Teamwork and Communication
Most healthcare providers believe in the value of having good teamwork and communication between members of the healthcare team. However, few have had the opportunity for any formal training in these areas. We try to be cooperative with our peers and staff from other cadres. We may work together on a task, help cover a chore that needs to be done while another staff member is busy, and inform one another about issues with patients when it seems helpful.
Yet, rarely do we think about teamwork and communication as a set of skills that must be learned and practiced in order for us to save lives.
Intervention and Clinical Knowledge
Emergency postpartum hemorrhage (PPH) care requires expert skills and careful thinking under pressure. Interventions must be timely and expertly done, often simultaneously. Having clinical knowledge is not enough; we must act and do so having full information about the patient to direct our decision making. To obtain the best outcome for our patients, it requires a truly professional healthcare team.
Think about a professional team, such as a sports team. What makes them successful? They carefully consider their opponents' strengths and weaknesses and create strategies and specific plays that they practice over and over again. They review the fundamentals and make sure they are in peak condition with sharp skills. Each member of the team knows their role and how to maximize their contribution to the team in every play. They have staff members who assure their equipment is in perfect condition before every game. They review videos and films of previous performances to know what they are doing well and what could be done better. All of this effort is put into winning games and putting points on a scoreboard.
We as healthcare providers have much more on the line than points in a game. Women’s lives are in our hands. How much more should we be working together to create a successful professional team to address obstetric emergencies? What does it take for us to be a truly professional team?
- Create the strategy and steps to address PPH emergencies with specific roles for every team member
Have you ever been in a situation on the ward when someone calls for help in an emergency and every staff member within hearing comes running to see what they can do? In some cases, you have a room full of people talking at once and tripping over each other. Everyone has a panicked feeling, and while each clinician may know the interventions and skills required, it feels chaotic and uncoordinated. There is another way.
Creating A Strong Team
With a practiced, professional emergency team, specific staff members are always ready to respond when there is an emergency. They show up quickly when the alarm is sounded, and they know their roles. One team member is the team leader who helps the team be coordinated, but each member of the team is looking out for the patient, making sure interventions are done in a timely fashion and considering next steps. Communication is limited to what is needed to inform the team of clinical findings and interventions. Care is efficient, effective and coordinated because it has been strategized and practiced, and chaos and panic is replaced with confidence and professionalism.
The first step is to know the evidence-based interventions for PPH emergencies and when/how to use them. Consider who is available to be on the emergency response team and assure each member has a role. In very small facilities with few staff, this may even require the involvement of members of staff who are not medically trained to do specific jobs such as hand the clinician supplies, hold a light, communicate with the patient and family, etc.
Below is an example of possible roles for members of an obstetric emergency response team in a well-staffed facility. You will need to determine what will work in your facility. The circles represent where each member should stand during the emergency.
Further, here are a list of mandated steps that each team should abide by. Following these steps below will provide a strong foundation for a professional and repeatable response by the treatment team.
1) Assure each member has the skills and knowledge to perform the interventions required during the emergency.
While each person has specific jobs during the emergency, each member of the team should know PPH pre-surgical management and should be able to perform all the necessary skills.
As much as possible, each member of the team should be expert in the interventions, the order of the interventions and what clinical signs are significant to change management. This allows for fewer instructions and more action. For example, if bleeding is severe and medications have not been effective, one member of the team may perform aortic compression, while another does an exam and a third prepares the UBT or NASG.
2) Assure equipment is functioning and readily available where it will be needed.
Each day (or each shift, in busy facilities) all emergency equipment should be checked to see that it is ready and functioning. All medications should have expirations dates checked and cold chain should be assured. All items must be organized so they can be found immediately when needed, and items should be located in or easily moved to the location where they can be at hand for efficient use without leaving the patient’s side.
3) Assure there is an alarm mechanism to summon the team immediately once a PPH is diagnosed.
Determine where each member of the emergency team will be working and assure that there is a mechanism to summon all members at once. This can be a loud bell or buzzer, a shout with specific words, an intercom or other method.
4) Practice as a team with simulations and drills on a regular basis.
The key to all professional teams is practice. On a frequent and regular basis, the emergency response team should perform a simulation or drill. The alarm should be sounded, and the team should be assembled and presented with an emergency scenario which they can then address to practice the emergency response. Use another staff member as a model patient. Make sure all interventions are remembered and performed at the right time; practice effective communication with each other and with the patient; assure supplies are located in the most efficient place; note knowledge gaps and study to improve them. Work to assure the response to an emergency will be as efficient and effective as possible.
7)Evaluate performance for continued improvement through a debrief.
After every simulation or real emergency, the team involved should gather immediately following the event for team building, self-reflection and evaluation for improvement. They should be sure to also celebrate success. A standard set of questions is helpful in this situation. We suggest:
- How do you feel?
- What went well?
- How can we improve?
At the conclusion of the discussion, identify any concrete steps needed for improvement. Assign action items to specific individuals so the team can benefit.
8) Use other standardized communication tools to assure every healthcare team member is fully informed and able to make expert decisions.
Standardized communication tools are extremely useful ways of assuring full information will be exchanged with all members of the healthcare team effectively. These tools are common throughout team-training literature. A few examples are below in the list.
9) Utilize call-backs when necessary.
A call-back is used during the emergency to assure information that is given is received and acted on correctly. Each directive from a member of the team to another is repeated back.
Example 1:
Team leader: Mary, place an IV.
Team member: I’m placing a 16 gauge IV in the left arm now.
Example 2:
Team member: Pulse is 110, Blood pressure 70/45
Team leader: Tachycardia and hypotension, the patient is in shock. We need to…
10) Utilize SBARs when necessary.
SBAR is a hand over tool. That is, SBAR is used to communicate needed information about the patient whenever a new clinician is assisting with or assuming her care.
Here is an example of an SBAR when the obstetric emergency response team arrives to manage a PPH. The birth attendant (who may also be a member of the team) give the SBAR.
S – situation: Mary had a normal spontaneous delivery 40 minutes ago, but as soon as the placenta delivered, she began pouring blood.
B – background: This is her first baby. She had anemia during her antenatal course but is otherwise healthy. She received 10 units of oxytocin within a minute of delivery. Estimate blood loss so far is about 500 cc. I’ve already checked, and I see no tears.
A – assessment: It appears she may have bleeding due to atony and is still bleeding briskly with a soft uterine fundus.
R – recommendation: I am placing an IV now and will hang oxytocin. We need to address her PPH immediately.
The team at this point can assume their roles in the emergency response team.
11) Practice a huddle formation as necessary.
A huddle is the gathering of the clinicians and staff members responsible for a patient in order to review and plan. It may be used when a patient’s condition changes or becomes worrisome, a transfer has been called in and a patient is expected, a patient and family are upset and need an issue addressed, etc. Just like a huddle during a timeout in a sports game, this allows the team members caring for a patient to be informed of a potential situation before it develops or worsens and to work to mitigate the severity of that situation. Any team member may call a huddle and it can take only a few minutes. In that time, the team members will develop a shared understanding and plan so they can work together on behalf of the patient for the best outcome.
You and your healthcare team may already be doing many of the things mentioned in this section. However, if you have not initiated a specific strategy for teamwork and communication in your facility, you have an opportunity to create a real and significant change in the culture and effectiveness of your workplace. Patients will be safer and better cared for, and job satisfaction for each member of the team will improve as they are part of a truly professional team that saves lives.
