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Creating Successful Emergency Department and Intensive Care Unit Team Dynamics

From the Department of Emergency Medicine (C.M.C., H.A.H.), Division of Pulmonary and Critical Care Medicine (R.A.O.), Department of Anesthesiology and Perioperative Medicine (D.A.D.), Critical Care Independent Multidisciplinary Program (D.R.B.), and Division of Infectious Diseases (P.S.), Mayo Clinic, Rochester, MN. H ospital emergency departments (EDs) and intensive care units (ICUs) are part of the frontline response to the coronavirus disease 2019 (COVID-19) pandemic, caring for both infected and uninfected critically ill patients. To maintain effective sustainable multidisciplinary teams of health care workers, team dynamics and institutional support structures must be strong. During this pandemic, health care workers in EDs and ICUs have been susceptible to unique influences and fears. Mayo Clinic responded to concerns of their health care workers by rapidly implementing changes in communication approaches throughout the institution, which EDs and ICUs used to meet the needs of staff in these strategic areas. Many staff working in EDs and ICUs expressed concerns about the risk of contracting COVID-19 themselves or infecting their families. Concerns were especially high early in the pandemicwhenkey facts about the infection, including its mechanism of spread, were unknown. Recommendations for personal protective equipment (PPE) have changed over time on the basis of a better understanding of modes of transmission as well as on the basis of local and global PPE supplies. Doubt among health care workers followed changes in the recommendations, particularly when the rationale for change was not transparent. The need for extended use and reuse of some components of PPE was especially challenging to communicate and operationalize.

H ospital emergency departments (EDs) and intensive care units (ICUs) are part of the frontline response to the coronavirus disease 2019 (COVID-19) pandemic, caring for both infected and uninfected critically ill patients. To maintain effective sustainable multidisciplinary teams of health care workers, team dynamics and institutional support structures must be strong. During this pandemic, health care workers in EDs and ICUs have been susceptible to unique influences and fears. 1,2 Mayo Clinic responded to concerns of their health care workers by rapidly implementing changes in communication approaches throughout the institution, which EDs and ICUs used to meet the needs of staff in these strategic areas.
Many staff working in EDs and ICUs expressed concerns about the risk of contracting COVID-19 themselves or infecting their families. 3 Concerns were especially high early in the pandemic when key facts about the infection, including its mechanism of spread, were unknown. Recommendations for personal protective equipment (PPE) have changed over time on the basis of a better understanding of modes of transmission as well as on the basis of local and global PPE supplies. Doubt among health care workers followed changes in the recommendations, particularly when the rationale for change was not transparent. The need for extended use and reuse of some components of PPE was especially challenging to communicate and operationalize.
Media coverage has substantially affected staff. Information on COVID-19 disseminated through print, television, Internet, and social media varies widely in reliability and scientific rigor. In some cases, team dynamics and morale received boosts by reports of community support for health care workers or highlights of successes of health care teams. Other times, reports of unproven or experimental treatments of COVID-19 created unique challenges to care delivery, led to false hope, or fostered misunderstanding of the dangers of infection. Images of health care workers in biosafety level 3 PPE, while visually striking, were especially damaging because they were not congruent with the World Health Organization, 4 Centers for Disease Control and Prevention, 5 or our institutional guidelines.
Considering the challenges described above, it quickly became evident that robust communication would be key during the pandemic for managing and reassuring teams across the practice. At Mayo Clinic, infection prevention and control staff worked with staff from the Hospital/Health Care Incident Command System to publish recommendations, guidelines, and workflows on a centralized website. Given the large size and diverse needs across departments and disciplines at our institution, individual practice leaders, including those from EDs and ICUs, were asked to actively monitor the website and communicate changes to their staff. Although labor intensive, this effort turned out to be highly beneficial. Local communication of updates to staff by their direct supervisors was better received, possibly because the messages were more specific for the work unit and its workflows. Health care professionals are analytical by nature, and with their increased personal risk, it was important that they be assured that recommendations were being made on appraisal of evidence regarding COVID-19. At Mayo Clinic, a Rapid Literature Review Task Force was formed to streamline the process of assessing rapidly expanding information on the disease and disseminating that information to staff involved in decision making.
Too little or too infrequent communication early in the pandemic fed into fear of the unknown, caused concern about our state of preparedness, and fostered rumors among staff. It became clear that asynchronous leadership messaging (print, e-mail, podcast, and video) would not be enough to drive team adoption of necessary practice changes. Most effective were in-person meetings and updates by practice leadership to frontline staff at daily huddles, at rounds, and in town hall meetings that included question and answer sessions. These types of communication methods helped to allay staff fears, allow for input regarding necessary improvements in EDs and ICUs, identify remaining gaps, and build trust. Messaging with careful justification for each recommendation, along with key supporting documents, was archived on searchable reference websites to improve staff buy-in and ensure their ability to remain up-to-date with the frequent changes. Timely and accurate information that provided the rationale for practice change was crucial for fostering teamwork. Notably, considerably more effort was required to debunk circulating myths and misconceptions about COVID-19 than to implement de novo practice changes before the pandemic.
The Centers for Disease Control and Prevention 6 recommends helping staff maintain agency and control during emergencies. To this end, engaging staff by identifying and matching skill sets to the needs of the practice has kept teams involved, motivated, and cohesive. Designating and reevaluating roles, including having individual team members lead discrete initiatives in their specific areas of interest, has been valuable. For example, staff have taken on the roles of PPE champions to answer questions or address concerns from colleagues (elevating new or important questions to the practice leadership) or have become PPE buddies to check coworkers' use of PPE during donning, doffing, and cleaning procedures, which has added another layer of safety.
The importance of culture cannot be overstated. Mayo Clinic's culture of teamwork and patient-centered care creates an environment of trust and camaraderie such that staff generally trust one another to do the right thing across different disciplines and departments. Because this team-based approach is pervasive at Mayo Clinic, an important and necessary progression has been increased focus on safety and wellness of the individual and their coworkers during the pandemic. Practice leadership has been able to foster this focus directly and indirectly both through communication and by their organization of the response to the pandemic. Compassionate and motivational messaging has been helpful, as has open, honest, and transparent messaging when facts are unknown or data are lacking. This type of communication paired with flexible real-time responses (biased toward safety) and a defined path to finding answers through expert consensus with clear justification has been effective at managing and reassuring teams.
In conclusion, EDs and ICUs are crucial to the pandemic response. Coronavirus disease 2019 has placed enormous pressure on staff and threatened their ability to function effectively as care teams. 2 These new challenges can be managed with careful attention to communication and engagement. Addressing misinformation directly in a timely manner, justifying differences in PPE strategy, and acknowledging and supporting the wellbeing of staff have been especially helpful in maintaining a culture of safety and reinforcing effective and cohesive ED and ICU teams.

ACKNOWLEDGMENTS
Editing, proofreading, and reference verification were provided by Scientific Publications, Mayo Clinic. This supplement is sponsored by Mayo Clinic Foundation for Medical Education and Research and is authored by experts from multiple Departments and Divisions at Mayo Clinic.