If the words of command are not clear and distinct, if the orders are not thoroughly understood, the general is to blame – Sun Tzu
Communication During Resuscitation
Communication continues to be a major issue in virtually all high-stress, time-sensitive environments. This has been discussed a number of times on EMCrit, most recently in Podcast 230: Resuscitation Communication. This post reviews some of those key elements and some of the literature to support these concepts.
Failure of communication has been cited as a primary contributor to a number of mishaps and accidents in different industries1,2 as well as the world of clinical medicine.3,4 In resuscitation, communication is paramount. It is critical to understand important aspects of good communication: what should or should not be said, how it should be said, when it should be said, and who should be saying it.
Clean, Crisp, and Direct
The structure of our communication is critical. During emergency situations when time pressure exists and the cognitive load on individual participants is high, being explicit is important. It is best to avoid vague or noncommittal statements, known as mitigating language, and cut right to the chase.5 In combat, language is structured such that the most important information comes first, followed by information that augments the most critical content. The mantra used in these circumstances is “Directive, descriptive, informative.” (See Podcast 99 Combat Aviation Paradigms for Resuscitation) For example, if a helicopter crew was flying and began to take fire from the ground below, the expected syntax from crew members to the pilot might be as follows: “Break right, break right! [directive] Small arms fire 8 o’clock low [descriptive]”. The corollary in resuscitation might be, “John, please place a right humoral intraosseous access immediately [directive]. We have no other vascular access after several attempts [descriptive] and need to administer medications emergently [informative]”. Even in the civilian world, experts in communication and Crew Resource Management agree that being both clear and concise are critical.6,7
Variability is the Enemy
In general, standardization and reduction in practice variability is important in resuscitation. It is particularly important when it comes to the language we use. First and foremost, team performance is more efficient when standardized terminology is used.8,9 When people hear expected or predictable words or phrases they are able to coordinate activities and perform critical tasks more effectively. This seems to hold true when validated team performance tools are used to compare the work of teams that use a standardized vernacular to teams that communicate in non-standardized ways. It is important to mention that standardization does not mean ruthlessly strict or rigid communication. Resuscitation is a dynamic team sport and we often encounter novel or unique situations. Under such circumstances, flexibility is important and necessary to manage life-threatening situations.10
Timing Is Key
Knowing when to communicate is equally imperative. At times, team members are so focused on activities or busy completing other critical tasks, they may not be prepared to receive a message. Furthermore, sometimes limiting information to what is most important right at that moment is also helpful. Otherwise, the communication may simply be distracting. Under high-cognitive workload conditions, decreased (or limited) team communication actually correlated with better team performance.11 Anticipating that a team member may need a key piece of information relayed is paramount as well. Studies demonstrate that an important characteristic of high-functioning teams is that members anticipate the needs of others and communicate important information before it is requested.12
Silence Is Golden
Part of understanding timing is also knowing when not to communicate. Non-essential communication can actually be distracting and have deleterious effects on ones ability to concentrate on critical tasks.13,14,15,16 Limiting communication, therefore, during important procedures and key phases of resuscitation might improve safety.17,18,19,20,21,22 This concept, often referred to as the “Sterile Cockpit”, is discussed at length with a review of the evidence here.
Close the Loop…Seriously, Close It
In 2020, many people have been introduced to this concept as it is a part of many standardized, widely-accepted resuscitation courses. Yet ensuring that certain information is heard, acknowledged, and processed by individual team members is still a challenge. Therefore, it is important to emphasize the importance of closed-loop communication. This means that instructions between team members are reinforced by verbal feedback.23,24 The loop can be closed immediately; for example, “John, please administer 1 mg of epinephrine IV” followed by a response, “1 mg of epinephrine administered.” Alternatively, it can be requested at a time in the future: “John, please draw an arterial blood gas and when the results return please alert me immediately.” The important aspect of this behavior is that information is provided to the message originator with positive confirmation that a task is complete.
Get Everyone on the Same Page
A shared mental model, or common understanding of a situation, is critical to optimal team performance. When members of a resuscitation team are all acting independently or don’t fully understand the “big picture”, there seems to be an association with increased adverse events.25 Evidence from various high-stress occupations demonstrates that when everyone understands their role as well as the overarching team objectives, they demonstrate better coordination, adaptation, and anticipation.26,27,28 Teams also seem to be, at least subjectively, less stressed by unknown information and ambiguity when a team leader’s mental model is shared.29 In addition, shared mental models provide a comprehensive picture of the resuscitation trajectory and enhance situation awareness among team members.30,31,32 Finally, there is improved goal-directed behavior and task focus when team members understand where their job fits within the context of the resuscitation.33
There are a number of structured communication tools that have been suggested for providing and updating a team leader’s shared mental model. In the hospital, when a resuscitation team is preparing to receive a patient, Eve Purdy and Victoria Brazil have provided an amazing framework for team briefing (see figure below).34 One of my favorite tools in the prehospital and retrieval setting is the PIVOT tool developed by Critical Care/Flight Paramedic Ami Tomaszewski (@AmiTomaszewski).35 PIVOT can be used to continually update the team at key phases of a resuscitation, at critical decision points, or at resuscitation stop points.
- Patient Identification: age, sex, important medical history
- Illness/Injury: the major clinical issue(s) being addressed
- Vital signs: patient stability and quantitative trajectory of vital signs
- Other interventions: what has already been accomplished
- To do: what are the next critical steps that the team needs to do
Fig 1. – A team briefing designed to build relational coordination (RC) in an ad-hoc team34
Sometimes we disagree with a particular decision or notice that something isn’t safe. Under these circumstances, it is important to speak up. Problems with cognitive overload or challenges addressing authority gradients have been found to cause communication breakdown and untoward results.36,37,3 Therefore, in many high-risk occupations team members are taught to speak up. Perhaps more importantly, they are trained how to use increased grades of assertiveness to bring important information to light. One common method is using the four-step PACE communication method developed by Besco.38 In this graded communication approach, one starts by asking a probing question, then escalates to an alert, followed by a challenging statement, and ultimately an emergency warning if the concern is still not acknowledged.
Body Language Counts Too
In addition to spoken words, the accompanying body language is critical too. Non-verbal communication is the deliberate or unintentional signaling of emotional state without words. In certain situations authors have suggested that during face-to-face communication the majority of communication (up to 55%) is non-verbal.39 Facial expressions, body posture, hand gestures, eye movements are all critical accompaniments to the words we use.40 For these reasons, it is important that body language is directly aligned with verbal communication so that the verbal message is appropriately reinforced.
Communication counts in resuscitation. Experience teaches that it can be particularly challenging in stressful circumstances. The literature, likewise, echoes its importance. Finally, it’s important to recognize that communication is a skill and, like any other skill, it often takes time and deliberate practice to manifest improvement.
Also check these out…
- Learning to Speak Resuscitese
- Improving Verbal Communication in Critical Care Medicine
- Team Leadership with Cliff Reid
- The Contamination of the Beach Incident at British Nuclear Fuels Limited, Sellafield, November 1983. London, UK: HMSO; 1983.
- Air Florida Inc. Boeing 737-222, N62AF, Collision with 14thStreet Bridge near Washington National Airport, Washington, DC January 13, 1982. (NTSB Report Number AAR-82/08). Washington, DC: National Transportation Safety Board; 1982.
- Sentinel Event Alert, Issue No. 30. Oak Brook, IL: Joint Commission for the Accreditation of Healthcare Organizations; 2004.
- Medication errors related to potentially dangerous abbreviations. Sentinel event alert, Issue No. 23.Oak Brook, IL: Joint Commission for the Accreditation of Healthcare Organizations; 2001.
- Gladwell M. The ethnic theory of plane crashes. In: Gladwell M, Patel VI, eds. Outliers. New York, NY: Crown Publishers; 2008.
- Brindley PG. Patient safety and acute care medicine: lessons for the future, insights from the past. Crit Care. 2010; 14(2):217-222.
- Handbook of communications in anaesthesia and critical care. In: Cyna Am, Andrew MI, Suyin GM, Tan SGM, Smith AF, eds. A practical guide to exploring the art. Oxford, UK: Oxford University Press; 2010.
- Kanki BG, Lozito S, Foushee HC. Communication indices of crew coordination. Aviat Space Environ Med. 1989; Jan: 56-60.
- Kanki BG and Smith GM. Training aviation communication skills. In: Salas E, Bowers CA, Edens E, eds. Improving Teamwork in Organizations. Mahwah, NJ: Lawrence Erlbaum; 2001.
- Tushman M. Special boundary roles in the innovation process. Admin Sci Quarterly. 1977; 22: 587-606.
- Orasanu JM. Decision-making in the cockpit. In: Wiener EL, Kanki BG, Helmreich RL, eds.Cockpit Resource Management. San Diego, CA: Academic Press; 1993.
- Volpe CE, Cannon-Bowers JA, Salas E. The impact of cross-training on team functioning: An empirical investigation. Hum Factors. 1996; 38: 87-100.
- Gaba DM, Howard SK, Small Situation awareness in anesthesiology.Hum Factors. 1995; 37(1): 20- 31.
- Howard SK, Gaba DM. Factors influencing vigilance and performance of anesthetists.Curr Opin Anaesthesiol. 1998; 11(6): 651-657.
- Healey AN, Sevdalis N, Vincent CA. Measuring intra-operative interference from distraction and interruption observed in the operating theatre.Ergonomics. 2006; 49(5-6): 589-604.
- Berg LM, Källberg AS, Göransson KE, Östergren J, Florin J, Ehrenberg A. Interruptions in emergency department work: an observational and interview study.BMJ Qual Saf. 2013; 22(8): 656-63.
- Ornato JP, Peberdy MA. Applying lessons from commercial aviation safety and operations to resuscitation.Resuscitation. 2014; 85(2): 173-6.
- Fore AM, Sculli GL, Albee D, Neily J. Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit‐based project.J Nurs Manage. 2013;21(1):106-11.
- Federwisch M, Ramos H, Shonte’C A. The sterile cockpit: an effective approach to reducing medication errors?.Am J Nurs. 2014; 114(2): 47-55.
- Broom MA, Capek AL, Carachi P, Akeroyd MA, Hilditch G. Critical phase distractions in anaesthesia and the sterile cockpit concept.Anaesthesia. 2011 ;66(3): 175-9.
- Cyna AM, Andrew MI, Tan SG, Smith AF, eds.Handbook of Communication in Anaesthesia & Critical Care: A Practical Guide to Exploring the Art. Oxford, UK: Oxford University Press; 2010.
- Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents.Aviat Space Environ Med. 1992; 63(9): 763-70.
- Gaba DM, Fish KJ, Howard SK. Crisis Management in Anesthesiology. New York, NY: Churchill Livingstone; 1994.
- Gaba DM. Dynamic decision-making in anesthesiology: cognitive models and training approaches. In: Evans DA, Patel VI, eds. Advanced models of cognition for medical training and practice. Berlin, GE: Springer-Verlag; 1992.
- Wilson K, Salas E, Priest H, Andrews D. Errors in the heat of battle: Taking a closer look at shared cognition breakdowns through teamwork. Hum Factors. 2007; 49: 243-256.
- Cannon-Bowers JA, Salas E, Converse S. Shared mental models in expert team decision making. In: Castellan, ed. Individual and Group Decision Making: Current Issues. Hillsdale, NJ: LEA; 1993: 221-246.
- Klein G. Cognitive task analysis of teams. In: Schraagen JM, Chipman SF, Shalin VL, eds.Cognitive Task Analysis. Mahwah, NJ: LEA; 2000.
- West M. Reflexivity, revolution, and innovation in work teams. In: Beyerlein D, Johnson D, Beyerlein S, eds. Product Development Teams. Stamford, CT: JAI Press; 2000: 1-29.
- Serfaty D, Entin EE, and Johnston JH. Team coordination training. In: Cannon-Bowers JA, Salas E, eds. Making Decisions Under Stress: Implications for Individual and Team Training. Washington, DC: American Psychological Association; 1998.
- St Pierre M, Hofinger G, Buerschaper C. Crisis management in acute care settings: human factors and team psychology in a high stakes environment. New York, NY: Springer; 2008.
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- Ripley A. The unthinkable: who survives when disaster strikes – and why. New York, NY: Crown Publishers; 2008.
- Cannon-Bowers JA, Salas E. Individual and team decision making under stress: Theoretical underpinnings. In: Cannon-Bowers JA, Salas E, eds. Making Decisions Under Stress: Implications for Inidividual and Team Training. Washington, DC: American Psychological Association; 1998.
- Purdy E, Alexander C, Shaw R, Brazil V. The team briefing: setting up relational coordination for your resuscitation. Clin Exp Emerg Med. 2020: 7(1): 1-4.
- Tomaszewski A. CRM in Patient Care: The PIVOT Point. In: Critical Care Transport Medicine Conference; 2017 Apr. San Antonio, TX.
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- COMM CHECK: More On Resuscitation Communication - July 16, 2020
- Invictus: Survival, Sustainment, and Service in the Era of COVID-19 - April 25, 2020
- COMM CHECK: On Checklists - January 3, 2019
Practicing in a dual tiered system it’s the nature of the beast that I don’t have a set resuscitation team aside from my partner. The education and experience level of my BLS team mates varies so my communication has to adjust. I agree totally that the simpler and clearer the communications the smoother the resuscitation. I’ve gotten feedback that my team members appreciate bending part of the team instead of spectators that get put to work.
This and episode 230 are awesome and really should be standard issue in any Emergency Medicine training program, thank you for doing this! My question is how do you address an issue during a resuscitation (or even during the pre-brief) that could be potentially harmful to the patient, especially with the ever growing push to emphasize protecting your teammates feelings over patient safety. How can you nicely say “you’re doing something wrong” in a resus, without causing personal offence.
I think the PACE method discussed above would be a good starting point,
This is such an amazing article,
I really liked reading this kind of interesting articles.
deep explanation, and references are accurate, may read more article from you
Good stuff, really helpful to have it all written out. Curious what your thoughts are on encouraging statements during these situations. I’ve seen plenty of people get yelled at during codes and so I’ve tried to make it my practice to keep giving encouraging feedback to people during codes (excellent chest compressions, keep it up etc) but am always a bit worried I’m talking too much. Nurses seem to really like it though