Step Up

Topic Progress:

Pearls for STEPping UP

1. Communicate, communicate, communicate.
2. Share your mindset with your team.
3. Ask for simulations to practice.

The Zero Point Survey: STEP UP

S – Self

Can be divided into physical and cognitive self

Physical 

  • PEE before PPE
    • Empty your bladder prior to donning your PPE (trust us)
  • Donning and doffing of proper PPE 
    • Most important part – PRACTICE, PRACTICE, PRACTICE!

Cognitive 

  • Beat The Stress Fool”4
    • Breath – Tactical breathing exercises to slow your breathing and bring down your heart rate 
    • Talk – Positive self-talk.  Remove the idea of imposter syndrome from your mind
    • See – Mental rehearsal of a task/procedure; walk it through in your mind.  E.g. Tube 🡪 clamp 🡪 cuff inflation 🡪 ETCO2/in-line suction 🡪 viral filter 🡪 ventilator 🡪 unclamp
    • Focus – have a “trigger word” to centre yourself.  “We got this” prior to entering a negative pressure room.  

T – Team

Leader

  • Incredibly important to oversee the resuscitation.  One central “commander” to guide the team. Otherwise, multiple orders could be given all at once leading to confusion and disorganization amongst the team.  
  • Can be a fluid model where the team leader position can pass back and forth.  E.g. – team leader moves to head of bed with the primary intubator during the intubation process.  They then become task oriented and therefore lose situational awareness of the room. The airway nurse can then take over as team leader to ensure situation awareness is maintained.  After intubation, the roles switch back.  
  • Co-leaders as in nurse-led ACLS.  Even more cognitive load occurs during the protected cardiac arrest of a COVID-19 patient.  The nurse leader can act as the air-traffic controller running the ACLS algorithm while the doc-leader can think about reversible causes, use ultrasound accordingly, speak with family, etc.  Only utilize this approach if you’ve already been using it in your department. 

Roles 

  • Establish clear roles prior to entering the room.  Minimize exposure to the team – therefore only 3 members enter the room (team leader, primary intubator, airway nurse).  Then ensure there are back-up members fully donned in PPE in the anteroom (secondary intubator, secondary nurse) and team members outside the room (spotter/runner, secondary RRT).  
  • Ensure all members are comfortable in their roles.  If they are comfortable, they will communicate more efficiently.  

Brief

  • What do we know?
    • We know we have a COVID-19 patient in severe respiratory distress and requires intubation.
  • What do we expect?
    • This to be a highly dangerous procedure yet one we can successfully undergo
    • Anticipate the potential for difficult intubation
  • How do we prepare?
    • Gather the equipment we require; utilize checklists to help walk us through the procedure
    • Ensure we are properly donned in our PPE
    • Ensure we have verbalized a Plan A, B, C and D to the intubation process

E – Environment

Equipment 

  • Checklists
  • Pre-made “grab & go” bags
    • Focus on bringing into the room what you need to minimize ins and outs into negative pressure room (while being cognisant not to waste materials)

Ergonomics

  • Room layout – standardized room setup 

Psychological Safety

  • Debriefing 
    • a rehab session for future resuscitations
    • Not about public shaming, but rather an opportunity to become curious about your team members and the decisions made.
    • Can be Hot or Cold in nature
      • Hot = focuses more on safety and logistics (e.g. INFO model; STOP for 5)
      • Cold = focuses more on emotions (once things cool off)
  • SIM! SIM! SIM! – simulate these situations out regularly and debrief amongst the team.  Provides crucial feedback without harm to actual patients.

Summary

  1. Use social contagion to fight another contagion – create a hive mentality amongst your team
  1. Develop a highly functioning team using 3 key elements:

Organization 🡪 ZPS (prepare yourself, your team and your environment)

Communication 🡪 10 in 10 and tactical pause to provide updates and shared mental models 

Psychological Safety 🡪 Debriefing (debrief after simulation and after all resuscitations to strengthen team relationships 

  1. These elements allow for the resuscitative team to move forward as a cohesive unit, utilizing their social contagion to fight another and continuing to work better together!

References

1. Google dictionary. Contagion [Internet]. Available at https://www.google.com/search?client=safari&rls=en&sxsrf=ALeKk02UHc4tul6T3kBF2GtReHy-X6qCcQ:1587054727825&q=Dictionary&stick=H4sIAAAAAAAAAONQesSoyi3w8sc9YSmZSWtOXmMU4-LzL0jNc8lMLsnMz0ssqrRiUWJKzeNZxMqFEAMA7_QXqzcAAAA&zx=1587054733103#dobs=contagion

2. Wikipedia.  Behavioural Contagion [Internet]. Available at https://en.wikipedia.org/wiki/Behavioral_contagion

3. Reid C, Brindley P, Hicks C, et al. Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med. 2018;5(3):139–143. doi:10.15441/ceem.17.269

 4. Lauria MJ, Gallo IA, Rush S, Brooks J, Spiegel R, Weingart SD. Psychological skills to improve emergency care providers’ performance under stress. Ann Emerg Med. 2017;70:884–90.

5. Hicks C.  High performance teams: the secrets of success.  Available at https://litfl.com/high-performance-teams/

6. Angus MacDonald, Zero Point Survey.  EMcenterED blog. September 23, 2019.  Available at https://emcentered.com/step-up-your-resuscitation-skills-with-the-zero-point-survey/

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