Non-technical skills in resuscitation

We will now look at each of these four key elements individually.

5. Situational awareness

This can be defined as "awareness of what is happening in the current environment in order to understand the impact that information and actions (of both self and others) will have immediately and in the near future." This is essential during the management of a critically ill patient when there are often many events happening simultaneously and particularly true during a cardiac arrest where there are a number of situational awareness factors, which will have an impact on actions and outcome. Examples would be:

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• Obtaining information from staff about the events leading up to the arrest, what has been done and what happened as a result
• Who is present, what are their names and skills
• Communicating with the team, assessing the current situation, determining immediate needs
• Considering the likely impact of such actions

It is likely that all the team members will have a degree of situational awareness, but it is important that only important and relevant information is shared, otherwise there can be too much "noise" and distraction.

7. Decision making

This is the "ability to assimilate information from team members and personal observations to allow the performance of appropriate interventions". During resuscitation, decision making usually falls to the team leader, and he or she will have to assimilate the information from their own observations and that provided by the team members. They must then utilise this to try and determine the correct course of action. This clearly requires a significant degree of both knowledge and experience. Examples would be:

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• Failure to achieve IV access and decision to proceed with an IO needle
• All the reversible causes of cardiac arrest been eliminated
• Should the resuscitation attempt continue?

Once a decision has been made, it must be communicated clearly to all the team members and appropriate checks made to confirm understanding and implementation.

9. 3a. Team working

This is a major non-technical skill that contributes to the successful management of critical clinical situations. A team can be defined as "a group of individuals with a common goal or purpose". Teams work best when they know and are supportive of each other. They must feel that what they are doing is meaningful and that they are being asked to perform roles within their competence. Information must be exchanged in all directions; this facilitates coordination of their activities. Finally, the team must have a good team leader – more of that shortly.

10. At a cardiac arrest therefore:

• Everyone should have been introduced, names should be ascertained and used
• The team believe that the resuscitation attempt is worthwhile
• Role allocation is sensible; ask the anaesthetist to manage the airway
• Everyone needs to know when a shock is about to be delivered and safety maintained. This ‘timely communication will prevent interruptions in CPR, and minimise hands off time’.

11. 3b. Team leadership

The team leader is "the person who influences and leads the team to achieve a common goal". They lead by example and integrity and therefore need experience, not simply seniority. Consequently it can be considered a process and available to all those who aspire to it.

A number of important attributes are recognised in good team leaders; they require a high level of situational awareness, constantly aware of what is happening and how this may impact on the future, managing time and an ability to delegate appropriately, this means knowing the team by name and their capabilities. They must have credibility in terms of knowledge, skills and experience and as such act as a good role model for the team, have good communication skills, both in terms of giving and receiving information and have empathy with the team members. Finally they need assertiveness, but also know when to show tolerance. Examples of good team leadership include:

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• Members of the resuscitation team meeting at the start of their shift or period of duty. This allows the team leader to make introductions, identify competencies and allocate roles. If the team only meet for the first time at an arrest, the person taking the role of leader must be identified and established within 30 seconds for this to be effective.
• Ensuring that current guidelines are followed, identifying and correcting any errors or omissions.
• Assess the situation and plan the next course of action during periods of chest compressions.
• Ensuring that the team are supported and safe in their actions.

13. Task management

This consists of "planning, coordination and control of actions of the team" and is the responsibility of the team leader; above all this requires good communications. There is also a need for prioritisation and being prepared for the unexpected as well as the expected.
At a cardiac arrest examples include:

• Briefing the team, preferably before patient contact
• Ensuring that the team’s actions are prioritised correctly; defibrillation before trying to obtain a IV line in a patient in a shockable rhythm
• Making sure everyone is safe before a shock is delivered
• Managing conflict between team members
• Monitoring the team for fatigue and stress; changing the person doing chest compressions regularly
• Debriefing the team at the end of the resuscitation and ensuring audit and adverse incident reports are completed appropriately

14. We have noted the importance of good communication already and this because poor communication occurs in the greater proportion of adverse incidents or near misses and is often evident during clinical emergencies and resuscitation attempts.

Communication fails because the information given; lacks detail and structure which mean that the urgency of the situation is not conveyed. This poor quality information means that the recipient is uncertain as to the nature of the emergency they are about to face which increases anxiety and impedes performance.

A structured approach to communication ensures honesty, clarity and efficiency by conveying facts and urgency.

Two commonly used tools are SBAR and RSVP; these enable timely, effective communication between individuals from different clinical backgrounds and are ideal for ‘handover’ in the emergency situation.

We’ll now spend some time looking at the assessment of non technical skills in the emergency situation:

15. To assess the non-technical skills of a team is complex, but a tool has been introduced and validated that helps to achieve this. Resuscitation Council UK has modified the ‘Team Emergency Assessment Measure’ for use on the ALS course. TEAM tool looks at ten different domains of leadership, teamwork and task management, giving examples of each. Each domain is scored from zero to four. This tool will made available to you during your advanced life support course to allow you to feedback to your peers.

16. We would like you to use this tool to assess the non-technical skills of a team in the short video that follows. To make this easier, you should print off a copy of the tool from additional resources and refer to this whilst watching the video, making notes about what non-technical skills you see or don’t see happening. Please do not concentrate on the clinical management, which you may find surprising.

The video will be narrated by Mr Martin Bromiley, the husband of late Elaine Bromiley who died from a routine operation. Mrs Bromiley was fit and well and presented for elective sinus surgery. Problems began when general anaesthesia was induced and the anaesthetist was unable to insert a laryngeal mask airway and Mrs Bromiley’s oxygenation became low. Mr Bromiley descirbes the events as they took place. After you have watched the video, there will be a review of the important points around the non-technical skills aspects that you should have identified.

17. Video

18. Some important points were raised by Mr Bromiley about what went wrong during his wife’s operation. The technical skills of each healthcare professional involved in her care were not in doubt but together they displayed a lack of non-technical skills as a team responding to an emergency situation. You should have been noticing these whilst you are watching the video. If there were any points that were missed, please feel free to review the video as many times as you like.

Leadership

Despite the huge amount of experience of the consultants and nurses, there was no clear team leader who was able to co-ordinate and direct the team. None of the consultants remained hands off in order to monitor the situation. There was also a lack of delegation.

19. Teamwork

There was a breakdown of communication between team members. The awareness of the gravity of situation was not shared between them. It was not clear whether the team made use of the nurses and their skills in the emergency situation. The nurses described being aware of what was going on and what needed to be done and acted on their own accord, but found it difficult to communicate back to the team in the room. Whilst the team appeared to act with composure and control, there was a failure to adapt to the changing situation or to anticipate potential actions. Rather than this being a team, it was a number of experienced individuals.

20. Task management

There was a failure to prioritise tasks with an inappropriate focus on intubation. The guidelines on the management of Can’t intubate can’t ventilate situation were not followed.

21. This concludes our review on non-technical skills in resuscitation. To summarise,

• Non-technical skills are an important aspect of resuscitation
• Key elements are: situational awareness, decision making, team working and task management
• Good communication is a feature at all stages
• There will be practice of and feedback on non-technical skills during CASTEACH scenarios