Building teamwork to improve outcomes

The importance of teamwork in critical care

Patients admitted to the ICU have a high acuity, are older, and require complex and costly care by interdisciplinary critical caregivers. The caregivers’ charge is to carry out evidence-based protocols and guidelines of care while meeting the individual needs of the patient and family. This takes place in a fast-paced environment with constant change and states of readiness. Care requires considerable coordination across caregivers working in concert, executing their contribution to the care of patients in this complex environment. With the increased need for ICU beds, efficient use of resources and throughput of patients across the healthcare system are of high priority. The emphasis on using current best evidence to guide practice, advances in critical care research, and knowledge makes keeping up with best practices difficult. With the challenge of providing quality care in the complex ICU environment, teamwork is essential for efficient care in the ICU.

Healthcare regulatory agencies, commissions, and professional organizations also value team collaboration to achieve quality outcomes. The Society of Critical Care Medicine (SCCM) focuses on delivering the right care at the right time with an integrated team of dedicated experts. In 2015 the American College of Critical Care Medicine updated the 2001 guideline on processes of care and ICU structure, reaffirming recommendations for intensivist-led, high-performing multidisciplinary teams as a key part of delivering effective care. Further, an expert panel conducted a systematic review on shared decision making in the ICU and recommended that clinicians consider using a interprofessional decision-making process whereby information is exchanged, there is deliberation among the team, and treatment decisions are made jointly. In a concise definitive review, Donovan and colleagues (2018) found robust literature to support an interprofessional approach as part of achieving high quality of care in the ICU. They illustrated the patient and family surrounded by a host of interprofessional care team members, integrating care through an intersection of unique expertise with valued contributions toward a common goal.

The importance of teamwork and collaborative practice extends to health professional education. The Association of American Medical Colleges (AAMC), along with five other health professional programs, created the Interprofessional Education Collaborative (IPEC) to advance interprofessional education. The IPEC revised their expert report in 2016, outlining core competencies related to teamwork across interprofessional teams. Currently, a multitude of health professions include interprofessional teamwork in their accreditation standards and competencies. These include but are not limited to nursing, pharmacy, respiratory therapy, nutritional support, physical and occupational therapy, and social work. Goldman and colleagues (2017) found interprofessional competencies are important for affecting competencies in skills and beliefs, but that organizational, environmental, and resource factors greatly affect the ability of team members to enact these competencies in the real-world setting.

Leaders are gaining an appreciation for how organizational structures and processes affect patient outcomes and the importance of highly functional teams. The best systems are those that allow teams to function at the highest level to reduce costs and improve patient outcomes. Successful hospitals are those that attract, train, and retain expert team members in an environment where they experience meaningful work and thrive within effective teams. Top hospitals build environments with top-notch teamwork, are intolerant of poor performance, and are supportive of team members who vocalize concerns.

Components of effective teamwork

Broadly, teamwork is defined as two or more people working dynamically together to accomplish a common goal. Important components include communication, competence, trust, cooperation, coordination, respect, interdependence, accountability, conflict resolution, and shared decision making. ^, Although the term teamwork is widely used to describe interventions across teams and is valued by caregivers, ^, results from some qualitative and ethnographic studies indicate that in their work together, critical caregivers are performing activities that are more indicative of interprofessional communication interactions such as collaboration, coordination, and networking, rather than what are considered “idealized” definitions of teamwork, as defined by a shared team identity, interdependence, integration, and shared responsibility. ^,

Historically, healthcare professionals have practiced as individuals, demonstrating autonomy in their respective field of practice supported by its own body of research. ICU patients require complex and multifaceted interventions by an interdisciplinary team of experts. This process requires moving away from isolated practice toward collaborative practice with other healthcare providers. Ongoing interaction among the interdisciplinary team focused on patient-centric goals fosters greater collaboration and communication and can optimize patient care and outcomes. Through the exchange of ideas and expertise, practitioners become familiar with the nature and scope of one another’s practice and are able to assess individual competence. This can build trust and promote the understanding of the unique contributions of team members and their interdependence for providing care. Focusing on the common goal to provide the best possible care for patients is key to minimizing team conflict. ^,

Over time, trust and open communication promote respect. Team members begin to appreciate each other’s skills, knowledge, and judgment. In collaborative practice, responsibility is shared, so that goal setting and decision making occur jointly.

Being a good team player is key to a team’s success. Given the ethical obligation to provide the best care for patients, every team member has the responsibility to make an optimal contribution during team communications or rounds, speaking up and providing relevant input, and listening actively to others’ input while maintaining an open mind. Mutual support among the team (encouraging expression of ideas and positive professional communication) is important to build confidence in and perceived value of the team. These actions can lead to collective intellectual capital by the team and potentiate clinical effectiveness.

Team leadership is also critical to performance. Good leaders generate two-way trust, respect, and communication. They have vision, self-confidence, enthusiasm, tolerance, and a commitment to excellence. They are organized and prepared, fulfill commitments, inspire shared missions, grow new leaders, model behaviors, challenge processes, tolerate ambiguity, and remain calm. Leaders who think out loud help novices develop their teamwork skills and competence. Leaders set the tone for the function of the group and must demonstrate respect for the collective contribution of its members. Team members must ask for help when needed and express concerns without retribution in an environment that is psychologically safe. To have high-quality ICU teamwork, each team member should possess some leadership characteristics, as team leadership often changes, depending on the issue at hand.

Impact of teamwork on outcomes

Despite the support for teamwork and the development of an interdisciplinary team model for the care of critically ill patients, research on the relationship to outcomes is limited. ^{, ,} ICU patients are highly susceptible to medical errors. Severity of illness, intervention complexity and number, invasive devices, and ICU length of stay (LOS) put critically ill patients at a higher risk for adverse events and errors. One comprehensive review of critical incidents in intensive care showed an increased incidence of adverse events when there was a deficit in nontechnical skills, including elements of teamwork.

Ineffective communication and poor teamwork have been identified as significant contributors to patient errors and critical incidents in the ICU. ^, Improved communication may reduce adverse events and errors. ^,

A systematic review and meta-analysis demonstrated improvements in outcomes with pharmacist participation on the ICU team. Interventions by pharmacists during ICU team rounds were associated with reduced odds of mortality, lessened LOS, and reduction in preventable/nonpreventable adverse drug events. Another initiative was aimed at improving early mobility in ICU patients through active engagement of the multidisciplinary team. Multidisciplinary team engagement significantly improved rates of mobilization within the first 24 hours of ICU admission. A pediatric study on the effect of team training for resuscitation demonstrated that training increased the chance of survival after in-hospital cardiopulmonary arrest.

Whereas some studies have shown improvement of team performance outcomes associated with improved teamwork, research on patient outcomes are less often seen. Intensivist-led multidisciplinary teams have been espoused as an ideal model for critical care. However, insufficient numbers of trained intensivists exist to meet current or future demands, and a limited number of ICUs have implemented intensivist staffing. Furthermore, outcome studies on intensivist-led care demonstrate mixed findings. ^, One large patient cohort study compared the mortality outcomes from hospitals with daily multidisciplinary team rounds with and without intensivist models. Hospitals with high intensivist staffing and multidisciplinary team care had the greatest reduction in odds ratio of death. Interestingly, hospitals with multidisciplinary care but low physician staffing also had significant odds reduction in mortality, reinforcing the idea that patients benefit from care by a multidisciplinary team. Mortality has been significantly reduced in patients with acute lung injury cared for by multidisciplinary teams led by full-time critical care physicians. A literature review summarized that the team model for ICU care delivery was associated with reduced mortality, ICU and hospital LOS, and cost of care.

One hospital in Illinois implemented evidence-based bundles of care and a multidisciplinary daily goals rounding tool, resulting in decreased ICU LOS, improved protocol compliance, reduced ventilator-acquired pneumonia (VAP), bloodstream infections, falls, and pressure ulcers in surgical ICU patients. Multidisciplinary teams developed to respond to shock in nontrauma patients resulted in decreased time to treatment, intensivist arrival, and admission to the ICU. This led to a significant reduction in mortality and improved patient outcomes.