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Contagious cohesiveness is key to combatting the current global pandemic that is COVID-19. Information about COVID-19 and how we manage patients infected with SARS CoV-2 seems to change hourly.

One thing that will never change is the importance of team function while caring for these patients. In fact, teams are of crucial importance to any patient resuscitation at any time.

In order to continue the fight against COVID-19 we need to learn how to use one contagion to fight another. We need to develop contagious cohesiveness.

A contagion is defined as “communication of disease from person to person.”¹ In this case, SARS CoV-2 is the contagion we are all facing.

Contagious Cohesiveness

However, let’s look toward a different type of contagion as a means to combat this virus.  Social contagion theory is defined as “a tendency for a person, or people, to copy the behaviour of others within their vicinity.”² If we’re not careful, we can spread harmful ideas amongst team members.  For example, not listening to information provided from your team or “yelling” at team members would be detrimental to the way any team functions. 

However, we can utilize social contagion theory to our advantage to create a hive mentality amongst our team.  A mentality where we share knowledge and ideas so that we think and act as a community. This allows us to develop our own social contagion model where we as health care workers move forward together, as a cohesive and highly functioning team, fighting the current COVID-19 pandemic for the betterment of our patients. 

We can utilize 3 key items to create our highly functioning team.  These are:

Organization

Communication

Psychological Safety

Organization

There’s really no better way to organize our team for a high-stakes resuscitation than with the Zero Point Survey (ZPS).³ The ZPS begins prior to the primary survey of the patient and can often be started before the patient arrives in your department. 

The ZPS utilizes the “STEP UP” (Self, Team, Environment, Patient, Updates, Priorities) approach to better organize ourselves, our team and our environment, thereby setting our team up to provide the best possible care to our patient.  Let’s explore this approach as it relates to intubating the COVID-19 patient.  (Please keep in mind this general approach can be extrapolated to any resuscitative situation).

S – Self

Can be divided into physical and cognitive self

Physical

• PEE before PPE
  • Empty your bladder prior to donning your PPE (trust us)
• Donning and doffing of proper PPE
  • Most important part – PRACTICE, PRACTICE, PRACTICE!

Cognitive

• “Beat The Stress Fool”⁴
  • Breath – Tactical breathing exercises to slow your breathing and bring down your heart rate
  • Talk – Positive self-talk.  Remove the idea of imposter syndrome from your mind
  • See – Mental rehearsal of a task/procedure; walk it through in your mind.  E.g.  Tube, cuff inflation, ETCO2/in-line suction, viral filter, ventilator, unclamp
  • Focus – have a “trigger word” to centre yourself.  “We got this” prior to entering a negative pressure room. 

T – Team

Leader

• Incredibly important to oversee the resuscitation.  One central “commander” to guide the team.  Otherwise, multiple orders could be given all at once leading to confusion and disorganization amongst the team. 
• Can be a fluid model where the team leader position can pass back and forth.  E.g. – team leader moves to head of bed with the primary intubator during the intubation process.  They then become task oriented and therefore lose situational awareness of the room.  The airway nurse can then take over as team leader to ensure situational awareness is maintained.  After intubation, the roles switch back. 
• Co-leaders as in nurse-led ACLS.  Even more cognitive load occurs during the protected cardiac arrest of a COVID-19 patient.  The nurse leader can act as the air-traffic controller running the ACLS algorithm while the doc-leader can think about reversible causes, use ultrasound accordingly, speak with family, etc.  Only utilize this approach if you’ve already been using it in your department.

Roles

• Establish clear roles prior to entering the room.  Minimize exposure to the team – therefore only 3 members enter the room (team leader, primary intubator, airway nurse).  Then ensure there are back-up members fully donned in PPE in the anteroom (secondary intubator, secondary nurse) and team members outside the room (spotter/runner, secondary RRT). 
• Ensure all members are comfortable in their roles.  If they are comfortable, they will communicate more efficiently. 

Brief

• What do we know?
  • We know we have a COVID-19 patient in severe respiratory distress and requires intubation
• What do we expect?
  • This to be a highly dangerous procedure yet one we can successfully undergo
  • Anticipate the potential for difficult intubation
• How do we prepare?
  • Gather the equipment we require; utilize checklists to help walk us through the procedure
  • Ensure we are properly donned in our PPE
  • Ensure we have verbalized a Plan A, B, C and D to the intubation process

E – Environment

Equipment

• Checklists
• Pre-made “grab & go” bags
  • Focus on bringing into the room what you need to minimize ins and outs into negative pressure room (while being cognisant not to waste materials)

Ergonomics

• Room layout – standardized room setup

P- Patient

In this situation, this involves the task at hand which is intubating the COVID-19 patient in severe respiratory distress. 

Communication

U – Update/P – Priorities

• Checklists that force us to cross-check with our team prior to moving forward with certain tasks during our resuscitation.
• “10 in 10” – the idea that we pause for 10 seconds every 10 minutes during the resuscitation to allow for a shared mental model within the team⁵
• The tactical pause – yields direction and invitation (Recap, happening now, priorities and next steps) “Have I missed anything?” invite the team to make suggestions. 

Psychological Safety

• Debriefing
  • a rehab session for future resuscitations
  • Not about public shaming, but rather an opportunity to become curious about your team members and the decisions made.
  • Can be Hot or Cold in nature
    • Hot = focuses more on safety and logistics (e.g. INFO model; STOP for 5)
    • Cold = focuses more on emotions (once things cool off)

• SIM! SIM! SIM! – simulate these situations out regularly and debrief amongst the team.  Provides crucial feedback without harm to actual patients.

The Protected Intubation for COVID-19

The link to our entire YouTube channel (including parts 2 & 3) is located here.

EPICC Connection

If you’re one of our awesome nursing colleagues (or anyone for that matter), be sure to check out the COVID-19 resource spearheaded by our great friends over at EPICC learning here. I’m sure you’ll find this living resource useful! Many thanks to the EPICC crew for allowing us to be part of it.

Summary:

1. Use social contagion to fight another contagion – create a hive mentality amongst your team
2. Develop a highly functioning team using 3 key elements:

Organization = ZPS (prepare yourself, your team and your environment)

Communication = 10 in 10 and tactical pause to provide updates and shared mental models

Psychological Safety = Debriefing (debrief after simulation and after all resuscitations to strengthen team relationships

3. These elements allow for the resuscitative team to move forward as a cohesive unit, utilizing their social contagion to fight another and continuing to work better together!

References

1. Google dictionary. Contagion [Internet]. Available at https://www.google.com/search?client=safari&rls=en&sxsrf=ALeKk02UHc4tul6T3kBF2GtReHy-X6qCcQ:1587054727825&q=Dictionary&stick=H4sIAAAAAAAAAONQesSoyi3w8sc9YSmZSWtOXmMU4-LzL0jNc8lMLsnMz0ssqrRiUWJKzeNZxMqFEAMA7_QXqzcAAAA&zx=1587054733103#dobs=contagion
2. Wikipedia.  Behavioural Contagion [Internet]. Available at https://en.wikipedia.org/wiki/Behavioral_contagion
3. Reid C, Brindley P, Hicks C, et al. Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med. 2018;5(3):139–143. doi:10.15441/ceem.17.269
4.  Lauria MJ, Gallo IA, Rush S, Brooks J, Spiegel R, Weingart SD. Psychological skills to improve emergency care providers’ performance under stress. Ann Emerg Med. 2017;70:884–90.
5. Hicks C.  High performance teams: the secrets of success.  Available at https://litfl.com/high-performance-teams/
6. Angus MacDonald, Zero Point Survey.  EMcenterED blog.  September 23, 2019.  Available at https://emcentered.com/step-up-your-resuscitation-skills-with-the-zero-point-survey/