The 3 C’s of Succcess

Helicopter Emergency Medical Services (HEMS) is a culture all its own, but it is not without the same issues most healthcare providers encounter. In my opinion, one of, if not the most significant issues is communication, a vital component of better patient health outcomes  (Agency for Healthcare Research and Quality (AHRQ), 2019). Since HEMS utilizes an inter-disciplinary approach within its models. I am going to discuss communication between medics and RN’s, and how we can enhance communication to improve patient outcomes.

I will do my best to illustrate the best methods of communication for those of us who work within this somewhat and sometimes chaotic environment. My objective is to concisely provide you with evidence-based information for the benefit of you, your partners, and your patients; maybe in that order and maybe not. Either way, at the end of this article I hope that you find something to use during your next transport that benefits all three of those components, but I will be pleased if it is just your patient who benefits.

Currently, the model I work in is a nurse / medic team, and although our backgrounds differ, our end goal is the same. That goal being, getting from point A to point B with a patient who has improved from when we picked him or her up. For this to occur, our team must communicate effectively. So, let us discuss how this is accomplished and some methods that work. The evidence was readily available; it is just a matter of application to our specific environment.

For effective communication to exist, we must begin with consistency. Communication can be difficult when partners change from shift to shift, especially if you have yet to work with the individual. This was proven when a group of Harvard Business School professors chose to study teams performing innovative heart surgery. The surgeons and teams varied; however, the most proficient teams were not necessarily the most experienced but rather, teams who had worked together before (Geer, 2000). Gawande (2002) discussed the same study, and when compared with surgeons who chose their teams at random, those teams had poorer patient outcomes and higher rates of mortality. What this tells me is that it is crucial to work with someone you are familiar with or familiarize yourself with.

What is even more exciting about the study mentioned is that despite its new approach, and the short training provided, those who worked in teams familiar to them performed better. In HEMS, we continuously are working under dynamic situations without much advance notice of what to expect; however, if we are partnered with someone consistent, our outcomes should still be positive. What I suggest is, get to know your partners when you can. If you do not work with them frequently, make conversation before the shift begins and discuss strategies if a situation arises during a “routine call.” Anecdotally, a nurse whom I never worked once called a day before our first shift to get to know each other and make sure I was comfortable. This effort did not go unnoticed and frankly made our shift much more comfortable.

Communication is more than just a simple handshake, hello, and small talk during the non-patient leg of a run. It is also essential to speak up when something is not right; doing so also has shown to lead to better outcomes (Okuyama, Wagner, & Bijen, 2014). One way of ensuring the ability to speak up is through the use of checklists. Despite the ever-changing scenery, a checklist assists with assuring that all standards of practice are met (Makary, 2012). Using a checklist is not new to us in the HEMS environment, nor is it new to us who have had the chance to participate in an Advanced Cardiac Life Support (ACLS) course. I am not suggesting we cookbook ourselves into a corner, but rather ensure that what should be done is done.

In essence, what I am suggesting is that whether we know our partner or not we have a checklist that provides us with information that has a set of objectives or goals. For instance, a patient who is being transferred was one facility to another and is being placed on your transport ventilator. Ideally, the checklist would be used by both providers to meet the objectives for that patient. This might include auscultating breath sounds, looking at x-rays, jotting down pre-transfer ventilator settings, obtaining an arterial blood gas, making sure the ventilator is checked at a standardized time for documentation purposes. In a recent article in the International of Nursing Sciences, checklists not only improved understanding of goals but also decreased intensive care unit (ICU) length of stays (Wang, Wan, Lin, Zhou, & Shang, 2018). Checklists work; it is just a matter of finding the best means of implementation. If you do not like my word, ask a pilot.

So far we have discussed consistency and checklists, and now to something I have used a lot: closed-loop communication. In a 2015 observational study, the use of closed-loop communication was looked at during pediatric traumas (El-Shafy et al., 2018). The study showed that the use of closed-loop communication prevented errors, but also can speed up and increase efficiency. Closed-loop communication is basically the ability to exchange information in a clear and concise manner, and then the other person confirms the information by repeating it back to that person (Peyre, 2019).  Below is an example of closed-loop communication:

Here is an exchange between two providers preparing to and then administering medication. “Jan, please draw up 100 milligrams in one ml of medication A.” “Okay Jim, I am drawing up 100 milligrams in one ml of medication A.” “Jim, I have 100 milligrams in one ml of medication A drawn up.” “100 milligrams in 1 ml of medication A, thank you, Jan”.  Seems simple enough, but research shows this is more difficult to achieve than I have led you to believe (Hargestam, Lindkvist, Brulin, Jacobsson, & Hultin, 2013). However, I would suggest this practice for everything you are performing during patient care, so that the individual you are working with is aware and able to keep track, especially if he or she is using a checklist.

Let us summarize; communication is key to better patient outcomes (Agency for Healthcare Research and Quality (AHRQ), 2019). We know that consistency works best. However, if we do work with a different partner, talk with them before a shift and even before a run; even if it is just an introduction (Geer, 2000). The use of checklists improves communication and ensures that we speak up when something is not right or when we have a question about something (Makary, 2012). Furthermore, checklists have shown to reduce medical errors as well as LOS in ICU patients (Wang et al., 2018). The use of checklists helps us communicate and assists us with meeting standards of care finally, that we use closed-loop communication when possible, especially during situations that are time sensitive, like traumas and code situations (El-Shafy et al., 2018).

So in closing, let us communicate better with these evidence-based tips and provide our patients with the best possible outcomes we are capable of. Do not be afraid to speak up when something does not feel right. Use checklists, closed-loop communication, and if at all possible, consistency aka working with the same people more often.

Agency for Healthcare Research and Quality (AHRQ). (2019). Communication between clinicians.Rockville: U.S. Department of Health and Human Services.

El-Shafy, I. A., Delgado, J., Akerman, M., Bullaro, F., Christopherson, N. A., & Prince, J. M. (2018). Closed-loop communication improves task completion in pediatric trauma resuscitation. Journal of Surgical Education, 75(1), 58-64.

Gawande, A. (2002). Complications.New York City: Picador.

Geer, H. (2000). Inside the OR: Disrupted routines and new technologies. Harvard Business School: Working Knowledge.

Hargestam, M., Lindkvist, M., Brulin, C., Jacobsson, M., & Hultin, M. (2013). Communication in interdisciplinary teams: exploring closed-loop communication during in situ trauma team training. Emergency Medicine Research, 3(10).

Makary, M. (2012). Unaccountable: What hospitals won’t tell you and how transparency can revolutionize health care.New York: Bloomsbury Press.

Okuyama, A., Wagner, C., & Bijen, B. (2014). Speaking up for patient safety by hospital-based health care professionals: a literature. BMC Health Services Research, 14, 1-8.

Peyre, S. E. (2019). CRICO operating room team training collaborative: Closed loop communication. CRICO.

Wang, Y.-Y., Wan, Q.-Q., Lin, F., Zhou, W.-J., & Shang, S.-M. (2018). Interventions to improve communication between nurses and physicians in the intensive care unit: An integrative literature review. International Journal of Nursing Sciences, 5(1), 81-88.


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