arrest, post-resuscitation care, recovery of spontaneous circulation, neuroprotection, nursing.
Background:
In the pediatric emergency department (PED), resuscitations require medical teams form ad hoc, rarely communicating beforehand. Literature has shown that the medical community has deficiencies in communication and teamwork. However, we as medical providers do not know or understand the perceived barriers of our colleagues. Physicians may perceive a barrier that is different from nurses, respiratory therapists, pharmacists, or technicians. Perhaps we do not know in which area of teamwork and communication we are deficient. Only when we understand the perceptions of our fellow coworkers can we take steps toward improvement in quality resuscitations and therefore patient safety.
Objective:
The primary objectives of this study were to describe and understand the perceived barriers to effective communication and teamwork among different disciplines forming spontaneous resuscitation teams at a tertiary urban PED and to determine if providers of different disciplines perceived these barriers differently.
Methods:
This was a mixed-methods study conducted in a single, tertiary care freestanding children's hospital emergency department. Survey questions were iteratively developed to measure the construct of barriers and best practices within resuscitation teamwork, which was administered to staff among 5 selected roles: physicians, nurses, respiratory technicians, PED technicians, and PED pharmacists. It contained open-ended questions to provide statements on specific barriers or goals in effective teamwork, as well as a priority ranking on 25 different statements on teamwork extracted from the literature. From the participant data, 9 core themes related to resuscitation teamwork were coalesced using affinity diagramming by the authors. All statements from the survey were coded to the 9 core themes by 2 authors, with high reliability (κ = 0.93). Descriptive statistics were used to summarize the prevalence of themes mentioned by survey participants. A χ test was used to determine differences in prevalence of core themes by role. Rank data for the 25 statements were converted to a point system (5 points for most important, 4 points for second most important, etc), and a mixed within-between analysis of variance was used to determine the association of role and relative rank.
Results:
There were 125 respondents (62% response rate) who provided 893 coded statements. The core theme of communication-in particular, closed-loop communication-was the most prevalent theme, although no differences in the proportion of themes represented were seen by PED staff of different roles (P = 0.18). There was a significant effect from the core theme (P = 0.002, partial η = 0.13), with highest priority on team leader performance (mean points out of 5 = 2.5 ± 1.9), but neither effect nor interaction with role (P = 0.6, P = 0.7).
Conclusions:
When answering open-ended questions regarding barriers to effective resuscitations, all disciplines perceived communication, particularly closed-loop communication, as the primary theme lacking during resuscitations. However, when choosing from a list of themes, all groups except physicians perceived deficiencies in team leader qualities to be the greatest barrier. We as physicians must work on improving our communication and leadership attributes if we want to improve the quality of our resuscitations.
This article describes emergency department care work teams designed to improve team communication and coordination and reduce error. The core of this teamwork system is the teaching of teamwork behaviors and skills, development of teamwork habits, and creation of small work teams, all of which are key teamwork concepts largely drawn from successful aviation programs. Arguments for enculturating teamwork into ED practice are drawn from a retrospective study of ED malpractice incidents. Fifty-four incidents (1985-1996), a sample of convenience drawn from 8 hospitals, were identified and judged mitigable or preventable by better teamwork. An average of 8.8 teamwork failures occurred per case. More than half of the deaths and permanent disabilities that occurred were judged avoidable. Better teamwork could save nearly $3.50 per ED patient visit. Caregivers must improve teamwork skills to reduce errors, improve care quality, and reduce litigation risks.
We analyzed the debriefing sessions of real-life trauma resuscitation teams during the most intensive period of resuscitation: the first 30 minutes of patient admission to a trauma center. The debriefing sessions were from participants reviewing their performance in videotaped trauma resuscitation. Nineteen videotaped cases were reviewed in 37 debriefing sessions. Adaptation of team structure was noticed in response to task urgency and criticality, even though there was a preference for teams to maintain a hierarchical structure. We propose a set of archetypes of team structures based on the debriefing session and discuss how the archetypes could be used as a way to capture how teams adapt their structures.
An experiment examined the effects of seating distance, sex of subjects, and sex of moderator on moods, evaluations, attraction, and attitude expression in the context of a small group discussion. The main focus was on how these dependent measures changed from before to after interaction. Groups of three subjects and a moderator completed ratings, discussed a socially relevant issue, and again completed ratings. During the discussion, group members either sat very close to each other or were free to choose their own seating position. As expected: (1) negative feelings lessened, while attraction and positive feelings increased as a result of the discussion; and (2) the results for seating distance showed that females chose closer seating among themselves, and subjects sat closer to a female moderator than to a male moderator. Results for ratings are interpreted in terms of Zajonc's (1968) "mere exposure" hypothesis and deindividuation theory. Results for seating distance confirm previous findings and suggest that the ranking person helps define the appropriate spacing norms in a group.
To learn how groups arrange themselves, pairs of students were observed in a cafeteria where interaction was encouraged and in a library where interaction was discouraged. In the former situation, people chose to sit across from one another while in the library people chose a distant seating pattern. Several paper-and-pencil instruments were used to gauge seating preference in casual, cooperating, competing, and co-acting groups. In general, casual groups prefer corner seating, cooperating groups to sit side-by-side, co-acting in a distant arrangement, and competing groups opposite one another. The role of eye contact in regulating spatial arrangements of small groups is discussed.
Emergency medicine (EM) presents many cognitive, social, and systems challenges to practitioners. Coordination and communication under stress between and among individuals and teams representing a number of disciplines are critical for optimal care of the patient. The specialty is characterized by uncertainty, complexity, rapidly shifting priorities, a dependence on teamwork, and elements common to other risky domains such as perioperative medicine and aviation. High-fidelity simulators have had a long tradition in aviation, and in the past few years have begun to have a significant impact in anesthesiology. A national, multicenter research program to document the costs of teamwork failures in EM and provide a remedy in the form of an Emergency Team Coordination Course has developed to the point that high-fidelity medical simulators will be added to the hands-on training portion of the course. This paper describes an evolving collaborative effort by members of the Center for Medical Simulation, the Harvard Emergency Medicine Division, and the MedTeams program to design, demonstrate, and refine a high-fidelity EM simulation course to improve EM clinician performance, increase patient safety, and decrease liability. The main objectives of the paper are: 1) to present detailed specifications of tools and techniques for high-fidelity medical simulation; 2) to share the results of a proof-of-concept EM simulation workshop introducing multiple mannequin/three-patient scenarios; and 3) to focus on teamwork applications. The authors hope to engage the EM community in a wide-ranging discussion and handson exploration of these methods.
The emergency department (ED) is a complex environment. Its equilibrium, or homeostasis, is critically dependent on the continuous action of feedback processes. For any system to function efficiently, it needs to know the outcomes of specific actions in a consistent, reliable, and expeditious way. Historical attitudes and the unique operating characteristics of the ED have combined to impose sanctions on the proper provision of feedback. The following features have been identified as obstructive to optimal feedback operation: incomplete awareness of the significance of the problem, excessive time and work pressures, case infrequency, deficiencies in specialty follow-up, communication failures, deficient reporting systems for near-misses, error, and adverse events, biases in case review processes, shift changeover times, and shiftwork. The result is that clinicians, nurses, and trainees are working in conditions that are suboptimal for the provision of safe care, as well as for learning and job fulfillment. Good feedback is a necessary condition for well-calibrated performance by individuals, and is integral to effective team function. More needs to be known about outcomes for feedback to work efficiently. The critical role of feedback in other aspects of ED function, such as education and human factors engineering, should be emphasized. The current interest in medical error and evolving attitudes toward a new culture of patient safety provide a unique opportunity to examine feedback and the critical role it plays in ED function.
A resuscitation is a complicated event that requires for its optimal outcome the effective completion of a distinct series of actions, some simple, some complex, most occurring simultaneously or in close proximity. In children, these actions are determined not only by the clinical situation, but also by a series of age and size factors particular to each child. Different tasks require different levels of cognitive load, or mental effort. Cognitive load describes the mental burden experienced by the decision maker and will be higher when the task is less familiar or more demanding. In the setting of resuscitation, it refers to the cumulative demands of patient assessment, the ongoing decisions for each of the various steps, and decisions around procedural intervention (e.g., intubation). In children, the level of task complexity and, hence, cognitive load is increased by the unique component of variability of pediatric age and size, introducing logistical factors, many of which involve computations. The purpose of this paper is to examine the effects of age/size-related variables on the pediatric resuscitative process and to explore how these effects can be mitigated using resuscitation aids. The concept of cognitive load and its relation to performance in resuscitation is introduced and is used to demonstrate the effect of the various aids in the pediatric resuscitative process.