Optimising ED team performance
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Optimising ED team performance
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Optimising ED team performance
- 1. Tom Cassidy Optimising Trauma Team Performance 1/3/2018
- 3. Tom Cassidy Optimising Trauma Team Performance 1/3/2018 Optimising ED Team Performance
- 4. A tragedy in 3 Acts ❖ Performing under stress ❖ Specific fixes ❖ Tom’s folly ❖ Throughout the tragedy the following case will act as our foundation…
- 6. What makes stuff Stressful? ❖ Time ❖ Resources ❖ Skills ❖ Other people ❖ Environment ❖ Stakes
- 7. What makes for the most difficult sick person? ❖ No warning
- 8. Major Trauma ❖ Multiple Body systems involved ❖ Airway, head injury, neck, thorax, abdomen, long bones, coagulation ❖ Multiple Procedures ❖ IVA, chest drains, intubation, pelvic binding ❖ Multiple Specialities ❖ ED, Gen surg, ortho, radiology, anaesthetics ❖ Competing interests ❖ Intubation vs ICC, CT abdo vs straight to OT, permissive hypotension vs head injury
- 9. –Douglas Adams I briefly did therapy, but after a while, I realised it is just like a farmer complaining about the weather. You can't fix the weather - you just have to get on with it.
- 10. Individuals ❖ Force them to introduce themselves and wear ID ❖ Challenge vs threat ❖ Mental practice ❖ Closed Loop Communication
- 11. The trouble with teams ❖ Going back to our case
- 12. A bird in the hand… ❖ Utilise the time prior to presentation ❖ People, place, equipment, drugs, blood ❖ Pre-briefing -Assign roles ❖ Lay out a predicted course of management, including expectations and what to do if the case doesn’t follow the clinical course
- 13. –US Supreme Court Justice Potter Stewart “I know it when i see it.”
- 14. Tom’s Folly
Editor's Notes
- Why are we talking about this? Because sick people are complex, they would be complex if you had to fix them on your own but you can’t do it on your own. And that’s when other people get involved. Other people bring with them a heterogeneous mix of skills, beliefs and attitudes. Some people’s priorities are not the same as others. Also we have come so far scientifically. We can put people on ECMO in the ED. The last case I was involved with took 16 minutes to replace someones heart and lungs who was in refractory VF from an AMI. But during that time the patient didn’t receive aspirin. One of the few interventions that has been shown to confer a mortality benefit in the setting of MI, the medical student in the corner knew this. Before we go any further I want to change the title of my talk.
- SJA are 7 minutes away - A car has been found on its roof with a single unconscious person inside. Looks to be about 50-60yo, can’t find wallet. GCS 6-8, Airway is patent but there looks to be some facial fractures, RR 30, sats 82 15LNRB, 60/40, HR 125. What do we need to do?
- All these things lead to a stress response. Increased cortisol, HR, etc leading to a reduced level of function. A caveat - some stress is good. well researched that there is an optimal amount of stress for peak performance. It is rarely a problem that the arousal with the team isn’t high enough, sometimes in sim i sense the urgency isn’t quite there. Time- The patient is trying to die, we can’t get a line in, the blood is taking forever to get here Resources - I don’t have the stickers to get the blood, we’ve run out of rapid transfusion sets Skills - Shit i don’t know how to do a FAST, thoracotomy, ECMO lines Other People - The general surgeon wants a CT but they’re unstable, the RMO is useless Environment - Its noisy, you’re worried about getting in someones way, lead isn’t comfortable. Stakes - this patient has 2 young kids…
- Give me examples of your nightmare patient in terms of critical illness and what makes them so? For me its the mother running in with the blue baby. The time you get prior to a patient’s arrival is manna from heaven. At this point you have no one on front of you can predict what you need and plan accordingly. At this stage you can assign roles and give a prediction with how things will go and the different paths it could take. “Tim you take airway, work with Mel, it sounds like they will need intubation Ask a nurse how long a paid infuser takes to set up. Ask a clerk how long it takes to get proper stickers
- This is attitude is not what we’re on about. We need to fix our environment that we manage critically ill patients in. every facet of it. I am talking mainly abut fixes within the team on an individual level and ht the leader can achieve. Firstly we need to be honest to ourselves and say, we don’t do it perfectly. we can improve. As a psychiatrist told me when I was a student. “If it ain’t broke, fix it”.
- Don’t want to focus on individuals too much but these are some ways to help. These are things we can do from the point of knowing something is coming in. Obviously it would be great if we could have a team of Rippeys but that’s not realistic. Although cloning has come a long way. Who are you? I ask this all the time and I get looked at as if i’ve insulted someone’s mothers heritage. This goes for everyone in the team, succinctness and efficiency should not be confused with rudeness, if it is then fuck off. Don’t be English, think more South African. i.e. you’re just this side of earning punch in the face.
- In attendance are ED SR, juniour reg, RMO and intern, Anaesthetics registrar, gen surgery reg and nursing staff Anaesthetics reg sees that intubation will be likely and asks for sizes 3 and 4 CMAC, D-Blade and to have a fiberoptic on standby, also want some atracurium and Alfentanyl for intubation. Gen surgery registrar, wants transport monitoring applied because nothing else matters but the CT to find out where the bleeding is. The ED juniour reg is attempting an arterial line. The RMO and intern are doing a difficult IV. Let’s go through some of the difficulties here. A great way of mitigating an impending disaster is the pre-briefing
- When asked if he could define pornography, he couldn’t but offered this instead and i think the same is with leadership. Comes in all shapes and sizes but we know good leadership when we see it. Think of Tony “iceman” Celenza vs James “thinly veiled threat of violence if you don’t do what i say” Wheeler
- Paucity of evidence zone.
- Tenerife 1970s, 2 747s collided. Lack of teamwork partly to blame. Airline industry has often been touted as the model for us to look towards and i think this is true for say elective surgery but I think other fields may be more helpful in terms of modelling leadership qualities and the resuscitation of a sick patient.
- Chef Pros Direct requests, very good closed loop communication - I need 3 fish, 2 steak and 1 chicken - yes chef!, they then let the chef know when it’s ready. Also constantly checking in with the crew - how’s that fish coming, not enough sauce on the last chicken etc. Cons Reputation of belittling their team, doesn’t allow for constructive feedback, fixates on failures, demoralises. Also the head chef will often stand at the pass and check the finished meals prior to going out. Not actually looking at their team. This is bad body language and shows a lack of interest in the process as long as the outcome is ok. Example the BP may have been stable for the last half an hour but it has required increasing amounts of inotropes and blood products to achieve. They themselves will often be the most senior person in the room and if they get embroiled in a procedure that requires a bit of skill they can lose their situational awareness.
- Calmness is contagious, fear as well. I wonder harking back to the beginning of my talk whether that guy is seeing his work as an opportunity to succeed or he feels threatened.
- The professorial approach is somewhat different. It considers all the information, analyses it thoroughly, will often ask for others opinions. Professors are good, they rarely miss anything and they are generally pleasant to work with. However professors are slow, inefficient and if speed is required they can become a bit mollified. By and large they can be polite as well, in life this is a good way to be but pleasanteries can make you slow. No ps and qs in critically unwell patients. As i said before be less English.
- Think of the General Physician running a trauma or similar medical case even. Very knowledgeable, amazing breadth and depth, why then are they not the perfect people to runt these cases? They are not temporal specialists. We are. That is the crux of our speciality, sure we have a breadth of knowledge and procedural skills that rivals any single speciality but what really makes us different is our ability to manage time and to prioritise. We are temporal specialists. The ability to manage time rivals communication in terms of hierarchy of skills needed in the management of the critically ill patient.
- Similar to the chef is the Army officer. Very direct, unambiguous, efficient. Certainly manages time well. But like the chef they instill fear and dangerously for the patient and somewhat differently to the chef will blindly follow an order. You could imagine Ramsay ordering one of his chef de parti’s to put ‘more fucking salt on the next white chocolate souffle you twat’ when what he really meant was please put more Creme anglais on the next white chocolate souffle and the chef de party will do the right thing, lest he risk a bollocking. The soldier however will follow the order to the letter. In the army officers defence they do face their troops and they do worry about the process and not just the finished product. The sense of urgency they give to a situation as well gets things done.
- You can imagine an army officer approach would be helpful in the situation where it is you with lay-people. The out of hospital arrest for example.
- Now we come to what may be as close as we get to the perfect model for a trauma team leader. The conductor of a symphony orchestra. Many independent groups performing complex tasks and allowed some innovation within the confines as to what the leader deems appropriate in an effort to achieve the same goal. They are literally all signing from the same hymn sheet. And the end result is beautiful. But therein lies the problem. They have sheet music/roles that they all perform admirably but if there is a massive deviation from what they thought was coming, they struggle. Also to perform at the level that they do requires practice, a lot of it and with the same people doing the same roles. We can attempt this but in reality it isn’t feasible.
- Great when you have a very experienced team. We experience this scenario frequently when it comes to teams and critically ill patients. Not as frequent now but ask some of the more established ED guys abut the early days of trauma. Run by Surgeons. People who spend most of the day doing very intricate and focused work - yes time critical but very different to managing a team.
- SJA are 7 minutes away - A car has been found on its roof with a single unconscious person inside. Looks to be about 50-60yo, can’t find wallet. GCS 6-8, Airway is patent but there looks to be some facial fractures, RR 30, sats 82 15LNRB, 60/40, HR 125. Teams A and B, 1A, 2A, Nurse A, 1B, 2B Nurse B I am the team leader Get the registrars up as the A team
- The patient is here Airway - I want you to evaluate the airway fro compromise and let me know if you think you’ll need to be able to intubate and what you’ll need to do so. Circulation - I need the biggest IV you can manage and send off for trauma bloods plus X match 4 units. Let me know when the drip is placed. Nurse - Set up the rapid infuser and let me know when it’s done. Airway Ax - when he hasn’t checked for facial mobility chew him out mercilessly, Where is the fucking IV! failed - get task focused on getting an IV. “Hang on i need to do this.”
- The Patient starts bleeding from drips and cuts, indicating traumatic coagulopathy. Now this is interesting - Traumatic coagulopathy is a very complex distinct entinty, it is not just a consequence of being cold and acidotic but we should correct both of those. Of note is that Fibrinogen is depleted the quickest of all constituents of the cutting cascade. However the current evidence we have from PROPPR study is the only hard evidence we ave at the moment. therefore lets continue with a 1:1:1 transfusion protocol but have cryoprecipitate ready once the ROTEM results are ready. I for one eagerly anticipate the outcome of CRYOSTAT - 2, a trial looking into the early use of cryoprecipitate in trauma. The patient starts obstructing their airway Now there are a number of schools of thought when it comes the obstructed airway in the setting of facial trauma…
- You on airway - give a jaw thrust and suction that airway, not like that, do it like you mean it. Nurse - Prepare for intubation. Size 8 and 7 ETTs at the ready. I want 200mg Propofol and 100mg of Rocuronium for my drugs. Double time, unlike you this patient cannot breathe and therefore speak through his Anus. Preoxygenate as best you can. Know give all the propofol and all the rocuronium, I want him good and asleep so we don’t get any spikes in his BP when you butcher his vocal cords.
- The Patient’s loses their BP and has a PEA arrest. Ask for the B team Say very little, Give summary “Arrest post too much induction agent in the setting of trauma”
- Leading a team in the management of a critically unwell person is a unique challenge. I think we can learn from different mindsets and approaches from different fields. I don’t think we can apply one set of rules or approaches to this leadership role but need to display many different facets, knowing these styles is only half the battle, knowing when to utilise which style is just as important.