together to resolve the issue (cardiac or respiratory arrest; city wide disaster responses). These temporary teams often cannot train together. An element of both categories of teams is that all the necessary skills be present to achieve a positive outcome. Leadership refers to the need for one distinct leader for the emergency response team. The leader directs the team throughout the emergent event toward the common goal. For cardiac arrest teams, the goal is successful resuscitation; in disaster management, it is the safe evacuation of all in the disaster’s path; in a fire, it may be the safe removal of patients and extinguishing the fire. The goal will vary depending on the exact situation. In CRM, the leader is considered an oversight role, not an active participant; the leader decides, prioritizes, and delegates to the team members the tasks to be completed to achieve the desired outcome (Fanning et al., 2013). The leader coordinates team members’ activities by ensuring that the team has the resources needed, communicates clearly, and acknowledges that directions are understood and changes in goal attainment are shared in real-time (Gangaram et al., 2017). Leaders are encouraged to also empower all team members to speak up with any pertinent information they have that can assist in patient care and decision making. The leader can be determined by skill set or institutional hierarchy. In medical situations such as a cardiac arrest, the leader is usually a physician or licensed independent provider (LIP), such as a nurse practitioner authorized to implement ACLS care. In some institutions, the leader may be the most experienced provider present but could also be a provider-in- training with an experienced provider or supervisor providing close supervision and support. The most critical point of leadership is that there must be one clearly identified person in charge. The leader needs to state this when assuming the role so all those responding are aware. Team training courses teach leadership skills emphasizing how to clearly articulate that they are filling the leadership role. For example, the leader declares in a loud voice, “I am Dr. Jones, and I will be leading this code blue.” This statement clarifies for all involved who is in charge. For any team with a leader, there must be followers. What defines the role of followers in an emergency? Followers also have distinct responsibilities based on their roles. The leader will direct all team responders in the follower role, and the roles will vary depending on the type of response. In a cardiac arrest, responders perform different standardized roles to administer ACLS protocols: performing cardiopulmonary resuscitation (CPR); assessment of pulses; timing of tasks; medication administration; performing medical procedures; and documentation/scribing of the event. For a fire, the roles may include extinguishing the fire, removing patients, activating the emergency response (911, code red, etc.), or shutting off the main oxygen. During a weather emergency, the responsibilities include ensuring adequate staffing, securing replacement staff, utility, and facility management, and troubleshooting issues that may arise. All followers should be adequately trained and competent to fulfill their roles; for example, skilled in using a fire extinguisher or appropriately licensed and knowledgeable for the role. For example, pharmacists are the knowledge experts on medications; from administration to ensuring that the medications are used appropriately during a cardiac arrest. Role clarity, which is when responders are aware of their responsibilities during the emergent situation, is necessary to organize the team and minimize chaos. Roles may be assigned by a leader, self-assigned by the team member, or designated by a specific skill set. The leader must know that all essential roles are filled by a competent team member. These roles are dynamic depending on the emergent situation and the responding staff. The leader must clearly identify who specifically should be performing a role/task. When a leader states, “can someone please monitor the patient’s pulse” there can be confusion on who should be completing the task, leading either one person, four people, or no one (if everyone assumes that someone else filled the role) to monitor the pulse. The leader must specifically identify someone by name or by some descriptor. It is common that temporary formed responding teams may not know each other by name, especially in rarer emergencies such as disasters.
For example, if you state, “Can you in the red sweater please write down all the patients that we send to the evacuation unit?” The person in the red sweater must then close the communication loop by acknowledging that they received the message. These small steps will help reduce confusion in chaotic situations and prevent delays in achieving the common goal. Occasionally the roles are defined by the task being performed. Most cardiac arrest teams include a respiratory therapist and an anesthesiologist, who position themselves at the patient’s head during the response. For example, some hospitals have standardized locations for where each responder should stand during a cardiac arrest in relation to the patient. When a standard role map is used in an institution, the leader can assess visually when a role is not filled and reassign someone to that task. Workload distribution addresses the performance of multiple critical tasks that must be completed simultaneously. The leader is responsible for ensuring that all delegated tasks occur effectively by those most competent for the role. Workload distribution includes appropriate role delegation in an ever- changing emergent situation. Role delegation is not intuitive for many healthcare providers and is one reason why CRM behaviors are taught and practiced (Fanning et al., 2013). Leaders must continuously reassess the situation and confirm that the tasks are performed by the most competent person present at the time. Leaders also must consider the need to adjust roles within the emergency. Reassigning staff when a person’s skill set may be better utilized in a different role falls to the leader. If a nurse is needed during a cardiac arrest to administer medications, the leader may ask the medical student who is BLS-certified to perform cardiac compressions and move the nurse to the nursing specific role. If the leader is the only provider competent in a specific task, then the role of the leader must be filled by another competent provider during the time the leader is otherwise occupied. This may occur when the leader is the only one present to perform a procedure such as a needle decompensation of a pneumothorax. The leader should ask another physician to assume the role of leader. For example, “Dr. Jones, can you assume the role of leader, while I perform this procedure.” By stating this out loud, the entire team is aware that the leadership of the situation has changed. The leader understands that the concentration needed to perform the procedure precludes him from monitoring the entire team response. The final concept under teamwork is requesting help in a timely manner. The hesitation in calling for help has been shown to increase adverse outcomes (Leonard et al., 2004; Ozekcin et al., 2015). Barriers to calling for help include personal (I may come across as not being smart), interpersonal (the person needed may have yelled at the leader in the past), cultural (I am in charge, and it is my job; SWAPNet, 2018). Calling for help early allows for the arrival of others who can offer second opinions, extra hands to complete all the tasks, and skilled team members to fill specialty roles. One example of improved patient outcomes is the initiation of rapid response teams (RRT) to respond to situations immediately once a clinician suspects a subtle or noticeable decline in patient status. Hospitals that utilize RRT responses demonstrate improved patient outcomes by intervening before the patients experience cardiac or respiratory arrests (Jackson, 2017). An important skill is knowing when to call for help and which level of response is needed. Many institutions have an internal disaster and emergency response plan. In today’s changing world, there is a need for emergency responses of healthcare teams, for situations such as natural disasters (earthquakes, hurricanes, tornadoes), mass casualty events (train derailments, plane crashes, mass shootings, terrorist attacks) and infectious disease epidemics (COVID, Ebola). Internal disasters include events such as a power outage, infant abduction, or a combative patient. The Joint Commission requires hospitals receiving Medicare and Medicaid reimbursements to have established disaster planning and health system readiness, for disaster management (Al Harthi et al., 2020; Lagan et al., 2017). Plans can be developed
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Book Code: ANCCUS2423
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