ICN Victoria presents Dr Andy Buck, Emergency Physician and Director of the well regarded Emergency Trauma Management course, talking on managing the resuscitation room, a teamwork approach to CRM.
Thanks Warwick & Helen
Emergency Physician
Work at Alfred & Royal Darwin Hospital – my views in this talk are my own & not those of my employers
Grad Cert in Clinical Simulation Monash Uni
Co-wrote and have directed ETM Course for 18 months – 14 courses
Director of ETM – the company that runs the ETM Course
Paid a salary by that company
This is how we’ve all been taught trauma - the linear, single operator approach
Must not proceed to the next element until the previous element has been fully addressed
DISCUSS CASE IN DARWIN THAT TRIGGERED ETM
This results in resus rooms full of people, all doing their own linear thinking
BUT THE PROBLEM IS THATInformation does not arrive from the patient in this nice linear sequence!
If everyone is on their own linear path:
THIS IS HOW I WAS TAUGHT – “JUST GET IN THERE AND RUN IT” – WITH NO TEACHING ABOUTHOW TO DO IT
So we find that people are often out of sync
AND
Deconstructing the linear ABCDE model and reconstructing it on the fly RESULTS IN COGNITIVE INEFFICIENY & ERROR
AND IT OFTEN LEADS TO CONFLICT:
Some effects of this include:
Cognitive overload,
Divergent plans
Marked staff frustration
Delays
Conflict
Error
At some point stickers started showing up, so people had roles allocated
NOT SURE WHERE THIS CAME FROM OR WHY IT HAPPENED – NO DOCUMENTATION AVAILABLE!
Present in many ED’s around Aus/NZ now
HOWEVER: This doesn’t work well if people are still using a linear thought model
Everyone kept using the word “team” but it didn’t feel right – as this was a bunch of strangers showing up to try & work together & didn’t feel like a team.
In 2006 Mark Fitzgerald published this article
This is the defining article of the modern approach to the trauma patient
Coined the phrase: “Reception & resuscitation”
The patient is received into the ED & Resuscitated by a team
One key phrase in this article defines modern ED Resuscitation
Multiple simultaneous events Proceeding at different rates
So we tried to come up with a new diagrammatic representation of this
This is one of the first iterations
Represents multiple simultaneous processes proceeding at different rates
THESE VARY WITH:
PATIENT FACTORS (Age, co-morbidities, weight)
INJURY PATTERN/PATHOLOGY
TREATMENT GIVEN
TREATMENT OMITTED (IN ERROR) OR DELAYED (eg due to long transport times)
MORE OF A DYNAMIC, PARALLEL PROCESS MODEL
This is another version, that shows that the sequence is less relevant
Any element can go in any order, as long as all are covered/checked
And you can go back & forth between elements
And this is another version THAT MOST ACCURATELY REPRESENTS WHAT WE TEACH ON ETM
In which specific tasks are allocated to different staff/team members
Who report to, and are overseen by a Team Leader OR KEY DECISION MAKER
GOOD POINT TO SEGWAY INTO DISCUSSION ABOUT TEAMS
What team do you barrack for?
Ask several people. How well do you know your team?
Then ask - WHAT IS A TEAM?
Like trauma - there is no definition
Psychologists studying this use different definitions = makes research hard to interpret
USUALLY = GROUPS OF PEOPLE WHO KNOE EACH OTHER
Well known to each other
Drilled
Practice frequently
Individualised
Equipment
Roles
Intense analysis
Human performance
Opposition/competition
Strive for excellence
EVEN TEAMS WHO KNOW EACH OTHER DON’T ALWAYS FUNCTION WELL
WHY IS THIS?
PERSONALITY: narcissisim, sociopathy, ANXIETY DISORDERS (OCD)
KNOWLEDGE GAPS
FEAR OF LOSING CONTROL
LIFE ISSUES – new baby/no sleep, marital problems, exam stress, crap job/crap boss…
NEXT SLIDE – VIDEO OF TEAM WORK
RRM is a new concept, spawned from the frustration of
Near death experiences
Abusive behaviour
Lack of co-ordination of ED & specialty units
CRISIS/CREW RESOURCE MANAGEMENT DOES NOT APPLY TO ED TEAMS
It’s an industry specific set of skills that does not cross-translate to our environment
ALSO
Many CRM papers end up defining lists of 10-15 skills/behaviours = can’t remember this is a crisis and of no practical use on the floor
We have incorporated these into practical skills that can
This is “evidence based”
Scott Tannebaum & Eduardo Salas
Coined the phrase “flash teams”, and “dynamic teams
Applies to groups with changing or dynamic composition
MUCH MORE APPLICABLE TO ED TEAMS
Teaching familiar teams = teach the whole team
Teaching dynamic teams = teach the individual cross-transferable skills
That’s what we’re doing at ETM
There’s not a lot of research, but what there is, we’ve utilised
You’re all asking - so what do you want us to do?
WHO’s THIS? WE CAN’T ALL BE CLIFF! – this is one of the key challenges of this concept
BENEFITS OF AN IDENTIFIED TEAM LEADER?
Clear who’s in charge – ESTABLISHES LEADERSHIP & FOLLOWERSHIP
Removes cognitive load from participants – can focus on doing tasks well – NO NEED TO MULTITASK (as we can’t)
Point of contact for new members/visiting clinicians
SELF: HALT, mood, posture, body language, tone of voice
TEAM: Roles, Names, Skill check – can be VERY HARD – SOCIALLY AWKWARD when new people arrive
ENVIRONMENT: Layout, lighting, equipment, NOISE LEVEL
PATIENT: know your medicine, anticipate problems/complications, dynamic prioritization, expedite treatment & disposition
This is an arbitrary delineation
May need to vary roles/tasks depending on staffing, skill mix, resources
This is an arbitrary delineation
May need to vary roles/tasks depending on staffing, skill mix, resources
This is an arbitrary delineation
May need to vary roles/tasks depending on staffing, skill mix, resources
This is an arbitrary delineation
May need to vary roles/tasks depending on staffing, skill mix, resources
This is an arbitrary delineation
May need to vary roles/tasks depending on staffing, skill mix, resources
What happens when you order a pizza?
Maccas drive through?
Airlines
Why don’t we do this a routine?!?!
Periodically Summarise the A/B/C/D/E’s
Say it out loud to the group
When?
After any intervention
When you feel “lost”
“Next 3 Steps”
Allocate to individuals, not the room
STANDARD & STRUCTURE:
Clearly defined roles
Establishes leadership & followership
Tasks allocated
Task performance/difficulties communicated amongst group
Whole group “on the same page”
Aims to improve communication, reduce conflict
Aims to improves functioning of flash or dynamic teams
Aims to improve staff and patient experience in ED resuscitation
Aims to improve patient flow through ED & hopefully will positively effect outcome.