Trabajo en Equipo en la Sala ER: Evitando Errores y Mejorando la Moral
Time is one of the most important predictive factors on the outcome of emergency patients.
The effects of readiness and organized response on outcomes for patients receiving emergency care have been well studied and involve the accessibility of the equipment as well as the implementation of a proved method by a trained veterinary team. The combination of solid knowledge, solid communication skills, regular team work training and readily accessible organized equipment is the formula for success.
The Veterinary Team
Emergency medicine requires profound knowledge of physiology, physiopathology, internal medicine, toxicology, pharmacology and drug interactions to be able to readily diagnose the most important life-threatening problems and basic principles of treatment for any emergency patient.
Ideally, the emergency team should have at least 3 trained members. Each member should have an assigned role (Table 1). It has been proved that the veterinary team that has received training in emergency care acts with more confidence, responsibility, and reduced level of stress, and thus has been able to provide better patient care. In a rapid changing area as "emergency care," continuing education is fundamental. The Veterinary Emergency and Critical Care Society recommends at least 40 h of continuing education for specialized doctors and 24 h for technicians over 2 years.
Table 1. Team tasks
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Team tasks
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Secretary
• Answers the phone (provides instructions for transport)
• Establishes the need of emergency triage
• Keeps owners calm and calls for the doctor
• Asks for owner information and starts anamnesis
• Link between the owners and the veterinary team
• Provides treatment costs and asks for signed consents and payment method
• Explains what could be done in the case of cardiorespiratory arrest and obtains resuscitation orders
**The last 2 may be performed by the veterinary team but it should be clearly assigned
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Assistant
• Refills the emergency cart
• Prepares the exam table, fluids and cage
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Technician
• IV catheterization/starts fluid therapy
• Establishes vital signs
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Veterinary trained doctor
• Team leader. Strong knowledge and communication skills.
• Emergency and critical care training
• Knows the ABC method
• Establishes the procedures and gives orders
• Performs advanced maneuvers: endotracheal intubation, tracheostomy, arterial cauterization, etc.
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Adherence to ABC (Airway, Breathing, Circulation) or CPR protocols can only be accomplished if the personnel receive effective, standardized training and regular opportunities to refresh their skills. Emergency training should include didactic components targeted at cognitive performance and opportunities to practice hands-on skills with quality feedback. Simulated situations and structured debriefing after real emergencies, allowing participants to review and critique their performance and the performance of the team as a whole are recommended. Open, honest discussion about opportunities for improvement immediately after an emergency and once-a-week scheduled discussions about the more complex cases can lead to significant enhancement of the team dynamic, emergency performance and better patient outcomes.
The team leader, should be a veterinary doctor with natural leadership capacity and specific training in emergency care. Specific leadership training is also recommended. Crucial roles include distributing tasks to other team members and enforcing rules and procedures to ensure a shared mental model among team members, actively soliciting input from team members to encourage situation awareness and identify issues and ideas from all members of the team, and assigning individual tasks to team members. Team performance can also be enhanced by using focused, clear communication directed at individuals when tasks are assigned.
In order to reduce errors, misinterpretation, and even the lack of performance of the required action, loop communication is recommended. Loop communication means that the requestor should say the name of the person that should perform the order and the order. Then the receiving team member should repeat the order back to the requestor to verify the accuracy and the receiver's perception, the requestor should then ratify the message and finally the receiver should inform that he/she has performed the order. For example:
Team leader: Mary, administer 0.25 ml of epinephrine IV
Mary: 0,25 ml of epinephrine IV
Team leader: that's right 0,25 ml of epinephrine IV
Mary: epinephrine on board
Moreover, the message should include all the important information and nothing else. When there is a prehospital team like ambulance personnel, the information should include this four pieces of information: Mechanisms of trauma, Injuries, Symptoms (GCS, vitals, etc.), and Treatment MIST. During resuscitation the important information includes name of the person that should perform the task, name of the drug, dose and route of administration.
Equipment Organization and Cognitive Aids
The presence of cognitive aids such as checklists, algorithm charts, and dosing charts has been shown to improve compliance with the ABC emergency method.
Access to readily accessible, organized and consistently audited crash carts has demonstrated improved outcomes. It should have 3 to 4 drawers containing only all the elements that you need to use in the first five minutes.
The spaces for drugs should be clearly labeled with the name of the drugs and dose in mg/ml and in ml/kg to facilitate patient dosage.
A list of all the contents of the cart should be available so that daily replacement and after each patient is warranted. The assignation of a person for daily cart replacement reduces the chances for overlooks.
The availability of clear visible ABC algorithms and dosing charts (Table 2) increases the compliance to the ABC method and reduces time for implementation. Formal training of personnel in their use is crucial to effective utilization during a crisis.
Comprehensive, directed well-kept medical records are also very important.
Table 2. Adapted from the Veterinary Emergency and Critical Care Society
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CPR
Drugs/Dose in ml/kg I/V
Double the dose for intratracheal administration
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Emergency drugs
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Dose
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2.5 kg
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5 kg
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10 kg
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15 kg
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20 kg
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25 kg
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30 kg
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35 kg
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40 kg
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45 kg
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50 kg
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Low epinephrine 1:10000 0.1 mg/ml
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0.01 mg/kg
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0.25
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0.5
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1
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1.5
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2
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2.5
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3
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3.5
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4
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4.5
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5 ml
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High epinephrine 1:1000 1 mg/ml
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0.1 mg/kg
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0.25
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0.5
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1
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1.5
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2
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2.5
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3
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3.5
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4
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4.5
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5 ml
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Atropine 0.5 mg/dl
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0.05 mg/kg
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0.25
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0.5
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1
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1.5
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2
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2.5
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3
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3.5
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4
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4.5
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5 ml
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Lidocaine 20 mg/ml
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Dogs 2.0 mg/kg
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0.25
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0.5
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1
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1.5
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2
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2.5
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3
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3.5
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4
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4.5
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5 ml
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Lidocaine 20 mg/ml
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CatsW 0.2 mg/kg
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0.025
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0.05
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Na bicarbonate 1 mEq/ml
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1.0 mEq/kg
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2.5
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5
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10
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15
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20
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25
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30
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35
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40
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45
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50 ml
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Ca gluconate 100 mg/ml
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50 mg/kg
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1
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2.5
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5
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7.5
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10
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12.5
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15
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17.5
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20
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22.5
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25 ml
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Magnesium 4 mEq/ml
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0.2 mEq/kg
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0.1
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0.25
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0.5
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0.75
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1
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1.25
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1.5
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1.75
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2
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2.25
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2.5 ml
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Vasopressin 20 U/ml
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0.8 U/kg
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0.1
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0.2
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0.4
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0.6
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0.8
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1
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1.2
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1.4
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1.6
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1.8
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2
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Amiodarone VF 50 mg/ml
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5 mg/ml
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0.25
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0.5
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1
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1.5
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2
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2.5
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3
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3.5
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4
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4.5
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5
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Defibrillation external
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2–10 J/kg
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20
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30
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50
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100
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200
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200
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200
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300
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300
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300
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360
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Internal
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0.2–1 J/kg
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2
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3
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5
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10
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20
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20
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20
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30
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30
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30
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50
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*Advanced life support W extreme precautions
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References
1. Bliven Maura. Animal health technicians in emergency hospital. The Veterinary Clinics of North America: Small Animal Practice. 1981;11(1):9–22.
2. Crowe Dennis T Jr. Tomada de decisão para o paciente gravemente traumatizado con ênfase nas primeiras 24 horas de cuidado. En: Cardoso Rabelo & Crowe Dennis T. Fundamentos de Terapia Intensiva Veterinária em Pequenos Animais. L.F. Livros de Veterinária LTDA. 2005;16:149–162.
3. Fletccher D, Boller M, Brainard B, Haskins S, Hopper K, McMichael M, Rozanski E, Rush J, Smarick S. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines. J Vet Emerg Crit Care. 2012;22(S1):S102–S131.
4. Devey Jennifer, Cardoso Rabelo Rodrigo. Estableciendo a clínica de emergencia. En: Cardoso Rabelo & Crowe Dennis T. Fundamentos de Terapia Intensiva Veterinária em Pequenos Animais. L.F. Livros de Veterinária LTDA. 2005;4: 27–36.
5. Kirby Rebecca. Critical care - the overview. The Veterinary Clinics of North America: Small animal practice. 1989;19(6):1007–1020.
6. Lacroix Charlotte, Noling Deidre. Advanced directives and do-not-resuscitate orders. In: Wingfield & Raffe, eds. The Veterinary ICU Book. 1st ed. Jackson: Teton NewMedia; 2002;88:1217–1225.
7. Osborne Carl. The problem oriented medical system. Improvement knowledge, wisdom, and understanding of patient care. The Veterinary Clinics of North America: Small Animal Practice. 1983;13(4):745–790.
8. Rollin Bernard. Ethics in veterinary critical care medicine. In: Wingfield & Raffe, eds. The Veterinary ICU Book. 1st ed. Jackson: Teton NewMedia; 2002;87:1205-1216.
9. Wingfield Wayne. 2002. Equipping an emergency/critical care veterinary hospital. In: Wingfield & Raffe, eds. The Veterinary ICU Book. 1st ed. Jackson: Teton NewMedia; 2002;83:1147–1167.
10. VECCS. Recommendations for Veterinary Emergency and Critical Care Facilities. http://veccs.org/guidelines.php (VIN editor: link could not be accessed on 5/26/17).