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Closed Loop Communication Training in Medical Simulation

Editor: John V. Ashurst Updated: 1/23/2023 12:59:07 PM


Effective interprofessional teamwork and communication are integral to patient safety. The Institute of Medicine highlighted the effect of poor communication on deleterious healthcare outcomes in the 1990s.[1] Detrimental outcomes caused by preventable errors are commonly the result of multiple human factors, as opposed to one single error by an individual. Reason et al. argue that in medicine, every sequential step in a process has the potential for failure, and medical professionals should be vigilant of this reality.[2] Commonly, such failures are the result of inadequate communication. Miscommunication is to blame for up to 30% of malpractice awarded lawsuits, where a patient is incapacitated or killed, according to the Control Risk Insurance Company.[2]

The future of patient safety and avoidance of medical errors should be predicated upon systems based error prevention as opposed to sole reliance on a healthcare provider’s vigilance. Handoff periods are particularly vulnerable to deficiencies in verbal communication due to language impediments, misunderstandings, interruptions, and hesitation to speak up against authority.[3] Successful communication strategies are fundamental to productive team structure, collaboration, and task completion.[4] Standardized communication systems have been developed to reduce the risk of inappropriate information transfer. The field of aviation has led to significant changes in team training concepts to increase patient safety, known as Crew Resource management.[5] Closed-loop communication (CLC), including a call-out(CO), is based upon the use of standardized terminology and procedures to ensure safe communication.[6] A CO is a primary verbalization used to make the team aware of a meaningful change or observation in regards to patient care. CLC is a communication model originating from military radio transmissions based on verbal feedback to ensure proper team understanding of a meaningful message. CLC is a three-step process, where 1) the transmitter communicates a message to the intended receiver, utilizing their name when possible, 2) the receiver accepts the message with acknowledgment of receipt via verbal confirmation, seeking clarification if required and 3) the original transmitter verifies that the message has been received and correctly interpreted, thereby closing the loop.[7]


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The adoption of Crew Resource Management by the aviation industry has revolutionized safety and error prevention through the improvement of effective communication via standardized terminology and procedures.[8] Bowers et al. report that during simulation training comparing various communication styles between flight crews, high-performing crews utilized CLC more frequently and repeated commands more often than low-performing crews.[10] CLC is not only efficacious in high-intensity fields such as aviation, the military, and the nuclear industry, but is also applicable in emergency medicine, obstetrics, and anesthesia.[9] CLC has been shown to reduce the risk of preventable errors in medicine by maintaining clear communication and optimizing team dynamics through collaboration and orientation toward a common goal.[10] Trauma resuscitation is a field ripe with opportunity for refinement of CLC with the aim of optimal patient care. Webman et al. report over 337 errors in 39 pediatric trauma activations, where over 51% of errors were not acknowledged or compensated for by the team.[13] The Agency of Healthcare Research and Quality and the Department of Defense developed team guidelines and policies to improve safety, efficacy, and quality of health care communication with a significant emphasis on CLC.[11]

In terms of simulation training in cases of emergency obstetric care, teams that utilized CO and CLC were more successful in completing critical tasks than teams with more complex communications. Teams that used CLC were quicker to administer a magnesium infusion to an eclamptic patient emergently.[9] Based on these findings, the inference is that learning during simulation training can be extrapolated to the clinical environment, and the use of CO with CLC may increase patient safety.[12] It is important to note that the communication style of a team leader can influence a teams’ success in task execution. Leadership style, whether egalitarian or authoritarian, can determine team culture as well as the comfort level of team members to speak up when unanticipated and urgent changes occur in a patient’s condition.[13]

Issues of Concern

Trauma teams’ use of CO and CLC was found to be useful in goal-oriented task completion, and utilization was more common in providers with significant professional experience. CO encouraged team members to verbalize completed tasks or substantial changes in a patient’s condition. Complications can arise when there are too many CO’s being verbalized with no direct recipient, as these commands can lead to confusion instead of action. Siassakos et al. found that direct commands were more likely to be executed and lead to overt action as opposed to indirectly articulated commands.[17] Indirect commands were also likely to lead to task overload for resuscitation team members, thus having a detrimental impact on the teams’ performance.[12] Excessive communication by non-leaders in the team environment was deemed inconvenient and decreased efficiency toward completing a particular task. If all team members were to initiate CO and CLC, communication overload can result in a lack of leadership and delayed patient assessment and intervention.

Although communication overload is alarming, appropriate, and timely vocalization of concerns on behalf of the patient is integral to a successful interprofessional team. Egalitarian team leaders were more likely to encourage active team members who vocalized their concerns. Authoritarian leaders lead to the less frequent use of CLC in trauma teams. CLC utilizing effective and clear communication does not always come naturally for team members, which is why its use in simulation activities requires emphasis. Factors including time pressure, excessive workload, and organizational hierarchies can negatively impact the use of CLC. Although the risk of miscommunication in surgical teams becomes reduced with the use of CLC, repetitive practice via simulation is imperative to successful implementation.[14] A study by Hargestam et al. found that exposure to two or more simulated trauma courses was associated with more frequent use of CLC in a clinical situation, as opposed to practitioners with no such experience.[15]

Curriculum Development

Salas et al. suggest utilizing the routine use of CLC because it can reduce tension between members of trauma teams.[6] Although the aviation industry has shown evidence-based improvement in patient safety with CLC, there is little empirical evidence to demonstrate its usefulness in the healthcare field. Structured handoff tools are often useful to improve handoff quality and avoid sentinel events and unexpected deaths.[16] While Salas’ model of teamwork underscores team orientation, Burford et al. claim that practitioners often identify with members of their area of expertise.[17] In the dynamic healthcare environment, input from various healthcare professionals should be sought and requires emphasis over a single subspecialty group.

Education is one of the most important means by which to arm faculty and trainees in terms of improvement in patient safety. As stated by the US Institute of Medicine (IOM), teams that work together should train together.[18] One of the IOM’s core competencies includes “working as interprofessional teams,” which allows improved understanding of different team members’ roles via concurrent training. Comprehensive team training in surgery and obstetrics has been shown to prevent errors and improve patient safety. Merien et al. reported that team training in obstetrics not only improved knowledge but lead to enhanced APGAR scores and reduced hypoxic-ischemic encephalopathy.[19] Neily et al. also reported a 50% reduction in risk-adjusted surgical mortality rate in team-training groups compared to control groups across over 100 hospitals.[20]

Immersive simulation scenarios allow for in-depth debriefing regarding roles, responsibilities, and information sharing as they relate to patient management. With proper debriefing, simulation provides insight into different interprofessional teams’ vantage points, allowing for an environment of mutual support. Culture change can occur in an environment where the patient is at the center of a shared mental model. interprofessional simulation allows for the development of mutual respect and trust via a team rather than an individual-oriented approach. The simulation, therefore, represents a safe environment for the deliberate practice of efficient communication strategies. Video recordings of participants during simulation activities can help facilitate learning along with a structured debrief. A meta-analysis of 609 studies suggests that simulation can aid in the augmentation of medical knowledge, time management skills, process, and procedure skills.[21]

Clinical Clerkships

Trainees (both team leaders and team members) must hone their CLC skills through simulation activities. Simulation continues to grow as an essential training modality in healthcare, while CRM is acknowledged as a foundation for improving healthcare teams’ collaboration and communication. CLC is an indispensable aspect of CRM and is utilized to ensure safe and secure team communication. These concepts are used in courses such as advanced trauma life support, advanced cardiac life support, and TeamSTEPPS training.[22] Appropriate handoff and communication skills require deliberate practice and training in simulation environments that depict real-life practice- including daily stressors, distractions, and interruptions, which can negatively impact team performance.[23] Emergencies should be routinely recreated via simulation to integrate CLC into everyday workflow practices. Because CLC is time-consuming and potentially increases workload, it may not come naturally to individuals in the simulation team. Repeated role modeling of CLC by team leaders is essential, as hierarchical and interpersonal factors can become rate-limiting steps to the successful execution of CLC. Repetitive simulation exercises with CLC will allow the formal integration of this mode of communication into everyday practice for health professionals.

Procedural Skills Assessment

An important technique for CLC instruction and refinement is blindfolding of the team leader, known as the blindfolded code training exercise. This method of instruction is cost-effective and requires the team leader to utilize critical thinking skills and a sound conceptual framework to organize the management of patient resuscitation. Trainees in emergency medicine, anesthesia, and critical care specialties need extensive training in leadership strategies and CRM to perform in high-acuity situations effectively. It is unclear how to teach techniques to improve real-time ineffectual behavior or bad habits that may persist despite structured learning in the simulation lab.[24]

The theory of neuroplasticity, or the brain’s ability to evolve and reorganize neuronal activity over time, has been suggested as a means to improve communication in the field of medicine. After blindfold placement, other senses become heightened once the team leader loses his/her sense of sight, known as cross-modal neuroplasticity.  Functional magnetic resonance imaging (MRI) of the brain has revealed augmentation of other senses when the examinee gets deprived of one. Researchers found that blind adults processed auditory and tactile stimuli in the visual cortex, as compared to patients with sight who did not experience this phenomenon. This suggests that deprived areas of the brain can become amenable to alternative sensory stimulation.[25] The removal of visual stimuli from the team leader during simulation should, therefore, improve CLC by compelling explicit message verbalization and confirmation.

Medical education may not be taking full advantage of the concept of cross-modal neuroplasticity in regards to developing advanced means of communication amongst teams. The lack of visual cues in an arrest situation requires trainees to develop highly attuned communication skills. The blindfolded code training exercise exemplifies the importance of strong leadership skills during a team simulation, allowing trainees to integrate the leadership and communication training they have received. Closed-loop commands are useful in such a setting as members of the resuscitation team cannot perform maneuvers or initiate patient management without explicit orders from team leaders.

Continuing Education

Medical errors and failure to rescue are commonly attributed to ineffective communication during operative care in “low frequency, high acuity” events, including trauma resuscitation and cardiac arrest situations.[26] In such precarious scenarios, effective communication is critical to the avoidance of preventable harm to patients. The 2016 National Patient Safety Goals by the Joint Commission strongly advocate for improved communication amongst caregivers as a means to this end.[27] Nontechnical skills, which refer to the cognitive and interpersonal skills of healthcare professionals, underlie their ability to work and communicate effectively in an operative team environment.[28] Coaching of nontechnical skills and simulation interventions strongly relies on adopting CLC strategies. CLC accentuates precision, efficiency, reduction of ambiguity, and accuracy towards a teams’ goal-oriented approach to intervention.

Clinical Significance

Modern healthcare is optimally delivered by multidisciplinary teams who should prioritize teamwork and communication to facilitate safe patient care. There is, however, an unacceptable incidence of preventable medical errors commonly attributed to communication failures between health professionals. Effective teams rely on a foundation of mutual respect and trust, shared mental models, and CLC for effective care delivery. Several challenges prevent the facilitation of such effective teams, including educational, organizational, and psychological challenges.[29] Although active educational interventions promote effective teamwork principles, allowing for the realization of team members’ roles and perspectives, and aiding in the development of communication strategies, they are not sufficient on their own to enable optimal healthcare delivery. Hierarchies and professional silos, along with organizational obstacles, increase the odds of communication failures and unintended patient harm.[29]

Medical professionals from multiple disciplines must effectively communicate and facilitate healthcare delivery via teams rather than individual providers. Failures of inter-professional teamwork and communication can lead directly to compromised patient care, medical errors, increased sentinel events, staff burnout, tension, and inefficiency. [30] Barriers to team communication in healthcare can be overcome by teaching trainees’ effective communication strategies, utilizing structured handoff tools, training interdisciplinary teams in a cohesive environment, utilizing simulation for team training, and redefining disparate interprofessional teams to an integrated group with common goals.[29] Open team communication becomes stimulated by creating democratic teams where each members’ input is both encouraged and valued. Checklists, handoff tools, and briefings should be regularly utilized to develop a top-down organizational culture where inter-professional collaboration is encouraged to maximize patient safety.

Enhancing Healthcare Team Outcomes

Despite widespread attempts at implementation of improved communication strategies with CLC, errors associated with ineffective communication are far too common. There has been a leap from problem recognition during operative training to solution implementation, failing to explore communication lapses among teams.[31] The differences in communication patterns between clinical subspecialists (anesthesiologists, surgeons, and nurses) suggest that a more in-depth understanding of specialty-specific practices may yield further insights into quality improvement.

Salas et al. proposed a model for five elements of effective teams, including team leadership, mutual performance monitoring, backup behavior, flexibility, and team orientation, with a groundwork of mutual trust and CLC.[36] Strong leadership involves task coordination, team development, inspiring motivation, and fostering a positive environment. Performance monitoring requires enough knowledge of team members to allow identification of failures or task overload, while backup behavior requires supportive behavior from team members, including redistribution of workload and altered task delegation. Flexibility or team adaptability enables a team to acutely respond to changes in a dynamic clinical environment, while team orientation is the willingness to take the perspectives of others into account and the valuation of team goals over individual ones. Shared mental models lead to common situational awareness and an integrated treatment plan for the patient while taking into account the roles and tasks of individuals. This shared mental model allows for effective team-based problem solving and decision making.

A meta-analysis of 72 studies with 4795 teams across a range of industries revealed that successful information sharing predicted team performance.[32] Information sharing is most crucial during periods of handoff, including interdepartmental transfers from the emergency room to the operating room or intensive care unit, during a change of shift, and across professional boundaries, including physician to nurse.[33] In a British study of handoff to the medical floor, less than half of residents felt confident in their patient handoffs.[34] In the same vein, in an observational study of operating room procedures, Lingard et al. reported over a quarter of communication events as failures, where 36% of these had adverse outcomes, including operating room delays, waste, staff disgruntlement, and procedural errors.[40] Mazzocco et al. found that teams that engaged in information sharing less frequently at the start of an operative case or at postoperative handoff time had more than double the risk of surgical complications than teams that shared information more regularly.[41] There is evidence to suggest that specific techniques to improve information sharing can also enhance the clinical management of patients in high acuity settings. Verbalizing observations aloud and involving team members in decision making during a crisis aids the team in sharing a mental model. 

One of the limitations to the enhancement of CLC among professionals is that different groups have different expectations regarding the content, timing, and generalized structure of information transfer, and may not grasp the roles and priorities of other groups. [35]Medical training predominantly occurs in ‘silos,’ and few providers receive teamwork training.  Differing levels of education and stark separations of disciplines may contribute to impediments in teamwork.  Hierarchical challenges also exist in medicine; while senior staff members are comfortable utilizing commands, junior staff may be more reticent to challenge decisions or offer suggestions of alternative plans in regards to patient care. This hierarchical structure has been shown to have disastrous consequences in the aviation industry, where junior crew members failed to challenge ill-advised decisions of their seniors, leading to catastrophic outcomes.[36] Every member of the healthcare team requires empowerment to contribute to information regarding patient safety.



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