Is EMS a Team Sport?

BY HOWARD BACKER, MD, MPH, FACEP ON NOV 4, 2015

Photo credit: NHTSA

Reprinted with permission from EMSA Dispatch Newsletter.

EMS providers are never alone on a case, yet teamwork is often lacking. Teamwork does not mean a strict division of labor, it means using the combined skills and judgment of the team to potentiate one another’s skills. Effective teams practice and train together, but ironically, healthcare professionals rarely train together and often have revolving partners, making it more difficult to develop the understanding and trust required for optimal team function. Healthcare providers are traditionally trained to function as individuals in hierarchical arrangements rather than as a functional team.

Task Assignment

Potentiating one another’s skills does not preclude specific roles—known as the "pit crew"or"assigned task model." Examples of assigned task models in healthcare include CPR and trauma teams. Each member has a specific task, but for efficient function, each team member must have familiarity with the whole process and how the roles interact. Teams require interaction and coordination of members to be in sync with your colleagues. A team shares mission requirements and collective responsibilities to accomplish a shared goal. Not surprisingly, our military has tremendous experience in developing functional teams that must operate under extreme stress, with high consequence of error. Their model is being analyzed and utilized for other types of teams in high stress and high consequence situations, including emergency medicine and crisis decision making in many other disciplines.

Use of organizational teams in medicine and in other fields leads to greater productivity, better decisions and problem solving, better services, and increased innovation. High functioning teams require communication, common goals, trust, and balance of responsibilities. For this reason, the basic steps to having an effective team have been incorporated into the ACLS and the ATLS guidelines.

On the other hand, poor teamwork has been linked to medical errors. Teamwork is integral to a working environment that is conducive to patient safety and care. I review cases regularly where the senior health team member used poor judgment but the other team members remained silent, and the outcome was tragic.

Research across professions shows that disciplined group decision making consistently outperforms individual. This does not mean there is no role for leadership, but it does mean that a good leader solicits opinions of his/her team when time and circumstances allow. And there is no excuse for a more junior person to not speak up and offer suggestions if he or she sees wrong decisions being made. George Patton said: “If everyone is thinking alike, then somebody isn't thinking.”

Avoiding Medical Errors

Patient safety problems have been a concern in hospital operating rooms. Despite having a team of staff in the operating suite, there was a distinct hierarchy and, in some cases, the surgeon at the top exhibited an unapproachable attitude, resulting in limited teamwork, no overlapping responsibility for safety, and hesitancy of staff to speak up. This led to numerous medical errors with bad outcomes, from instruments left inside the patient to operating on the wrong patient or the wrong part of the body. To enhance patient safety, all staff present stop and go through a checklist together prior to anesthesia and even engage the patient when possible to confirm the right person, the right operation, and the right part prior to beginning. Patient safety is a shared team responsibility.

One way to avoid medical errors in EMS is to foster a true team culture and ask your team whether anyone has any other suggestions before carrying out a difficult decision.

Recent studies have focused on aircraft carrier flight operations that may be one of the most complex and dangerous operations in an extremely unstable environment with great tension between safety and reliability. Everything we know about organizations is challenged by the fact that the crew is mostly young and largely inexperienced, and the management staff of officers turns over half of its personnel every year. The working environment must rebuild itself every 18 months.

Some of the success factors in this naval environment may be the tradition, policies and procedures, and structure, but there is a high degree of delegation and responsibility. Flexibility, overlap of skills, and monitoring of each task are other factors. Many of these elements can be applied to EMS, (see Van Stralen and Thomas Mercer, 2013) including the following:

Do not ignore small errors, since these compound and cascade into major failure. Poor airway management is a good example of how a small error can develop into a larger failure.
Be sensitive and conscious of operations; do not take shortcuts. Base medical decisions on a complete medical evaluation and then follow your medical protocols.
Be reluctant to simplify. Don’t automatically and routinely go for the easiest diagnosis without considering all the information. Evaluate information carefully and use more than one point of view.
Defer to available expertise. Utilize on-site knowledge and the experience of your team.

An optimally functioning team can take a long time to develop, or may never emerge if the members do not understand and embrace these concepts.

Teamwork Systems

Research has shown that training in the team process can result in behavior changes with positive impact. TeamSTEPPS® is an evidence-based teamwork system based on military and civilian research aimed at optimizing patient care by improving communication and teamwork skills among health care professionals, including front-line staff. It includes a comprehensive set of ready-to-use materials and a training curriculum to successfully integrate teamwork principles into a variety of settings. Based on military experience, training for health care teams emphasizes competency in four areas:

Team leadership
Mutual performance monitoring
Mutual support or backup behavior
Communications

Check the TeamSTEPPS website for the basics and begin to discuss with your colleagues.

Bibliography

Emergency Team Coordination Course. United States Army Research Institute for the Behavioral and Social Sciences. November 1995. Available here.
Risser DT, et al. The potential for improved teamwork to reduce medical errors in the emergency department. Annals of Emergency Medicine 1999; 34(3):373-383. Available here.
Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the medteams project. Health Services Research 2002; 37(6):1553-1581. Available here.
Does Team Training Work? Principles for Health Care Eduardo Salas, PhD, Deborah DiazGranados, MS, Sallie J. Weaver, MS, Heidi King, MS. Academic Emergency Medicine 2008; 15:1002–1009. Available here.
Clancy CM, Ornbert DN. TeamSTEPPS: Assuring optimal teamwork in clinical settings. American Journal Medical Quality 2007; 22(3): 214-7.
Hunziker S, et al. Teamwork and Leadership in Cardiopulmonary Resuscitation. Journal American College Cardiology 2011; 57:2381–8. Available here.
Van Stralen D, Mercer TA. EMS and High Reliability Organizing. JEMS. June 2013: 60-63. Available here.