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
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- 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.
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- 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.
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- 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.
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