Emergency Department Preparation for Resuscition

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Protocol: Pre-Briefing
Protocol: Preparation Mnemonic: AEIOU
Approach: EMS Handoff of Resuscitation
References
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II. Protocol: Pre-Briefing

First 2-3 minutes prior to patient arrival is critical to successful Resuscitation and survival
Gather Resuscitation team together prior to Ambulance arrival
1. Review known information with expected course and interventions
2. Discuss backup plans
3. Leader scripts the first 3-5 minutes of Resuscitation with specific tasks for specific team members
Roles are assigned prior to patient arrival (consider applying labels to front of gowns)
1. Provider Running the Resuscitation or code stands at the foot of the bed
2. Provider managing the airway and neurologic evaluation stands at the head of the bed
3. Divide into teams for certain complex tasks (e.g. airway management)

III. Protocol: Preparation Mnemonic: AEIOU

Advanced Airway equipment
1. Place in Resuscitation room
2. Provider responsible for airway is at head of bed
End-Tidal CO2 detector
1. Connect and prepare device
Intraosseous Line
1. Confirm IO kit is available
Organization and Order
1. Gather and role assignment (see above)
2. Delegation of tasks allows for cognitive unloading (see above)
  1. See Decision Making Strategy
  2. Employ decision making aids (e.g. Broselow Tape)
3. Sustain a Shared Mental Model
  1. Summarize and walk through decision making out loud
  2. Train together in simulations to develop strategy and patterns of communication
4. Keep two way communication open
  1. Make team members comfortable with offering suggestions, feedback
  2. Team leader may ask "What am I missing?" to open conversation for suggestions
Ultrasound
1. Place in Resuscitation room and prepare (turn on, select probe and apply gel)

IV. Approach: EMS Handoff of Resuscitation

Paramedic report and transfer of care should be initial focus on patient arrival
1. Allow Paramedics to give history, findings, answer team questions, relay Resuscitation efforts
2. Avoid chatter that interferes with the team hearing Paramedic report
Additional team management techniques
1. Establish clear leadership roles at the time of presentation
  1. Annnounce your role as team leader (if not already established in preparation as above)
  2. Be the sole voice in the room, periodically updating the team
  3. Elicit feedback throughout the code from team members
    1. Ask for additional ideas (e.g. "what am I missing?")
    2. Ask the medication nurse, is our Intravenous Access adequate?
    3. Ask the respiratory therapist, are the ventilations difficult?
2. Use closed loop communication
  1. Use precise language directed at a specific person by name you intend to perform a task
  2. Practice clarification and acknowledgement of assigned tasks
  3. Divide clinical work evenly to avoid overwhelming individual team members
    1. Limit orders to no more than 2 to 3 per each team member at a time
3. Offer feedback with graded assertiveness (Mnemonic: CUSS)
  1. Concern expressed regarding interventions with unclear reason or that are unsafe
  2. Uncomfortable
  3. Safety
  4. Stop
4. Other measures
  1. Allow for patient access in a near 360 degree circle around the patient
  2. Ensure monitors are visible from all patient care positions
  3. Keep highly used Resuscitation equipment near bedside including bedside procedure carts
  4. Keep a Running code log of interventions visible to all (e.g. white board)

V. References

Herbert et al in Herbert (2016) EM:Rap 16(3): 5-6
Swaminathan and Hicks in Herbert (2019) EM:Rap 19(12): 8-9
Swaminathan, Petrosoniak and Hicks in Herbert (2021) EM:Rap 21(9): 4-6

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