Chapter 9: The Team Approach to Health Care
Introduction: the team approach to health care
As an emergency medical technician (EMT), you are a critical member of the emergency health care team which includes first responders, paramedics, other EMTs, physicians, nurses, and hospital staff who care for the patient across the continuum of injury or illness.
Your role includes bringing emergency medicine into patients' homes, assisting with advanced patient care skills, and ensuring effective transfer of care to ED staff on arrival at the hospital.
A key goal of EMS Agenda 2050 is to design EMS systems that are inherently safe to minimize exposure to injury, infections, illness, or stress.
Safety of all is a priority in EMS decisions; EMS should cultivate a culture of safety.
Just Culture and Safety Culture in EMS
Foundational elements of a culture of safety: data collection, just culture, coordinated support and resources, EMS education initiatives, EMS safety standards, and reporting/investigation of errors and near misses.
Just Culture is a leadership approach that balances fairness and accountability and encourages reporting of errors and near misses.
Focus is on risk management: proactively identifying system problems that could lead to errors or safety improvements.
In a Just Culture, both the EMS system and individual providers are held accountable for safety.
Error categorization in a Just Culture: human error, at risk behavior, or reckless behavior.
Human error is considered to be a function of three factors:
1) a person intended to do the right thing but committed an error (e.g., choosing the wrong treatment),
2) a person performed a skill incorrectly, or
3) a person intended to do something but did not follow through.
When errors occur, the reasons are investigated and the individual may be counseled or educated.
At risk behavior is when a provider knowingly makes a risky choice—believing the risk is insignificant or justified in the moment; typically requires coaching and heightened awareness.
Reckless behavior involves conscious disregard for a significant and unjustified risk and usually results in disciplinary action.
A positive safety culture is linked to fewer errors and near misses.
Elements that influence safety culture can yield both positive and negative outcomes depending on implementation and practice.
Team Roles and Continuum of Care
EMS is moving toward a team-based approach that spans from first contact to patient discharge (continuum of care).
Community paramedicine and mobile integrated health care (MIH) teams illustrate the team concept by delivering care within the community and coordinating with hospital and community providers.
MIH programs have shown improvements in patient outcomes, satisfaction, and reduced health care costs when EMS teams operate cohesively with hospital and community partners.
Differences among teams: EMS providers vary in background, certification (e.g., EMT, AEMT, paramedic), employment type (volunteers, part-time, full-time), and bases (police/fire, hospital, private agencies).
Because of these variations, sharing patient information and integrating new arriving providers can be challenging; the solution is effective communication and mutual respect, viewing new responders as joining the team rather than taking over.
Types of Teams in EMS
Regular teams: EMTs consistently work with the same partner(s) and often train together, leading to smoother transitions between steps in care.
Temporary teams: Responders who do not regularly interact, requiring explicit communication and cooperation; training together when possible is beneficial.
Special teams: Teams formed for specialized roles (e.g., fire/rescue, HazMat, Tactical EMS, special events EMS, in-hospital care techs, MIH technicians).
Groups vs teams (NIMS distinction):- A group is an organizational level under NIMS that divides incident tasks across functional levels and may operate across geography; groups perform specialized functions (e.g., triage, treatment, transport at a mass casualty incident).
A true team is a coordinated unit with assigned roles and interdependent work under a designated leader, aiming for a common goal.
Five elements historically defined for a group (C. S. in 1945, Center for Group Dynamics):- A common goal,
An image of themselves as a group,
A sense of continuity of the group (may work together again in similar/different configurations),
Shared values about how to get things done,
Different roles within the group that are often self-assigned.
Dependent vs Independent vs Interdependent groups:- Dependent: task assignments and decisions flow from a group leader; limited adaptability in field conditions.
Independent: individuals own their areas; may receive guidance but can act without waiting for assignments; risks siloed actions.
Interdependent: true teams with shared responsibilities, accountability, and a common goal; collaboration is essential for best outcomes.
Core Elements of Effective Teams
Five essential elements (as introduced in the chapter):
1) A shared goal: all providers—from EMTs to physicians—must be committed to the best possible patient outcome.
2) Clear roles and responsibilities: everyone must know what to do and what is expected.
3) Diverse and competent skill sets: treat different certifications and backgrounds as opportunities to fill roles; practice together to build familiarity with tools and capabilities.
4) Effective collaboration and communication: critical for success in high-stress, multidisciplinary environments.
5) Supportive and coordinated leadership: the team leader provides role assignments, coordination, oversight, and support; leadership should facilitate coordination rather than merely command.
Pit crew CPR (cardiopulmonary resuscitation) as an example of effective team structure:- Defines each intervention (compressions, defibrillation, airway,vascular access, medications, training) and rapidly assigns roles to team members based on training/experience.
Demonstrates how training together allows responders with different certifications to come together quickly to improve outcomes.
Diverse and competent skill sets should be leveraged rather than seen as obstacles; practice with one another to become familiar with each other’s tools, techniques, and preferences.
Communication and Crew Resource Management (CRM)
Four important elements of team communication:- Clear message: speak calmly, confidently, concisely; specify recipient by name or rank when giving directions.
Closed loop communication: repeat back messages to confirm understanding (e.g., a teammate confirms a plan or corrects a misheard instruction).
Courtesy: polite interaction among all team members.
Constructive intervention: respectfully question or correct a team member or leader when a mistake is suspected or a needed procedure is not being performed.
Example of closed loop communication:- EMT Aziz: "Let's go with of oxygen."
Partner Becky: "Got it. I'll put him on of oxygen."
Aziz: "No. Not . We need to go with ."
Becky: "Got it. I'll put him on of oxygen."
P.A.C.E. mnemonic for raising concerns when a problem is detected:-
P: Probe — Look or ask to confirm the problem.
A: Alert — Communicate the problem to the team leader.
C: Challenge — If not corrected, challenge the current plan and propose an alternative.
E: Emergency — If there is an immediate safety issue, alert the entire team.
CRM does not override the chain of command or the Incident Command System (ICS/ NIMS); it empowers team members to provide immediate feedback to protect patient and crew safety. It promotes open lines of communication and ensures every input is considered.
Transfer of Patient Care and Handoffs
Transfer of care is a point at which errors can occur; minimize transfers and use strict guidelines when unavoidable.
Like a relay, a proper transfer allows continuous care and movement forward; incorrect handoffs can halt progress and waste time.
Best practice: when feasible, a single team leader coordinates the transfer and reports patient information.
Verbal handoffs should meet guidelines:- Uninterrupted critical care whenever possible (e.g., continue chest compressions during transfer if needed).
Minimal interference: transfer occurs with as little disruption as possible.
Respectful interaction: acknowledge each role’s importance.
Common priorities: focus on critical assessment findings and vital patient information.
Common language/format: use a standardized handoff format when possible (see Chapter 4 on communications and documentation).
Basic Life Support (BLS) and Advanced Life Support (ALS) cannot operate in isolation; BLS activities (e.g., CPR, defibrillation) form the foundation that ALS builds upon throughout the continuum of care. EMTs may initiate BLS early and must coordinate with ALS tools and techniques as the patient progresses.
All team members must work toward one goal: high-quality patient care; all licensure levels share responsibility for safety of patient, crew, and bystanders.
EMTs should speak up when they detect dangerous situations or potential errors; professionals should listen with an open mind.
Scope of Practice, Training, and Advanced Procedures
The boundary between basic and advanced life support varies by EMS system; some skills are considered EMT vs paramedic scope, and some may be common across EMTs in certain contexts.
Understand your local scope of practice, standard of care, and protocols; performing skills beyond scope can create legal liability even if you are unaware of the restriction.
EMTs can assist with advanced life support skills by training and practicing together with ALS providers to improve patient outcomes.
A great EMT possesses foundational knowledge to understand advanced procedures and focuses on patient problem-solving rather than simply completing a procedure.
Assisting with advanced life support skills generally follows a four-step process:
1) Patient preparation,
2) Equipment setup,
3) Performing the procedure,
4) Continuing care.
Specific steps for assisting with advanced airway skills and vascular access are addressed in later chapters.
Decision Making and Critical Thinking in EMS
In many EMS systems, the EMT partner may be the primary decision maker on the ambulance; life threats require critical decisions that influence outcomes.
Sound decisions are based on up-to-date knowledge and information gathered from the patient history and physical examination.
Decision-making process stages:- Pre-arrival: Dispatch information helps the team prepare; mental rehearsal of steps; designate a leader; discuss roles, needed help, equipment, and destination; e.g., pediatric cardiac arrest: consider compression:ventilation ratio and equipment size.
Arrival: scene size-up; request additional resources; position equipment for easy access.
Assess and intervene for life threats: rule out worst-case scenario (a common memory aid).
Leader's process:
Gather data from dispatch and patient history/exam,
Interpret data to identify patterns and determine if more information is needed,
Develop a plan,
Communicate the plan to the team and implement it; invite feedback,
Evaluate the plan by reassessing the patient and situation; adjust as needed.
Example: chest discomfort patient who initially appears not short of breath may later develop mild shortness of breath; plan may change to administer oxygen.
After the call: debriefing is important; informal debriefs (back-step) after simpler calls; formal debriefings for complex cases may involve medical director and supervisory staff; aim to improve future performance.
Moving from novice to expert requires willingness to listen to feedback and adapt practices.
Decision Traps and Bias in EMS
Decision traps: biases that cause overestimation or underestimation of probability and failure to consider all reasonable possibilities.
Common traps:- Bias: fixed beliefs that limit data gathering (e.g., assuming alcohol intoxication in a fall-related Head Injury case due to alcohol odor and not exploring head injury signs).
Anchoring: settling on one cause early and neglecting other possibilities (e.g., asthma patient who later has an anaphylactic reaction not recognized due to early focus on asthma).
Overconfidence: overestimating one’s own abilities and ignoring dissenting viewpoints, potentially harming patients or teams.
Avoiding decision traps:- Build a solid knowledge base and a consistent, thorough approach to patient care.
Recognize blind spots and biases (e.g., intoxicated patients, obese patients, older adults) and take extra care to avoid traps on those calls.
Conflict Resolution and Team Dynamics
Conflicts are inevitable in high-performing EMS teams; apply five techniques to minimize negative impact:
1) The patient comes first: prioritize patient needs over interpersonal conflicts; if the issue does not affect immediate patient care, defer discussion until after the call.
2) Maintain your composure: if conflict touches a critical aspect of care, use PACE to address it; otherwise, breathe and reset.
3) Separate the person from the issue: focus on behavior and not the individual to facilitate productive discussion.
4) Choose your battles: value the diversity of team members; avoid conflicts over minor patient-care issues that reflect different styles.
5) Leverage diversity as strength: different backgrounds and approaches can strengthen team performance if managed constructively.
The overarching goal remains patient safety; constructively addressing concerns helps improve patient outcomes and team efficiency.
Practical Implications for Practice
Always aim for a shared goal of the best possible patient outcome; maintain open, respectful, and clear communication across all levels of care.
Practice and reinforce CRM concepts: maintain situational awareness, share critical information, listen to input from all team members, and be prepared to adapt plans quickly.
Emphasize training together to improve interoperability among providers with different licensure and from different agencies.
Use structured handoffs and avoid unnecessary transfers to minimize errors; when transfers are necessary, follow guidelines to preserve critical care and reduce miscommunication.
Stay aware of decision traps and actively seek data and feedback to avoid bias, anchoring, and overconfidence.
Continually debrief after calls to identify opportunities for improvement and to support moving from novice to expert practice.
Real-World Relevance and Ethical/Practical Implications
The team approach reduces errors and improves outcomes by integrating multiple skill sets and maintaining a culture of safety.
Ethical obligation to speak up when safety concerns arise; professional responsibility to listen and adjust plans to protect patients and crew.
Practical implication: EMS systems should implement and reinforce CRM, standardized handoffs, regular joint training, and structured debriefings to optimize patient outcomes and maintain crew safety.
The integration of community-based models (e.g., MIH) demonstrates the real-world benefits of teamwork extending beyond the traditional ambulance-to-hospital pathway, including cost reductions and improved patient satisfaction.
References and Cross-References
World Health Organization: Being a Team Player.
American Heart Association: Chain of Survival.
Chapter Four: Communications and Documentation (patient care reports).
Chapter Three: Medical, Legal, and Ethical Issues (scope of practice and liability).
Chapter One: EMS Systems (MIH model and continuum of care).
1945: Five essential elements of a group defined by the Center for Group Dynamics.
Agenda 2050: EMS safety and a culture of safety across EMS systems.
Key Definitions
Emergency Medical Technician (EMT): A critical member of the emergency health care team responsible for bringing emergency medicine into patients' homes, assisting with advanced patient care skills, and ensuring effective transfer of care.
EMS Agenda 2050: A strategic plan aiming to design EMS systems that are inherently safe, minimizing exposure to injury, infections, illness, or stress.
Just Culture: A leadership approach that balances fairness and accountability, encouraging the reporting of errors and near misses while focusing on risk management.
Human Error: An unintended deviation from appropriate care, where a person intended to do the right thing but made a mistake, performed a skill incorrectly, or failed to follow through.
At-Risk Behavior: When a provider knowingly makes a risky choice, believing the risk is insignificant or justified in the moment.
Reckless Behavior: Involves conscious disregard for a significant and unjustified risk, often resulting in disciplinary action.
Safety Culture: A positive organizational environment that emphasizes data collection, just culture, support, education, safety standards, and reporting of errors to reduce incidents.
Continuum of Care: A team-based approach in EMS that spans from the first patient contact to patient discharge, integrating care across various providers and settings.
Community Paramedicine/Mobile Integrated Health Care (MIH): Teams that deliver care within the community and coordinate with hospital and community providers, improving patient outcomes and reducing healthcare costs.
Regular Teams: EMTs who consistently work and train together, leading to smoother transitions in patient care.
Temporary Teams: Responders who do not regularly interact, necessitating explicit communication and cooperation.
Special Teams: Teams formed for specialized roles such as fire/rescue, HazMat, Tactical EMS, or in-hospital care techs.
Group (NIMS distinction): An organizational level that divides incident tasks across functional levels and may operate across geography, performing specialized functions.
Team: A coordinated unit with assigned roles and interdependent work under a designated leader, aiming for a common goal.
Dependent Group: Task assignments and decisions flow from a group leader, with limited adaptability.
Independent Group: Individuals own their areas and can act without waiting for assignments, though this risks siloed actions.
Interdependent Group: True teams with shared responsibilities, accountability, and a common goal, where collaboration is essential.
Pit Crew CPR: An example of an effective team structure where each intervention is defined and roles are rapidly assigned to team members based on training/experience to improve outcomes.
Clear Message: Communication that is calm, confident, and concise, specifying the recipient by name or rank.
Closed Loop Communication: Repeating back messages to confirm understanding, ensuring that instructions are correctly received and planned actions are affirmed.
Constructive Intervention: Respectfully questioning or correcting a team member or leader when a mistake is suspected or a needed procedure is not being performed.
P.A.C.E. Mnemonic: A structured approach (Probe, Alert, Challenge, Emergency) for raising concerns when a problem is detected.
Crew Resource Management (CRM): Empowers team members to provide immediate feedback to protect patient and crew safety, promoting open communication and ensuring all input is considered without overriding the chain of command.
Transfer of Care: A critical point in patient care where responsibility is shifted from one provider or team to another, requiring strict guidelines to minimize errors.
Basic Life Support (BLS): Foundational emergency medical care activities like CPR and defibrillation.
Advanced Life Support (ALS): Advanced medical procedures and interventions that build upon BLS throughout the continuum of care.
Scope of Practice: The legal boundaries defining the skills and procedures an EMS provider is authorized to perform.
Decision Traps: Biases that cause overestimation or underestimation of probability and lead to a failure to consider all reasonable possibilities.
Bias (Decision Trap): Fixed beliefs that limit data gathering, potentially leading to incorrect assumptions.
Anchoring (Decision Trap): Settling on one cause early in the assessment and neglecting other possibilities.
Overconfidence (Decision Trap): Overestimating one’s own abilities and ignoring dissenting viewpoints to the detriment of patient or team safety.
Debriefing: A post-call discussion, informal or formal, to identify opportunities for improvement and support professional development.