Resuscitation Teamwork, CCF and Improving Patient Outcomes
Many people think of ACLS as the drugs that we give, and sure, that’s an important aspect of care. However, the way we approach a resuscitation from the team perspective is arguably just as important. Teamwork can be a dynamic and complex concept within these settings, dependent on a multitude of factors such as the number and makeup of the team members, the types of activities needing to be performed, workload, management of information and urgency of action. Effective teamwork isn’t easy! This is why it plays such a heavy role in resuscitation training and education.
We know teamwork is important. Hosseini et al. (2021) and Mathew et al. (2022) found effective teamwork being linked to faster patient defibrillation, increased Chest Compression Fraction (CCF) and improved patient outcomes. Chest compression fraction (CCF) is the cumulative time of chest compressions given during resuscitation divided by the total time taken for the entire resuscitation (e.g., CCF = actual chest compression time / total code time). The goal is to limit interruptions to chest compressions in order to achieve a CCF of greater than 80%. When a high CCF is coupled with high-quality CPR, blood flow to vital organs is maximized, including increased coronary perfusion pressure, thereby improving the likelihood of attaining ROSC (Return of Spontaneous Circulation). High quality CPR includes chest compressions rate between 100–120 per min, depth of at least 2 inches, and avoiding excessive ventilation.
There are several reasons why providers may interrupt CPR, thereby decreasing CCF. Some of these are perhaps unavoidable, such as the rhythm and pulse checks (although newer technologies and strategies help us limit this) (Mathew et al., 2022). However, many pauses in compressions are related to avoidable factors, such as poor coordination, communication breakdown, distraction, fatigue, confusion, or lack of knowledge and inability to perform certain skills efficiently. Some of these factors might be related to individual performance, however, many are the result of team dynamics. Poor teamwork has been linked to poor team performance which can negatively impact patient safety and outcomes (Hosseini et al., 2021). In fact, Hosseini et al. (2021) found that CCF decreased when the length of the resuscitation lasted longer, when defibrillation was more frequent, when the number of team members increased, and also when the number of people giving chest compressions increased. These particular findings were typically associated with increased confusion and strained leadership/coordination. This is where teamwork can play a vital role in reducing these types of interruptions.
There are several strategies that can help improve effective teamwork during a resuscitation. First, human factors are always a major consideration and we often adopt the model of Crisis/Crew Resource Management (CRM) to address some of the elements. Some examples include establishing leadership, role clarity, distribution of workload, anticipation and planning, and effective closed-loop communication. Another strategy is designating a CPR Coach, a new role within the Heart & Stroke Foundation of Canada Resuscitation Guidelines introduced in 2020. This role has someone dedicated to supporting the performance of high-quality BLS and allowing the Team Leader to focus on other aspects of clinical care. This includes coordinating CPR and the compressors, provider coaching/feedback, stating the targets, and minimizing interruptions in compressions. Often this role is combined with another, such as the monitor/defibrillator role, but the takeaway is that someone on the team other than the Team Lead is responsible for ensuring these priorities are attended to.
It takes PRACTICE as a team in order to identify areas for improvement and set corrective goals. This is why we focus so much on simulation as a team during our Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS) Provider courses. For many, the opportunity to participate in resuscitations are often infrequent and ACLS and BLS provides an opportunity to help close those gaps by allowing participants to practice, make mistakes, and then learn from them in a safe and controlled environment.
Hope you enjoyed the read and thanks for checking out our first ResusReady blog post!
Additional Information
This was an interesting article on a new resuscitation teamwork model that I came across in my research. Check it out: https://www.sciencedirect.com/science/article/pii/S0196064424010746
References
Heart & Stroke Foundation of Canada. (2020). Advanced Cardiac Life Support. Canada.
Hosseini, M., Heydari, A., Reihani, H., & Kareshki, H. (2022). Elements of Teamwork in Resuscitation: An Integrative Review. Bulletin of emergency and trauma, 10(3), 95–102. https://doi.org/10.30476/BEAT.2021.91963.1291
Mathew, D., Krishnan, S. V., Abraham, S. V., Varghese, S., Thomas, M. R., & Palatty, B. U. (2022). Chest Compression Fraction and Factors influencing it. Journal of emergencies, trauma, and shock, 15(1), 41–46. https://doi.org/10.4103/JETS.JETS_36_21