The Resus Room Life Guard

armstriconI was lucky to be accompanied through much of my emergency medicine training and specialist work in the UK by Bruce Armstrong. We shared many resuscitation cases together in hospitals and in prehospital care.
When preparing the team in resus, Armstrong used to appoint a ‘safety officer’. This could be a nurse or physician – it didn’t matter. Their role was to stay hands-off and be the eyes, ears, and mouth that would identify impending hazards and verbally intervene to thwart them.
This process seemed so natural that I rarely gave it a thought, but its glaring absence from every place I’ve worked since has only recently hit me.
Because my son goes swimming.
Photo on 29-12-12 at 10.31 AMMy three year old son attends a swimming class. There is usually one other child in the class. Recently a third child joined the class and I found myself getting uncomfortable. How could the instructor stay vigilant? What if while holding one child one of the others sank under water out of her field of view? My own obsessive reading about the limitations of human perception and cognition has convinced me that no-one can really focus on more than one thing at a time.
A friend of mine has coached kids at swimming so I asked him how they solve this. The answer was obvious – you rely on the life guards whose sole role is look out for everyone’s safety. Duh.
And then it came to me. Armstrong knew this all along. He got this idea from his prehospital experience working with fire & rescue crews and brought it into the ED. It didn’t occur to me that no-one else did this. It was just him.
Keen to explore whether anyone else had embraced this idea, I decided to go to the top when it comes to patient safety, and contacted Martin Bromiley. He told me he hadn’t come across the role in this specific setting, although did point out a great example from the BBC Documentary ‘Operation Iceberg’, in which ‘a group of scientists boarded an iceberg with someone watching over the big picture of polar bears and the berg cracking as well as fog etc’. Martin directed me to the Clinical Human Factors Group on LinkedIn, where interest was shown in the concept although it was apparent others haven’t come across it.
I went back to Armstrong to push him on further thoughts:

Yes a thought….in every other high risk environment they have a specific safety officer, whether it be nuclear industry, airline etc.

The role is specific not an add on to another role.

In healthcare we are seen as successful the more we do by one person. Think lean… think ‘efficiencies’ in the health service. Other industries focus on safety. Get safety right, your brand is safe and the public go with you. If you don’t put safety first it is only a matter of time before disaster strikes. In healthcare we have too many serious incidents. The time has come to believe in and practice safety in health care rather than ticking boxes and not applying CRM and human factors.

So here’s a proposed checklist for a Resuscitation Room Safety Officer. It’s a first draft to get the idea out there and start the conversation – just click the image below to enlarge. I’ve written (and used) checklists in resus before, but none specifically for a safety officer.

Safety Officer Checklistsm

I would like to hear if anyone’s already doing this anywhere, and how it’s been working.


13 thoughts on “The Resus Room Life Guard”

  1. Not using it yet – but bloody path we should be! I guess we do a hybrid eg: during a roadside RSI I might instruct someone to monitor SpO2 and to tell me to do something different if falling (move from plan A to plan B etc).
    But I like the idea of an ED safety officer – not another Numpty with a clipboard chasing meaningless targets…but someone who is there to actually ensure safety and who is empowered to effect change – not for the organisation per se, but for the safety of patient and clinical team as they navigate a high risk scenario
    Interesting. And so good you spoke to Bromiley.

  2. So simple it’s obvious. So obvious it’s simple! This is a great quality initiative, like the “hands off’ handover. I especially like the focus on safety as a brand mark.

  3. thanks Cliff!
    I will ask the obvious question.
    what is the difference between the proposed role and an existing team leader role?

  4. Hi Cliff
    Glad you wrote on this subject, one that we’ve talked about previously. It is so obvious that it seems crazy that the role is not widespread. I have experience with this role from being involved in USAR teams before I did medicine. Also I often delegate someone the role of watching all the monitors etc in simulations when I anticipate that major distractors are about to appear. I’ll often give the job of monitor watching to a med student in an RSI. However, unlike Bruce, I’ve never followed through to assigning this role as a routine in a resus or other complex team-based situation… Now I wonder why the hell not?
    I think efforts to formalise and popularize this role will be well spent – great post Cliff!
    PS: Minh – the safety officer is not there to coordinate the team or support them in their roles, he/she serves as an extra set of eyes and ears focused solely on monitoring the team’s activities and environment to improve situational awareness without the burden of decision making.

  5. Cliff,
    Great post. Atul Gawande’s The Checklist Manifesto describes his experience with the WHO’s Surgical Safety Checklist, which was shown to reduce deaths by a third. Emergency medicine absolutely needs to get on board with this important initiative. Perhaps the format for the WHO’s checklist might inform and improve yours.
    Jay Baker
    Washington Post article re: WHO Surgical Safety Checklist

  6. thanks Chris for your comment.
    perhaps Cliff and his team might be able to produce a SMACC SImwars video entry demonstrating the role of this Safety person?
    I am having trouble visualising how the role would gel into a trauma or resuscitation setting. I imagine the person in the role needs to be fairly senior or experienced, to be able to see where things are going not so right or getting risky, to be able to anticipate the course of the resucitation etc.
    thereforeI can see conflicts of authority occuring unless the role is specifically delineated with the team leader and team.
    You cite that Martin Bromiley had yet to come across this role. to me that suggests it may not be as clear cut . In the tragedy of his wifes infamous case, such a proposed safety officer role may have well helped, but the authority gradient issue needs to have been sorted out first. but for the fact that a theatre nurse went and got the tracheostomy tray and declared it was available in her hands, and then was ignored by the anaesthetists involved, suggests a specific safety role may get ignored unless underlying human factors are addressed primarily. Whats the first thing we do with an annoying monitor alarm? turn it off..thats human factors at play.
    Which is why I suggest such a safety role may well be already best suited to the designated team leader of sufficient authority and seniority that direction will be taken when given.

  7. Great post Cliff. As we’ve discussed there are loads of improvements that can be made to ED resuscitation, and a safety officer checklist is a great start.
    For those that are interested, I’ve started a new site, Resus Room Management (RRM), (technically in beta still, but this is a timely article to mention it on…) dedicated to nutting out how we can optimally run Emergency Department resuscitations, not with “CRM” (and you’ll see why when you read the blog), but using RRM, a concept has been developed to help Emergency Department medical and nursing staff develop a skill set that will allow them to better manage resuscitation cases, to enhance group dynamics and functionality, improve communication, to deal with external “help” in an optimal fashion, expedite disposition, minimse error and maximise patient safety.
    Please check out the site, as I very much want RRM to be a dynamic, evolving concept with input from expert resuscitationists. WIll definitely do a post about your safety officer checklist Cliff!

  8. Hi Minh
    When I lead a tough resuscitation, I really appreciate a second hands-off pair of eyes and ears. My bandwidth is usually occupied with diagnosis, making procedures (eg. RSI) happen the way I want them, herding the cats and using my persuasion powers. I might need to focus on one thing, such as difficulty in ventilation, during which my peripheral awareness dwindles to almost bugger all. Think about the difference between an incident commander and safety officer at an extrication scene – this is bread and butter PHARM being brought to the ED.
    A positive spin-off from the way Bruce used to do it was the effect on the team dynamic. He would sometimes appoint a relatively junior staff member as safety officer and make it clear to the rest of the room how important they were. This wasn’t just good for that individual’s morale – it set the tone that getting things right was the priority and I think it made everyone feel more empowered to speak up.
    I think more important than having a senior person in the role is having a permanent staff member. Often the leader may be new, temporary (locum) or an infrequent ad hoc roster filler. They may not be familiar with systems and policies, and an appointed safety officer can keep them on track without directly competing for the leader role.
    BTW I deliberately reworded that with as few mentions of ‘team’ as possible, thanks to Andy’s pesky meddling with my mind!

  9. Collegues…
    Interesting debate.. I have also had the pleasure and honor to work with the legendary B Armstrong during my time in UK EDs… and he and his safety officer has certainly saved my ar… and the patient when sh.. hits the fan!
    However, let keep right thing for the right time… where Armstrongs safety officer comes to right are in the complex situations.. ie patient transfer to trolley, surveys, parallel actions (thoracostomy, intubation and IV access, splinting, you name it.. ) and this is where human factors plays an action…
    BUT for at standard RSI in ED, ICU or theatre, there should be NO NEED for the safety officer….!!
    Lets keep this for the complex resuscitations, the critical events, the multitasking teams, the situations with difficult team dynamics (ie the non cooperative surgeon…= MUPPET)…
    PS:One could fill a whole blog with tips and tricks from Armstrong…..

  10. …sounds like someone needs to podcast this Armstrong fella.
    I do like the idea of delegating to the junior member of team. Yes, there are authority gradients and all those other human factor issues to overcome. But in a complex resus I reckon the TL is busy enough dealing with the meta stuff, not checking that the basics.
    My tppence worth.
    Minh, you shoudl interview this guy

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