There’s no doubt that for the small rural emergency department, a critically unwell patient can quickly overwhelm available resources. Like many small rural hospitals in Australia, there is one doctor on call for emergency presentations, with the ward-based nursing staff (two in out location) responsible for ward care, assessment of outpatient attendances as well as care of patients in the ED. Not surprisingly this can be a big ask…and thankfully extra nursing and medical staff are available if needed (typically the oncall theatre team)

As we ramp up into the tourist season on Kangaroo Island, I’ve been thinking about how we deal with critical patients in our rural ED. Having the appropriate training and equipment is obviously important – as well as an appreciation of resus room feng shui.

https://vimeo.com/90004722

A recent retrieval case brought the issue of improved team communication to mind. I wont go into details; suffice it to say that this case required the attention of two doctors, seven nursing staff, one paid paramedic and four volunteer ambulance officers….and subsequent retrieval. The demands of one critically ill patient … plus several other ED attendees … plus ward care can quickly overwhelm local resources, without a robust oncall system.

But no matter how well equipped, how well trained or even how well staffed the ED is, there HAS to be effective communication between members. We did quite well, but on reflection afterwards I felt that it was hard to keep track of who did what and when. This is often the case in a resus team, particularly occasionalists or the ‘flash team’ or individuals who have not trained together.

The traditional and practiced role of a resuscitation team is based on that of team leader, with subsequent role allocation and closed-loop communication between members, all operating with a common goal or ‘shared mental model’. This is the sort of stuff we teach on the ETMcourse, focussing not just on the technical skills of trauma care, but also on the nuances of effective teamwork in trauma.

In recent times I have become a fan of using the whiteboard as ‘glue’ to hold the resus team together. In any resus, it is common to delegate one person to scribe. It’s important to have a record of drugs given, interventions delivered and arrival/departure of team members etc. But many people, myself included, find that the furious writing by one team member of all events & drugs on a piece of paper that noone else can see does little to add to team effectiveness in a critically ill patient. Scott Orman over at Auckland HEMS has posted a nice summary of why a whiteboard is so useful for prehospital handover – I think this applies equally for rural hospitals.

Why is that? Well – it’s pretty simple. In a small team, we need every hand on deck – delegating a clinical member to scribe may take them out of circulation. But that’s a minor gripe – the main problem with the scribe is that noone else can see what he/she has written unless they take time out to read their notes. In short, there is no shared mental model when all documentation goes via the scribed notes. Moreover, the scribe may accurately capture all the interventions and their timing from multiple sources – but this knowledge is not shared between team members.

“often the scribe has all the critical information – noone else does!”

This makes sense – the resus can be chaotic, especially when team members haven’t trained together and there is a lack of leadership or followership, unclear role allocation nor closed loop communication. Instead there is frenetic activity, cross talk, repeated interruption and a requirement to re-hash essential elements of history and interventions with the arrival of each new team member…

This is where the resus whiteboard comes into play – I’ll be the first to admit that ours is not big enough – but it’s a start. I would hope that every rural ED has a whiteboard available at the head of the bed or adjacent. Documenting initial prehospital handover, subsequent interventions and obs, as well as arrival/departure of key players can help the whole team.

A whiteboard gives a clear indication of who did what, when, and why…as well as response to intervention. New arrivals to the resus can stand back and get a summary without having to interrupt.

More importantly, I find that having a summary on the whiteboard where everyone can see it gives a shared mental model – of where the patient was on arrival, the therapeutic goals and the steps needed to get there – a readily available shared mental model for all team members without the need for repeated interruptions and cross-questionning which is inevitable as additional team members enter the resus.

“closed loop communication between team members and a dedicated scribe may work well in a single trauma team – but as team members come and go, vital information is lost.

Rather than have to re-hash information, the whiteboard can give a quick summary of where we started, where we are now…and where we want to be.

It can also help open up communication – how much easier is if for a team member to raise a hand and ask “Excuse me team leader…I see that we have a goal MAP of 70 but the current MAP is only 55. Do you want to do X, Y, Z?” or “Hey everyone, we’ve transfused four units of packed cells in the last 20 minutes – we’re now into the agreed trigger for massive transfusion protocol…can we organise as agreed earlier per protocol?”

Of course we still need to keep a written record – I am not suggesting that the whiteboard alone will suffice – but in a resource-limited and time-critical resus, the whiteboard can truly be the glue to keep the team on target and ensure what needs to be done is done, and that everyone knows about it! Here’s how the ‘ideal’ resus flow of information would work via whiteboard…

Prehospital Notification

AT-MIST AMBO or ISBAR can be used as a structured handover tool, allowing anticipated needs to be identified and role allocation of team members.

AT-MIST : Age/Time/Mechanism/Injuries/Symptoms&Signs/Treatment provided&Trends

AMBO : Allergies/Meds/Background/Other

ISBAR : Identity/Situation/Background/Assessment/Response+Readback

Key equipment needs may be anticipated based on pre-notification eg: traumatic head injury means probably need blood, fluid warmer, TXA, RSI equipment. Drugs such as ketamine (for both analgesia and induction) can be pre-drawn and emergency drugs doses calculated & written down (especially for paediatric cases or uncommon scenarios). This is a good time to call in other staff – especially if multiple injuries or if solo operator and one critical patient. The more resus I do nowadays, the lower my threshold to call in a colleague. It’s just so much easier to share the cognitive load…

Patient Reception & Pre-Hospital Handover

Unless in extremis, take 30 seconds for a structured handover from the ambos before the patient is transferred off their stretcher. This is a high risk time. There is usually a flurry of activity as well-meaning individuals attempt to take history, remove clothes, gain IV access and set up monitoring. Seriously – stop!

Studies show that less than 50% of information relayed by prehospital services is retained by emergency department staff – this can be increased by use of a structured handover tool. Whichever handover method is used, this is a time for everyone to STFU and listen!

Unless the patient is in cardiac arrest or needs immediate intervention (airway at risk etc), take 30 seconds and use the whiteboard to confirm elements of prehospital handover history and baseline obs.

I use this to determine resus goals for the team. You will be amazed at how much information is missed at handover – especially when the receiving team ‘get busy’ with lines, blood pressure and monitoring – when they should be listening and coming up with a game plan! And don’t get me started on 1-2-3 vs ready-brace-move for the actual transfer!

https://vimeo.com/96407447

Rural Resuscitation

Once obs are done and as the primary survey is completed (again, calling out the findings so can be scribed to whiteboard), ensure a shared mental model of early treatment goals is established. I don’t know about other rural docs, but I find that a rural resus is hard work – we do this stuff infrequently, yet attention to detail can make all the difference. Critical care is mostly about doing the basics, well.

Treatment goals may be as simple as “let’s keep the patient warm, maintain oxygenation, target MAP >70 and stop the bleeding” or may be a little more nuanced “Let’s secure the airway – we’ll optimise position and pre-oxygenate; use the challenge-response checklist whilst drawing up drugs – then once intubated immediately perform a finger thoracostomy and ongoing resuscitation with warm blood whilst packaging for transfer”

Obs can be scribed to show trends and response to interventions. Key times & doses of drugs given are recorded.

Having a shared mental model allows opening up of communication of goals aren’t being achieved. Rather than challenge the team leader (which can be difficult where there is an actual or perceived authority gradient), this approach allows truly patient-centric team collaboration.

Of course this will be concomitant with closed-loop communication between team members, something that is easily practiced on courses such as ETM. Subsequent or parallel scribing to clinical notes is possible when time allows.

Handover to Retrieval Team

As mentioned above, the whiteboard can serve as a good global summary for the arriving retrieval team (or indeed anyone who arrives to the resus after a period of time) and allows a structured handover with salient points highlighted. A photo of the whiteboard summary can be forwarded to the receiving facility as an initial SITREP. Whilst the camera is out, there’s also the chance to catch some selfies with long-lost friends…

Before team arrival use any spare time to ensure all documentation is in order (if not already performed) and for notes to be written (often as the referring clinician I have been too busy to write anything until retrieval team arrive!). An ABC type transfer checklist can be a useful summary (mine runs from the letter A to the letter O!). Of course patient care should take precedence over documentation! In a real rush I’ve been known to write on the patient!

Debrief

A hot debrief can be useful after a resus. At this stage Country Health SA doesn’t routinely audit resus cases locally, which means there is little chance to improve performance not have open and honest communication on what went well and what didn’t. Most improvement will be about aspects of communication, equipment availability and use, as well as practice as a team for realistic scenarios. The feedback from peripheral team members can be very important – the volunteer ambos, the cleaner, the ward clerk…and again the whiteboard debrief can help identify any problems in patient care and improve team resilience.

“without honest feedback from team member on cases, there can be no audit…

…and without audit, no improvement in clinical care”

In short, the whiteboard can help improve individual situational awareness via the early establishment of a shared mental model, opening up communication between team members. There should be one in every rural ED – use it!

Whiteboards have been shown to aid the following in a resus:

task management

team attention management

task articulation and tracking

resource planning and tracking

synchronous and asynchronous communication

multidisciplinary problem solving and negotiation

team building

References

Prehospital to ED Handover (inc use of whiteboard) from Auckland HEMS http://aucklandhems.com/2012/11/26/pre-hospital-to-ed-handover/

Talbot R & Bleetman A (2007) Retention of information by emergency department staff at ambulance handover: do standardised approaches work? Emerg Med J. 2007 Aug;24(8):539-42. http://www.ncbi.nlm.nih.gov/pubmed/17652672

The Importance of Shared Mental Model from TEAM STEPPS http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igsitmonitor.html#m4SL13

Xiao Y et al (2007) What whiteboards in a trauma center operating suite can teach us about emergency department communication Ann Emerg Med. 2007 Oct;50(4):387-95. Epub 2007 May 11. http://www.ncbi.nlm.nih.gov/pubmed/17498845

Transfer Checklist A-O https://ruraldoctorsdotnet1.files.wordpress.com/2013/04/transfer-abc.pdf

TRANSFER CHECKLIST

Airway

Breathing

Circulation

Disability

Exposure

Fluids given

Gut (fasted/NG)

Haematology

Infusions

JVP (filled/under-filled)

Kelvin (temp)

Lines

Monitoring

Notes & Next of Kin

Other Stuff…