In a successful team, each member knows and understands their role and responsibilities, as well as everyone else’s roles and how they interact to accomplish the goal. In any team model — whether it be a sports team, a work group, or something as vital as an ACLS clinical team, outcomes depend on roles working well together. This dynamic doesn’t come by accident, but rather with awareness, careful intention, and prior planning.
One of the most important models for teams is the ACLS resuscitation triangle. This team structure features six roles, with three key roles positioned around the patient’s body in a triangle. Each role in this model has a unique job in ACLS and similar life-support scenarios. Let’s take a closer look at this model and how to apply that model to all resuscitation scenarios for more efficient, effective life support.
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Effective High-Performance Team Dynamics
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A team is truly effective when its performance produces something that is greater than the sum of its parts. An ACLS team is not just a group of individuals performing individual roles in the same room. It is a group that:
- Anticipates each other’s needs.
- Communicates continually.
- Recognizes each other’s strengths and weaknesses and uses that information to complement each other for better performance.
- Performs constructive criticism, seeking to continually improve.
Whether an ACLS team consists of two people or ten, the basic roles and structure are fluid and adaptable. This model is called the ACLS resuscitation triangle. Maintaining the important ACLS team roles with a solid structure, and clear communication is the powerful key to success that carries through all possible ACLS scenarios and creates the best possible patient outcomes.
Resuscitation Triangle Roles and Responsibilities
The basic structure of the ACLS team revolves around the triangle. However, it can include several roles and responsibilities, depending on the resource and people available. No matter how many team members there are, the core triangle functions are performed effectively and consistently as the basis for resuscitation.
There are six defined roles within the high-performing ACLS team, divided into two categories: resuscitation triangle roles and leadership roles. When fewer than six people are present, these same tasks must be prioritized and assigned to the team by the team leader. The roles are:
Resuscitation Triangle Roles
- Compressor
- AED Monitor or Defibrillator
- Airway Role
Leadership Roles
- Team Leader
- IV/IO Medications
- Timer/Recorder
Here are the responsibilities of each role in an ACLS clinical scenario:
Team Leader
Every resuscitation team must have a defined leader. It is helpful to designate the leader ahead of time — whether the role is pre-defined (such as the responding physician or provider) or defined by a department or shift plan.
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Role responsibilities:
- Assigning roles to team members.
- Making treatment decisions.
- Providing feedback to the rest of the team as needed.
- Assuming the functions of roles that are not assigned.
Compressor
This critical role is non-negotiable. If the team only has two or three people, this person may alternate with the AED/Defibrillator role and may also take over team leader responsibilities.
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Role responsibilities:
- Assesses the patient.
- Performs five cycles of compressions.
- Alternates with AED/Defibrillator every five cycles or two minutes (or when becoming fatigued).
AED, Monitor, or Defibrillator
This critical triangle role is also non-negotiable. If the resuscitation scene location does not have an AED or defibrillator available, the scene is considered BLS rather than ACLS.
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Role responsibilities:
- Brings and operates the AED or defibrillator/monitor.
- Alternates with Compressor every five cycles or two minutes (or when becoming fatigued)
- Positions the monitor where it is visible to the team leader (and others).
Airway Role
The airway role is essential and must always be a priority. Even after an artificial airway is placed, it can easily get dislodged during CPR and ACLS activities. Continuous focus on and maintenance of the airway is critical.
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Role responsibilities:
- Opens the airway by positioning the patient correctly.
- Provides bag-mask ventilation.
- Inserts adjunct airway when appropriate.
- Continuously monitors correct placement of the airway and airway effectiveness.
IV/IO Medications
This important role may also be delegated to others on teams of five or fewer people.
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Role responsibilities:
- Initiates IV/IO access.
- Administers medications per the team leader and ACLS algorithm.
- Ensures IV/IO access remains patent (open and not blocked).
Timer/Recorder
This role is sometimes discounted, but documentation and timekeeping are important for decision-making and team direction. Documentation is also critical when reviewing the episode for improvement opportunities and debriefing.
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Role responsibilities:
- Records the time of interventions and medications (and announces when these are next due).
- Records how often and how long interruptions in compressions last.
- Communicates this information to the rest of the team, including the team leader.
When roles are unclear, performance suffers greatly. Chaos can occur when everyone is trying to help in an unorganized way. This makes it easy for tasks to get missed or needlessly repeated. It is important to remember that all of these roles are designed to be performed simultaneously like in a well-oiled machine. Short, closed-loop communication can be initiated by any team member (not just the leader) to ensure everyone is on track.
Team Dynamics
No team is exactly the same, but they can all be effective with certain common characteristics in place! Team dynamics are the “rules of the game” that make the team work well.
Know Your Limitations
Everyone on the team should understand their own skill level and limitations. The team leader should also be familiar with these for effective assignments and decision-making. For example, if a team member knows that they are not good at starting IVs under pressure, or have never done an IO, then that role is not a good fit.
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A high-pressure situation like a Code Blue is not the time to practice or learn new skills. If a team member needs help, they should be encouraged to speak up! This is not a sign of weakness, but one of responsible, effective teamwork.
Constructive Interventions
It is everyone’s responsibility to intervene if they see an action occurring that is inappropriate at that time. It is important to be tactful rather than confrontational. Emergency response is no time for egos and confrontation.
- Scenario Example A: Team leader directs that a drug be given in an incorrect dosage.
- Constructive intervention: “Are you sure that is the right dosage? I think it should be X.”
- Scenario Example B: IV/IO person starts to give dose two of epinephrine.
- Constructive intervention: “According to my timekeeping, we aren’t quite ready for that drug yet. Should we hold off?”
Knowledge Sharing
Sharing information is an important component of the team, not only for those that have less experience and knowledge, but for everyone. One specific type of error to avoid is the fixation error. This is a human cognitive error that traps a person into one way of thinking.
For example, a person who has been in the healthcare field for a long time may have been trained on a previous ACLS version that has since changed, yet they remain fixated on the “old way.”
The three common types of fixation errors are:
- “Everything is okay.” – This demonstrates an avoidance of reality.
- “This and only this is the correct path.” – This demonstrates inflexibility.
- “Do anything but this.” – This introduces bias towards certain courses of action.
It is important to talk as a team, questioning everything when resuscitation efforts have been ineffective. Everyone should ask, “Have we missed anything?” and search for any errors or unexplored options.
Summarizing and Reevaluating
It is essential for the team leader to constantly reassess progress in the resuscitation efforts and review the assessment. It is also good practice to summarize this information out loud so that the entire team understands the thought process and the patient’s condition.
The team leader should always clearly draw attention to significant changes in the patient’s clinical condition and talk through supportive interventions.
Closed-Loop Communication
This communication technique is useful for all clinicians to master, especially in high-pressure, time-sensitive situations. It is a bare-bones communication technique, the opposite of open-ended communication that leads to a more in-depth conversation. The intent of closed-loop communication is to verify that the message was heard, understood, and is being carried out.
- Example A: “Can someone recheck the patient’s blood pressure soon, please?”
- This example is likely to result in delays because no one is clear about who should be checking the B/P and may forget if something else happens first.
- Example B: “Henry, can you check a manual blood pressure right now and report back to the team?”
- This request is specific and time-bound. The team leader should make eye contact with Henry, and Henry should communicate out loud, “Rechecking blood pressure right now.”
Example B is much clearer and more effective than example A.
Conclusion
Every ACLS resuscitation team must be composed of highly trained clinicians, but not everyone has the right communication and teamwork skills to ensure the best performance as a whole. This is why it is important to learn the roles and team dynamics that are proven to be most effective. More importantly, it is critical to practice them with others in your organization.
After each practice, the team leader and recorder should walk back through the entire scenario, assessing not just clinical performance but team roles, communication, and leadership. Through this continuous process of refining important skills, the ACLS team can reach its highest potential — working together to save lives.
If you would like to learn more about drugs, ECG rhythms, clinical scenarios, and other topics related to ACLS, AMRI has study materials that can help you develop your understanding. Accredited by the National Board of Emergency Care Certifications (NBECC), AMRI has helped more than one million medical professionals earn their ACLS, BLS, and PALS certifications or recertifications since 1983.
Register for your exam with AMRI today to gain access to premium study materials and our widely accepted certification program.
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