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Learning about human factors in the emergency department

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In May 2022, Holly and Joe, two students on the joint QMUL and DFTB PEM MSc, created video presentations on human factors. We’ve incorporated some of our favourite elements from their presentations in this blog post.

You’re in the paediatric emergency department, typing some notes for the child you’ve just discharged. You’re just about aware of the tannoy in the background. Then you hear the words coming out of the speaker, “Paediatric code black. Paediatric code black”.

You actually run down the corridor. Your heart is thumping, pounding in your ears. You’ve heard the phrase code black before – it’s a traumatic cardiac arrest. You know what to do, in principle, but you’ve never seen one before.


…You burst into resus.

A teenager lies on the resus trolley. They’re getting CPR. Your eyes are drawn to their chest. They have been stabbed. Blood is everywhere – on the patient, the bed, the floor. A shocked friend is being ushered out of the way.

Your heart rate cranks up another notch. You feel it pounding in your chest. The feeling of stress is building inside you. You look around.

There are… people…. everywhere.

The noise is overwhelming.

You hear, “Bougie, ETT!”

You’re pushed aside as a trolley with a thoracotomy kit is wheeled into the bay. You spin in terror.

What you’re feeling is an acute stress response.

The Zero Point Survey and the acute stress response

This kind of stress impairs our cognitive ability, the ability to multitask and our ability to communicate. It can be so profound that it affects your physiology: your heart rate increases, and your blood pressure rises.

We reach our peak level of performance with an intermediate level of stress. Too little, and we’re bored and uninterested and don’t perform at our best. Too much, and we become overloaded. Moderate stress is manageable, motivational, and possibly even performance-enhancing. Our hearts beat a bit faster. We feel a sense of clarity and alertness. Our brain and body are fired up. It’s that little extra push we need in resus or when a hard deadline looms. You’re invested.

But intense stress can lead to a fight, flight or freeze response. As our anxiety ramps up, our hearts beats even faster. It’s unsettling, distracting, and even nerve-wracking. It’s time to rein it in.

Let’s try a little exercise.

Feel your heart beating in your chest.

Breathe in over four seconds.
Hold the inhale for four seconds.
Breathe out over four seconds.
Hold the exhale for four seconds.

This is a simple form of heart rate variability biofeedback training. Guided breathing decreases systolic blood pressure, and heart rate and improves heart rate variability. It also decreases perceived levels of stress.

It’s the first step in the Zero Point Survey, a way to prepare to receive the patient before the point of first patient contact. Ready yourself. Ready your team. Ready your environment. And ready your system.

Ready yourself. The ZPS allows us to take 30 seconds for ourselves. Walk the long way around to the resus room and gain 30 seconds of headspace. This is time for a quick personal pep talk. Clear your mind, focus on the task at hand, formulate a plan, and control our ‘fight-flight’ response.

Ready your team. Resuscitation is a team sport. Cohesive teams are better at providing the best patient care. Prepare the team. Assess the pre-alert. Activate the team. Allocate appropriate roles. And anticipate what this resus may entail.

When expecting the unexpected, set out a shared plan. What is the best-case scenario? What is the worst-case scenario? Share your mental model..

Ready the environment. Consider the environment. Is it ready? Is there enough space? As Shane Broderick so eloquently says, When it comes to equipment, it’s better to look at it than look for it. Check and re-check equipment. Consider any additional equipment that may be required.

And when the patient arrives, ask, What’s happening? What info is available, and am I aware of it? What does that mean? Synthesise the information into something that makes sense. And, What’s going to happen? What are the likely paths for this patient, and what does this mean I need to do?

These are the three facets of situational awareness. We’ll come to these in a moment.

Let’s rewind.

This time when you hear the tannoy, you take a deep breath. You know a paediatric code black means paediatric traumatic cardiac arrest. You know what to do, but you’ve never seen one before. You know you’ll need a team.

You turn to your colleague and ask them to put out a crash call and join you in resus.

You prepare yourself. You go the long way round to resus – it gives you the headspace to do some slow, steady breathing, settle your heart rate, and improve your ability to think on the spot.

You run through the paediatric trauma equipment in your head and are satisfied that you know where everything is – airway kit, circulation drawer, drugs, chest drains, thoracostomy kit.

As you arrive in resus, so too do half the children’s hospital.


It’s crowded and chaotic. It’s mayhem.

Ok, so let’s fix that.

Crowd control

Crowd control is vital in any paediatric resus. Not only do you have the paediatric arrest team, but you often have the adult trauma team in cases of a traumatic arrest. Plus, everyone else wants to be helpful. Larger teams lead to larger challenges. There are challenges in coordinating care, maintaining clear communication, and maintaining roles and sticking to them.

Role stickers or role aprons with names are simple measures to highlight resuscitation roles. But crowd control can still be an issue.

A study in Denmark in 2021 explored barriers to effective resuscitation in over 900 in-hospital resuscitations across six hospitals in Denmark. The commonest barrier was overcrowding or a lack of crowd control. It made it hard to listen, communicate, and access equipment. The most effective strategy to overcome this was to allocate a dedicated person to monitor crowd control. This lets the team leader focus on resuscitation.

Noise implies chaos. It may be a paper-perfect resuscitation, but if people have to raise their voices oe even shout to be heard, it can be disruptive.

Ok, let’s shift gears a second. I want to tell you about a simulation in Dublin a few months ago. Picture the simulation lab. There were 15 doctors and nurses from three paediatric EDs. It was the first simulation of a day-long course. One brave registrar volunteered to go first.

He was brought into the simulated resus bay. There was a pause, and he was asked to put a blindfold on. The simulation started. It was the most phenomenal resuscitation. It was so quiet. The team leader had to rely entirely on verbal communication, with his sense of sight removed. We could hear everything that was said. There was incredible closed-loop communication, and the team successfully resuscitated a child who would otherwise have died.

Closed loop communication

There’s good evidence that a closed loop does work. During a study of 90 real-life trauma resuscitations in a paediatric trauma centre, two independent reviewers watched recordings of them, classified all communication by the trauma team leader and correlated them with the impact of a pre-alert and level of trauma team activation. There were almost 400 verbal commands. On average, tasks were completed 3.6x faster when closed-loop communication was used. A pre-alert, or early activation, of the team, did not impact the time to complete tasks. Closed-loop communication not only improves safety but also speeds up task completion.

Situational awareness

Let’s go back to situational awareness, the final components of the zero-point survey – the patient, updates and priorities. This means.:-

  1. What’s happening? What information is available, and do I have it?
  2. What does that mean? Synthesising the information into something that makes sense
  3. What’s going to happen? What are the likely paths for this patient and what does this mean I need to do?

Ten for ten

For a team to function effectively, they need a common goal based on a shared mental model of what is happening, why it’s happening and what they are collectively trying to do about it. These are the three core facets of situational awareness that can be shared with the team at the start of the zero-point survey.

But resuscitation evolves. The mental model changes. 10 for 10 is a lovely model to keep the team updated. Simply put, it stands for 10 seconds every 10 minutes and represents the need for the team to touch base regularly to reaffirm or change the collective view:

Recap on what has been achieved (or not) so far.

Summarise what’s happening now.

Agree on the next most important steps.

Prioritise the next steps, allocating personnel, equipment and timelines if possible:

“We need to be ready to go scan in 10 minutes.”

And so, let’s rewind one last time.

You’ve heard the tannoy. You’ve taken a deep breath, put out a trauma call to gather your team, and taken the long way round to resus to prepare yourself.

When you arrive at resus, the team member gives you a quick update – a 15-year-old teen brought in by a friend after a stabbing, in cardiac arrest. The team is prepping for resuscitative thoracotomy.

The paediatric trauma team arrives. There’s a quick round of introductions, and stickers are put on, with roles allocated. Someone is allocated to be at the door for crowd control.

The resuscitation is quiet. Communication is closed-loop, with a shared collective mindset.

A hole in a ventricle is identified at thoracotomy and occluded with a finger. Then the patient is rapidly moved to the operating theatre.

The resuscitation bay is cleared, and you gather your team for a hot debrief.

Hot debriefs

Hot debriefs are clearly valued by experienced ED staff and help reduce emotional toil. They lead to increased team cohesion and are often best led by people involved in the event. They are a judgement-free session focussing on events that occurred.

Stop for 5 is a simple hot debrief model. the debriefer starts by simply asking, “Is everyone ok?” If the team feel ready, the debrief continues and states:

“We’re going to have a 5 minute debrief. The purpose is to improve quality of care – this is not blaming session. Participation is welcomed but not compulsory. All information shared in the debrief is confidential.”

And then the debrief runs through STOP:

Situation – a recap of the resuscitation, including the reasoning behind decisions made

Things that went well

Opportunities to improve

Points of action – equipment issues or whether a case review is needed

And so, after the hot debrief, you pause. Take a break. And then head back to the Paeds ED. After all – children are waiting, and you never know what will come through the doors next.

Further learning

Check out these two videos that were created as part of the Queen Mary University of London Paediatric Emergency Medicine MSc by Joe and Holly:

Selected references

Diaz-Navarro C, Leon-Castelao E, Hadfield A, Pierce S, Szyld D. Clinical debriefing: TALK© to learn and improve together in healthcare environments. Trends in Anaesthesia and Critical Care. 2021;40:4-6

El-Shafy IA, Delgado J, Akerman M, Bullaro F, Christopherson NAM, Prince JM. Closed-Loop Communication Improves Task Completion in Pediatric Trauma Resuscitation. Journal of Surgical Education. 2018;75(1):58-64.

Gilmartin S, Martin L, Kenny S, Callanan I, Salter N. Promoting hot debriefing in an emergency department. BMJ Open Quality. 2020;9(3):e000913.

Green B, Oeppen S, Smith W, Brennan P. Challenging hierarchy in healthcare teams – ways to flatten gradients to improve teamwork and patient care. British Journal of Oral and Maxillofacial Surgery. 2017; 55(5); 449-453. DOI:https://doi.org/10.1016/j.bjoms.2017.02.010

Gundrosen, S., Andenæs, E., Aadahl, P. et al. Team talk and team activity in simulated medical emergencies: a discourse analytical approach. Scand J Trauma Resusc Emerg Med. 2016; 24(135): 1-10.DOI: https://doi.org/10.1186/s13049-016-0325-1

Janicki AJ, Frisch SO, Patterson PD, Brown A, Frisch A. Emergency Medicine Residents Experience Acute Stress While Working in the Emergency Department. The western journal of emergency medicine. 2020;22(1):94-100.

Lane PS. Critical Incident Stress Debriefing for Health Care Workers. OMEGA – Journal of Death and Dying. 1994;28(4):301-15.

Lauridsen K, Krogh K, Müller S, Schmidt A, Nadkarnic V, Berg R, Bach L, Dodt K, Maack T, Møllerh D, Qvortruph M, Nielseni R, Højbjergj R, Kirkegaarda H, Løfgrenab B. Barriers and facilitators for in-hospital resuscitation: A prospective clinical study. Resuscitation. 2021; 164: 70-78. DOI:https://doi.org/10.1016/j.resuscitation.2021.05.007

McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Quality and Safety in Health Care. 2009;18(2):109.

Salik I, Ashurst JV. Closed Loop Communication Training in Medical Simulation. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2021. PMID: 31751089.

Steffen PR, Austin T, DeBarros A, Brown T. The Impact of Resonance Frequency Breathing on Measures of Heart Rate Variability, Blood Pressure, and Mood. Frontiers in Public Health. 2017;5.

Sugarman M, Graham B, Langston S, Nelmes P, Matthews J. Implementation of the ‘TAKE STOCK’ Hot Debrief Tool in the ED: a quality improvement project. Emerg Med J. 2021;38:579–584. doi:10.1136/emermed-2019-208830

Authors

  • Joe is a paediatric trainee specialising in PEM. He is passionate about teaching, enjoys rugby, field archery and time with his family.

  • Holly is a Paediatric Sister who specialises in Emergency Care and Critical Care Outreach, based in London. She is passionate about nursing education and development, and is a student in the QMUL DFTB MSc. She loves cooking, travelling, dungarees and her dog Maisie. She/her.

  • Dani Hall is a PEM consultant in Dublin, member of the DFTB executive team and senior clinical lecturer on the Queen Mary University of London and DFTB PEM MSc. Dani is passionate about advocating for children and young people, and loves good coffee, a good story and her family. She/her.

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