Combined Team Training

     For professions that operate in dynamic environments, developing and improving team performance is a significant issue. Paramedics often utilize advanced, high-risk, low-frequency clinical procedures such as endotracheal intubation, rapid sequence induction, needle chest decompression and surgical airways. These procedures are performed in a team environment alongside EMTs and first responders. Though these groups (paramedics and EMTs/first responders) operate together on scenes, if they come from different organizations, they may rarely train together. By combining the training they receive, each of these groups can improve their cybernation, or the high degree of preparedness and skill achieved when a team performs its individual and collective tasks not only correctly, but also with the rapid and smooth automaticity that's the hallmark of high-performance teams.

     Woodbury (MN) Public Safety is a combined department consisting of a police division, a fire division and an EMS division that provides both BLS and ALS services to a rapidly growing community east of St. Paul. Woodbury's ALS has traditionally been provided by both full-time police officer/paramedics and part-time non-officer paramedics who patrol the city 24/7. BLS and patient transport is provided by the fire service through a combination of full-time career and paid on-call firefighter/EMTs. In 2007, ALS transport capabilities were enhanced with the addition of full-time firefighter/paramedics, which allowed the police officer/paramedics to return to law enforcement duties.

     Until 2004, each of Woodbury Public Safety's divisions trained separately, but they responded and operated as an integrated team. That summer, the city began experimenting with a combined team training program that would provide education and training that more realistically represented the integrated team response. The model of separate training for police paramedics and fire service EMTs continued, but a number of combined training events were conducted, drawing positive feedback from all divisions. Due to the endeavor's success, a combined team training (CTT) model was fully implemented in January 2005.

CTT CONCEPT
     Team training is nothing new; sports teams and the military have used forms of it for years. Starting in 1988, the U.S. military began to focus on team training research and development. Researchers in industrial, organizational and clinical psychology began exploring what makes a team work and, more important, what makes a high-performance team good. Three areas have been found to improve team performance and distinguish a high-performance team from other teams. These are interpositional knowledge, team communication and shared mental models.

INTERPOSITIONAL KNOWLEDGE
     Interpositional knowledge (IPK) is knowledge that individuals acquire through cross-training on each other's jobs. To develop IPK, the cross-training must include the procedures, skills, duties and responsibilities of all team members. This allows each team member to understand their role on the team, and how each member's role integrates and interrelates with the roles of other members. Developing IPK allows team members to predict, anticipate and coordinate individual and team procedures more efficiently and effectively.

     0EMS teams can especially benefit from IPK during high-risk, low-frequency tasks. When utilizing advanced airway procedures, for instance, an EMT's IPK would allow him to know or anticipate, without the need for verbal communication, that the paramedic needs suction or assistance positioning the patient.

TEAM COMMUNICATION
     Individual and team communication is essential for combined EMS teams to accomplish their goals effectively. Components of effective communication are proper terminology, brevity, completeness and clarity. Combined team training allows team members to develop understandings of each other's roles, but also to work on effective communication skills in non-stressful environments. This leads to positive, more effective and nonjudgmental communication when working together on a scene.

     Focuses of such training should include verbal and nonverbal communication skills, the use of timely or informational communication, and verbal acknowledgement. During the training, if communication could have been clearer, timelier, more complete, more refined or couched in more proper terminology, the team can stop and discuss how it could have been better. Improved team communication helps develop a shared mental model of what is occurring, has occurred and may occur to the patient or the team.

SHARED MENTAL MODELS
     Shared mental models allow individuals to develop similar visions of what needs to happen to accomplish a team's goals. Team members who possess accurate and equally detailed mental pictures of the requirements for a team function have a shared mental model of the situation. EMS teams operate in extreme environments where clear, precise, timely and complete communication isn't always possible, but the development of a shared mental model can compensate by improving both verbal and nonverbal communication.

     For first responders and EMTs to develop a shared mental model with paramedics, they will first need to develop IPK. Through combined paramedic, EMT and first responder training, EMTs and first responders will learn when, how and why paramedics perform procedures, administer medications and prioritize treatment, and how best to assist them. At the same time, first responders develop the IPK to assist the EMTs, and paramedics develop the IPK to better understand the frustrations first responders and EMTs encounter.

     Ultimately, IPK, effective team communication and the development of shared mental models are required for any team to become a high-performance team.

DEVELOPING CTT
     Combined team training can occur at many levels, from the bottom up. It might start with a single four-person fire-rescue crew working to develop IPK between them, or a two-person EMS crew from the same service attending as much training as possible together to begin building shared mental models. Training then could advance to the crews working together during an auto extrication session. By moving rescue and EMS crew members into each other's roles, a CTT session would occur.

     Regardless of the size of the CTT session, there are five components that must be addressed. The first is determining the broad overall goal you want to accomplish (e.g., improving the management of cardiac arrest patients in your system). The second is determining whom the team members are on a cardiac arrest. Sometimes they are evident, other times they aren't. At Woodbury, the obvious team members are firefighters, police officers, police officer/paramedics, non-officer paramedics and command staff. The not-so-obvious team members are community service officers, police dispatchers and support personnel (for instance, the clinic receptionist when someone walks in with chest pain).

     Once all the team members are identified, you can begin work on the third component: determining what role each team member plays. Start with, for example, the ABCs. Any one of these elements—say, the A (see Figure 1)—can be further broken down into individual skills, procedures and knowledge. Once the duties of each team member have been determined, it's time to begin work on the fourth component, which is defining what each team member needs to know about the other team members' roles (see Figure 2). Each team member needs to work in each position, actually performing the skills or procedures, to develop IPK.

     When you've determined everything members need to know about each other's roles, the final component of CTT is deciding your goals and objectives for the session. They can be team or individual. Team goals can be things like improved communication, better load-sharing at specific times (e.g., seeing a team member unable to control bleeding, a colleague grabs the TraumaDEX and more bandages without being asked) or reduced trauma scene times. Individual goals can include things like situational updates (e.g., "The dopamine is hung and ready to go if you need it,"), decreasing the time needed to complete a procedure or setting up an esophageal detection device for the team member intubating.

     Initially, the CTT may be structured or nonstructured. In a structured situation, use the goals and objectives you developed. In a nonstructured format, let the training unfold and individual team members bring up what went well and didn't. In systems that haven't done formalized team training, beginning with the nonstructured format lets members see the value of CTT before they move on to a more structured approach. This enhances buy-in.

SCENARIOS
     Developing CTT simulations is not drastically different than with other types of training. All of Woodbury's CTT sessions review selected guidelines, medications and BLS and ALS skills and procedures—the foundation of what we do. Topic areas reflect National Registry paramedic recertification requirements, spread out over two-year periods. By spreading them out, it does not matter if a provider recertifies in an odd- or even-numbered year; either way, they'll have the appropriate hours for each required area.

     With a structured format, you have three components: the preview, the simulation and the post-simulation discussion. (With a nonstructured format, omit the preview.) The preview can be as simple as letting the staff know what the next training session will cover—say, newborn delivery and resuscitation simulations—or as in-depth as an hour-long PowerPoint lecture. Start with what type of simulation will be presented. Cover what's needed in a medical history, a typical delivery and what each team member's responsibilities are, newborn assessment, BLS resuscitation tools, the Apgar score, OB delivery guidelines, and what's in your OB kit. This is similar to a professional sports team's pre-practice discussion: a review of key plays, information, roles/responsibilities and other pertinent information.

     Next, present the simulation. Following a preview, staff will typically be more involved because they're more confident in their skills and knowledge. First, decide what goals, team or individual, the simulation will focus on. Then determine two or three objectives related to that goal that you want to achieve. Now you're ready to write the simulation. It can be as detailed as you want, but initially straightforward scenarios (e.g., a normal newborn delivery) work best. Later you can add complicating factors and begin moving EMTs into paramedic roles and paramedics into EMT roles. Once the simulation is over, it's time for the post-simulation discussion. Typically, you should have 3–6 talking points focused on team and/or individual objectives. A team talking point could be, Did all team members have defined roles? If not, why? What could have been done to improve this?

     We have found following many CTT sessions that we are only able to get through one or two talking points because of the in-depth peer-led discussions that occur.

CRITICAL THINKING LAB
     An integral part of Woodbury's CTT program is the critical thinking lab (CTL), which was an outgrowth of other labs initiated by Regions Hospital EMS, which provides Woodbury's medical direction, when the SimMan became available. Initially, Regions' medical director and clinical supervisor would bring the SimMan to Woodbury for quarterly CTT sessions. Woodbury Public Safety later purchased a SimMan and now uses it at all monthly CTT sessions.

     Quarterly CTL sessions differ from monthly ones in that they're led by an EMS clinical supervisor and medical director or emergency medicine resident. (The monthly CTL sessions are peer-led.) This allows EMS staff to see and interact with a medical director. Usually, 2–3 paramedics and 3–6 EMTs attend quarterly sessions, which are three hours long and cover the same goals and objectives as are covered in CTT sessions occurring at the same time.

     The CTL is now home to the SimMan. The room is set up like a living room, with a couch, chair and tables. The instructor is next door, viewing the simulation through one-way glass and controlling the SimMan via laptop computer. Simulation participants have to interact with the patient. If they want to know a blood pressure, they have to take one. If they want to know what the lungs sound like, they have to listen. This is made possible by the speaker on the SimMan and some inexpensive baby monitors. This way the staff stays focused on the patient and/or bystanders, not the instructor.

THE FUTURE
     For years in EMS, the focus has been on individual skills and knowledge, even though every EMS system operates as a team. When was the last time an ACLS or PALS class had both paramedics and EMTs attend and practice together? If individuals cannot coordinate and integrate their individual skills and knowledge into a team effort, those skills and knowledge are worthless. Every EMS system should incorporate some combined team training into its yearly training calendar.

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Scott Tomek, MA, EMT-P, has been a paramedic for 23 years, 20 with Lakeview Hospital EMS in Stillwater, MN. He oversaw EMS staff development at Woodbury Public Safety for five years, during which time he developed and implemented the CTT program. He is a faculty member with the Century College paramedic program, and a curriculum development specialist.