CRITICAL CARE TEAM (CCT)
Critical care involves the use of life-sustaining, high-technology medicine catering to a patient population that extends to both extremes of age. In his report, Ibsen described critical care as a specialty that delivers collaborative and multidisciplinary care. At its broadest definition, critical care is an all-encompassing specialty with almost limitless boundaries.1 The size of critical care units and the ratio of beds allotted to Intensive Care Unit ICU in any given hospital has increased over the last few decades. Intensive care units today handle more complex patients than ever. The last two decades have seen rapid advancements in the field of critical care medicine. We now have several sophisticated gadgets and technical expertise for advanced monitoring to support the seriously ill and as a consequence there are increasing expectations for a positive outcome from patients’ families. The fact that multiple complex processes have to happen in parallel, more often than not, dictates that the doctors and teams running the ICU should not only have the medical knowledge and technical knowledge, but more importantly have the ability to perform as a team under high pressure.
Dartmouth surgeon William Mosenthal, established the first ICU in the United States in 1955. His concept was to group the hospital's sickest patients in one place and concentrate nursing resources to allow monitoring under one roof. Prior to that acute and non-acute patients would be spread randomly through a hospital's wards. Once this unit opened, grass root negotiations concerning care of critically ill began between the practicing nurses and physicians. As care givers intimately involved in caring for complex patients, physicians and nurses tested new boundaries, as there were none to guide such a system at that point in time. This process demanded that there be a2 constant dialogue between the care providers. This was the beginning of the critical care team (CCT)—an era that marked the beginning of a culture where physicians relinquished sole authority over their patients and came forward to share decision making with nurses.2 As the number and complexity of medical and technical therapies increased over decades it became difficult for just the physicians and nurses to keep up with the advances while keeping up their skills in every single domain. It also became clear that the critical care specialist (Intensivist) who was and is, to this day, the team leader of the CCT cannot always spare time to monitor complex therapies or stay on top of all the data that flows from the monitoring of an individual patient. It is this understanding that enabled the critical care physicians and nurses to collaborate with pharmacists, dieticians, infection control nurse, physiotherapists, respiratory therapists and social workers, who came together to share knowledge and collaborate for better patient care in the ICU and whose expertise in their respective domains complement the skill and knowledge of every other member in the critical care team thus providing a “Zone of Safety” for patients. These teams not only provide better patient care, but also reduce length of ICU stay, costs and improve quality indicators of ICU care.3 Multidisciplinary teams are the functional units of the ICU in current times. Published data suggests that such teams have a positive impact on ICU outcomes, a finding that has not been replicated by solely increasing ICU physician staffing. This is possibly because the multidisciplinary approach acknowledges the complexities of modern critical care and the important role of communication between providers in delivering comprehensive care. Such a model is endorsed by the Society of Critical Care Medicine and the American Association of Critical Care Nurses.4–7
Published studies have not detailed whether changes in team organization and unit culture coincided with or resulted from changes in physician staffing. Indirect evidence suggests that observed reductions in patient mortality are not simply a result of more physician time at the bedside. Otherwise, adding in-house intensivists to provide care at night (in addition to day) should have resulted in lower patient mortality compared with day-only intensivist staffing.6,8
The above data makes it clear that a team, especially one whose members have complementary skill sets are not only desirable but also necessary for achieving favorable patient outcomes. This chapter aims to highlight the principles that aid the Intensivist to build and manage multidisciplinary teams in the ICU, while elaborating the role of the Intensivist as the team leader. Before proceeding any further, it is imperative to understand what exactly is meant by a team. By definition “A team is a group of people with a full set of complementary skills required to complete a task, or project. Team members operate with a high degree of interdependence, shared authority3 and responsibility for self-management. They are accountable for collective performance and work towards a common goal”.9–11
MEMBERS OF MULTIDISCIPLINARY CRITICAL CARE TEAM
A multidisciplinary team is a group composed of members with varied but complementary experience, qualifications, and skills that contribute to the achievement of the organization's specific objectives. In the ICU, the multidisciplinary team, also known as the CCT comprises of:
- The Consultant Intensivist: The Intensivist is the team leader and is responsible for the proper functioning of the unit. He/she takes care of the patients by doing regular ‘rounds’, oversees the organizational issues such as staffing, ensures ongoing training to update skills and assigns roles and specific tasks to each member of the CCT. He/she also plans goals for the entire day and foresees an emergency situation and discusses a contingency plan, should such an incident occur. He/she is available for any assistance or clarifications and also ensures regular communication with the family. Various models of engagement of Intensivist is there in Closed, Open and Semi Open/Closed Units.12
- Junior doctors (referred to as Residents, Registrars, Fellows, Trainees or Medical Officers): They follow rounds, help the attending physicians and consultant Intensivist by briefing the significant findings and investigations during rounds, perform procedures and liaise with nursing staff and other members of the CCT where necessary, to ensure continuity of care. They participate in formal training sessions and also acquire practical knowledge and skills by interacting with senior doctors.
- Senior nurse who is in charge of the unit: The ICU charge nurse (Also referred as ICU Nursing Director or Nursing Officer) is the nursing team leader and makes decisions during or after rounds with the goal of ensuring adequate patient care and a fluent flow of activities in the ICU. ICU charge nurses make organizational decisions, particularly relating to human resource management and technology, and is often involved actively in decisions relating to purchase and maintenance of equipment. These decisions contribute significantly to the workflow of the ICU. A vast number of these decisions were shown to be ad hoc decisions13 concerning the entire ICU. This is mostly a multi-professional process in which several decisions are needed to complete one task.13
- Registered nurses are key members in day to day care. It is very important to ensure that the nurse who is providing care for the patient is involved in decision making. This creates a better understanding of the specific orders written for the patient that need to be carried out and the expected outcome.4
- Infection control nurse: Healthcare Associated Infections (HAI) are a major concern and can affect up to 33% of patients during their stay in the ICU. Preventing HAI can reduce costs, ICU length of stay (LOS), mortality and morbidity. The role of the infection control nurse is to monitor, guide and evaluate the preventive strategies, to allow for benchmarking and quality improvement, and also to educate the nurses in the unit about infection control practices.
- Clinical pharmacist: It is still not a common practice in ICUs across India to include a Clinical Pharmacist in the CCT. Availability and additional cost involved are the commonly the reported reasons. It is important to understand that a pharmacist as a member of CCT, can play a key role in identifying drug interactions, ensure appropriate dosing and also reduce medication errors in ICU where polypharmacy is common. They also help in medication reconciliation at admission and discharge for patients who have multiple co morbidities.
- Dietitian: The dietitian has become an integral part of the CCT in recent years as it is increasingly understood that nutrition support is an important component of treatment of hospitalized patients. The dietitian works with the team in ensuring appropriate route of nutrition, plans and ensures caloric and protein goals are met and more importantly interacts with the CCT on maintaining fluid and electrolyte balance and optimal blood glucose levels.14
- Respiratory therapist (Often replaced by ICU technicians in Indian ICUs) helps in management of patients requiring various forms of respiratory support (mechanical ventilation, noninvasive ventilation, pulmonary toilet, oxygen supplementation) and play an active role in assessing readiness for extubating ventilated patients.15 Additionally, it is common practice in Indian ICUs for ICU technicians to assist with common procedures and help with maintenance of equipment.
- Physiotherapist helps in mobilization, chest physiotherapy when appropriate and rehabilitation of patients. A dedicated team of physiotherapists would be ideal for the ICU environment although not always practical depending on the size of the ICU and manpower limitations.
- Social worker (Counsellor): Social workers in the ICU acknowledge the complex psychosocial circumstances and financial difficulties that trouble families. They clarify potential misperceptions, enhance communication with families of patients and the medical team members. They help to reduce the likelihood of decision-making conflicts and also make it easier for families to cope with the stress relating to life and death battles of their loved ones.16
Ideally the CCT should have all the above members. But this is not mandatory and who all should constitute the team depends on the size of the ICU, patient demographics (medical, mixed medical-surgical or surgical), acuity of illness, the patient volume the ICU handles and whether the ICU is a tertiary or secondary level ICU.
The essence of a CCT, like any other team, is shared commitment. Without it, groups perform as individuals; with it, they become a powerful unit of collective performance. The best teams translate their purpose into specific performance goals (like improving patient outcomes, improving adherence to quality control initiatives, lowering ICU infection rates) and its members become accountable to their teammates. Having understood the traits that differentiate a team from a group of individuals, one cannot emphasize more the need for strong teams that deliver care to critically ill patients, where the stakes are very high. There is tremendous pressure to deliver highly efficient, well-coordinated care around the clock. This demands not only “hard skills” such as the technical know-how, medical knowledge and expertise but also “soft skills” such as interpersonal skills and communication skills.
Teamwork in the ICU refers to the leadership, decision-making, communication, and co-ordination behaviors used by multidisciplinary team members to provide patient care.17 Intention is not enough to foster a culture where groups perform as a team. It requires deliberate effort on part of the Leader (Intensivist) to inculcate these attributes among every member of the team. There are easily implementable frameworks used in the business world to transform a group into high-performance teams. One such framework that can be adapted to CCT is the ‘S.C.O.R.E.’ (Table 1.1) that outlines the complementary set of characteristics when possessed, make a team highly effective.18
HOW TO BUILD TEAMS?
The key to success of team training tools in health care is identification of domain-specific team skills required for effectively managing routine and emergency scenarios.17 Data suggests that trained teams share more unique information, transfer knowledge better, have interdependence, and produce higher quality solutions.19
However, team building doesn't happen instantly. It is a science in itself and can be built by leveraging on the energy (how much each member contributes to the team) and engagement (how much each member communicates with the team) of its members and the ability of its leader to identify and channel these in the right direction. There are many behavioral science concepts that positively impact the functioning of teams. Manthous et al have written extensively about these attributes and how they affect the psychology of team members in various situations in the ICU.36
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Those most relevant to the Intensivist are discussed below.
Psychological Safety
This was the first among the five most important traits that characterized effective teams, listed by Google in November 2015. It was coined by Amy Edmondson, a Professor at Harvard, who stumbled upon this trait incidentally, while studying what differentiated the best performing groups in hospitals. Psychological safety is a shared belief that the team is safe for interpersonal risk taking.20 In psychologically safe teams, members feel accepted and respected. It is the most enabling condition and often studied in group dynamics and team learning research.21 Most often junior residents and nurses who are motivated at work and want to share an idea for improving performance, do not speak up because of the fear of being judged. This may be counterproductive for patient safety and increase the risk of adverse events in the ICU. There are inherent limitations to memory and also added effects7 of stress and fatigue. Even the most experienced or skilled physician may miss important findings or make mistakes. In the absence of psychological safety team members cannot express concerns over key factors in patient safety. Hence it is very important that the Intensivist establishes this trait as a culture in the ICU. In order to achieve this, one of the following pathways may be adopted.10,21,22
Framework as Learning Problems, as Opposed to Execution Problems
Edmondson says, “Make explicit that there is enormous uncertainty ahead and enormous interdependence”. In other words, be clear that there are areas that still require explanation and that each team member's input matters. When brainstorming treatment options on a difficult patient, the Intensivist should encourage his team members to speak up by saying “This is a very complex patient, I would like to hear a perspective very different from my own, that helps my decision making more clear. Two minds are always better than one”.
Acknowledge your own Fallibility
Make simple statements that encourage peers and subordinates to speak up, such as, “I may miss something - I need to hear from you.”
Model Curiosity by asking a Lot of Questions
The Intensivist should encourage team members to open up and speak out by asking questions that elicit clear responses. For example, “Why do you think this patient is still having fever?”, “Would you consider it appropriate to de-escalate antibiotics on this patient?”. This provides an opportunity for knowledge sharing among various members of the team.
Accountability
Accountability is the glue that ties commitment to results. Even highly capable teams will fail to show results due to the lack of this quality. Psychological safety and accountability interact to produce a high-performing team in an environment where there is uncertainty and interdependence. Leaders who allow for questions and discussions, and also hold their employees accountable for excellence, create the “learning zone,” or the high-performance zone. By contrast, leaders who only hold their employees accountable for excellence without creating psychological safety fall into the “anxiety zone,” which can be dangerous. Leaders who only create psychological safety without holding their employees accountable for excellence remain in the “comfort zone,” and often do not create high performance teams.228
Transactive Memory
Transactive memory theory is based on the idea that individual members can serve as external memory aids to each other.14 Members are able to benefit from each other's knowledge and expertise, if they develop a good, shared understanding of who knows what in the group.23
A study published in the journal of emergency medicine suggested that lack of familiarity between teammates is linked to worsened safety in high risk settings like emergency departments.24 Hunziker and colleagues examined 50 teams that performed cardiopulmonary resuscitation (CPR) simulation exercises. They concluded that hands-on time and time to defibrillation, the two performance markers of CPR with a proven relevance for medical outcome, are negatively affected by shortcomings in the process of ad-hoc team-building. The study suggested that physicians should be aware that early structuring of the team is a prerequisite for timely and effective execution of CPR.1 Teams that have worked together before perform more effectively than newly formed ones, irrespective of skill levels. That is because experienced teams develop trans active memory which enables each member to identify the skills and abilities of the other members in the team that leads to effective delegations of tasks. In a CPR scenario for example, the nurse with best IV access skills can be asked to secure a peripheral IV, whereas the one with better understanding of airway can be asked to take charge of the intubation equipment.
Research has shown that a transactive memory system is primarily developed through interactions between team members. Group training has been shown to assist in the development of a trans active memory system. In one study when group members trained together, they recalled more information about the process, and made fewer errors compared to teams where individuals had gone through the same training but separately. This information is of value for the Intensivist. Trans active memory among ICU teams can be developed by simulation training, team training workshops, extensive discussions and sharing of knowledge during rounds.
Leadership Style
“A leader is one who knows the way, goes the way, and shows the way. Ultimately, leadership is not about glorious crowning acts. It's about keeping your team focused on a goal and motivated to do their best to achieve it, especially when the stakes are high and the consequences really matter”.
—John C Maxwell
There cannot probably be a more appropriate definition of leadership than this, in the context of team leading in the ICU. “The True Measure of9 Leadership is Influence—Nothing More, Nothing Less. True leadership cannot be awarded, appointed, or assigned. It comes from influence, and that cannot be mandated. It must be earned”. The ‘prevailing myth is that leading and managing are the same. Leadership is about influencing people to follow, while management focuses on maintaining systems and processes. It is not the position that makes the leader; it is the leader that makes the position and that holds true for the leader of a critical care team.
Factors that make an Intensivist a great team Leader:21
- Character (Who they are): The Intensivist must be able to provide psychological safety to the team members. He/she must be willing to listen and instill a sense of inclusiveness among the team members. The Intensivist must also be open to suggestions and corrective measures.
- Relationships (Who they know): Maintaining healthy relationships not just with the team members but with fellow consultants and administrative personnel in the hospital.
- Knowledge (What they know): Information is vital. The Intensivist needs to make rounds informative and interesting by making plans based on evidence based protocols and encouraging members to ask questions and educating them.
- Intuition (What they feel): The Intensivist must be able to sense fatigue, stress and burnout among team members and address those issues in the interest of patient safety.
- Ability (What they can do): Ability to provide tools and methods to solve various problems that arise in the day to day running of the ICU and ability to perform under pressure and provide direction to the rest of the team.
Multidisciplinary Rounds in the ICU—The Role of Intensivist as the Team Leader
The Intensivist should:
- Value inputs of others in the team during rounds: Safe and effective care occurs only when multiple disciplines collaborate and formulate a complete plan keeping in mind every minute detail of patient care. The Intensivist must be proactive in creating a situation awareness of the patient25 and then involving every member of the team to express their views before writing down the plan for the day. This results in a shared vision or common goal for patient management for the entire team.
- Listen to others: This is the key component of effective communication and it is important to listen without judgement to create a culture where there is psychological safety. The Intensivist should in fact ensure that the entire team actively works on improving communication at all times, as this does not just happen overnight and without effort on part of the team.10
- Refrain from abusive behavior: If an issue needs to be discussed with a particular team member, it is better to hold that conversation privately and assure confidentiality. If there is a conflict between the orders issued by another doctor in the setting of an “open ICU” it is better to discuss and sort it out. It is the responsibility of the Intensivist to clarify any confusion amongst the nursing staff on conflicting orders written by various specialists.
In addition, as the team leader, the Intensivist should define the essence of the team, i.e. who is in the team, what goals are agreed on during rounds by the team and clarify the roles and responsibilities of every member of the team to avoid any confusion which may negatively impact team performance.
In discharging the above duty, the Intensivist assumes different leadership styles based on the situation. The first is a “democratic or consensus” based leadership style.3 This is apt while doing unit assessment rounds on a daily basis. Problems are identified, investigations are reviewed and the patient is examined. All findings are then vocalized to create a situational awareness among the team for each patient. Procedures that need to be done are delegated to the appropriate personnel and any immediate tasks planned without delay. Contingency plans are discussed where appropriate. Key plans are noted down and explained to the team to make sure they are in agreement. The initial rounds are usually followed by a management round. At this time the Intensivist walks around the ICU keeping an eye on trainees and assisting them as and when they need, with procedural skills. Reassessment of patients is done when there are new events. Any barriers that prevent execution of tasks planned in the morning are identified and addressed. This is also a great opportunity to teach residents and junior staff and familiarize them with the protocols of the unit and clarify their doubts.
The second leadership style is an “autocratic” or the “commander in army” style.3 This is appropriate while leading a trauma code or a Code blue or an emergency situation. The Intensivist here is usually the most senior or experienced person, the stakes involved are high and there is no scope for error. He/she assumes the role of a leader who gives clear orders to his team, defines each person's role within the team and encourages closed loop communication. However, it is of importance to note that psychological safety is very important in this situation, members should be able to pitch in and defer with the leader, if a particular order is not in the interest of the patient.
The leadership style is dynamic and needs to be adapted based on the needs of the unit, the experience of the staff and the contingency of the situation. It is also important that the Intensivist acknowledges the fact that in critical care units, crisis is an everyday occurrence, this in turn leads to staff burnout, fatigue and may also affect their outlook towards work. It is11 therefore important to name and celebrate victories such as survival of a very critical patient, excellence in quality measures, research publications, and suggestions and implementation of projects for improvement.
Leadership in the ICU arises from within specific situations that cannot always be predicted. It is a process that needs to be understood, developed and practiced by individuals on informal positions of leadership. The Intensivist has to understand the multifactorial nature of the exercise of leadership, acknowledging that context issues which may be difficult to predict or control may arise. Team members bring their own cultures, pressures and issues. However, a unifying focus for all is patient safety and it is the responsibility of the leader to ensure that the team works towards common goals at all times.
SUMMARY
- Multidisciplinary teams are the functional unit of an ICU. It has been shown that such teams favorably impact outcomes such LOS, mortality and also cut costs
- The Intensivist is the team leader and is responsible for defining roles of the team members, map out clear expectations from each role and foster a culture that encourages honest, open and effective communication between all members
- Psychological safety, transactive memory and mutual accountability are the behavioral science attributes that impact the functioning of ICU teams
- There is a need for incorporating leadership and team building skills as a part of critical care training programs.
REFERENCES
- Finfer S, Vincent JL. Critical Care — An All-Encompassing Specialty. N Engl J Med. 2013;369(7):669–70.
- Fairman J, Lynaugh JE. Critical care nursing: a history. University of Pennsylvania Press; 1998. pp. 175.
- Manthous C, Nembhard IM, Hollingshead AB. Building effective critical care teams. Crit Care. 2011;15(4):307.
- Durbin CG. Team model: advocating for the optimal method of care delivery in the intensive care unit. Crit Care Med. 2006;34(3 Suppl):S12–7.
- Brilli RJ, Spevetz A, Branson RD, et al. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med. 2001;29(10):2007–19.
- Kim MM, Barnato AE, Angus DC, et al. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010;170(4):369–76.
- Pronovost PJ, Holzmueller CG, Clattenburg L, et al. Team care: beyond open and closed intensive care units. Curr Opin Crit Care. 2006;12(6):604–8.
- Katzenbach JR. The work of teams. Harvard Business School Press; 1998.
- Katzenbach JR, Smith DK. The discipline of teams. Harv Bus Rev. 71(2):111–20.
- Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: An evidence-based review. Crit Care Med. 2008;36(10):2888–97.
- Divatia JV, Baronia AK, Bhagwati A, et al. Critical care delivery in intensive care units in India: defining the functions, roles and responsibilities of a consultant intensivist. Indian J Crit Care Med. 2006;10:53–63.
- Lundgrén-Laine H, Kontio E, Perttilä J, et al. Managing daily intensive care activities: an observational study concerning ad hoc decision making of charge nurses and intensivists. Crit Care. 2011;15(4):R188.
- Wegner DM. Transactive memory: A contemporary analysis of the group mind. In: Mullen B, Goethals GR (Eds). Theories of group behavior. New York: Springer-Verlag; 1986. pp. 185–208.
- Taylor B, Renfro A, Mehringer L. The role of the dietitian in the intensive care unit. Curr Opin Clin Nutr Metab Care. 2005;8(2):211–6.
- Rose SL, Shelton W. The Role of Social Work in the ICU. J Soc Work End Life Palliat Care. 2006;2(2):3–23.
- Reader TW, Cuthbertson BH. Teamwork and team training in the ICU: where do the similarities with aviation end? Crit Care. 2011;15(6):313.
- Centre for Executive Education - SCORE Team Framework [Internet]. [cited 2017 Jan 17]. Available from: http://www.cee-global.com/33/score_framework
- Patterson PD, Pfeiffer AJ, Lave JR, et al. How familiar are clinician teammates in the emergency department? Emerg Med J. 2015;32(4):258–62.
- Building a psychologically safe workplace: Amy Edmondson at TEDxHGSE | Minds [Internet]. [cited 2017 Jan 18]. Available from: https://www.minds.com/blog/view/309963740936146944/building-a-psychologically-safe-workplace-amy-edmondson-at-tedxhgse
- Rentsch JR, Delise LA, Mello AL, et al. The integrative team knowledge building training strategy in distributed problem-solving teams. Small Gr Res. 2014;45(5):568–91.
- Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350.
- Hunziker S, Tschan F, Semmer NK, et al. Public-access defibrillation and survival after out-of-hospital cardiac arrest. N Engl J Med. 2004;351(7):637–46.
- Salas E, DiazGranados D, Klein C, et al. Does team training improve team performance? A meta-analysis. Hum Factors. 2008;50(6):903–33.
- Reader TW, Flin R, Mearns K, et al. Team situation awareness and the anticipation of patient progress during ICU rounds. BMJ Qual Saf. 2011;20(12):1035–42.