Leadership, teamwork and resuscitation aids

Published on 10/02/2015 by admin

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3 Leadership, teamwork and resuscitation aids

Chapter Contents

Introduction

Pointers for effective team leading

Conclusion

Introduction

Leadership competence is often overlooked as a core proficiency in clinical medicine. In emergency medicine, the ability to influence a team of personnel treating a critical patient is vital for a successful outcome. In the ED, since a team of rescuers is usually working simultaneously on a patient, this group must have a team leader to direct their efforts towards a common goal. Furthermore, a well-organized team of people can perform rapidly and achieve a great deal in a short time.

Too often this imperative is overlooked and mayhem is the order of the day, with too many people calling the shots with no apparent direction, or no-one willing to take the lead, resulting in a laissez-faire cop out. The patient bears the ultimate brunt of this failure to lead a team of individuals toward the common goal of effective and efficient resuscitation.

The good news is that leadership in this context is a skill that can be learnt and improved upon. For example, it has been shown that even one person trained as an ALS team leader can impact survival positively. Here are a few pointers to assist you:

Pointers for effective team leading

1. A leader must firstly be identified – either a willing volunteer or a pre-appointed senior clinician could assume this role. If possible, pre-allocation of roles, especially the team leader role, can avoid delay and consternation when an actual resuscitation is encountered.

2. Confidence comes from practice and is vital for a resuscitation team leader. It comes from knowing the resuscitation guidelines (or other protocols) well enough to apply them automatically. Do as much clinical work as you can under an experienced team leader whom you respect. Confidence also comes from good quality, practical, integrated, scenario-based training (see Box 3.1).

3. Self-confidence is also derived from knowing where to access the information you need during the management of an emergency. It is important to know where to get the information, the relevant algorithms and resuscitation aids, as well as how they work. Do not be pressured into trying to recall information, dosages and causes. It will be far more accurate and consistent to refer to resuscitation aids (see Box 3.2).

4. The leader should delegate functions to each team member in accordance with their expertise, experience and abilities. This can either be done immediately as the team forms around the patient or at the beginning of the shift in an ED.

5. Management by objectives is an age-old leadership tool which can neatly be applied in the resuscitation setting. The objectives for the resuscitation or medical procedure (e.g. rapid sequence intubation), as well as how these will be achieved, must be clear to all concerned. These should be voiced during the actual resuscitation so that everyone involved knows what is intended, or which algorithm is being followed, or what is being prepared and anticipated.

6. Managing by measurement is another leadership strategy which, when translated into ED practice, dictates that the ultimate goal beyond a single resuscitation is to improve performance by learning from experiences, mistakes and successes. The only way to improve quality is to measure everything that is being done, so that this can be assessed and reflected upon to identify gaps, errors, and areas for improvement. The time taken to perform interventions, the sequence of events, all results, drug and defibrillator energy dosages should be recorded to help the team leader keep track of progress, and to document a detailed synopsis of the resuscitation for the clinical records. This is vital for meaningful review and research purposes.

7. In terms of feedback, remember to give the positive first, then the ‘negative’, followed by another positive once again. It is imperative that the team leader is an encouraging person, who is able to positively reinforce behaviour on the one hand while also easily able to correct poor performance in a constructive manner on the other. The effective team leader must embrace the role of mentor and coach, and engage in teaching during the resuscitation. All too often the team leader shouts and manages the process aggressively, being critical, insulting and humiliating. This is unprofessional and unnecessary, and is rather a reflection of the lack of competence and confidence of the team leader. Unless the team leader inspires and cheers the team on, teaches in a constructive way, and organizes the resuscitation in a quiet and controlled manner, they should not expect anybody to eagerly volunteer to participate in their resuscitations ever again!

8. To ensure effective teamwork, all team members need to feel safe enough to contribute meaningfully to the process. They must feel that there will be no retribution for offering input when they notice something awry, for asking a question, or for suggesting something that has been overlooked. It is only a mature and confident team leader who is able to receive advice or feedback from a more junior member of the team, especially when the team leader has made an error. Team leaders also make mistakes and are not infallible demigods (see Box 3.3)!

9. In the same way that ‘commentary driving’ is used in advanced driving courses, ‘commentary resuscitation’ can be practised in the ED. This is a technique that forces the team leader to concentrate and focus on what is happening at that instant, and then to verbalize and discuss it out loud. This is an excellent way to summarize and review the progress, including where the team is in the management process or on the algorithm, what has been done and what still needs to initiated. It allows those listening to hear the thoughts and thought processes of the team leader, and so is a powerful teaching tool. It further helps to structure the thoughts of the team leader, and so take control of what sometimes appears to be a runaway process.

10. Ideally, the management or resuscitation of every critically ill or injured child should embody the principles of action-centred leadership: the team leader has to simultaneously be aware of the needs of the group, each individual in that group, and the common task at hand. In order to succeed at the task (which is of supreme importance) both the requirements of the group and the individuals must be addressed. Each individual should be encouraged, coached and assisted to perform their tasks where necessary. Their contribution to the group effort should be acknowledged and welcomed. The team dynamic must be established and maintained.

Box 3.1 Simulation training for paediatric emergencies

Simulation training is an essential component of preparing and honing skills for paediatric emergencies, both for the individual and the team that will be involved. Simulation is particularly useful for high-risk events (such as invasive procedures) or critical low-frequency events (such as cardiac arrest resuscitation).

Medical simulation training is aimed at imitating real patients, patient anatomy and clinical tasks which may be required in a real-life situation. It is intended to not only limit the risks associated with practising procedures on real patients but to offer the advantage of ‘anytime practice’ as opposed to waiting for a patient. This helps to reduce errors and improve patient safety.

The features that simulation offers which make it educationally sound are:

• Allows the chance for hands-on practice.

• Allows for repetition.

• Enables the trainer to provide immediate feedback as well as debriefing.

• Allows for practice to be done in a team environment.

• Errors are valued – they raise an awareness of where performance can be improved upon without the fear of poor outcomes or reprisal.

Although many of the advanced life support courses offer simulation-based training, the evidence shows that there is poor long-term skill and knowledge retention. This is likely due to the amount of time between initial and refresher courses. For simulation training to be more effective, practice with mock scenarios should be occurring on a weekly basis.

There is also evidence to support the use of ‘high-fidelity’ (anatomically correct manikins) over ‘low-fidelity’ simulators and simulations. The feedback from ‘high-fidelity’ simulators helps to better provide the real-life feel to the scenario and is more important for first-time training and for junior personnel. The maintenance of skills and proficiency in teamwork can be done on low-fidelity simulators (such as a simple CPR manikin) on a weekly basis.

Although most of the evidence deals with teamwork in cardiac arrest scenarios, there are simulators for many aspects of paediatric emergency care. Any aspect of acute care that requires teamwork (such as rapid sequence intubation, trauma resuscitation or neonatal resuscitation) should be practised regularly, with role players endeavouring to immerse themselves completely in the scenario. This will create an effective, confident team and will ultimately result in better patient care. Simulation has become an indispensable part of acute care and must be embraced by all healthcare providers who might be involved in the emergency management of children.

Box 3.2 Resuscitation aids in paediatric emergency care

There is an increasing emphasis on the need to use supplementary resources during the resuscitation of children. The intellectual and emotional stress that doctors experience during the resuscitation or emergency management of children in the ED may negatively impact on their ability to provide optimum treatment – partly through delays in determining drug doses, fluid volumes and flow rates or equipment sizes. Although there is considerable uncertainty about the actual dosages of many drugs that are used in emergencies, some experts believe that ‘cognitive paralysis’ or ‘paralysis by indecision’ resulting in a delay to institute treatment may be a more significant risk of poor outcome than an error of dosage. The use of resuscitation aids should be considered mandatory in the emergency management of children: they reduce delays in medication delivery; they reduce dosing errors; and they increase the confidence of the treating team in their management. The choice of a weight-estimation system should also include a consideration of how that system functions as a resuscitation aid, or as part of a resuscitation aid.

The ideal resuscitation aid, in whatever form it takes, should provide the following comprehensive paediatric resuscitation assistance.

It should:

• Assist in changing non-automatic thinking and decisions, with respect to drug dosage and equipment sizing, into automatic* processes so that critical thinking can be uninterrupted and dedicated to medical management.

• Eliminate the need for any calculations.

• Provide an accurate estimate of weight based primarily on length.

• Provide accurate guidance on resuscitation equipment.

• Provide accurate information on fluid therapy, bolus drug dosages, drug dilution and volumes to deliver.

• Provide accurate information on the preparation and delivery of drug infusions.

• Provide accurate information on initial ED ventilator settings.

• Provide useful age-linked reminders with regard to drug dosing, e.g. the need for relatively higher doses of suxamethonium in infants.

• Provide relevant information to every member of the team, e.g. not just a milligram drug dose for the doctor to order, but also instructions for the nurse on how to prepare and dilute the drug.

Resuscitation aids are about critical information, about thinking processes and about teamwork. They should be used during simulated and actual patient management until all healthcare providers are proficient with them. There is little doubt that to use resuscitation aids is to improve the quality of emergency care delivered to those patients most vulnerable to errors and indecision.

* This change is the foundation of resuscitation aids and is best explained by this analogy: when you start driving a car you have to think about everything – which pedals to push, which levers to pull, how to do every little thing. After a few years everything is done completely without thought, automatically and reflexively. Reading an instruction is automatic. Performing memory tasks and calculations is not. Thinking time needs to be spent where it is most needed – on patient management rather than trivial but essential distractors.

Box 3.3 The teamwork imperative – team dynamics, the checklist story

One of the lessons of the WHO surgical checklist (which, when used, has been shown to reduce postoperative complications dramatically), is that facilitating communication within the operating room team has excellent results. It emboldens each team member to contribute to the management – a medical student may notice something that the consultant has missed but will not mention it unless the team dynamic has been correctly established. Many traditional medical approaches need to be abandoned in emergency medicine to ensure optimum treatment for the patient.

Conclusion

The essence of leadership is to influence others to do a better job together as a team than any one person would be able to do by themselves. By measurement and evaluation, gaps can be identified and changes implemented to ensure each successive resuscitation effort is improved upon. Leadership is the art of getting others to want to do what you need them to do! Enjoy the privilege.

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