Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care

Assessment of patients with stroke for hyperacute treatments such as thrombolysis and thrombectomy must be timely, precise, and effective to achieve the best clinical outcomes. Stroke care has advanced significantly over the years with the emergence of new hyperacute therapies including late-window thrombectomy, advanced imaging, and the creation of systems of care. Current challenges, including the COVID-19 pandemic, have exerted stress on existing stroke clinical pathways, exposing potential quality gaps in emergency preparedness. This is especially poignant during the hyperacute phase as providers form ad hoc teams to evaluate and resuscitate patients.

Elements at play include patient factors, health-care resources, team dynamics, and well-being of providers. These notions span the chain of survival in stroke from hyperacute assessment to admission and discharge. Specific to hyperacute assessment, the concept of a protected code stroke (PCS) has emerged, highlighting the importance of screening, adherence to infection prevention and control measures, and coordinated team responses.

The Foundation of Crisis Resource Management in Stroke Care

Knowledge and mastery of technical skills are key to the successful execution of a code stroke. However, there are a myriad of nontechnical skills that are equally critical. Crisis Resource Management (CRM) provides a framework for these skills including situational awareness, triage and prioritization, cognitive load reduction, role clarity, communication, and debriefing.

These principles were originally described as "crew resource management" in the aviation industry, where human error can similarly have disastrous consequences. CRM is increasingly recognized within medicine and has already taken root in specialties such as emergency medicine, critical care medicine, and anesthesia. These specialties share a common thread with hyperacute stroke care—the unifying premise is resuscitation that bridges stroke with neurocritical care.

Providers in code strokes face a high-acuity scenario and effectively function as "brain resuscitationists." The implementation of CRM principles ensures that when additional health-care system pressures arise, stroke teams remain equipped to deliver effective resuscitation.

Core CRM Principles for Stroke Teams

The Zero Point Survey Framework

CRM combines several essential elements that span the team, environment, and individual provider. In the resuscitation setting, these nontechnical components should be considered prior to hands-on patient assessment as a "zero point survey," prior to the primary survey and resuscitation. This framework includes:

S - Self Check

• Mental readiness assessment

• Physical readiness evaluation

• Stress and fatigue awareness

T - Team

• Determination of code stroke leader

• Role clarity establishment

• Pre-brief with team members

E - Environment

• Space assessment and crowd control

• Noise management and lighting optimization

• Equipment verification

P - Patient

• Primary Survey: ABCDE approach

• Clinical History gathering

• NIHSS assessment preparation

U - Update

• Share mental model of patient status

• Ensure team alignment on assessment

P - Priorities

• Identify team goals

• Set mission trajectory

1. Situational Awareness

Situational awareness encompasses full awareness of self, team, and environment. To be effective, providers must recognize "cues" in the environment that are pertinent to patient assessment, comprehension of the environment, and projection of future status. These cues require synthesis to arrive at focused differential diagnoses and patient trajectory.

In stroke care, this is critical when:

• A patient's hemodynamic and/or airway status is tenuous

• Providers must perceive all available clues and predict impending decompensation

• Teams need to initiate appropriate resuscitative measures before deterioration occurs en route to the scanner or neuroangiography suite

For Protected Code Stroke (PCS):

• Ensures safety of the team and minimizes environmental contamination

• Includes safety leader designation and proper PPE protocols

• Maintains awareness of mask placement on patients

2. Triage and Prioritization

During stroke resuscitation, the number of tasks can be overwhelming and often not congruent with immediately available resources. Prioritization of medical tasks (neurologic exam, blood pressure control) and nontechnical tasks (communication with neuroangiography, medical imaging, and critical care) while triaging their effectiveness is imperative.

Key strategies include:

• Utilizing knowledge gained from previous code stroke debriefings

• Implementing lessons learned from simulation sessions

• Rapid triaging in cases of simultaneous code strokes

• Leveraging assistance from other teams during dynamic scenarios

• Completing zero point surveys prior to patient arrival

3. Cognitive Load Management

As a high-stakes scenario, decision-making in stroke resuscitation presents itself as cognitively taxing. Human cognition has limited working memory, capable of holding finite information simultaneously. This limitation affects novel information acquired through sensory processes.

Two decision-making models apply:

System I Thinking: Fast judgments based on intuition and experience - allows quick decisions from learned responses to similar presentations

System II Thinking: More analytical and deliberate logical reasoning - slower but necessary for complex situations requiring careful analysis

Cognitive load reduction strategies:

• Task delegation to appropriate team members

• Use of memory aids and tools

• Removal of unnecessary steps to reduce cognitive clutter

• Implementation of "buddy systems" for safety leads

• Clear communication protocols between resuscitation leaders and external team members

4. Role Clarity

Clear understanding of team members' roles and responsibilities optimizes team dynamics and maximizes efficiencies. This ensures all clinical care is carried out efficiently while minimizing duplication and preventing errors of omission.

Implementation includes:

• Pre-patient arrival briefings for team introductions

• Ensuring team members know each other by name

• Familiarity with skills, capability, and experience of team members

• Spatial allocation of team members during resuscitation (pit crew approach)

• Use of role designation stickers during protected code strokes

5. Communication

Communication is essential throughout the entire stroke care pathway. Breakdown in communication is a leading cause of medical error and can lead to patient harm.

Effective communication ingredients:

• Closed loops of communication: Information vocalized by team member, repeated by receiving clinician, and reported back

• Brevity and precision: Stating key information in calm, collected manner

• Clear handovers: Maintaining precision during transfers to other units, centers, or operative settings

• Patient/family communication: Assigned team member responsibility, especially for informed consent

6. Debriefing

After the initial resuscitation period, a debriefing should be held between all team members, ideally as a "hot debrief" shortly after the acute scenario. This is especially important in cases with suboptimal outcomes or safety issues.

Hot Debrief Process:

1. Initiate - Announce quick debriefing, encourage participation

2. Safe Space - Ensure psychological safety and flat hierarchy

3. Review - Discuss chronological progression, allow team perspectives

4. Participate - Ensure equal opportunity for all members to speak

5. Follow-up - Track concerns and allow private discussions

Simulation and Training

Translation of nontechnical skills into clinical practice requires deliberate and repeated exercise. Simulation provides opportunity for repeated exposure to clinical scenario variations in safe environments. With repeated exposure to simulated high-stakes situations, clinicians undergo stress inoculation and become more likely to recognize immediate threats and respond appropriately.

Benefits include:

• Effective transfer of CRM skills to clinical settings

• Improvement in patient outcomes and mortality

• Enhanced communication behaviors and teamwork

• Addressing challenges encountered with ad hoc teams

Implementation During Crisis

The current environment offers a unique opportunity to introduce CRM within stroke care. Implementation of CRM principles in day-to-day practice can enhance team cohesion and satisfaction, thereby improving team performance. This can potentially translate to improved outcomes including:

• Culture of safety enhancement

• Reduced post-resuscitation length of stay

• Improved patient satisfaction

• Better survival rates

Conclusion

Crisis Resource Management principles are uniquely positioned to address current needs and future emergency preparedness in stroke care. The therapeutic tools available in stroke care are only as effective as the teams working together to deliver them to patients. As stroke care processes continue to evolve, the importance of consistent, safe, and efficacious care facilitated by CRM principles offers a unique avenue to alleviate human factors and support high-performing teams.

Both hyperacute stroke care and follow-up care provided on stroke units rely heavily on multidisciplinary teams. Systems and pathways must develop the ability to adapt rapidly to acute and emergent stressors. To be prepared for future adversities with high-performing teams, routine implementation of CRM principles will be of significant value to stroke care delivery.

Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness

Cliff Reid, Peter Brindley, Chris Hicks, Simon Carley, Clare Richmond, Michael Lauria, and Scott Weingart
"The primary survey assessment is a cornerstone of resuscitation processes. The name itself implies that it is the first step in resuscitation. In this article, we argue that in an organized resuscitation the primary survey must be preceded by a series of steps to optimize safety and performance and set the stage for the execution of expert team behavior. Even in the most time critical situations, an effective team will optimize the environment, perform self-assessments of personal readiness and participate in a preemptive team brief. We call these processes the ‘zero point survey’ as it precedes the primary survey. This paper explains the rationale for the zero point survey and describes a structured approach designed to be suitable for all resuscitation situations." - paper abstract,  see original paper
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Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care

Phavalan Rajendram, Lowyl Notario, Cliff Reid, Charles R. Wira, Jose I. Suarez, Scott D. Weingart, and Houman Khosravani (corresponding author)
"Background and purpose: Management of stroke patients in the acute setting is a high-stakes task with several challenges including the need for rapid assessment and treatment, maintenance of high-performing team dynamics, management of cognitive load affecting providers, and factors impacting team communication. Crisis resource management (CRM) provides a framework to tackle these challenges and is well established in other resuscitative disciplines. The current Coronavirus Disease 2019 (COVID-19) pandemic has exposed a potential quality gap in emergency preparedness and the ability to adapt to emergency scenarios in real time.
Methods: Available resources in the literature in other disciplines and expert consensus were used to identify key elements of CRM as they apply to acute stroke management.
Results: We outline essential ingredients of CRM as a means to mitigate nontechnical challenges providers face during acute stroke care. These strategies include situational awareness, triage and prioritization, mitigation of cognitive load, team member role clarity, communication, and debriefing. Incorporation of CRM along with simulation is an established tool in other resuscitative disciplines and can be incorporated into acute stroke care.
Conclusions: As stroke care processes evolve during these trying times, the importance of consistent, safe, and efficacious care facilitated by CRM principles offers a unique avenue to alleviate human factors and support high-performing teams."  - paper abstract,  see original paper
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