Effects of team coordination during cardiopulmonary resuscitation: A systematic review of the literature

Journal of Critical Care (2013) 28, 504–521

Effects of team coordination during cardiopulmonary resuscitation: A systematic review of the literature Ezequiel Fernandez Castelao a,⁎, Sebastian G. Russo b , Martin Riethmüller a , Margarete Boos a a

Department of Social and Communication Psychology, Georg-August-University Göttingen, Germany Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Centre Göttingen, Germany

b

Keywords: Cardiopulmonary resuscitation; Advanced life support; Coordination; Communication; Leadership; Planning; Teamwork

Abstract Purpose: The purpose of this study is to identify and evaluate to what extent the literature on team coordination during cardiopulmonary resuscitation (CPR) empirically confirms its positive effect on clinically relevant medical outcome. Material and Methods: A systematic literature search in PubMed, MEDLINE, PsycINFO and CENTRAL databases was performed for articles published in the last 30 years. Results: A total of 63 articles were included in the review. Planning, leadership, and communication as the three main interlinked coordination mechanisms were found to have effect on several CPR performance markers. A psychological theory–based integrative model was expanded upon to explain linkages between the three coordination mechanisms. Conclusions: Planning is an essential element of leadership behavior and is primarily accomplished by a designated team leader. Communication affects medical performance, serving as the vehicle for the transmission of information and directions between team members. Our findings also suggest teams providing CPR must continuously verbalize their coordination plan in order to effectively structure allocation of subtasks and optimize success. © 2013 Elsevier Inc. All rights reserved.

1. Introduction Every 5 years, international resuscitation organizations (eg, such as the European Resuscitation Council) publish updated guidelines based on the latest medical research on cardiopulmonary resuscitation (CPR) [1]. The Advanced Life Support (ALS) Guidelines provide an algorithm for how CPR subtasks should be optimally ⁎ Corresponding author. Tel.: +49 551 397954; fax: + 49 551 3912496. E-mail address: [email protected] (E. Fernandez Castelao). 0883-9441/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcrc.2013.01.005

organized and synchronized during the resuscitation process. Task synchronization requires assignment and coordination of responsibilities among rescue team members, which can be an additional challenge yet essential for efficiency of CPR as well as patients’ and team members’ safety [2,3]. During CPR, the team of health care providers typically functions in a setting characterized by high levels of stress [4], time pressure, and impending danger to the patient [5]. It is because of these inherent characteristics of CPR—highstakes, complex, team-administered, and clarity of shared goal—that we conduct a systematic literature review of team

Effects of team coordination during CPR coordination in CPR to establish how team coordination contributes to the quality of CPR. Team coordination is defined as the management of interdependencies of subtasks by regulated action and information flow in order to achieve a common goal, that is, the performance of high quality CPR [6]. This comprises task management, leadership, and communication as essential prerequisites of effective teamwork and, thus, the resulting quality of CPR and patient safety [7]. Faulty team coordination has been widely recognized as a factor contributing to medical errors [8], and the positive relationship between effective teamwork and patient outcome is supported in other dynamic domains of healthcare [9]. The coordination requirements of CPR are well described by Tschan et al [10], who provide a hierarchical task analysis (HTA) on the basis of the aforementioned ALS Guidelines. Their HTA identifies the goal dependencies which emergency teams have to manage during CPR and what types of coordination mechanisms are suitable to successfully accomplish these goal dependencies. The core goals outlined are (1) diagnosing the cardiac arrest, (2) oxygenating the brain, and (3) attempting to re-establish spontaneous blood circulation, which are further broken down into hierarchies of subgoals. The benefits of effective team coordination in CPR are substantive. For example, Fernandez Castelao et al [11] showed a positive relationship between well phrased leadership utterances, functioning as a coordination mechanism, and no-flow time. The provision of less or poorly articulated leadership utterances was found to be related to treatment delays, which in turn correlate with morbidity [12]. International guidelines [1,13] all focus on describing the optimal sequence of medical actions during a CPR but without specific reference to coordination as the facilitator for seamless transition between completions and beginnings of each subgoal to avoid time loss and thereby increase survival rate [14]. Based on task analysis [10] and related empirical findings [9,15], team coordination and CPR performance seem to be closely linked. The literature also contains a rich body of research regarding team coordination methods in emergency medical teams, how the nature of a task defines whether explicit or implicit methods are optimal, and how these 2 general methods interact to achieve team goals [16–18]. This review examines whether and to what extent team coordination in CPR is empirically confirmed as affecting clinically relevant outcome, with particular focus on findings that contribute to improvement of current ALS Guidelines. Furthermore, the quality of the included articles will be assessed by defining level of evidence (LOE)—which indicates risk of bias—and level of concreteness (LOC)— which indicates lucidity of the reckoning coordination behavior. Finally, we aim to organize the findings into meaningful patterns by deducing a coordination mechanism model based on Hacker's (2003) action regulation theory (ART) [19]. As the ART perceives thought and action of individuals as an interlinked process it was widely used as a

505 theoretical approach for structuring and designing work processes [20]. Thus, the ART provides the necessary background for creating a model to reflect and analyze goal-oriented interpersonal action processes like CPR in order to improve effectiveness [19].

2. Methods 2.1. Search strategy for identification of relevant papers The procedure to identify publications relevant for this review is based on the Cochrane guidelines for designing systematic reviews [21]. 2.1.1. Step 1 A computerized literature search of electronic databases PubMed, MEDLINE, PsycINFO, and CENTRAL was performed in September 2011, limited to the last 30 years. The search focus was journal articles on potential impact of coordination behavior regarding CPR, using all meaningful combinations of two groups of search terms (Fig. 1). Keyword combinations within each of the 2 groups were not applied. Duplicates were excluded from the sample resulting from Step 1. 2.1.2. Step 2 All study titles were screened by the lead author (EFC) for relevance to this review. To assure selection reliability, a second author (MR) independently reviewed a random 20% subset of the titles (n = 1008). The inter-rater agreement was almost perfect (κ = 0.91) [22]. 2.1.3. Step 3 The abstracts of the remaining publications were further screened for relevance. Inter-rater agreement between EFC and MR—based on the decision whether to include or discard each of the remaining articles (n = 462)—at this step was also almost perfect (κ = 0.81) [22]. The references of the end-selected articles were perused to identify further appropriate literature, which were then added to the starting pool of this same step. 2.1.4. Step 4 The remaining articles were screened according to our two criteria: (1) the main findings offer empirical evidence of team coordination in CPR or related medical emergencies (eg, trauma resuscitation) concerning a link between coordination efforts and performance effectiveness; and (2) the article was published in a peer reviewed journal. Once again, inter-rater reliability between EFC and MR was calculated based on the decision whether to include or discard the remaining articles (n = 191) (κ = 0.81) [22]. 2.1.5. Step 5 The selected articles were sorted into topic categories and assessed for quality, with particular attention to the

506

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Fig. 1

Selection flowchart. *In step 5, several of the 63 articles were categorized into more than one topic.

development of coordination behavior classes influencing CPR performance. The categories were inductively generated out of the focal contents of the studies in order to create a comprehensible overview of the findings, simultaneously providing an expandable basis for the allocation of future empirical results.

2.2. Article quality assessment The LOE scales we applied are a unified version of the International Liaison Committee on Resuscitation (ILCOR) LOE scales: scale for studies of therapeutic interventions, scale for prognostic studies and scale for diagnostic studies [23]. The ILCOR LOE scales are used as part of a standard approach to create systematic reviews in order to support the development and update of guidelines for the management of several cardiovas-

cular emergencies, including cardiac arrest. ILCOR experts developed the LOE scales after a detailed review of comparable classifications in common use aiming to ensure external validity [24]. Each of the reviewed classifications—for example, GRADE [25]—was designed by expert task forces who in turn consulted at that time existing rating systems used for the generation of several treatment recommendations for different medical fields [26]. Thus, the quality of the studies included in this review can be assessed with confidence by applying a rating procedure based on the ILCOR scales. For our purpose we generalized the ILCOR LOE scales to their common quality criteria—the potential for bias—into one single scale to make the assessment easier to apply. Based on our LOE scale (lower number, less potential of bias), studies rated LOE 1 (highest score) were those that (a) provide qualitative, quantitative, and temporal aspects of the impact of coordination on CPR outcome, and (b) minimize risk of

Effects of team coordination during CPR

507

bias (eg, randomized controlled studies). Studies rated LOE 2 were those without true randomization (eg, alphabetical randomization). If information included in a study was archival (eg, analysis of medical records), we rated it LOE 3. Case studies were rated LOE 4. Studies not directly related to specific context of CPR were rated LOE 5, including reviews in which no comparable evidence criteria were defined. The LOC, defined as “clarity of the described/measured coordination behavior,” was rated using a 5-point Likert scale developed by the authors. LOC score (1) was awarded if the description of the investigated, discussed, and/or recommended coordination behavior was so clearly depicted that the reader would be able to exactly reconstruct the behavior, including the appropriate moment of its initialization. The initial inter-rater agreement for the LOE and LOC rating was κ = 0.84 and κ = 0.74, respectively; all disagreement s were discussed afterwards by the authors to reach full agreement. Table 1 describes the LOE and LOC scales in detail.

papers for thematic categorization as well as LOE and LOC ratings. Of these 63 papers, 4 (6.34%) were rated LOE 1; 5 (7.93%), LOE 2; 2 (3.17%), LOE 3; 18 (28.57%), LOE 4; and 34 (53.96%), LOE 5. Regarding LOC, 12 papers (19.04%) were rated LOC 1; 10 (15.87%), LOC 2; 11 (17.46%), LOC 3; 14 (22.22%), LOC 4; and 16 (25.39%), LOC 5. The median LOE and LOC were 5 and 3, respectively. Table 2 presents the characteristics of the included studies.

3. Results

3.3. Integrative model of team coordination mechanisms affecting CPR performance

3.2. Categorization by topic Empirical evidence of the papers included in this review rendered three interlinked team coordination mechanisms within CPR treatment: (1) planning, (2) leadership, and (3) communication. Because these mechanisms are associated with each other and in some cases were included within the same article, some papers were classified into more than one topic category. All papers were thematically allocated into at least one of the above 3 categories.

3.1. LOE and LOC assessments The flow diagram (Fig. 1) shows the selection procedure of the papers included in our review, which produced 63

Table 1

Our integrative coordination mechanism model (Fig. 2) summarizes the literature findings. This model is a combination of a deductive and inductive reasoning process,

Definitions, numbers and percentages of LOE and LOC allocations No. of allocated studies (%)

LOE LOE 1:

LOE 2:

LOE 3: LOE 4: LOE 5:

LOC LOC 1:

LOC 2: LOC 3: LOC 4: LOC 5:

Randomized controlled studies, meta-analyzes and systematic reviews of randomized controlled studies which are directly related to our research question: identifying and quantifying the link between team coordination and clinically relevant medical outcomes. Studies using concurrent controls without true randomization, meta-analyses or systematic reviews of these type of studies (eg, non-controlled pre-post studies). Retrospective studies (eg, studies based on past reports). Studies with no control group (eg, case studies). Studies are not directly related to the research question (eg, trauma resuscitation) but they provide information to be included in this review. Coordination behavior is depicted in detail. (eg, content of verbalization is documented word by word). On the basis of these descriptions an accurate reconstruction of effective coordination is easily possible. Coordination behavior is depicted in detail but some of these behaviors remain intangible to some extent. Coordination behavior is depicted partly in detail but to some extent these behaviors cannot be simply reconstructed. Coordination behavior is partly depicted on a very perfunctory level. Coordination behavior is mainly depicted on a very perfunctory level. A concrete reconstruction of these behaviors turns out to be difficult, due to missing details (eg, “good” communication).

4 (6.34%)

5 (7.93%)

2 (3.17%) 18 (28.57%) 34 (53.96%)

12 (19.04%)

10 (15.87%) 11 (17.46%) 14 (22.22%) 16 (25.39%)

508 resulting in a dynamic organization and a linkage between the three main coordination mechanisms revealed in this review: planning, leadership, and communication. The inductive part of our reasoning process consisted in the definition of our three topic categories—planning, leadership, and communication—based on the coordination mechanism(s) mainly focused by the authors of each study included in this review. The deductive part in the screening consisted of pertinent teamwork frameworks—eg, ‘Big Five’ of Teamwork [27], the Structure of Teamwork Behaviors [28], or the FEMPIPO model of group coordination [16]—in order to confirm our defined topic categories as coordination mechanisms affecting team performance. In fact, planning, leadership and communication are interrelated coordination mechanisms empirically confirmed as performance influencing mechanisms in all types of team tasks. As planning, leadership and communication are coordination mechanisms which cannot be completely regarded as disjunct, we postulated a partial interrelation between them. The interrelation is based to the facts that, effective communication is needed for transmitting plans, planning is defined as a function of leadership and in turn communication is needed to be an effective leader. In our model the interrelations of planning, leadership and communication are represented by the overlapping of the inner circles (Fig. 2, inner core). Excerpts from articles included in this review, which are highlighted in the next paragraphs, clarify these interrelations. The structure of our integrated model is based on a theoretical reasoning. Adaptive application of the three coordination mechanisms affects team members’ action regulation to obtain an ideal result [19]. According to the structure of the action process [29], our model exposes the requirement for CPR teams to first orientate themselves within the clinical situation (eg, by monitoring the patient), conceptualize a treatment procedure (eg, plan whether to attempt defibrillation depending on the assessment of the initial rhythm), orchestrate and execute the appropriate actions (eg, first defibrillation and then check breathing), and evaluate and modify strategy (eg, heart rate check) (Fig. 2, four elements of outer ring). The model is a meaningful complement of Tschan's HTA of the CPR task [10] as it merges empirical findings related to coordination demands with a theoretical background (Hacker's ART) [19]. Furthermore, on the basis of the ART—the frame of our model—it becomes apparent which steps teams have to run through to accomplish each subgoal. In sum, by inter-connecting the coordination mechanisms and each of the ART phases and explicitly stating that the four phases of the CPR action cycle are iterative, we underline that, depending on the subtask at hand, teams providing CPR repeatedly run through these action phases. In order to accomplish these phases, teams constantly have the aforementioned 3 interrelated coordination mechanisms at their disposal: planning, leadership and communication. These 3 coordination mechanisms are equally important to succeed in CPR, but according to the ART, each phase is

E. Fernandez Castelao et al. characterized by particular coordination demands. Thus, our model depicts the interrelated coordination mechanisms (Fig. 2, inner core) and the iterative CPR coordination demands (Fig. 2, outer ring) to accomplish each subtask. Evidence for each mechanism of the model and their interrelations are depicted in the following 3 paragraphs.

3.4. Planning as a CPR coordination mechanism influencing medical performance Our analysis of the empirical evidence identified “planning” as a key performance mechanism affecting coordination requirements in CPR situations. A total of 26 papers were categorized into this topic. We also detected in ten studies that leadership tasks of prioritization and distribution of subtasks among the team members—before the CPR begins (pre-process) as well as during the CPR treatment (in-process)—is statistically related to a variety of outcome: reduced hands-off time [30], faster treatment completion [31–33], higher algorithm adherence [2,34–37], and prevention of interruptions [38]. Pre-process planning in three studies was positively associated with return of spontaneous circulation (ROSC) [39], and initiation of crucial treatments (eg, time to first defibrillation) [40,41]. Simulation training as a means to improve planning behavior of CPR teams was successfully evaluated in six studies; improvements of medical outcomes were reported after multidisciplinary resuscitation trainings [42,43]. In one study, the impact of the training on treatment times was rescinded by the integration of new team members into concomitant plans [44]. Two other team trainings evoked augmented planning activities by team members [45,46]. Both training concepts aimed to enhance CPR performance by teaching CPR planning skills, although CPR performance quality as a potential result of improved planning was not quantified. Students reported to be aware of the importance of planning within CPR after completing a crisis resource management (CRM) training including planning recommendations [47]. Planning behavior is empirically proven to directly affect the improvement of chest compressions (CC)—an essential CPR performance marker—by ensuring the minute-byminute rotation of CC providers [48,49]. Planning is closely related to leadership behavior. Participants of 2 interview studies underline that an effective in-process task distribution can be hindered by “hands-on” acting of the team leader (TL), which in turn reduces the leader's capacity to overview the process [50], and that the early establishment of a plan should be clearly transmitted to the team by the TL [51]. One literature review focused on teamwork behavior in dynamic domains of healthcare, including CPR teams, and reported that task distribution (mostly performed by the TL) is one important aspect relevant to the quality of patient care [9]. In summary, pre- and in-process planning, i.e. task distribution, role assignment, and timing of tasks, are crucial

Main characteristics of the studies included in this review

Authors, year of publication [Ref.]

Aim of the paper

LOE

LOC

Topic category PL

Adams et al (2005) [67]

Andersen et al (2010) [50]

Arshid et al (2009) [56]

Bergs et al (2005) [84]

Bernhard et al (2007) [41]

Blum et al (2005) [87]

Bogenstätter et al (2009) [85]

Determination of which physicianstaffing model ― emergency medicine residents or staff hospitalist physicians ― is best for cardiac arrest teams. Identification of non-technical skills suitable for improving CPR team performance and description of barriers to the use and implementation of such skills. Determination of CPR quality during pediatric resuscitation training sessions and to assess the awareness of the team leaders on the CPR quality and their team members. Evaluation of communication during multidisciplinary trauma resuscitation.

Investigation of whether the intervals between admission, diagnosis, and treatment can be reduced and if mortality can be improved by employing treatment algorithms. Evaluation of information sharing during critical event simulation training. Examination of factors influencing the accuracy of information transmitted to nurses and physicians joining a medical emergency situation.

LDS

Setting

Major findings

Code blue activation

Teams led by emergency medicine residents reestablished ROSC faster. No differences in survival rates.

Undefined

List of recommended non-technical behavior with regard to the improvement of resuscitation training.

Simulation

Suboptimal CPR performance. Team leaders failed to address poor CPR performance.

Emergency room

Knowledge transfer is not optimal. Trend towards better communication during the exposure of severely injured patients. Higher diversity in major teams (12 persons) in comparison to minor teams (b 12). Significant reduction of intervals and mortality after algorithm introduction.

COM

4

5

x

5

1

5

5

5

3

4

3

5

5

x

Simulation

4

4

x

Simulation

x

x

x

x

x

x

Emergency room

Effects of team coordination during CPR

Table 2

Significant difference in information sharing from the 1st scenario to the final scenario. Training was reported as useful. Information transmitted to team members who join a CPR process is only partly reliable.

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(continued on next page)

510

Table 2 (continued) Authors, year of publication [Ref.]

Aim of the paper

LOE

LOC

Topic category

Setting

Major findings

Bradley et al (2009) [43]

Identification of effects of interprofessional resuscitation skills training―including attitudes, leadership, teamwork, and BLS skills―on medical and nursing students. Evaluation of formal team training with regard to improvement of teamwork in the trauma resuscitation bay and its link to clinical outcome. Ethnographic exploration of the culture of a trauma team in relation to human factors.

4

4

x

Simulation

Training improved leadership, coordination behavior and BLS skills.

4

5

Simulation

Improvement of teamwork and medical performance after intervention.

5

4

x

Emergency room

2

x

Simulation

5

1

x

Resuscitation t+eam call

4

3

x

Simulation

4

4

x

Emergency room

Leadership performance and experience influence team performance. Leadership has to be trained specifically. Role awareness and consideration of the others’ skills have positive influence on team behavior. Conflict is detrimental. Communication affects cohesion. Training improves leadership performance. Training was widely accepted. Correlations between structuring behavior by the team leader and adequate CPR performance. Team leader structuring behavior is negatively affected by hands-on participation. Role allocation seems to lead to better performance when combined with team skills training. The fastest teams are those where tasks have been allocated before the patient arrives. The risk of personnel listening or reporting to the team leader moderated by the number of team members.

2

PL

Capella et al (2010) [60]

Cole & Crichton (2006) [51]

Cooper (2001) [76]

Cooper & Wakelam (1999) [58]

Driscoll & Vincent (1992) [40]

Experience report of a crisis team simulation training that is focused on team organization. Determination of to what extent time differences within trauma resuscitation are affected by the structure of the trauma team.

x

x

COM

x

E. Fernandez Castelao et al.

De Vita et al (2005) [42]

Evaluation of the effectiveness of a leadership development seminar. Determination of the linkages between leadership behavior, team communication, and CPR performance.

LDS

Exploration of factors that may be associated with nurses participating in resuscitation.

5

5

Fernandez Castelao et al (2011) [11]

Evaluation of the impact of video-based interactive CRM training on NFT and on proportions of team member verbalizations during simulated CPR. Further, to investigate the link between team leader verbalization accuracy and NFT. Exploration of the role of simulation in providing CRM trainings to manage evolving critical situations.

1

1

5

3

Evaluation of ratings of performance through the assessment of clinical and teamwork performance during simulated crises. Presentation and evaluation of an educational intervention with regard to long term increase of leadership skills. Determination of internal medicine residents’ perceptions of the adequacy of their training to serve as in-hospital cardiac arrest team leaders. Assessment of the impact of a formal, structured resuscitation team for in-hospital cardiopulmonary resuscitation over the year following its creation. Evaluation of the effect of an identified command–physician on resuscitation performance. Validation of a simulator as an evaluation tool of trauma team resuscitation skills. Description of physician behavior as team leaders in a simulated cardiac arrest during inter-hospital transfer.

5

4

2

Flanagan et al (2004) [47]

Gaba et al (1998) [37]

Gilfoyle et al (2007) [75] Hayes et al (2007) [73]

Henderson & Ballesteros (2001) [39]

Hoff et al (1997) [66] Holcomb et al (2002) [46] Høyer et al (2009) [36]

x

Undefined

x

x

Simulation

x

x

x

Simulation

x

x

x

Simulation

4

x

x

Simulation

5

5

x

4

5

4

4

4

2

x

5

5

x

Undefined

x

x

x

Delays caused by nurses occur due to insecurity during CPR. Their team members might influence this level of insecurity. CRM training reduces NFT and improves team leader verbalization proportions.

Importance of CRM documented by statements of course participants. Coordination requirements in critical situations are listed. Correlations exist between team behavior and technical score. Behavioral rating system can be improved. Educational intervention does improve leadership skills. Skills were retained after 6 months. Perceived deficits in the training of residents ― lack of feedback and supervision ― to adequately function as CPR team leaders.

Code blue

Formation of formalized, well trained CPR team was associated with better ROSC rates.

Emergency room

Adherence to ALS algorithm significantly higher in teams in which a command-physician was identified. Significant improvement in team performance after 28-day trauma refresher course. Junior physicians performed CPR well. Deficiencies in task delegation were found in junior physicians.

Simulation

Simulation

Effects of team coordination during CPR

Dwyer & Williams (2002) [88]

(continued on next page)

511

512

Table 2 (continued) Authors, year of publication [Ref.]

Aim of the paper

LOE

LOC

Topic category PL

LDS

COM x

Setting

Major findings

Simulation

Low adherence to algorithms, lack of leadership, and communication misdiagnoses were identified during CPR. A prolonged process of team building and poor leadership are associated with significant shortcomings in CPR. Both interventions improve CPR performance. Leadership instruction was rated superior.

Characterization of the quality of resuscitation efforts and identification of targets for educational interventions.

5

3

x

Hunziker et al (2011) [52]

Description of the state of the science linking team interactions to the performance of CPR. Impact comparison between leadership instruction and general technical instruction on simulated CPR scenario performance. Exploration of effects of ad hoc teambuilding on the adherence to the algorithms of CPR among general practitioners and hospital physicians. Exploration and description of verbal and non-verbal coordination mechanisms employed by students during a simulated CPR. Establishment of the length of time over which an individual can maintain effective chest compressions. Specification of leadership challenges during resuscitations.

1

2

x

Misc.

2

2

x

Simulation

2

1

x

Simulation

Ad hoc formed teams had less handson time during early phase of CPR and made less leadership statements.

5

1

Simulation

Coordination implies a combination of bodily conduct and gestures and verbalizations.

4

5

Simulation

Best performance is maintained if CC roles changes every minute.

5

3

x

Undefined

Investigation of how the presence of an attending trauma surgeon during trauma team activation affects treatment times. Gaining new theoretical insights into team leadership in trauma resuscitation units. Examination of the incidence and nature of medication errors during simulated pediatric resuscitations. Systematic review of effective leadership strategies in critical care teams.

4

3

x

Trauma team activations

To manage team member aggressive behavior, effective task delegation and communication were identified as team leader challenges. Presence of trauma surgeon (leading person) leads to reduce treatment times.

5

1

x

Emergency room

Recommendation of dynamic delegation (shared leadership).

5

2

Simulation

5

3

Physicians and nurses made errors, even lethal errors; errors sometimes due to incomplete orders. Effective leaders play a pivotal role in promoting team performance.

Hunziker et al (2010) [12]

Hunziker et al (2009) [30]

Husebø et al (2011) [96]

Huseyin et al (2002) [49] Hynes et al (2006) [64]

Khetarpal et al (1999) [68]

Klein et al (2006) [54] Kozer et al (2004) [82] Künzle et al (2010) [53]

x

x

x

x

x

Misc.

E. Fernandez Castelao et al.

Hunt et al (2008) [62]

Description and evaluation of effectiveness of weekly pediatric resuscitation training.

4

4

Lubbert et al (2009) [61]

Analysis of trauma team functioning with respect to adherence to recommended guidelines. Development of a method to assess CPR skills of nurses and to contribute to the construction of an educational program. Impact evaluation of ALS and ACLS team leader training on resuscitation team performance. Identification of aspects of teamwork affecting quality and safety of healthcare.

5

5

x

Emergency room

3

5

x

Simulation

Defining and teaching leadership seems to improve CPR performance.

4

5

x

Resuscitation room

5

2

x

x

Determination of whether and how human factors affect the quality of CPR. Determination of first responders’ adherence to CPR algorithms CPR in simulated cardiac arrests in intensive care. Testing hypothesis that the process of teambuilding affects the quality of CPR during its early phase.

5

2

x

x

Simulation

5

4

x

x

Simulation

Teams led by ALS or ACLS trained leaders showed reduced defibrillation and drug administration times. Quality of collaboration, shared mental models, coordination, communication, and leadership are relevant to the quality of healthcare. Failure was associated with absence of leadership and explicit task distribution. First responders failed to build a team structure that ensured effective monitored and ongoing team activity.

3

5

x

Meerabeau & Page (1999) [3]

Reflection upon aspects of teamwork within CPR treatment.

5

2

x

Cardiology ward

Niemi-Murola et al (2007) [77]

Examination of medical and nursing students’ beliefs and attitudes toward CPR and current guidelines.

4

4

x

Undefined

Nishiyama et al (2010) [48]

Comparison of time-dependent deterioration of CC between two types of CPR (CC-only vs conventional). Examination of interns' perceptions of own performance; confidence in managing and/or participating in simulated and real CPR.

2

4

5

4

Mäkinen et al (2007) [57]

Mann & Heyworth (1996) [59] Manser (2009) [9]

Marsch et al (2004) [32] Marsch et al (2005) [70]

Marsch et al (2004) [33]

O´Brien (2001) [74]

x

Simulation

x

Misc.

Simulation

x

Simulation

x

x

Simulation/ undefined

Weekly training improves skills, and the introduction of new leading and non-leading team members leads to increased treatment times. Inadequate leadership was related to a higher number of algorithm violations.

Effects of team coordination during CPR

Lo et al (2009) [44]

Teams that were able to plan before the CPR treatment showed faster treatment times. The teambuilding process (incl. planning) leads to treatment delays. CPR teams do not have time for a teambuilding process. Leadership is important. Only 42% of medical students and 20% of nursing students felt confident about their ability to work as a CPR team leader. CC quality rapidly declined. Recommendation of changing CC roles after 1 min to maintain quality of CC. Importance of leadership, team communication, and role assignment during CPR was reported. Simulation training increases confidence and decreases individual stress level.

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514

Table 2 (continued) Authors, year of publication [Ref.]

Aim of the paper

LOE

LOC

Topic category PL

LDS

Setting

Major findings

Pediatric emergency room

Video recording is more effective for detecting errors (drug administration, coordination, communication). 40% of the recorded teams showed lack in leadership and team functioning. Training participants report that poor performance is based on lack of communication and coordination skills. After the training, self-evaluation showed NTS improvements. Poor communication between team members before and after CPR. Team leader selection is not always based on their CPR experience.

COM

Comparison of two methods (video recording vs. medical reports) to identify management errors in trauma resuscitations.

5

5

Østergaard et al (2004) [86]

Description of connections between multiprofessional team training and patient safety.

4

4

x

Simulation

Pittman et al (2001) [83]

5

1

x

Undefined

Quintana Riera et al (2007) [98]

Determination of CPR team communication before and after treatment. Examination of team composition and team leader selection during the treatment. Evaluation of health professionals tolerance providing uninterrupted CC.

5

5

Ritchie & Cameron (1999) [72]

Analysis of trauma team leader performance using video recordings.

5

4

x

Streiff et al (2011) [69]

Determination of predictors of leadership behavior in CPR.

4

2

x

Sugrue et al (1995) [71]

Assessment of the performance of trauma team leaders and definition of scope for improvement. Measurement of teamwork behaviors during delivery room care and its link to the quality of care. Evaluation of two team trainings (highfidelity and low-fidelity) and its impact on neonatal CPR quality.

5

5

x

5

2

x

1

1

x

Thomas et al (2006) [34] Thomas et al (2010) [31]

x

Simulation

x

Emergency room

x

Simulation

Emergency room x

Emergency room Simulation

Two minutes of uninterrupted CC is well tolerated physically by health professionals. Reticence of team leaders to verbalize their thoughts and clear instructions was observed. Video recording is a feasible method to measure team leader performance. Amount of leadership statements is determined by gender and personality and not by knowledge or experience. High scores for medical performance. Deficiencies in communication and delegation were found. Teamwork behaviors significantly correlated with resuscitation compliance. Teamwork behaviors significantly correlated with medical quality.

E. Fernandez Castelao et al.

Oakley et al (2006) [97]

Evaluation of the impact of a 1-day neonatal CPR training.

1

1

x

Tschan et al (2011) [99]

Determination of CPR team member activities and their attention focus during unnecessary interruptions.

4

3

x

Tschan et al (2006) [2]

Evaluation of the impact of leadership mechanisms on CPR performance.

5

1

x

Weinstock et al (2008) [78]

Specification of the concept of teamwork during trauma resuscitation.

5

3

Wright et al (2009) [35]

Examination of the link between observed teamwork behavior and objective measures of medical performance. Exploratory analysis of team leader functions relative to situational demands. Investigation of leadership and effectiveness of teams performing trauma resuscitation.

5

1

5

1

x

Emergency room

Identification of six leadership functions depending on the situation.

5

3

x

Emergency room

Linkage of leadership to team effectiveness, as moderated by relatively specific situational contingencies.

Xiao et al (2004) [100] Yun et al (2005) [63]

x

Resuscitation room

Simulation

x

x

Simulation

Undefined

x

x

x

Simulation

Training led to increased amount of teamwork components (eg, information sharing, Inquiry, assertion). Link to medical quality was not investigated. Team members mainly observed the monitor or dealt with the defibrillator during unnecessary interruptions and their attention was focused on these activities. Leadership and structuring partly explain differences in CPR performance. Emphasis of importance of teamwork in emergencies. Appeal for more useful learning methods, assessment tools, and qualitative scientific approaches. Positive relationship between teamwork skills and clinical skills in a simulation scenario.

Effects of team coordination during CPR

Thomas et al (2007) [45]

LDS, Leadership; PL, Planning; COM, Communication.

515

516 to attain adherence to the ALS algorithms. The results from our review reveal that the designation of a TL is a means to maintain the required in-process planning (i.e. task coordination).

3.5. Leadership behavior as a factor contributing to effective CPR performance The literature documents leadership as a substantial behavior in managing CPR task complexity and positively influencing CPR performance outcomes. A total of 38 papers were categorized into this topic. The pivotal role of leadership within CPR is supported by five review articles regarding CPR situations [52], as well as related medical fields (eg, trauma resuscitation) [9,51,53,54]. Hunziker et al [52] deduce five principles for effective CPR leadership: (1) consider situational demands, (2) facilitate contributions of the non-leading team members, (3) ask problem related questions, (4) keep hands-off, and (5) promote exchange of information. As a meaningful addition to these principles, St Pierre [55] defines further relevant leadership tasks that stipulate (6) to deduce a treatment plan based on medical knowledge and (7) to communicate and distribute tasks of this plan by assigning tasks according to individual skills and knowledge. The TL role has an impact on various CPR performance markers as reported in 16 studies: provision of CC (rate, depth, discharge) [30,56–58], reduction of no-flow time (NFT) [2,11,12,30,56], improvement of ventilation quality [30,56–58], medication conformity [58,59], quality of defibrillation [58,59], and the adherence to algorithms (overall medical performance) [2,32,34,35,37,57,60–63]. Several core leadership behaviors, partly overlapping with the above-mentioned principles, were considered to be required to manage challenging CPR situations effectively. First of all, it is important to be easily identifiable as a TL and to keep hands-off during the treatment in order to maintain a procedural overview [50]. Secondly, the TL should be capable of building a team structure by distributing tasks and communicating using comprehensible commands and responses [3,50,64]. Finally, the leading team member should radiate calmness and positively reinforce the other team members on desirable actions at every occasion [50,65]. The presence of a designated TL leads to reduced treatment times and optimized results [66]. Teams led by experienced TLs re-establish ROSC faster but show no differences regarding survival rates [67]. The presence of a board-certified surgeon who is considered by the team to be an expert for the case at hand reduces treatment decision times during straightforward as well as intrusive trauma resuscitations [68]. Interestingly, TL experience does not predict the amount of leadership statements (neither increases nor decreases) of students performing simulated CPR [69]. Failures in leadership—structuring failures, poor monitoring of the ongoing process [70], delegation deficiencies [71], and verbal reticence [72]—are also empirically documented. These deficits are observed in real-life settings

E. Fernandez Castelao et al. as well as in ALS training scenarios of medical residents [73]. On the other hand, leadership trainings are found to be effective by increasing participants’ confidence and by decreasing individual stress level while performing simulated CPR as a TL [74] by elevating the quality of TL statements [11,12] and by improving overall leadership skills [75,76]. Some of these studies focus on leadership behavior and do not empirically take into consideration the impact of leadership behavior on CPR performance [69,73–76]. Residents as well as students report to be unprepared to lead a CPR team [73,77] and underline the importance of taking part in leadership trainings [47]. The result of two exploration studies is the appeal to set a wider focus on the training of leadership skills after their examinations revealed that leadership behavior—as an essential element of teamwork—positively influences treatment quality [51,78]. In summary, the literature indicates trainable key functions (task distribution, monitoring, and comprehensible communication) of leadership behavior. Furthermore, there is empirical evidence that the designation of a TL and his/her experience level is related to shorter treatment times. Accordingly, the influence of communication properties (eg, common speech, verbalization) on the quality of leadership and results deserves to be especially focused upon, as was repeatedly reported in the literature [11,30,50,53,55,74,79].

3.6. Effective communication as a factor contributing to effective CPR performance The results reveal the influence of the process of communication as a medium for information-sharing and leadership statements on the medical success of CPR. A total of 23 papers were categorized into this topic. In medical emergencies, communication (defined as the transmission of information between one person to another person or group) [80] fulfils four functions: (1) building and maintaining team structure, (2) coordination of team processes, (3) information exchange, and (4) facilitation of interpersonal relationships [55,79]. A direct link between different elements of communication and CPR performance markers are reported in several articles: the accuracy level of TL verbalizations are found to be negatively related to NFT [11], failures of information sharing (eg, confirmation of drug administration) are linked to treatment errors [81,82], information sharing and inquiry are positively related to overall CPR performance [34], provision of directions for immediate action and inquiry correlate with cardiovascular support (provision of CC and defibrillation) [2], and teamwork skills (including communication defined as repetition of messages, usage of accurate terminology, establishment of a conventional speech, and unsolicited provision of information) are found to be positively linked to CPR performance algorithm adherence [35,37] and clinical care of trauma patients [60]. Communication is the vehicle for information sharing, as pointed out by ALS instructors [50]. We found evidence of

Effects of team coordination during CPR inadequate communication regarding different aspects: insufficient communication about individual team member skills, no or unclear designation of seniority or leadership roles before CPR treatment, and infrequent post-process team reflection of CPR performance (eg, no formal debriefing) [83]. At least one third of the trauma team communication was neither comprehensible nor audible [84]. Furthermore, the detail rate of verbalizations was found to positively correlate with the accuracy of ongoing tasks: the lack of detail in verbalizations can lead to inaccurate information transmission during treatment [85]; sparse communication between interns, nurses, and senior staff members was perceived by interns after performing simulated CPR, and also in real-world CPR situations [74]. A lack of clear messages was reported by nearly two-thirds of ALS course participants after performing a simulated CPR [86]. Recommendations of how to communicate effectively— that is, to coordinate teams—comprise the application of closed-loop communication (ie, to express orders explicitly and to confirm the receipt of orders verbally), avoidance of information overload, and use of terms known and shared by all team members [9,50]. Communication skill improvements were attained after different types of interventions as reported in several studies: a video-based CRM lecture that leads to self-reported improvements of trainees’ communication skills [87]; a 90minute CRM seminar that increases the quality of TL verbalizations [11]; and a 2-hour didactic session, a half-day workshop, and a 28-day trauma course that includes suggestions for effective team communication [46,60,75]. Additionally, simulated CPR scenarios followed by debriefing sessions are perceived as useful for improving communication by interns and students [47]. A mixed methods intervention—including role play, video examples illustrating desired behaviors and group discussions—leads to higher rates of inquiry and information sharing as compared to a standard training [45]. The literature also documents that communication behavior of medical students and nurses during CPR treatment is predicted by gender: female students make fewer leadership statements and tend to verbalize more emotional expressions [69]. In addition, personality traits like extraversion and negative agreeableness [69] and subjective attitudes towards own CPR skills [88] are reported to be related to the amount of communication behavior.

4. Discussion This systematic literature review is focused on articles reporting the impact of effective team coordination for high quality medical performance during CPR. Aside from differences in the coordination and performance measurement methods, all selected papers at least support by trend that team coordination is essential for managing CPR situations successfully. Based on our general understanding of the assessed

517 literature, we deduce the following: (1) Pre- and in-process planning, i.e. situation assessment and task distribution/role assignment, can compensate for the lack of team coordination depicted in the ALS algorithms. (2) The designation of a TL is a potential means for adequate in-process CPR planning activities. (3) How far coordination, ideally provided by the TL, leads to the desired results is affected by the quality of interpersonal communication as the vehicle for the transmission of information between team members. Our integrative model of team coordination of the CPR action cycle was created based on a screening and reviewing process of pertinent literature. In the model we deduced three interrelated team coordination components: planning, leadership, and communication. Planning represents a coordination mechanism essential before CPR treatment begins. According to the Coordination Mechanism Circumplex Model [89], the ALS algorithms can be considered as explicit pre-process planning mechanisms. Such documented guidelines were developed with the intention to inform health care team members about the exact sequence of CPR actions to be administered. However, CPR teams must compensate for the lack of outlined team coordination advice given in these algorithms with situation-specific in-process planning, that is, team coordination during clinic administering of CPR treatment, in order for CPR treatment to be effective. Planning, including pre-process and in-process planning, can be equated with the assessment orientation and conceptualization phases within the action regulation theory [19] because it implies upcoming action. The designation of a leading team member is repeatedly identified in the literature to be a necessary and efficient means to manage the transition from the planning phase into the execution phase in CPR treatments. The benefits are clear: because inherent time pressure makes a collective decision about the course of action ineffective, role allocation and task assignment are ideally performed by an experienced and suitably qualified person available—the TL. By the organization of subtasks and the monitoring of the CPR treatment without distraction of constant hands-on administering of process tasks, the TL is able to maintain and convey a shared plan of procedures. Further responsibilities of the TL are to gather relevant information, to provide feedback regarding the performance of the team members, and to make decisions about further treatments. This compilation of responsibilities of the TL reveals the complexity of leadership as a necessary coordination mechanism. The reported empirical relationship between non-optimal communication and treatment failures requires a closer consideration of linguistic factors and their influence on task performance. As mentioned before, verbal communication serves as the best medium for coordination mechanisms. For example, directive leading via assignments can be optimized if the receiver verbally acknowledges the assignment and a corresponding feedback of the person that initiated the assignment follows. Such communication that obeys closed loop principles is found to be

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Fig. 2

Integrative model of team coordination in CPR action cycle.

positively related to performance quality [90]. Each closed loop represents the completion of a subtask, which in turn reduces the level of workload if the corresponding subtask was accomplished in a desired manner. Furthermore, the non–directly involved team members remain updated about the current status of the process and are therefore able to adjust their own behavior to the given circumstances. According to the action regulation theory [19] and our integrative model, this function represents the evaluation and adjustment phase. The recommendation to express short and accurate utterances can be explained on the basis of the results of experimental approaches in the investigation of task load effects on language processing [91]. It is empirically confirmed that the communication process becomes vulnerable to both time delays and errors when the task load increases. In simulated CPR scenarios, the accuracy level of TL coordination demands is related to better NFT rates [11]. Thus, clear and comprehensible communication should be further focused on as a key coordination mechanism in CPR and emergency room settings.

This review has some limitations. It does not focus primarily on the quality of methods for measurement of teamwork. The rules that we apply for the LOE rating are based on the assessment of the psychometric characteristics as long as they are included in the article in question. Thus, we purposely dismiss reports of solely psychometric, thematically focused data in order to not lose our current study focus on coordination requirements. Regarding the methodical quality of the modified LOE scale, we suggest conducting a comprehensive validation in order to increase the validity of this measurement tool. A systematic validity test would enable a more veridical interpretation of the results of this review. Nevertheless, our generalized LOE scale can be regarded as having a certain degree of content validity. According to Moosbrugger and Kelava (2012) [101], content validity relies on experts’ logical and functional thoughts related to the research question at hand. Despite the validity limitation, it is eye-catching that only a small percentage of the articles were comprehensive enough to be rated LOE 1. This sheds light on the general state-of-theart of empirical research in the field. Thus, to expand existent

Effects of team coordination during CPR knowledge about the impact of coordination behavior on medical performance, randomized experimental studies should be applied more widely, allowing the controlled elimination of confounding variables (eg, medical knowledge, status). Beside experimental approaches, it is also crucial to obtain more detailed information about the processes of actual interaction in the real clinical world in order to assess ecological validity. We also suggest applying methods to study temporal dynamics, for example, effects of changes in staff, institutional values and/or functional backgrounds on CPR team coordination over time [92]. However, it will remain difficult to apply experimental designs and to assess process and outcome of CPR in the field because of security and other access problems to data. Hence, high fidelity simulators are likely to provide the best available context to organize experimental designs by creating a realistic situation [93–95].

5. Conclusion In summary, the results of our literature review confirm that team coordination—planning, leadership and communication —are well studied and highly relevant factors predicting CPR performance quality. Our findings also served as the basis for the development of an integrative model based on the ART elements of emergency procedure planning—role allocation and task distribution—through effective leadership applied via clear and comprehensible verbal communication as crucial coordination requirements in CPR treatments. Furthermore, we list the resources needed to meet those requirements: CPR skills training, communication workshops, simulated CPR scenarios and debriefing sessions. It is now clear that although the ALS Guidelines provide a detailed description of the sequence of medical actions, the accomplishment of situationspecific clinical treatment requires substantial additional coordination efforts to optimize the success of applied CPR. With inclusion of the above resources, we expect that the ALS Guidelines and, in turn, success rates of applied, clinical CPR can be improved in a significant way. The implementation of coordination advice into ALS guidelines will help rescuers to round out a more detailed representation of CPR task and team demands. This includes well-reputed medical demands—for example, chest compression, defibrillation, etc—and also knowledge about how to coordinate to effectively adhere to the CPR algorithm, which in turn will free more time for completing CPR subtasks. The advantage of saving time is especially beneficial to CPR teams who, by virtue of tending to medical emergencies, work under time pressure.

Acknowledgments This research was partly financed by the Courant Research Centre “Evolution of Social Behavior”, University of Göttingen, Germany. Special thanks to Margarita NeffHeinrich for her English-for-the-sciences proofreading.

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