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The Whole Team Approach to Care and Its Application in the Resuscitation Setting for a Paramedic


Every year, in-hospital cardiac arrest. (IHCA) affects more than 200 000 persons in the United States (Douma et al., 2021). The commencement of cardiac resuscitation and defibrillation as soon as possible is crucial for enhancing survival, as each minute of delay reduces survival by 10% (Merchant et al., 2020). To enhance their effectiveness and improve the patients’ outcomes after cardiac arrest, healthcare facilities have opted to devote significant resources to training medical professionals in resuscitation and establishing treatment center emergency response systems. Despite these significant efforts, incidence numbers of in-hospital survival following these incidents remain low, with significant variance observed among hospitals (Girotra et al., 2020).

This variance in survival after IHCA may appear odd at first glance. Established standards for advanced cardiac life support (ACLS) give rational, consecutive protocols that are generally acknowledged and utilized throughout most of the world; hence, most hospitals strive to administer the same therapies for the same purposes following the same ACLS training (Link et al., 2015). However, these algorithms are mostly used to guide humans through technical chores at a patient’s bedside. Inadequate non-technical skills are a leading cause of preventable failures in hospitals that harm patients, and it has been argued that non-technical training programs can substantially minimize harm and improve patient outcomes.

The Whole Team Approach

The whole team approach is currently largely acknowledged as an important instrument for transforming health-care provision into a more patient-centered, coordinated, and effective system (American Nurses Association, 2016). The whole team approach, also known as team-based care, is described as the delivery of health care services to people, households, and/or societies with a minimum of two medical practitioners who cooperate with healthcare providers and patients to the degree that each patient desires — to create coordinated, high-quality care by achieving common goals inside and across scenarios. Each member of the team must be aware of and respect the qualities and abilities of the others.

Cardiac arrest teams usually show up late. As a result, first responders, rather than cardiac arrest teams, are more important in surviving in-hospital cardiac arrests (Nollan et al., 2019). First responders are tasked with a number of critical duties, including accurately diagnosing the situation, summoning assistance, and initiating proper measures. As soon as assistance arrives, the arriving specialists must be briefed on the situation, and a speedy team-building process should be conducted to ensure effective collaboration. Although the necessity of fast response in resuscitation is widely recognized, there is little study focused on the earliest stages of resuscitation, and what is available is mostly based on the actors’ recollections.

Crew Resource Management (CRM)

The Crew Resource Management (CRM) was established between late 1970s and early 1980s in order to improve team depth perception and communication in aviation. CRM’s core components have an emphasis on cooperation and planning, the formation and understanding of positional awareness, and improved interaction. Healthcare, like aerospace, involves extensive collaboration among a large number of individuals, and is continually adjusting to new circumstances, and if communication breaks down, there is a serious risk of disastrous outcomes.

Because most hospital operations need several activities, e.g. handovers, noise, interruptions, and team role confusion, communication risks might occur. CRM lays the groundwork for highlighting the major roots of communication problems and limiting their consequences. Healthcare CRM effective teamwork requires selecting the team, studying the fundamentals of human behavior, then implementing what is studied to case studies and ultimately the field. Individuals, teams, and corporations may all benefit from CRM.

Many hospitals use checklists to assist team communication prior, throughout, and after medical treatments. The checklist ensures that all procedures are accomplished prior to continuing, which increases team situation awareness (Smith, 2021). Specialists, nurses, as well as other healthcare teams confirms the information of the patients using checklists. A team leader is in charge of informing the group including establishing links between members. As he monitors the team’s operations, the team leader will promote situational awareness. Team leaders, regardless of rank or status, listen to and interact with other members of the team to guarantee succinct and clear communication.

CRM provides the benefit of providing all members of the team a voice, including those who initially did not have one owing to hierarchy of traditional organizational. Any member of the team can oppose the leaders without fear of being punished if they have good communication skills. In healthcare, research has revealed links between improved nurse-physician collaboration and communication and improved health outcomes, like lower death rates, more contentment, and lower hospital readmissions.

The healthcare industry has long aimed to enhance patient safety and enhance health outcomes. Most CRM projects are designed to reduce communication failures in order to enhance patient safety. Several studies have indicated that systematic trauma team training in Non-technical abilities can increase collaboration in both simulated and real-world patient settings. In one study, residents who received a systematic simulation-based trauma-training program performed better on actual trauma resuscitation evaluations in crisis management and teamwork abilities than residents who just received didactic teaching. Pre-procedure talks, as well as the collection of opinion from all members of the team, increased managerial understanding, and the eradication of the fear of reprisal for reporting concerns, have all been incorporated.

Human factors

Human factors are a range of abilities that are becoming increasingly recognized in medicine, despite their importance in effective patient resuscitation. Human factors are the intellectual, relational, and individual resource abilities that support technical skills and contribute to task performance that is safe and efficient. It is generally understood that providing timely and efficient cardiopulmonary resuscitation (CPR) to individuals who have had a cardiac arrest is critical in reducing morbidity and mortality (Hunziker et al., 2013). Developing solutions that help medical teams live long and prosperous lives and reach their full potential benefits both practitioners and patients. The Systems Engineering Initiative for Patient Safety (SEIPS) model is a popular paradigm for understanding these system variables in healthcare (Holden et al., 2013).

SEIPS 2.0 is a methodology for integrating human factors principles to evaluate diverse and complex processes and systems in healthcare. The “work system” is defined by the SEIPS 2.0 model, which includes five interrelated elements: people, tasks, tools and technology, the physical setting, and organizational circumstances. These five interconnected factors have an influence on patient, staff, and performance effectiveness through influencing care and other associated activities. Any medical professional or team conducting patient care-related duties, a patient undergoing treatment, or associated family and support system might be the individual person at the center of the work system. Human factors models like SEIPS provide a more objective and holistic assessment of how goals are accomplished, reducing the focus on a single issue or area to “blame” and assisting in the identification of areas for development.

Non-technical Skills

Non-Technical Skills (NTS) are a significant component of Human Factors. The NTS are the social and cognitive skills that distinguish high performing teams and individuals. Leadership, communication, and collaboration, which form part of the social skills, as well as cognitive skills like decision-making, stress management, and situational awareness, have all been examined in a variety of situations and are now incorporated into resuscitation protocols everywhere around the globe (Greif et al., 2021).


Several studies have demonstrated that group leaders are important while doing CPR or other emergency procedures (Aase et al., 2020). As a result, modifications in-group composition are delicate stages that necessitate the establishment of a structure that coordinates. It is worth noting that this coordinating structure does not necessarily entail that higher-status experts must take charge.

Team preparation and role allocation

Because both tasks are time-sensitive, team preparations and role assignments will make commencing resuscitation and creating a working group framework easier. In a simulated environment, pre-formed teams were compared against teams formed ad hoc, filmed cardiac arrest circumstances in a potential randomized simulator-based experiment (Hunziker et al., 2013). The experiment had 50 general practitioner teams and 50 hospital physician teams. All of these individuals were placed in pre-formed teams randomly, that is, groups that have completed their team development phase prior to the beginning of an ad hoc or cardiac arrest teams, where a cardiac arrest happened with just one healthcare practitioner present, and the two additional healthcare professionals were asked to assist.

Ad hoc teams spent less time on the scene during the first 180 seconds of the event, took longer to administer the initial defibrillation, and made fewer authoritative remarks. As evidenced by less precise directives and work distribution guidelines, ad hoc teams struggled more than preformed teams to develop leadership during the trial. As a result, for effective CPR delivery, early team organization is critical.

Establishing leadership

In the United Kingdom, an anesthesiologist or intensivist with airway management skills frequently addresses cardiac arrest. Many nurses, particularly those working in intensive care units, also teach resuscitation-training classes. Based on the situation, even more information may be available. As a result, the medical registrar must present himself as the CPR team leader as soon as feasible in order to organize and maximize the available knowledge.

Previous studies have shown that even in teams with a clear hierarchy, the most competent individuals are not always capable of taking the reins. According to a meta-analysis (Mosaic Tasks, 2021), conscientiousness and extraversion were found to be the biggest indicators of leadership emergence in the early stages of medical situations. Other research emphasized aspects other than experience or knowledge, such as sexuality, height, and general talents.

Task management and teamwork

The team leader’s primary job is to manage the team and maintain a broad picture of what’s happening in order to synchronize resuscitation activities, communicate with colleagues, establish appropriate judgements, and take appropriate steps. Cooper and Wakelam used surveillance video of 20 true resuscitation efforts in an exploratory pioneering study to look into the link involving style of leadership, team behavior, and work effectiveness. Better and clearer leadership from team leaders was linked to improved task performance as well as more effective team collaboration.

Leaders who are “hands-on” during the situation are much less likely to be successful leaders, and as a result, the team’s performance dropped. This suggests that in resuscitation, leadership must be viewed as a distinct, time-consuming responsibility. Because leadership is necessary and first responder conduct is often critical, first-responding nurses should assume leadership as soon as possible. It has been proven first-responding nurses who are well trained can effectively manage a life-saving teams. The event’s leadership, on the other hand, may be dynamic. A shift in the makeup of the organization would require a new leadership structure. It is critical to stress that directive leadership must not be carried out in an obviously dictatorial manner, since this might have a detrimental impact on the team, with other participants refusing to share their opinions and thoughts (Rutherford, 2017).


It is critical to ensure that adequate CPR is performed. It is normal for essentials of operation, e.g. a no-try CPR rule, to be in force, and maintaining an eye on the CPR cycles and time as well as documenting supplied medications on a bit of paper, to be overlooked or forgotten. During a simulated trial, team members frequently forgot at least 18% of the information they required, such as defibrillation and cycle counts. Informing the team on the general progress and saying it clearly, what has been accomplished is a great strategy. According to the research, during emergencies, team members who think aloud are more likely to arrive at the proper diagnosis and prevent mistakes. A comprehensive study found that continuous verbalization had a beneficial influence on numerous CPR performance measures, demonstrating its usefulness as a technique of collaboration between team members.

Stress management

Everyone involved in CPR is under a lot of stress. This may cause substantial anxiety and attention deficits, leading to ineffective CPR and inadequate prioritization, which may exacerbate stress in a negative loop. Stress has a negative impact on cognitive skills like concentration, decision-making, and working memory. As a result, the team leader must retain a strong and cool voice tone while delivering precise directions to the members of the team. In Netherlands, researchers conducted a simulation-based random selection met-analysis; the significance of a relaxed team leader was validated by comparing the resuscitation teams’ technical performance and its connection with the team leaders’ Non-technical skills in two different contexts, using specific rankings. External stressors (noise from the radio and a distracting programed family member) were present in one scenario, whereas no external stressors were present in the other. When external stressors were prevalent, a strong association between technical and non-technical evaluation metrics was detected, although there was no indication of such a connection under control settings. In other terms, the team leader’s Non-technical talents get even more valuable when it comes to enhancing CPR efficacy in high-stress scenarios.

Situational awareness

Each cardiac arrest is unique, with unique conditions and workforce flexibility; hence, the team leader’s ability to react to changing situations is critical. In simulated cardiac arrest events, researchers looked at the cognitive basis of efficient collaboration to see what elements led to positive and negative outcomes. They used a checklist to assess team compliance with resuscitation standards and a proven teamwork coding system to assess team behavior. Surprisingly, successful teams departed from the resuscitation technique more, but flexible leadership and resilience determined the outcome.

A study explored the impact of Non-technical skills on clinical outcome and technical competence. By eliminating procedural mistakes, their findings revealed a beneficial relationship between technical and Non-technical skills. It was discovered that increasing situation awareness, in particular, lowered the rate of procedural errors. Another study found that technical mistakes were inversely connected with the surgeons’ situational awareness levels during elective laparoscopic cholecystectomies (Van der Vliet et al., 2019). Being conscious of exhaustion among those providing chest compressions and changing them regularly is an illustration of situational awareness.


One of the most challenging aspects of CPR leadership may be making decisions. No defined procedure regarding how and when the resuscitation attempt should be stopped have ever been in place, and the choice is virtually entirely up to the clinical opinion of the specific doctor. Nevertheless, there are always some useful practices that may be gleaned from published research, such as stopping resuscitation after 20 minutes of a non-shockable pulse and continuing as long as VF continues. Patients’ comorbidities must be taken into account while making a decision, since individuals with low functional status, hepatic insufficiency; renal failure, hypotension, metastatic cancer, and pneumonia are unlikely to benefit from extended CPR. Advanced age and fragility are sometimes considered indicators of a bad prognosis. According to a comprehensive analysis of patients aged 70 and beyond, Survival rates for in-hospital CPR are relatively low and decrease with age.

Crucial decisions should be communicated as plainly as possible to team members. In certain cases, such as hypothermia, performing CPR for an extended period may be a prudent course of action. As a result, a clear conversation among team members about whether to continue or stop CPR is required, along with sound grounds for the choice that are communicated publicly at the scene. This will prevent conflicts from the team and the team leader, as failing to share these details might make certain team members uncomfortable with the leader’s decision.


Whole team approach is essential in handling cardiac arrest-related issues. Cardiac arrest is a real health condition that involves significant non-technical skills in addition to technical skills. To increase the performance of the team and the patient’s results, CPR leadership is essential. Non-technical skills should be used instead of technical skills since they help to identify good CPR leaders. As a result, CPR leader training is critical, and it may be done through simulation programs and post-cardiac arrest evaluation to assist in improving leadership behavior in combination with medical skills and expertise.


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