Leader : Thank you, please continue CPR. We have given 2 rounds of Epi. Prepare for the third dose, and given the potassium, let’s prepare to administer some potassium, Pharmacy do you have some suggestions? The leader in this example gathered information, summarized, and dynamically decided an action based on the information shared. This leader also demonstrated the use of expert knowledge in formulating the plan. Self-Assessment Quiz Question #8 The implementation of available resources, situational awareness, and use of cognitive aids are concepts utilized in what process? a. Stop the line. b. Dynamic decision-making. c. State of the union. d. Collateral communication. Situational awareness in healthcare is enhanced when team members notice the subtle cues presented and reassess these cues to prioritize actions specific to the situation (Fanning et al., 2013). An example is when a team is responding to a medical emergency of a person found unresponsive in a lobby located in the building where the diabetic and nutrition clinic is located, and the team leader uses data to evaluate the situation. This dialogue represents the clinical team’s use of situational awareness: Security guard : I did not see anyone nearby when I walked into the lobby and called the alert. It does not appear that this man was assaulted. RN : When I arrived, I found this person on the ground, unresponsive to touch and voice, low respirations and heart rate of 50. There is no one who knows this person. MD : Do we know if this person is wearing any medical condition alerts? Perhaps they are a diabetic since we are in the same building as the clinic. Nurse can you support respirations and security can you call for transport to ED? RN : No alert bracelet is on the patient. Security : There is a prescription bottle in this pocket for oxycodone. MD : Okay, let’s reconsider what may be happening. Nurse, can you get a blood sugar, monitor respirations, and consider the possibility of an overdose of narcotics? Let’s get him to the ED so we can give Narcan. The MD leader needed to adapt to new information presented and adjust actions to the situation. In this example, the lack of a medical alert bracelet and discovering a prescription bottle steers the physician from further assessment for critical alterations in blood sugar levels to potential opioid overdose. Medical dynamic decision-making uses patient observations of patient presentation and status and incorporating new data into making the appropriate decisions. Continued adaptation is necessary as priorities and interventions will constantly change throughout the situation. Members of the Royal College of Physicians and Surgeons in Canada (2017) have produced a comprehensive document on CRM in which they have divided the concept of situation awareness into three levels, including their corresponding definitions and potential risks (see Table 1). Level One is attention to diagnostic cues and prioritizing those cues most relevant to the situation. A practiced clinician will successfully hone in on essential cues based on experience and retain the relevant ones while disregarding less important or irrelevant ones. In this process, one must avoid fixation and overlooking other relevant cues that will aid in decision-making and potential alternative diagnoses. Level Two is synthesizing all cues, critically thinking about, and integrating, all presenting information to understand the situation completely. Novice clinicians will be
less capable of pulling cues and information together to gain a comprehensive picture of the patient situation. These skills emerge and evolve with experience. Level Three of situational awareness, which builds upon the previous two, is a prediction of outcomes. This process entails pulling together relevant cues, patient history, and clinician experience to predict what happens next. Again, more experienced clinicians will draw on their prior experiences and knowledge to minimize errors in prognosis and continue to react to new information and cues as they arise. Table 1. The Three Levels of Situation Awareness Level Pros Cons One: Recognition of Cues • Attention is focused • Attentional
blindness or fixation errors can cause premature cognitive closure because of reliance on assumptions and/or prior knowledge. • Tendency to favor common and easily retrievable patterns
more quickly on important cues. • Irrelevant cues are discarded to facilitate more efficient decision- making. • Prior experience and knowledge is used to more quickly and efficiently synthesize information. • Future events can be anticipated and planned for (i.e., being proactive rather than reactive).
Two: Synthesis of Cues
may result in misdiagnosis.
• Errors in predication can result in under- or over-cautious responses.
Three: Prediction
• Additional
resources can be prepared earlier in the treatment sequence.
Note . Adapted from Brindley, P.G., & Cardinal, P. (2017). Optimizing crisis resource management to improve patient safety and team per- formance: A handbook for all acute care health professionals . Royal College of Physicians and Surgeons of Canada. Resources Responders to a crisis must rely on multiple facets of information, including memory, past experiences, and established standards of care, to provide the necessary interventions during the emergency. Each team member needs to be able to obtain and process the information to prioritize care. Information sources used in an emergency include medical records (hard copies and electronic for past medical history, laboratory data, current hospitalization data) and internal and external internet resources (policies and procedures, protocols, medication guidelines, and standards of care). The leader may assign a responder to research data from these resources; a skilled leader may often ask a less technically skilled staff member to perform this task. Medical students at a code may be asked to review the patient’s record for lab results or pertinent history. The leader should know the non-technically skilled person’s knowledge level and ensure that the person assigned this task understands the context. When assigning the task of looking for pertinent lab values, the leader may need to provide guidance- “please look for all abnormal electrolyte values and report back”. Leaders of other members may need to provide more direction to the less experienced staff. The leader in the example above stipulated that they wanted a review of recent electrolytes for the potential diagnosis of cardiac arrhythmia.
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Book Code: ANCCUS2423
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