ICN Victoria: Buck on "Resus Room Management"

Editor's Notes

• #2: 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
• #3: Director of ETM – the company that runs the ETM Course Paid a salary by that company
• #4: 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
• #5: 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!
• #6: 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
• #7: AND IT OFTEN LEADS TO CONFLICT:
• #8: Some effects of this include: Cognitive overload, Divergent plans Marked staff frustration Delays Conflict Error
• #9: 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.
• #10: 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
• #11: One key phrase in this article defines modern ED Resuscitation Multiple simultaneous events Proceeding at different rates
• #12: 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
• #13: 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
• #14: 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
• #15: What team do you barrack for? Ask several people. How well do you know your team? Then ask - WHAT IS A TEAM?
• #16: 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
• #19: 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
• #20: RRM is a new concept, spawned from the frustration of Near death experiences Abusive behaviour Lack of co-ordination of ED & specialty units
• #21: 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
• #22: 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
• #23: There’s not a lot of research, but what there is, we’ve utilised
• #24: You’re all asking - so what do you want us to do?
• #25: 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
• #26: This is an arbitrary delineation May need to vary roles/tasks depending on staffing, skill mix, resources
• #27: This is an arbitrary delineation May need to vary roles/tasks depending on staffing, skill mix, resources
• #28: This is an arbitrary delineation May need to vary roles/tasks depending on staffing, skill mix, resources
• #29: This is an arbitrary delineation May need to vary roles/tasks depending on staffing, skill mix, resources
• #30: This is an arbitrary delineation May need to vary roles/tasks depending on staffing, skill mix, resources
• #31: What happens when you order a pizza? Maccas drive through? Airlines Why don’t we do this a routine?!?!
• #33: 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
• #36: 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.