How To Win the Race to Save Lives

Watch an auto race on TV. The speed of the cars captures the eye. A daring pass through traffic inspires the imagination. A terrible wreck catches the breath in your throat. What often goes overlooked, to all but the most avid race fan, is the work of the pit crew.

Each member of the crew probably has knowledge about what the others are doing and is proficient enough to do more than one job. But if, every time a car pulled into the pits for fuel and a tire change mid-race, three crew members reached for the gas can while no one made an effort to change the front tires, that racing team would have a very low success rate.

Instead, each crew member has a defined role, which they perform in practiced harmony to get their driver back into race a tenth of a second faster than the next guy. It goes a long way toward winning races, and it can do the same for saving lives.

That’s the theory at least behind the assigned task—or “pit crew”—model employed in some EMS systems’ responses to cardiac arrests. And it’s not new. But it is garnering new appreciation following a recent study in which paramedic students employed it for simulated STEMI patients.

According to Orlando/Orange County EMS Medical Director George Ralls, MD, who presented on the findings of the study (see Table 1) at the 2012 EMS State of the Sciences Conference (“Gathering of Eagles”), having assigned tasks for each crew member was linked to faster scene times and could hold promise for faster door-to-balloon times for real patients. Ralls also believes the model could work across a variety of call types, including trauma and extrication.

“We conducted 54 simulated-patient encounters—30 control  and 24 intervention encounters,” Ralls says of the study, done in conjunction with the Society for Academic Emergency Medicine. “The mean time-to-completion of each task was compared in the control and intervention groups, respectively. Time to obtain vital signs was 4:18 in the control group vs. 2:21 in the intervention group (P=0.001); time to ASA administration was 3:54 vs. 2:00 (P<0.001); time to EKG acquisition was 5:39 vs. 3:42 (P<0.001); time to EKG interpretation was 6:43 vs.  4:21 (P<0.001); time to IV access was 5:42 vs. 4:45 (P=0.05); time to STEMI notification was 7:19 vs. 4:26 (P<0.001); and time to scene completion was 9:02 vs. 5:27 (P<0.001).”

In each case, the time-to-completion goals (see Table 2) established for each position in the crew were exceeded.

Ralls says each of the intervention groups in the study operated as a three-person crew, with specifically pre-assigned tasks (see Figure 1). However, the model can be adjusted for a crew of any size.

“The ideal team size was not a component of what we studied, but based on our observations, and the experience with this approach in other settings, we feel it would enhance the operation of any sized team in EMS,” explains Ralls. “Two, three or even multiple providers on scene could be adapted to focus on a limited number of objectives, and limit the confusion that occurs when everyone is trying to do everything. However, in two-tiered EMS systems where more than one agency responds to a call, coordinating a process like this across agencies will require a commitment by both parties.”

And Ralls says the results of the study back up the supposition that the pit crew model can be applied broadly across EMS.

“The ‘assigned task’ model is commonly used for cardiac arrest management, as well as many other high-complexity tactical operations and processes,” Ralls says. “By strict assignment of tasks, outcomes are improved and objectives accomplished in areas such as hospital-based trauma resuscitation; vehicle extrication; urban search and rescue; and tactical medicine and firefighting, to name a few. Of course, every operational environment will require adjustment of the model, including use of more flexible parameters, if indicated.”

All of this supports the concept of EMS crews working as a team, rather than a collection of individuals with no clear direction. For agencies that haven’t already adopted the pit crew model formally, Ralls offer some advice.

“I would recommend starting with the two scenarios where most EMS personnel have experienced the effects of poorly coordinated efforts: cardiac arrest resuscitation and high-acuity trauma scenarios. One of the most honorable traits of EMS providers is our heartfelt desire to do everything we can to ensure the best outcomes for our patients. The eagerness that seems coded in our DNA may make it hard to accept that doing the best for our patients might, in fact, require focusing on fewer things.

“This becomes an important component of training programs for this model: ensuring teams believe the overall process will improve by eliminating individual will and adopting a disciplined team approach,” Ralls continues. “Based on our study, the management of acute coronary syndromes can be improved using assigned tasks as well, and can easily be introduced along the way. The method of training will certainly depend on available resources, but I would recommend using a simulation-based model as a starting point. We were able to train our intervention group in the study to use assigned tasks in a few hours. Numerous simulated chest pain scenarios followed this. Our goal was to determine if assigned tasks would improve time metrics in the chest pain scenarios, which it did. It is possible a similar approach could be used to help define the highest-yield staffing models, etc.”

As the study shows, working faster and smarter don’t have to be mutually exclusive. That’s the kind of revelation that can turn your agency into a winning team in the race to save lives.