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Why “teamwork” doesn’t work in Resuscitation

The majority of hospital resuscitations occur in Emergency Department resus rooms.  Except in the most organised institutions, the group that assembles in ED resus rooms does not fit the definition of a “team”.  Use of the word “team” leads to false expectations, and feelings of failure when “teamwork” has not occurred.

Teams train & practice together, know each others names, skill-set, abilities, strengths & weaknesses, teams are coached, critiqued and drilled, so that on game day, they perform at an optimal level.   Teams review their games and focus on improving on areas of weakness or mistakes.  Teams analyse their competition, and seek out ways to maximise their chances of winning.

ManU.jpg

Photo courtesy of mirror.co.uk

None of these attributes apply to groups of individuals who perform Emergency Department resuscitation.  Regarding just the ED medical staff, factors such as shift-work (meaning one rarely works with the same people), rotations of doctors through ED and out to other specialties, and having multiple mid to senior level doctors rostered on at the same time means a “team” can never form.  Add to this the same factors which apply to different specialties who come to ED to assist with resuscitations (mainly Anaesthetics & ICU), and your chances of assembling the same group of people in a resus room are exceptionally slim.  Then consider that another group – the nursing staff – will also vary with almost every resus, due to shiftwork, enforced meal-breaks, and skill-mix variations, and you are faced with the fact that a “team” cannot form in this setting.

Based on this, RRM aims to give the doctors in charge if running a resus (until now often called the “Team Leader” – ironic?), a skill set that allows them to manage a heterogenous group of individuals with varying skills and priorities and as well as managing the multiple simultaneous clinical events that occur in resus.  RRM aims to give individuals who arrive to participate in a resus (ED medical and nursing staff, and non-ED medical staff) a clear set of expectations of how they will behave and perform while attending an ED resus, and skill set that they can use to work with the Resus Leader to achieve optimal outcomes.

Manchester United is a “team”.
The heterogenous group of strangers who arrive to run most ED resuscitations is not.

 

 

Tug-of-war photo courtesy of: milwaukeecountyfirst.com

 

6 Responses to Why “teamwork” doesn’t work in Resuscitation

  1. Michael Eddie December 30, 2012 at 7:12 pm #

    Hi Andy,

    Just discovered your blog after a retweet from Cliff. Looks great, and will be added to my list of FOAMed feeds to follow!

    It is with great interest that I read your posts on CRM / teamwork – and the specific challenges that the resus environment provides. I pose this question, which do you (and the wider audience) think is more beneficial – teaching individuals to work in some form of team which is assembled ad hoc each time, or structuring departments / hospitals so there is some form of team developing?

    Our local hospital is due to start secondments for nurses in resus. Here the nurses will work for 3 months (I believe) full time in resus. If this could match with the rotations of the doctors then some semblance of common ground forms. Allowing for other specialities who also come down to ED would be more difficult though – but step one is getting the in house sorted!

    To help further this, I am a firm believer in inter-professional training – is it possible in your departments to pull these teams of people together and get them practicing together. I believe one of the aims of the resus secondments is to allow for the downtime in resus to be used as education time – which seems like a great idea. (Although the rest of the department might not approve when they are snowed under in majors!!)

    Finally, how do we measure success in the resus environment? As you rightly suggest, filming of real life resuscitations opens a whole can of legal/ethical worms. However, could high fidelity simulation within the department be used to assess the teams? Wheel a sim man into the department at an unknown time, and ask the team to perform as they would in their normal environment. I believe this could be the next best thing, and may help provide some debrief opportunities, or indeed opportunities to practice new ways of working.

    Obviously there is no perfect solution – and staff who work in ED will always need to be prepared for working in teams where they dont know everybody. However, I dont think the idea of teams and team-working should be written off just yet!

    I look forward to reading more of your articles.

    Mike

    • Andy Buck December 31, 2012 at 10:44 am #

      Hi Michael
      Great questions. Of course I would love hospitals to be staffed and rostered in a way that allowed for structuring of teams that could work together regularly, however the sad reality is that in the vast majority of hospitals this is just impossible. If you could get 2 or 3 doctors working together on a roster, you’d struggle to get the same nurses. Staff tunrover (doctors changing rotations, and nurses changing jobs/roles, plus people going on leave etc) would also hamper this. There are also basic barriers like the fact that nursing shifts and doctors shifts are not synchronised, meaning you’d struggle to get the same group present for a whole shift. I believe some ED’s do roster doctors on to “teams”, who work together for a whole rotation, but this is the exception. That is why I think teaching people skills to manage an ad-hoc group of assembled individuals is more relevant to what we actually do at work.

      Regarding the use of simulation, I think this an excellent idea, and have just implemented it where I’m working currently. I think this is a much more realistic way to train, as the “surprises sim” utilises whoever happens to be on the floor that shift. As far as videoing simulations, (which again, I think has huge learning potential), it is possible, but you do need everyone’s consent to be filmed, and you need some pretty safe data storage (or data erasing) processes, so it doesn’t end up on YouTube.

      Measuring success? This is a tough one, and I have wondered whether something like RRM is worth bothering with if it won’t improve outcomes. Hard outcomes like morbidity and mortality will be impossible to measure. There are however a lot of intangible (and possibly unmeasurable) outcomes that staff come away with after a well run resus such as improved morale and job satisfaction. Video taping simulation (with constructive debriefing) would be a way to measure performance, and teach error reducing behaviours.

  2. Domhnall December 31, 2012 at 6:59 am #

    Have you got too much time or something? This is a great little post. I heartily agree – the skills we need involve being able to function regardless of who assembles in the resus room, and continually assessing them as well as the patient. This must be transferable and flexible, and always clearly articulated. Domhnall

    • Andy Buck December 31, 2012 at 10:54 am #

      Thanks Domnhall, totally agree.
      And no, definitely do not have too much time! Just a bee in my bonnet about making resus run better.
      Cheers
      Andy

  3. Domhnall December 31, 2012 at 2:33 pm #

    Kind of like a schoolyard kickabout except you don’t know yet who the crap player to pick last is!!!

Trackbacks/Pingbacks

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