Analysis of Team Approach to Resuscitation: An Effective Team Leader in Cardiopulmonary Resuscitation (CPR)

Introduction

This assignment will describe the “Whole team approach” to resuscitation with a well-organised multi-disciplined team, taking in to account human factors, Crew resource management (CRM) and non-technical skills. The Resuscitation Council (UK) Guidelines 2015 outline advanced life support (ALS) algorithm which should be followed step by step for in hospital and out of hospital cardiac arrests, this providing the staff can perform and are trained in ALS (Resuscitation Council UK, 2015).

Influencing performance as an effective team leader in cardiopulmonary resuscitation (CPR) is a well-recognized and crucial factor, focusing on the task requirements for leadership training for leading and non-leading team members on crisis resource management (CRM). CRM is designed for team leaders of advanced life support that in turn supports the whole team in the resuscitation setting (Fernandez Castelao, et al., 2015).

In a case in 2005, a patient died as a consequence to failings within the National Health Service (NHS) and sparked an inquiry into her death. This showed that mistakes were made on this day but come down to the system failing due to training and communication within this team of clinicians. Sir Robert Francis who was the investigation officer into the failings in the Mid Staffordshire NHS Foundation trust has described ‘action plans’ of the national health service ‘as the worst disease of the English National Health Service (Bromiley, 2015).

The team approach to resuscitation

A well-coordinated team approach with defined roles is important as is high-quality skills for high-performance cardiopulmonary resuscitation (CPR). What goes into making a successful emergency team for an improved response to cardiac arrest resuscitation, is a multi-disciplined team with an effective team leader to improve the outcome for patients (Fernandez Castelao, et al., 2015). Early interventions for CPR and defibrillation are crucial to reducing mortality and morbidity in patients after cardiac arrest, every minute that CPR is delayed, the survival rate drops between seven and ten percent (Ibrahim, 2007). When someone has an out-of-hospital cardiac arrest (OHCA), there is a chain of events that can increase their chance of survival (Cardiac Science, 2019). This is known as the chain of survival, a term first coined by the American Heart Association in 1991, their paper ‘Improving Survival from Sudden Cardiac Arrest, which follows The Chain of Survival Concept’ highlights that all communities should recognise and accept the principle of early CPR and defibrillation (Cummins, et al., 1991). It is made up of four links; members of the public or community first responders who are trained in basic lifesaving and defibrillation skills can perform the first three links in the chain. This is known as basic life support (BLS) (Cardiac Science, 2019). Advanced life support (ALS) is the final link, which should to be carried out by paramedics with a disciplined team approach, ideally comprising of four individuals. They should between them preform roles such as team leader, management of the airway, deliver high quality chest compressions with minimal interruptions, gain vascular access and deliver advanced life support drugs (Resuscitation council UK, 2015). If good quality BLS and ALS are carried out in quick succession, a person’s likelihood of survival from a cardiac arrest is increased. The first link in the chain is early recognition of cardiac arrest and to call 999 for help. The second link in the Chain of Survival is early CPR; this involves performing chest compressions in order to maintain an element of tissue perfusion until a defibrillator arrives. Thirdly, early defibrillation to restore a patient’s heart to a normal rhythm, this could be a member of the public using a public access defibrillator (PAD) or a first responder trained in defibrillation. The fourth link in the chain is early advanced care (Zoll, 2019). This relates to having a fast response from paramedics who can perform more advanced lifesaving procedures, advanced life support and should arrive within eight minutes form the call for the best chances of survival (NHS England, 2017). The philosophy of basic and advanced life support are very similar for the out of hospital setting but can be influenced by a combination of factors, this including lack of trained staff, equipment, drugs, weather and access to the patient. Other considerations are the area in which the patient has collapsed and or found (Chen, et al., 2015). Treatment should be started promptly to identify and treat any immediate life-threatening problems known as the 4 H’s and 4 T’s, these are all reversible causes of cardiac arrest, these should be reversed to achieve return of spontaneous circulation (ROSC) (Save a Life, 2018). As soon as paramedics arrive, a team leader needs to be appointed, who has been trained in ALS resuscitation, has good communication skills, the ability to distribute tasks, gather information and maintain an overview of the tasks. The team leader should assign tasks to each clinician dependent on skill level and training (Fernandez Castelao, et al., 2013). Known as the ‘pit crew approach’ to resuscitation, 360-degree access should, if possible be achieved around the patient and each member of the team will be given a position from one to four (Hopkins, et al., 2016). Position 1 should be at the head end of the patient to manage the airway and have a full range of airway management skills to include; basic airway manoeuvres to intubation including emergency cricothyrotomy. Position 2 should ideally be on the left side of the patient and deliver high quality chest compressions and defibrillation, this position should be alternated every 2 minutes to overcome fatigue, but if available, a mechanical chest compressor known as a Lucas can be used. This device can perform chest compressions when moving the patient and provide continuous compressions when needed. Position 3 should be on the right side of the patient who can alternate with chest compressions, gain vascular or interosseous access; this team member will also deliver the ALS drugs to the patient if indicated. The fourth member of the team is the team leader, who can stand back and manage the resuscitation attempt and will only become involved if needed. The team leader oversees the whole picture and ensures the team are preforming high quality resuscitation in all areas (Resuscitation Council UK, 2015). Paramedics can remain on scene to achieve ROSC, though if any reversible causes that cannot be dealt with on scene and skills and interventions are not available, the patient should be transported to hospital immediately (Goodwin, et al., 2018). Clinical staff must ensure they are competent and up to date with current guidelines and algorithms in the skills they use to give the best possible care to their patients, this being achieved through training and clinical experiences (Rasmussen, et al., 2014).

Cardiac arrest statistics in England

Reducing premature death is a priority for the NHS. Each year in the UK, approximately 60,000 people sustain an out-of-hospital cardiac arrest (OHCA). In England in 2013, there were approximately 28,000 cases of OHCA resuscitations attempted by the Emergency Medical Services (EMS) (Hawkes, 2017). This equates to less than 50% of workable cardiac arrests. Resuscitation is not attempted for reasons such as advanced directives declining cardiopulmonary resuscitation, (do not attempt resuscitation (DNACPR)), or conditions unequivocally associated with death, as stated in the JRCALC, (2019). Approximately 80% of cardiac arrests happen in the home and 20% in public places, with only 20% being in a ‘shockable rhythm’. Ventricular fibrillation and pulseless VT are shockable rhythms, which can be treated with an automated external defibrillator (AED). The AED delivers a controlled shock to the patient’s heart; this presentation of a shockable rhythm has a much high success rate compared to a non-shockable rhythm (BHF, 2015). This could be even higher if a patient in cardiac arrest receives immediate and effective CPR from relatives or bystanders giving the patient the best chance of survival (American Heart Association, 2019). Out of the 28,000 who were treated for OHCA to hospital discharge in England is 8.6%. In contrast this is considerably lower compared to other developing countries for example; North Holland 21%, Seattle 20% and Norway 25%. This shows that England can make some changes to increase survive rates (BHF, 2015). In 2013 it was identified by the Department of Health in the Cardiovascular Disease Outcomes Strategy, it was a priority for the Resuscitation Council (UK), the British heart foundation (BHF) and NHS England to improve survival rates for OHCA across the United Kingdom (UK) (Gov.uk, 2013). The BHF is determined to tackle this, by creating a Nation of Lifesavers and improving survival numbers for OHCA. Ensuring that all students are educated in CPR and public access defibrillator awareness at secondary schools will be vital to achieving this goal (BHF, 2014).

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In England, if survival rates were increased from the overall average, which equates to approximately 8% to the national average of around 12%, it is estimated that an additional 1250 people could be saved from cardiac arrest annually (BHF, 2014). This compared to the best performing health system at 25%, saving an additional 4500 lives each year (Perkins, et al., 2015).

The team approach

The importance of education and training in the resuscitation setting is key to improving patient mortality (Sutton, et al., 2012). Medical errors and adverse events are alarmingly high in hospitals, and has been reported that one in eleven patients suffer from a medical procedure during their hospital stay (Edwards and Siassakos, 2012). Edwards and Siassakos, (2012) states many of the procedures have minor consequences but one in fourteen are fatal as in the Elaine Bromiley case, this healthy mother of two was admitted for an elective surgical procedure which did not take place as her airway suddenly become compromised when she was anaesthetised. This patent could not be intubated and could not be ventilated, a well-known emergency in anaesthesia, this is rare but a recognised complication (McClelland and Smith, 2016). Despite nursing staff setting up for an emergency airway procedure the team of surgical and anaesthetic doctors, managing this patient did not execute this option. Mrs Bromiley passed away some days later due to severe hypoxic brain injury (Bromiley, 2015). In this case, the team failed not because they were bad at their job, but because they had never been exposed to such an emergency before. In this vital lesson, the team delivered everything predictable but failed to deliver emergency contingency planes for emergency airway followed by admission to the intensive care unit. Bromiley, (2015) the husband of Elaine Bromily, formed the Clinical Human Factors Group (CHFG) in 2007 aiming to promote an understanding of human factors within healthcare. This brought a better understanding to clinicians who recognised the fundamental benefits of human factors, promoting safer outcome for patients in day-to-day practice.

Non-technical skills (NTS) are important to support teamwork on human behaviour and conduct. The core principles included in resuscitation are decision-making, leadership, task management, situational awareness and communication (Krage, et al., 2017). Poor NTS can potentially lead to poor patient outcome within the resuscitation team, resulting in significantly longer time off the chest and intervals between defibrillation (Andersen, et al., 2010). On the other hand, linking high quality effective education, local implementation and science can ensure clinicians are delivering high quality CPR to all patients. It is a well-known fact that high quality CPR relies not only on an individual clinical expert who can deliver high quality chest compressions, ventilations and deliver defibrillation shocks competently, but also interact with an expert team that can work closely together and respond to the complex and challenging conditions of a patient in cardiac arrest (Yeung, 2016). Previously teamwork had little value in resuscitation training; however, in the latest American and European resuscitation Guidelines, it states that teamwork and non-technical skills should be incorporated into the training to improve resuscitation and outcome. Crew resource management (CRM) training that was first introduced into the aviation industry has now been translated into the medical setting. This has seen a reduction in medical errors in the Emergency Departments (ED) with the introduction of CRM style training (Edwards and Siassakos, 2012). Andersen, et al. (2010) believes that NTS should be linked to the cardiac arrest algorithm to support teams of clinicians training in resuscitation. Positive results have shown that NTS has improved performance in multi-professional cardiac arrest teams; clearer leadership is linked with more efficient cooperation in the team, thus increasing task performance (Hunziker, et al., 2011).

Conclusion

This paper has described the whole team approach to resuscitation, taking into account human factors, crew resource management (CRM) and non-technical skills. It has shown that putting a good team of clinicians together with technical and non-technical skills, the patient in cardiac arrest can have a better out come by reducing mortality and morbidity. By combining high quality CPR and advanced life support with the ‘chain of survival’ and ‘the pit stop approach’ and having 360 degree access to the patient, more people are surviving out of hospital cardiac arrests.

With education and training for the likes of members of the public and community first responders who are quite often the first person on scene, can start the chain of survival by calling for help, stating CPR and early defibrillation if available. On the contrary, paramedics must arrive in a timely fashion to deliver high quality ALS and ideally comprise of four clinicians. Between them, they can undertake roles as team leader, airway management, deliver CPR and gain intravenous or interosseous access for ALS drugs. If ROSC cannot be achieved on scene, patients need a rapid transfer to the Emergency Department (ED).

Having a member of the team who has been trained in ALS and crew resource management as a team leader has seen an improvement in resuscitation, reducing the number of errors that frequently happen within healthcare as in the case of Elaine Bromiley. Communication and failings within the system were to blame, staff had not had sufficient training in the event of cannot intubate cannot ventilate scenario, leading to this patients death.