Joe ( after calling cardiac cath lab ): I called the cardiac cath lab and they stated they want us to call back when patient is stable to travel. Leader ( acknowledging receipt of message ): Thank you, Joe. Another form of communication used in CRM is known as “state of the response.” The state of the response involves the relay of information between the leader and team members on the activities and status of the response. These communications occur at frequent intervals and provide the team with the specifics on what has occurred, allowing the team members who arrive at different times to be updated on what has happened and the current status. The state of the response communication can also be used to solicit input from any team member on tasks completed or ideas on future interventions. The following is an example of this state of the response, or state of the union, communication by the leader during a cardiac arrest: MD Leader : “We are at 4 minutes. Patient Doe was found unresponsive and pulseless. CPR was initiated at that time; initial rhythm was identified as PEA (pulseless electrical activity). One dose of epinephrine administered at 2 minutes. We are now going to reassess the cardiac rhythm and pulse; CPR will continue if rhythm unchanged. We will explore the H’s & T’s to identify the cause of the PEA. Does anyone have anything to add?” RN : I sent the morning chemistry and the lab just called. The potassium is critically low at 2.2. MD Leader : Thank you, let’s consider hypokalemia as part of the issue and initiate some treatment. Pharmacist, can you prepare for an infusion of potassium? Also, we need to check magnesium level and should anticipate replenishing that as well.” During a cardiac arrest caused by PEA, the best way to treat the PEA is to identify the cause. The causes of PEA arrest are often referred to as the H’s & T’s. H’s T’s • Hypovolemia. • Hypoxia. • Hydrogen ion (acidosis). • Hypoglycemia. • Hypo/Hyperkalemia. • Hypothermia. • Tension pneumothorax. • Tamponade, cardiac. • Toxins. • Thrombosis-pulmonary. • Thrombosis-coronary. • Trauma. In this case, the nurse added that lab abnormalities potentially caused the situation. This technique allows for controlled conversations to occur among the team in a succinct way so that important information is not lost in the chaos of an emergent situation. Also, the summarization of events, and the naming of the situations like PEA for a rhythm or active shooter for an environmental response, gives all responders a shared mental model of the situation. All cardiac arrest team members usually have ACLS knowledge and know that the PEA algorithm is different from the ventricular fibrillation algorithm. Those in an environmental response know that an active shooter response differs from a fire response. In each situation, the leader may eventually become a person from outside the institution, such as the fire chief or the police responders. Attention to their instructions can be lifesaving. Experienced leaders may state something such as, “I am going to summarize the events so far; please keep performing your assigned tasks while I speak.” This prevents the disruption of crucial tasks but gains all members’ attention. This open sharing of information allows all members to actively be involved despite any preconceived hierarchy. Some institutions have a process called “stop the line” or CUS (concerned, uncomfortable, safety issue) in their emergent response procedures to give all members of the team a chance to pause actions if they feel something unsafe may be occurring (Cammarano et al., 2016; Hunt, et al., 2007). An example of
this may be ordering a medication for a situation that is not appropriate (an allergy, incorrect dose, or misidentification of the cardiac rhythm) to prevent an adverse outcome. “Stop the line”/ CUS should trigger a conversation where the leader explains the rationale for a specific action or clarifies the action. Stopping the line is a critical method of communication for nurses, who often have knowledge and experience in emergent situations, but may feel restricted in speaking out in a hierarchical team setting with those they perceive to have higher authority. An example may be in a teaching institution where the relatively inexperienced MD leader orders a dose of medication that is incorrect, and the experienced pharmacist responding to the situation states that the correct dose of that medication in this situation is different. Universal time-outs in the operating room and procedural settings were developed to equalize all team members around patient safety (Van et al., 2017). By stopping to check for the accuracy of the surgical site, correct procedure, and patient identification, serious errors may be prevented. Universal time- out procedures are an important safety process that allows for conversations that impact patient safety during critical situations when a patient may not be able to speak for themselves. This process allows all involved to speak up and raise concerns and is supported by the Joint Commission in the National Patient Safety Goals as a safety component helpful in reducing wrong patient and wrong side procedures (Gonzalez et al., 2018). Self-Assessment Quiz Question #5 What form of communication allows any responder to an emergent situation to pause action for clarification? a. Shared mental model. b. Equal hierarchy. c. Stop the line. d. Closed-loop communication. During a time of chaos, as in emergency responses, all responders must be aware of what they are communicating. During emergencies, a type of common communication that can occur is termed “collateral communication.” Collateral communication occurs when important conversations happen among multiple team members and may or may not be necessary for the situation’s outcome. An example of an important conversation may be one between the RT and anesthesiologist on the difficulty of placing the endotracheal tube. Anesthesiologist : I have the tube in place, but I did not have clear visualization of the vocal cords, are you meeting resistance in bagging? RT : I am meeting some resistance. I am going to check breath sounds. (RT listens to the chest and abdomen). Anesthesiologist : Are they equal? RT : There are diminished sounds on the left. You may be in the main stem. Anesthesiologist : I am going to pull this ET out and retry. Prepare AMBU ventilate. This conversation may impact the situation and should be shared with the leader: Anesthesiologist : We had difficulty with the first attempt at intubation. We are going to try again after re-oxygenation. Leader : Thank you for the update. Can you maintain the airway? Anesthesiologist : Yes, bag mask ventilation is effective. Leader : Let me know when you secure the airway. Another example is the conversation between the nurse and the pharmacist about the calculations for a drug dosage. RN : The leader wants us to prepare a dopamine infusion at 5mcg/kg/min. Pharmacist : The standard concentration of this infusion is in the code cart and is 400mg in 250 mL. Will you be administering via the infusion pump? RN : Yes, I will be using the smart infusion pump medication programming.
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Book Code: ANCCUS2423
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