Teamwork in resuscitation 1 Introduction Have you ever imagined a patient suffering from cardiac arrest and become loss of consciousness in front of you? Do you think you can handle it alone? Even though you are a well-experienced healthcare worker, the answer is certainly ‘No’. According to the American Heart Association (2003), an American will suffer an event of heart attack at about every 29 seconds. What the victim needed at once is probably the cardiopulmonary resuscitation (CPR) performed by a group of trained healthcare workers, and the soul of such process is definitely ‘Teamwork.’ In this paper, we would firstly take a look on the concept of CPR process running at the Queen Mary Hospital (QMH) and do some literatures review on the teamwork among healthcare workers, and then try to explore the teamwork at the CPR among the QMH using a conceptual model. Thus, to identify some areas that needed to have improvement and finally give recommendations accordingly.
Transcript
Teamwork in resuscitation 1
Introduction
Have you ever imagined a patient suffering from cardiac arrest and become loss of
consciousness in front of you? Do you think you can handle it alone? Even though
you are a well-experienced healthcare worker, the answer is certainly ‘No’. According
to the American Heart Association (2003), an American will suffer an event of heart
attack at about every 29 seconds. What the victim needed at once is probably the
cardiopulmonary resuscitation (CPR) performed by a group of trained healthcare
workers, and the soul of such process is definitely ‘Teamwork.’
In this paper, we would firstly take a look on the concept of CPR process running at
the Queen Mary Hospital (QMH) and do some literatures review on the teamwork
among healthcare workers, and then try to explore the teamwork at the CPR among
the QMH using a conceptual model. Thus, to identify some areas that needed to have
improvement and finally give recommendations accordingly.
A brief review of resuscitation process at the Queen Mary Hospital.
QMH is one of the public hospitals in Hong Kong and as attached to the University of
Hong Kong, it undertakes important teaching role and provides the most updated
knowledge and skills to many healthcare professionals. Besides, QMH has won the
Reader’s Digest Trusted Brands Gold Award from year 2007 to 2009, which means it
is the most trustable public hospital for Hong Kong citizens (Reader’s Digest, 2010).
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These are the reasons why QMH was selected as the target hospital in this paper.
Plenty of protocols are prepared to guide the behaviors and works of staffs in QMH
undergoing daily operations, in which the ‘Operation Manual for In-hospital
Resuscitation (2008)’ was drafted under the guideline of basic life support (BLS) and
advanced cardiac life support (ACLS) produced by the American Heart Association.
With reference to the operation manual, once the ward nurse found a patient arrested,
she should call for help as well as check the airway, breathing and circulation of the
patient immediately. If no breathings and heart rates are detected, all the nurses at the
ward should initiate the resuscitation process. Different nurses have different roles
and responsibilities, nurse A should perform the CPR with 30:2 chest compression to
ventilation ratio by the help of bag-valve-mask device. Nurse B checks the vital signs
like blood pressure, pulse and oxygen saturation of patient during the whole process
and make record of time and actions taken because documentation is critical at the
resuscitation process (Lyttle, 2000). The medical officer usually comes very soon after
receiving the emergency call and takes in charge of the process. He would stand in
front of patient’s head where can assess the whole body easily, maintain the airway
and breathing by bagging patient with the oxygen mask device, read and interpret the
electrocardiograms, make decision on what intravenous drugs should be used as well
as the need of defibrillator to provide electric shocks correspondingly. Nurse C would
Teamwork in resuscitation 3
be responsible for setting the intravenous line, preparing and administering all the
medications required. The health care assistants at ward can help clearing the
environment and moving out other patients if possible. Sometimes, the on-call
Anesthetist would come for insertion of endotracheal tube to protect airway and
maintain breathing if required. Besides, due to the large physical-demanding
workload of nurse A in doing the chest compression, all the nurses A, B and C would
shift the works regularly during the resuscitation. In general, the whole dynamic
process would last for at least 30 minutes, the patient will be certified dead if
resuscitation failed. In contrast, if cardiopulmonary functions of patient resumed, the
patient will be put on the mechanical ventilation and seek for further medical
management.
Literature review on teamwork among healthcare professionals
The word ‘Teamwork’ is defined by Xyrichis & Ream (2007) that two or more
healthcare professionals with complementary skills, open communication and
information sharing amongst members, as well as understanding of each
professional’s roles and having common goals.
On the other hand, some researchers claimed teamwork in healthcare is not well
defined in scientific understanding in research (Baker, 2006) and very little known
about how to measure and improve teamwork in healthcare. (Thomas et al, 2004).
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Therefore, the Institute of Medicine and others suggested taking the Crew Resource
Management at aviation industry as references (Helmreich & Merrit, 1998; Odegrad
2000) to conduct more research on investigating the teamwork among healthcare
providers. Their reasons was not just the two industries got similar features in the
development of trauma resuscitation system, but also the aviation industry did have a
longer history of measuring and improving teamwork to prevent and mitigate errors.
Researchers Thomas, Sexton and Helmreich developed a tool called ‘10 behavioural
makers’ in measuring the teamwork performance of healthcare workers in doing
neonatal resuscitation at the year 2004, which is based on the Line Operations Safety
Audit tool used in the aviation industry. Basically, all these 10 makers are observable,
non-technical behaviors that contribute to the teamwork performance. The point is,
coincidentally, almost all these behavioural markers matched a conceptual framework
that drafted by Dickinson and Mclntyre at 1997.
Dickinson and Mclntyre named this framework as the ‘Teamwork Model’ (Appendix
A) and it consists of three stages, which are the input, throughput and output and in
which it can be divided into seven components. They are communication, team
orientation, team leadership, monitoring, feedback, backup and lastly, coordination.
This ‘Teamwork Model’ will be used to explore the teamwork among the CPR
process in this paper. The reason for not choosing the 10 behavioural makers is, as the
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aim of this paper is not going to observe the teamwork in a real resuscitation scenario,
but mainly to focus on the concept of teamwork at the whole CPR process.
Exploring the teamwork in CPR process at QMH using the Teamwork Model.
Fundamentally, communication is the major component of the CPR teamwork
process, it means the exchange of information between all the team members
(Dessler, 2001). It is the mechanism that linked all the other 6 components of the
model throughout all the input, throughput and output stages. Many studies (Pilcher,
2009; Sargeant et al, 2008; Chang et al, 2009) showed the point that effective
communication among healthcare workers can enhance the collaboration and finally
promote better patient outcome, in other words which is the outcome of CPR here.
Nevertheless, some researches showing that 70-80% medical errors are associated
with poor team communication (Schaefer et al. 1994) and with reference to The
American Association of Critical Care Nurses (2005), it also pointed out that about
60% medication errors were due to the mistakes in communication. Most importantly,
Dagnone and Mcgraw (2008) showed that health workers do not possess essential
communication skills facing cardiac arrest despite of completion of the ACLS course.
Therefore, in order to have effective CPR, the enhancement of communication is of
paramount importance.
The input stage
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This consists of two components at the same level and both are inter-related. The first
component is team orientation, according to Dickinson and Mclntyre (1997), it means
the attitudes of members have toward one another, self-awareness and group
cohesiveness towards team task. Obviously, in the CPR process, the team goal of all
members is to save somebody’s life. However, there are various attitudes among the
team members, as the existence of medical domination in the career culture (Pilcher,
2009) and nurses’ inputs in decision making during collaboration are not always
received in the team (Thomas et al, 2003), doctors are tend to be more satisfied in
CPR care than nurses in achieving the team goal. Furthermore, as such CPR team at
QMH formed with an ad-hoc structure, which means a structure of purposeful
combined cognitive and behavioral activity that accomplished serially under time
constraint, with little or no chance of revision (Mendonca et al, 2007), the group
cohesiveness is certainly not as strong as other pre-formed teams.
Team leadership is another component, this is classified as the direction and structure
by formal leaders as well as by the other group members in achievement of goals
(Larson & Lafasto, 1989). In the CPR process, leadership is easily found at the doctor
in charge, who makes decision of interventions clearly and directly based on the
patient’s condition. Besides, the leadership style is apparently transactional, which is
more task oriented (Eeden et al, 2008), and also autocratic (Vilert, 2006), which is
Teamwork in resuscitation 7
stronger in direct commanding and transfer of information, and thus promote the team
performance in and effectiveness of the CPR process.
Therefore, in order to maximize the force in the input stage, the team orientation,
especially the group cohesion should be further improved.
The throughput Stage
Here comes to the second stage. Basically, monitoring is the first step, which has a
direct link to the next step in this stage and the component of the output stage
respectively. Bateman & Snell (2010) states that monitoring is an essential step for
leaders to control all the works in unit against unit’s goals and plans. In the CPR
process, actually all the team members do have monitoring every procedure they
performing. For instance, doctor would monitor the overall picture of the patient,
different nurses would monitor the corresponding drug effect after giving the
intravenous medication, the effect of chest compression as shown on the
electrocardiogram monitor, all the vital signs of patient, as well as the environmental
safety. The step of monitoring is extremely crucial, as any mistakes made would
certainly cause irreversible and fatal harm to patient consequently.
Feedback and Backup are the second step follow monitoring in this stage that linked
together of same importance. By Dessler (2001), feedback is defined as the receiver’s
response to the message that was actually received in the process, which is an on-
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going step making the CPR process more dynamic and functional. For example, the
nurse reported to the doctor that there is a drop in the blood pressure, the doctor will
prescribe drugs to boost up it accordingly. After the nurse has administered that drug,
she can report to the doctor what’s the effect and doctor can take actions
correspondingly. Feedback here is regarded as the flow of information through the
communication process among all the team members.
Backup, according to Dickinson and McIntyre (1997), is to assist the performance of
other team members, and that one who assists must know the skills in the task, and
willing to provide help. There are two good examples in the CPR process. One is the
inter-change of different nurses’ roles due to physical burden in doing chest
compression. Another one is the help of the on call anesthetist in inserting the
endotracheal tube rather than done by the doctor in charge himself. Therefore, the
backup system is well developed.
The output stage
Last but not least, coordination is the unique component in this stage. It refers to the
overall team performance and Yeatts & Hyten (1998) defined it as the act of
performing two or three steps of a work in a proper order. A study conducted by
Marzooq and Lyneham (2009) pointed out that the knowledge and skills of healthcare
workers on ACLS is crucial to make more smooth coordination during resuscitation.
Teamwork in resuscitation 9
Also, it showed some nurses can only poorly recall the CPR knowledge because of
the complexity of CPR tasks. What they suggested was institutions should provide
standardized, periodic and structured training on ACLS to healthcare employees and
evaluate it regularly.
Recommendations
Based on what observed, in order to promote the teamwork in the resuscitation
process in QMH, the concept of self-managed team (SMT) of CPR can be introduced.
Self-managed team is a group of employees, usually 5-15, who are responsible for
managing and performing technical tasks in deliver goods or services to customers.
(Yeatts & Hyten, 1998) and they are high in autonomy, identity and have authority to
make decision concerning other matters for the group (Cohen et al, 1997). Similar
concepts like the code team (Lyttle, 2000) in other countries, which a well-formed
resuscitation team will be called to a scenario and completely takeover the whole
process when incident happened.
The first reason of introducing self managed CPR team is it can improve the team
orientation. Self-empowered and self-willed SMT team members can ultimately lead
to stronger focus on team goal (Hensey, 2000), this can improve the attitudes,
especially nurses, towards the team goal. Also, SMT can further enhance the group
cohesion as it is a well self formed and managed team rather than an ad-hoc.
Teamwork in resuscitation 10
Secondly, SMT can have positive influence on the communication and coordination
among members (Yeatts & Hyten, 1998). Thus, it can bring many advantages in
making more effective team performance to enhance the CPR outcome.
Lastly, as SMT can choose own members and self-evaluate team performance
(Bateman & Snell, 2010), specific training on ACLS can be conducted and evaluated
systematically. Besides, Allcock and Wilson (1975) showed, many health
professionals feeling anxious during resuscitation, this would certainly cause negative
effect on doing CPR. If the team can choose members who are confident and
competent in emergency management, the CPR outcome would be promoted directly.
As a sum up, the idea of self-managed CPR team can improve the communication,
team orientation as well as the coordination components of the Teamwork model
efficiently and it is worth to take in further consideration.
Conclusion
Conclusively, after exploring the teamwork of resuscitation process in QMH, several
areas, like communication, team orientation and coordination, are identified and
needed further enhancement, the concept of self managed CPR team is therefore
recommended. Things are easier said than done, due to the complexity the public
health system and the difficulties in allocation of health service resources, the concept
of self-managed CPR team must need further systematic and in-depth consideration.
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