ATEAMS

E A dvanced T eam working in mergency and A cute S ituations M edical

Crew Resource Management

The Story of how to improve care

An average life of a doctor....

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Went to medical school

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Passed lots of exams

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Did lots of work on the wards/A&E with little feedback

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Passed more exams based on can you remember some facts that you could have ‘googled’ anyway

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I thought I knew everything.....

Then I became the man I hoped I’d never become......

But then

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...life changing event on ITU

• http://www.youtube.com/watch?v=JzlvgtPI of4

Patient safety in medicine

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We are taught in medicine to be the all powerful, all knowing consultant

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But actually that is not what we need

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We need to work in teams and to have knowledge of Human Factors and safety

The future of medical practise......

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Human Factors & CRM is starting to come to the fore especially in theatres

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But what about in life threatening situations in A&E, Acute Medicine and ITU

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Harder to assess

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Just as important

Application of CRM techniques in A&E/Acute Medicine?

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Just as vital, if not more vital than in any other specialty

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Lack of sterile ‘cockpit’

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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.......

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Recognise them as sick – NEWS and Lactate

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Get a Diagnosis (not always that important)

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Know how to treat them (get from SOPS/google)

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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

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From a junior doctor, who was debriefing after a patient died.”

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“ 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

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“A mistake is a tragedy. But if we don't learn from it, it is a disaster”

Learning from our mistakes

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Look at cases where things went wrong

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Look at why it has happened

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Look at how it could have been prevented

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Learn some CRM techniques

Case 1

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Trauma call that I was leading

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Young man 24, fell off push bike

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GCS 7. Needing intubation and CT scan

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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

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Did the central line really help?

Case 3

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Cardiac arrest

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ROSC following CPR

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Hb 6.0, 4 units X-match requested in post arrest phase

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Where is the blood?

Case 4

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2am, Septic patient

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High potassium on blood gas: not noticed by team

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Untreated for 30mins

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Nothing bad happened......but could have

Case 5

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Number of patients in resuscitation room

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Patient needed suctioning – no suction unit

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Patient aspirated and went to ITU

Case 6

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Patient unwell and needed fluids, CXR, bloods and antibiotics. A&E card not printed out yet

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Gave a number of instructions

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No antibiotics given for 45 minutes

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Was outcome affected?

So who suffered?

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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....

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In none of the cases were there incompetent doctors/nurses, nor were people out to do harm

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......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

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Must look at how we can improve our ‘non technical skills’ and organisational skills

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A&E/Acute Medicine have a lot to learn from ITU/theatres.

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All of us have lots more to learn from High risk industries

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Learn from our mistakes

How can safety be improved?

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Crisis resource management

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“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

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Ability to understand the content and significance of important elements within the environment.

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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

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......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

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Don’t tell anyone what you are picking

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Think about the card. Concentrate hard on this card

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Use positive messages to send me the card

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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?

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Normally ?

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When stressed?

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As quick as you can answer the next questions correctly……..??

Some questions?

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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

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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

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Lily pad took 47 days to get to half its size (or did you jump to 24 days?)

Question

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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…..

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The real answer is not to always trust our intuitions and check what we are doing

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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

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Persistent fixation on a single problem, failing to revise a diagnosis or plan despite contradictory evidence

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http://www.youtube.com/watch?v=MW PQVdjtqHE

This and only this...

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Eg: hypoxia following intubation.

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Assuming it is bronchospasm and not a blocked tube

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Counteract by not assuming first assumptions are true – back to basics

A non clinical example....

#Susanalbumparty

2. Everything but this

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eg. Hypertensive patient under anaesthesia/itu

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Assuming patient “too light” or in pain rather than medication error

3. Everything is OK....

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Persistent belief that there is not a major problem despite evidence to the contrary

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Reassuring signs are used to override worrisome evidence

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Worrisome data written off as artefact

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Eg: Low sats reading = artefact/dodgy signal

Preventing Fixation errors

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Be aware of possibility.

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Sterile cockpit attitude

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Continual checks and standing back

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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

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Leader should stand back if possible

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Leader’s engagement in hands-on task can impair group function and task completion

Other aspects of good leadership….

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Letting your team flourish Learning form educational studies – positive re-enforcement

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Using teams knowledge – letting them speak up about their ‘hunches’. Example from fire-brigade.

Good Leadership – counteract natural tendencies

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Bystander Effect

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Ringlemann Effect

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Abiline Paradox

Bystander Effect

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The murder of Kitty Genovesse

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Darly and Latane – 1968; the diffusion of responsibility in emergency situations

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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 2 3 8 Cap % 93 85 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

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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=qA gbpt7Ts8

To prevent this......

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Briefing prior to calls Name checks prior to patient arriving Flat hierarchy

4: Know your environment and team

Know your environment and team

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Long term – an organised department

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Short term just prior to patient arriving

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Started using a pre trauma activation SOP

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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

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Checking if people are ready to receive information

Communication

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Eye contact

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Asking if the content is understood

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Avoid jargon

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Pairing requests with names

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Communication through the team leader

Closed loop communication

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If used it could have speeded up how quickly the antibiotics were given (case 6)

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Now use it for all verbal orders

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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

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We should all know how to insert a central line

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But we often do it unsafely

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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

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Intubation is potentially one of the most dangerous times of a patients life

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Do we do it safely in the ED/ITU/the wards?

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How could we improve it ?

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Recommendations from NAP4

Recommendation

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“ 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

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Using them for CVP, intubation, sedation

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Initial scepticism

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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

C l i n i c a l E x a m p l e • • •

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

C l i n i c a l E x a m p l e • •

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

C l i n i c a l E x a m p l e

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

• C l i n i c a l E x a m p l e • •

Initial CPR management

2x cycle PEA throughout • Weak Pulse back after two cycles • • Repeat Blood gas pH<6.8, PO2 – 2 • ECG sinus tachycardia – T wave inversion in III

C l i n i c a l E x a m p l e

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

C l i n i c a l E x a m p l e • • •

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

C l i n i c a l E x a m p l e

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

• C l i n i c a l E x a m p l e

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 peri arrest), 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……..

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But despite there being evidence for the use they are not even policy in over 50% of hospitals

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Even when they are policy - not always used

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That is over two years since the recommendations made

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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 Practice characteristics Patient 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………

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Brief before patient arrive

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Use standardised communication tools

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Use check-lists

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Realise we are fallible and have a ‘sterile cockpit’ environment during stressful times

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Know your environment and where equipment is

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Plan for problems, don’t just react to them

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Debrief on all major events to learn from them

ANY QUESTIONS?

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“The very first step towards success in any occupation is to become interested in it.”

• Sir William Osler 1849 1919

Conclusions

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Different way of thinking

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You are the future http://www.youtube.com/watch?v=GA8z7 f7a2Pk

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[email protected]

Free safety conference at University of Sussex Monday 5 th jan