ATEAMS
Advanced Team working in
Emergency and Acute Medical
Situations
Crew Resource Management
The Story of how to improve care
An average life of a doctor....
• Went to medical school
• Passed lots of exams
• Did lots of work on the wards/A&E with little
feedback
• Passed more exams based on can you remember
some facts that you could have ‘googled’ anyway
• I thought I knew everything.....
Then I became the man I hoped
I’d never become......
But then
• ...life changing event on ITU
• http://www.youtube.com/watch?v=JzlvgtPI
of4
Patient safety in medicine
• We are taught in medicine to be the all
powerful, all knowing consultant
• But actually that is not what we need
• We need to work in teams and to have
knowledge of Human Factors and
safety
The future of medical practise......
• Human Factors & CRM is starting to
come to the fore especially in theatres
• But what about in life threatening
situations in A&E, Acute Medicine and
ITU
– Harder to assess
– Just as important
Application of CRM techniques
in A&E/Acute Medicine?
• Just as vital, if not more vital than in
any other specialty
• Lack of sterile ‘cockpit’
• Reduced ‘Bandwidth’
Problems in A&E
• Proportionally more errors for A&E
patients than any others
• 18 errors for every 100 patients presenting
to hospital. 2% of these potentially life
threatening.
• Fordyce J, Blank FS, Pekow P, Smithline HA, Ritter G, Gehlbach S, et
al. Errors in a busy emergency department. Ann Emerg Med.
2003;42:324-33.
So how can we improve care…….
4 things to think about when
looking after a sick patient.......
• Recognise them as sick – NEWS and Lactate
• Get a Diagnosis (not always that important)
• Know how to treat them (get from
SOPS/google)
• Deliver the care
3 ways of better delivering our
care
1. Knowing how to use our knowledge
2. Working in a team
3. Learning from our mistakes
Using out Knowledge
• From a junior doctor, who was
debriefing after a patient died.”
• “ I knew what to do, I had spent months
learning it for my exams. But I didn't’t
notice basic things which when I look
back were so obvious. If only I spent
more time with my eyes and ears open
and less with my head in a textbook.”
Working as a team
“ When it come to patient care, an hour
in the pub with your colleagues is worth
100 hours in the library with your
journals”
Learning from our mistakes
• “A mistake is a tragedy. But if we don't
learn from it, it is a disaster”
Learning from our mistakes
– Look at cases where things went wrong
– Look at why it has happened
– Look at how it could have been prevented
– Learn some CRM techniques
Case 1
• Trauma call that I was leading
– Young man 24, fell off push bike
– GCS 7. Needing intubation and CT scan
– Left hospital with severe brain damage.
HOW MUCH WAS SUB-OPTIMAL CARE, HOW
MUCH WAS THE TRAUMA?
Case 2
•
•
•
•
•
•
•
Septic Patient
In A&E started sepsis 6
Persistent low BP
Central line inserted
Inotropes started
Improved on ITU day 1-3
Day 4 developed MRSA and died
• Did the central line really help?
Case 3
• Cardiac arrest
• ROSC following CPR
• Hb 6.0, 4 units X-match requested in
post arrest phase
• Where is the blood?
Case 4
• 2am, Septic patient
• High potassium on blood gas: not noticed
by team
• Untreated for 30mins
• Nothing bad happened......but could have
Case 5
• Number of patients in resuscitation
room
• Patient needed suctioning – no suction
unit
• Patient aspirated and went to ITU
Case 6
• Patient unwell and needed fluids, CXR,
bloods and antibiotics. A&E card not
printed out yet
• Gave a number of instructions
• No antibiotics given for 45 minutes
• Was outcome affected?
So who suffered?
• The Patient ‘primary’ victim
• The ‘secondary’ victim
• Future patients – when we do not learn
from the available lessons
The Primary Victim – Kai Zaunter
The secondary Victim – Kimberly
Hiatt
So why was there these
problems....
• In none of the cases were there
incompetent doctors/nurses, nor were
people out to do harm
• ......but neither was it just bad luck or
one of those things
THE KEY REASON: LACK OF A
CULTURE OF SAFETY
So what can we do about these
simple errors
• Must look at how we can improve our ‘non
technical skills’ and organisational skills
• A&E/Acute Medicine have a lot to learn from
ITU/theatres.
• All of us have lots more to learn from High risk
industries
• Learn from our mistakes
How can safety be improved?
• Crisis resource management
• “Cognitive and teamwork skills that
facilitate the management of medical
events bearing a high risk to patients
well being”
CRM: Core Concepts
1. Maintain Situational
Awareness
2. Prevent fixation
errors
3. Working as a team
and
leadership/followersh
ip
4. Know your
environment and
team
5. Communicate
Effectively
6. Anticipate and Plan
7. Use cognitive aids Checklists
7. Call for help early
8 – Debrief and learn from
cases
1: Situational Awareness
Situational Awareness
• Ability to understand the content and
significance of important elements
within the environment.
• Improve your situational awareness by
working in a sterile cockpit type
environment
Poor situational awareness
• ....case 3- I was worried about the BP
didn’t hear the call out that blood
transfusion had rejected sample
• ......is it just me?
When we are stressed……..
1. We don’t notice things, which are
obvious
2. We make assumptions which are not true
3. We can be deceived
4. We think without really thinking & fail to
think outside of the box
1: Failure to notice
• https://www.youtube.com/watch?v=wg96R
SsrXk0
2: Making false assumptions
PARIS
IN THE
THE SPRING
We see what we expect to see
PARIS
IN THE
THE SPRING
More untrue assumptions
• http://www.youtube.com/watch?v=QdwD
OL34LIA&playnext=1&list=PLBFF0B6080D
A9E343
3. Easy to be deceived
• Don’t tell anyone what you are picking
• Think about the card. Concentrate hard on
this card
• Use positive messages to send me the card
• I will remove it from the pack
I have removed one card – did I
remove yours?
Did you miss the obvious?
Were you easily deceived?
4. Lose ability to think clearly &
think outside of the box
How good are you thinking
skills?
• Normally ?
• When stressed?
• As quick as you can answer the next
questions correctly……..??
Some questions?
• A bat and a ball cost £1.10p. The bat
cost £1 more than the ball. How much
did each one cost?
Answer
The ball cost 5p and bat £1.05p (Or did
you jump to the answer of 10p and
£1.10p)
Question
• A lily pad doubles in size every day. At 48
days it covered the whole pond. How many
days does it take to cover half the pond?
Answer
• Lily pad took 47 days to get to half its
size (or did you jump to 24 days?)
Question
• It takes five men five minutes to make
five widgest, how many minutes does it
take 10 men to make 10 widgets?
Answer
It took five minutes (or did you say it
took 10 minutes?)
60% of degree educated people get some
of these questions worng
(key stage 3 question)
The real answer…..
• The real answer is not to always trust
our intuitions and check what we are
doing
• You need a sterile cockpit to not make
mistakes……
Treat situational awareness by
Improving the ‘sterile cockpit’
Improved by ‘sterile cockpit’:
Systematic ways of checking
Good team working
Allowed to concentrate
Impaired by:
Task overloading
Fright / Distress
Lack of sleep
Preoccupation (fixation errors)
2: Preventing fixation errors
Types of fixation error
Three main types:
1. This and only this ...
2. Everything but this….
1. Everything is OK....
1.This and only this
• Persistent fixation on a single problem,
failing to revise a diagnosis or plan
despite contradictory evidence
• http://www.youtube.com/watch?v=MW
PQVdjtqHE
This and only this...
• Eg: hypoxia following intubation.
– Assuming it is bronchospasm and not a
blocked tube
• Counteract by not assuming first
assumptions are true – back to basics
A non clinical example....
#Susanalbumparty
2. Everything but this
• eg. Hypertensive patient under
anaesthesia/itu
– Assuming patient “too light” or in pain
rather than medication error
3. Everything is OK....
• Persistent belief that there is not a major
problem despite evidence to the contrary
• Reassuring signs are used to override
worrisome evidence
• Worrisome data written off as artefact
• Eg: Low sats reading = artefact/dodgy
signal
Preventing Fixation errors
• Be aware of possibility.
• Sterile cockpit attitude
• Continual checks and standing back
• Have a rapport with team so that others
can speak up
3: Teamwork - Leadership
and Followership
The problem
• Consistent teams produce high quality care
• But in the hospital. Are we consistent ?
• A trauma team: minimum of 7 members:
• Possible combinations
• = 18 x 8 x 12 x 11 x 34 x 13 x 9
• = > 75 million
So we need systems of leadership and followership….
Effective Leadership
•
•
•
•
•
•
•
Clear goal/vision and strategy
Promote clear and open communication
Identify and communicate priorities
Inspire confidence
Acknowledge limitations and ask for help
Understand personal limitations
Open to suggestions
Effective Leadership
• Leader should stand back if possible
– Leader’s engagement in hands-on task can
impair group function and task completion
Other aspects of good
leadership….
• Letting your team flourish
• Learning form educational studies –
positive re-enforcement
• Using teams knowledge – letting them
speak up about their ‘hunches’.
Example from fire-brigade.
Good Leadership – counteract
natural tendencies
• Bystander Effect
• Ringlemann Effect
• Abiline Paradox
Bystander Effect
• The murder of Kitty Genovesse
• Darly and Latane – 1968; the diffusion
of responsibility in emergency
situations
• Esmin Green, Kings County Hospital,
Brooklyn
RINGLEMANN EFFECT
• Rope pulling
experiments 1882
• Reduced
productivity with
increasing size of
team
• Coordination cost
• Can't see what the
individual does
Team
Cap %
2
93
3
85
8
49
ABILENE PARADOX
•
•
•
•
Edmondson 1996
Cohesive top down teams not always best
Psychological safety
Aids new skill pick up
Importance of being a good
follower…
• Good team member
• Prepared to speak out if necessary famous case of med student knew the
wrong kidney was being removed but
didn’t say anything
What happens when people just
do what they are told…..
So why don’t people speak out
• Why didn't the nurse (who didn’t tell
me and the reg about the potassium)
speak up – case 4?
• ....am I particularly scary or is it human
nature?
• http://www.youtube.com/watch?v=qAgbpt7Ts8
To prevent this......
• Briefing prior to calls
• Name checks prior to patient arriving
• Flat hierarchy
4: Know your environment
and team
Know your environment and
team
• Long term – an organised department
• Short term just prior to patient arriving
– Started using a pre trauma activation SOP
– Would have saved the problem with no
suction – case 6
• http://www.youtube.com/watch?v=qR6VO
rdzIa4&feature=relmfu
5. Communication skills
Between health care
professionals
Communication
• Closed loop:
• SBAR / SBAR
• Using standardised systems for raising
concerns e.g. PACE system
Probe
Alert
Challenge
Emergency
• Checking if people are ready to receive
information
Communication
• Eye contact
• Asking if the content is understood
• Avoid jargon
• Pairing requests with names
• Communication through the team leader
Closed loop communication
• If used it could have speeded up how
quickly the antibiotics were given (case
6)
• Now use it for all verbal orders
• Beware the problems of handover and
transfers
Handover
• A constant problem, with dangers
attached, if not done properly……
• http://vimeo.com/73094511
• Password brightonicu
6. Cognitive aids – check
lists and SOPS
Safe insertion of central lines
• We should all know how to insert a
central line
• But we often do it unsafely
• Not because we do it poorly – but
because we don’t follow checklists or
have simple grab boxes
Matching - Michigan
By not following a checklist we risk infection
to our patients – case 2
The story of matching Michigan…..
Safe Intubation
• Intubation is potentially one of the most
dangerous times of a patients life
• Do we do it safely in the ED/ITU/the
wards?
• How could we improve it ?
• Recommendations from NAP4
Recommendation
• “ A simple checklist based around
preparation of the patient,
equipment/drug, staff and potential
difficulty can identify potential
problems in a very short time and
improve patient safety”
• http://www.youtube.com/watch?v=15S12X
nhw5g
Using checklist
• Using them for CVP, intubation,
sedation
• Initial scepticism
• Starting to win the argument
For every free kick that maters, I
have practiced 1000.
Moving Beyond checklists for
procedures – using prompt cards
Prompt Cards/Checklists
• Had checklists for procedures
• Had ‘black book’ guide - not easy to
access on intranet
• No airline-type prompt cards
• I made a potentially serious error
• Needed to change the way I (and others)
worked
Clinical Example
Thrombolysis of PE
• 7.38am (after a very long tiring night)
• 73 year old man - ASHICE call probable AAA
• Pre-hospital Info on available on arrival
– Good quality of life
– Complained to wife of abdo to back pain.
– Recently discharged from hospital following
amputation
– By time Ambulance had arrived:
• un-recordable BP, Very slow weak pulse
• sats unobtainable,
• Unconsciousness
Clinical Example
On arrival
• Seen by A&E Consultant and Registrar
• Anesthetic team fast bleeped
– Abdomen soft. Fast scan – no free fluid – no enlarged
AAA.
• Quick look echo - poor contractility, no evidence
of tamponade
– Quick look chest US- no evidence of tension
pneumothorax
– Amputated leg, looked like a recent operation
Clinical Example
Initial Management
OPA, bag valve ventilation
Atropine
Fluids
ABG – pH = 7.03, pCO2 = 8.7, pO2 = 2.4,
BE = -13, lactate = 10. Hb- 12 ? Venous
but probably arterial
• Prepare to intubate
• After 2 minutes of being in resus - arrested
•
•
•
•
Clinical Example
Initial CPR management
• 2x cycle
• PEA throughout
• Weak Pulse back after two cycles
• Intubated (with checklist!) but quickly and with
adrenaline 100mcg pre intubation
• CO2 trace very poor (but consistent with being in
correct position)
• Repeat Blood gas pH<6.8, PO2 – 2
• ECG sinus tachycardia – T wave inversion in III
Clinical Example
Thought Processes
• Cause of Low BP
– From initial history ?AAA/ ? Thoracic dissection/ ?
Massive MI
– From assessment ? PE
• No time for CTPA as about to arrest again
• Decision for thrombolysis
Clinical Example
Thrombolysis Given
• Asked for thrombolysis drugs
• Tenectaplase found quickly
• No one sure of dose. Unable to locate
guidelines quickly on trust intranet) and no
time as about to arrest) –therefore given
full dose of 100mg iv stat
Clinical Example
Ongoing clinical events
• Rearrested 20 seconds after tenectaplase
given
• Eventually stabalised
• Went to ITU
• Discharged from hospital 7 days later with
normal quality of life
• Once stabalised went for CTPA/Echo which
confirmed a Massive PE
Clinical Example
Learning from Case
Correct Treatment
•
• But…….
–
–
–
–
Wrong Drug
Wrong Dose
I was lucky
If he had died - could I have justified not knowing or
being able to quickly find out correct dose?
Potentially, one of the solutions is prompt cards –
give space for the higher thinking to the clinician
whilst reduce errors
To w a r d s t h e S a f e r H o s p i t a l
The Range of Prompt Cards
The Range of Prompt Cards
RESUS PROMPTS
LOGO WILL GO
HERE
IF YOU SUSPECT MASSIVE PE & PATINET IS PERIARREST
1) Is it safe to go for CTPA? OR Should you just treat? SEE ‘CT TRANSFER’ PROMPT
2) COULD THIS BE – ?Tension Pneumothorax or ?Cardiac Tamponade
3) THROMBOLYSE.
 ARREST/PERI-ARREST: GIVE 50 mg IV BOLUS ALTEPLASE (arrest or periarrest), repeat after 15 minutes if no ROSC. (Max 100mg)
 STABLE: Alteplase (rTPA) 10mg IV over 1-2 mins, then 90 mg infusion over 2
hrs (max??? dose 1.5mg/kg in patients < 65 kg)
4) HEPARIN –After 3 hours if APTT ratio <2.0, start IV Heparin infusion - as per Standard
IV heparin protocol (5000 Unit bolus IV over 5 minutes, then 16 units/kg/hr & 6 hour
APTT Check.
5) Get LUCAS from Cardiothoracic Unit . If you thrombolyse in arrest, or they
subsequently arrest CPR should be continued for 60 minutes.
Plan for 2014 / 2015
But we need to change the
culture…..
Changing the Culture
I do not want Prompt Cards. Are you really getting on this
bullshit checklist bandwagon? – Anaesthetic SpR
I don’t use the sedation Prompt Card because I don’t need it. We
are experienced and can cover everything on the card. – ED Consultant
I’ve never seen any bad practice so why do we need these cards
– Anaesthetic SHO
The RSI checks aren’t needed – ITU Consultant
I’ve never had a problem yet so I don’t see why I need to use the
RSI prompts - Anaesthetic Consultant
Prompt Cards in Action
• “I used the prompt card challenge a doctor to stop the incorrect
rate and dosage of a naloxone infusion”
ED Sister/Charge Nurse
• “The intubation Prompt Card creates a minute to communicate
with the team and check everyone is clear on the plan. It helps
me signify we about to begin and I find that helpful.”
Anaesthetic SHO
• “I was able to rapidly look up the procedure for a drug infusion
that is not often used.”
ED Sister/Charge Nurse
• By me showing the prompt card the doctor went through the
sedation checks and we identified equipment was missing before
we started.
ED Staff Nurse
So……..
• But despite there being evidence for the use they
are not even policy in over 50% of hospitals
• Even when they are policy - not always used
• That is over two years since the recommendations
made
• Translational gap between evidence and practice
on the shop floor
Patients are dying because of a
lack of simple checks
Changing the culture?
• Not an easy thing to do
• But we are getting there
Individual
characteristics
Patient
characteristics
Practice
characteristics
Environmental
features
7: Calling for help
The single biggest mistake will all make
is not knowing what we don’t know and
thinking we are better than we are.
8: Learning from our
mistakes
How can we improve if we don’t know what
we are doing wrong in the first place?
The importance of clinical governance
Putting it all together
How to do things safer………
• Brief before patient arrive
• Use standardised communication tools
• Use check-lists
• Realise we are fallible and have a ‘sterile
cockpit’ environment during stressful times
• Know your environment and where equipment
is
• Plan for problems, don’t just react to them
• Debrief on all major events to learn from them
ANY QUESTIONS?
?
“The very first step
towards success in any
occupation is to become
interested in it.”
• Sir William Osler 18491919
Conclusions
• Different way of thinking
• You are the future
• http://www.youtube.com/watch?v=GA8z7
f7a2Pk
• drrobgalloway@gmail.com
• Free safety conference at University of
Sussex Monday 5th jan