Hospitals admit more than five million patients to ICUs across the U.S. each year. The severity of their condition means mortality rates are disturbingly high—the highest of any unit in the hospital. And particularly in times of crisis or disaster, like the COVID-19 pandemic, ICUs are often overloaded with the sickest patients requiring the highest level of care in the most chaotic time. This stresses not only the providers, but the resources, equipment, and technologies that they depend on to execute care effectively and efficiently.
All that considered, it clearly follows that hospitals are tasked with ensuring that their ICUs provide the highest quality patient care no matter what obstacles come—and that demands an equally high level of teamwork.
The critical care environment is extremely unique. It can be as fast-paced as the ER, but patients can be there long-term. The atmosphere can also be emotionally charged, complex, resource-demanding, and stressful.
In addition, the ICU requires a wide-ranging skill set that includes, at the physician level, intensivists, cardiologists, pulmonologists, and surgeons. Nurses, assistants, unit coordinators, and an array of specialists—therapists, pharmacists, social workers, chaplains, dieticians, and the like—round out the clinical staff makeup.
The multidisciplinary, multi-professional nature of the ICU means that providing critical care is a team sport that abolishes the notion of “silo-thinking” or dictatorial “I give the orders, you take them” behavior.
No one, not the intensivist, nurse, therapist, or other support staff, can manage extremely sick, frequently unstable patients alone. Instead, the team must respect each other, rely on each other’s expertise, communicate, and collaborate to coordinate patient care in the safest, most effective manner possible.
The importance of ICU teamwork
Why are we emphasizing the importance of teamwork in critical care so strongly? Because studies show that patients’ outcomes are better in ICUs that place value on such a partnership.
One study, by the National Institutes of Health, found that in units with mortality rates that were lower than predicted, staff members perceived their teams as functioning at higher stages of group development.
Team members were less dependent and more trusting than staff members of units with higher than predicted mortality rates, the study found. Staff members of high-performing units also perceived their teams as more structured and organized than did staff members of lower-performing units.
Studies have also shown that high-intensity staffing — ICUs where intensivists manage or co-manage all patients — is associated with a 30% reduction in hospital mortality and a 40% reduction in ICU mortality.
ICU teamwork defined
Teamwork in the clinical sense means to communicate and make decisions with the express goal of satisfying the needs of the patient while respecting the unique qualities and ability of each healthcare provider.
Teamwork in the intensive care unit refers to the leadership, decision-making, communication, and coordination behaviors used by multidisciplinary team members to provide patient care. Units with high levels of collaboration among the staff have improved patient mortality rates and reduced average patient length of stay.
Strategies for building and training a great critical care team
Building a great critical care team requires a high degree of training. With that in mind, here are seven training strategies, drawn from multiple sources, that can ensure your intensive care unit (ICU) teams work together effectively to deliver the best standard of care.
– – – – –
Deena Costa, Ph.D., R.N., critical care specialist at the University of Michigan Institute for Healthcare Policy & Innovation, suggests that ICUs take a page from football’s playbook when it comes to training.
She offers this advice.
1. Review and analyze interactions
In the same way that football teams analyze game footage to improve performance, Costa says that having ICU team members review and discuss video recordings of their interactions on the job could help improve communication, one of the most significant barriers to delivering effective care.
2. Set goals
Goal setting in the ICU needs to be more responsive to the ever-evolving needs of its patients and take into consideration the random variation of clinicians present at each shift, Costa says.
As in football, the use of huddles and timeouts may help dynamic teams connect and confirm their game plan in the face of changing targets.
3. Simulate exercises
ICU team members generally train within their own professions but have less experience working with other professionals in dynamic teams. Costa recommends enhanced simulation exercises, such as those used in football training, to help ICU teams coordinate more effectively.
An article in the medical journal Critical Care focuses on three related factors when it comes to building effective critical care teams: psychological safety, transactive memory, and leadership behavior.
4. Cultivate psychological safety
“Research conducted in health care and other settings indicates that psychological safety plays a central role in whether expertise diversity, status differences and temporary membership … facilitate or hinder team effectiveness,” the article said.
The article defines psychological safety as the degree to which individuals perceive their work environment as supportive of interpersonally risky behavior, such as asking questions, seeking help, reporting mistakes, raising concerns, or offering suggestions. It notes that the lack of a safe environment can have detrimental effects on team performance and patient outcomes.
By contrast, psychologically safe environments fostered better problem-solving, experienced a more successful implementation of new practices, and saw a lower patient mortality rate.
5. Develop transactive memory
Experienced teams often solve problems better than newlyformed teams, the article said. The reason: experienced teams develop what’s known as a “transactive memory system”—a group-level memory system—that enables them to make better use of everyone’s knowledge, skills, and abilities.
A useful metaphor is to think of transactive memory as a series of computers networked together in a peer-to-peer environment. Each has its own information, but all share a common directory.
Regarding training, transactive memory is probably more caught than taught and occurs only after a team has been together for an extended period when trust among members has had a chance to mature and grow.
The benefit is worth the time investment, the article asserts. Team members build a degree of overlapping knowledge so they can substitute for one another as necessary—an essential element in critical care settings.
6. Look to leaders
Leader behavior shapes the team climate and capabilities, the article said. Hence, it’s wise for team members to look to leaders as an indicator of what is expected and acceptable behavior of their own.
“How team leaders structure the team, define its purpose, remove organizational barriers, help individual members enhance their contributions to the team, and coach to help members use their collective resources to fulfill team goals all influence team success,” the article said.
It also alluded to the fact that leaders who set the climate through inclusiveness, seeking others’ input, making themselves available, and displaying fallibility promote the kind of psychological safety, referred to earlier, that enhances team performance.
7. Train like pilots
A final resource, also taken from Critical Care, likens ICU team training to aviation.
“In aviation, training strategies have focused on improving the skills required by aircrews to maintain effective decision-making under high levels of stress,” the article said. “Techniques include exposing teams to high-stress situations, training pilots to facilitate team discussions before and after stressful team activities, and cross-training aircrew team members to understand the demands and needs of one another’s role.”
Sounds a lot like the ICU, does it not?
Intensive care and aviation share similarities, according to the article: “Both settings involve team-centric, risky, time-pressured work. They are multidisciplinary and exhibit clear differences in the expertise and authority of team members.”
As such, it argues that the aviation model provides a strong platform against which to design and implement team training programs for the ICU.
Conclusion
Perhaps nowhere in the hospital are highlyfunctional teams more important than the ICU—particularly in times of crisis. As such, it’s necessary that teams not only be extremely skilled regarding their particular areas of expertise and responsibilities but also share a common bond built on trust that enables them to rely on one another—especially during high-intensity times when a patient’s life hangs in the balance or a virus is spreading uncontrollably.
“Teamwork makes the dream work,” the saying goes. So, whether you take a page from football’s playbook, focus on psychological safety and transactive memory, look to leaders, or train like pilots, take the time necessary to get the education and resources your critical care staff needs. Your patients and teammates deserve no less.
