Zero Point Survey
Anand Swaminathan MD and Cliff Reid MD
Print editor: Whitney Johnson MD MS
Take Home Points
- The zero point survey can be used to prepare yourself, your team and your environment prior to resuscitations.
- The STEP UP mnemonic: self, team, environment, patient, update, priorities.
- Resuscitation starts before the primary survey.
- We talk about the primary and secondary survey. When does the resuscitation actually start?
- Reid, C et al. Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med. 2018 Sep;5(3):139-143. PMID: 30269449
- What is the zero point survey? We have all experienced a resuscitation that felt messy or did not go according to plan. Sometimes this may be due to the severity of illness of the patient. Sometimes this may be due to us, the team dynamics, environment or communication. There are simple solutions to these issues, but it is best if you can preempt them as early as possible.
- We have been teaching the primary survey as the initial step in resuscitation but this is not when things start. Time zero on the clock might be when the EMS call arrives or you start your shift. As soon as you know you might be resuscitating, conduct a survey of the correctable factors that relate to yourself, your preparation, team readiness and preparation of the environment before you even see the patient.
- The STEP UP mnemonic can be used to frame the zero point survey.
- This refers to both physical and psychological preparedness.
- Be fit to do your job that day. Empty your bladder. Eat.
- You can use the I’M SAFE mnemonic from aviation safety (illness, medication, stress, alcohol and drugs, fatigue, eating and elimination).
- Psychological preparedness is about getting into the performance zone. Access the right mental state and interpret what you will have to do as a challenge rather than a threat. Remind yourself that you have the resources to deal with this. You have the training, the kit and team. This positive threat challenge appraisal can limit the harmful effects of your stress response and allow you to focus and perform.
- From Mike Lauria, you can use the Beat the Stress mnemonic; breathe, talk, see. Do controlled or combat breathing. Positive self-talk; “I can do this. I have the training and resources.” Visualization and see a successful resuscitation or procedure. This has been shown to enhance performance in multiple domains.
- Lauria, MJ et al. Psychological skills to improve emergency care providers’ performance under stress. Ann Emerg Med. 2017 Dec;70(6):884-890. PMID: 28460863
- Nominate a leader and establish roles. If you have any time, use any information you have to brief the team on what to expect. Share the model of what needs to be done and who will do it.
- We expect a standardized environment. However, the resuscitation room is not a cockpit. Ultrasound machines, resuscitation equipment can move around the field. Experienced prehospital providers are skilled at controlling their resuscitative real estate. This can be done in the ED or as a medical response team.
- You need enough space, enough light and enough heat. Avoid noise. Establish crowd control. You need 360 degrees of access around a sick patient. There is gravitational pull of clutter and people that will suck into that space.
- Primary survey and evaluation of the patient.
- Update and priorities. After completion of the primary survey, update the team. Get everyone on the same page and share the mental model of where you are and where you are going. “We have a N year old patient who is presenting with X and primary survey reveals they are likely to have Y. Let’s establish an airway and good vascular access with fluid resuscitation. I want this patient in the CT scanner within the next 15 minutes.” The whole team knows the deal and plan. Specific tasks can be broken down to sub-teams.
- You will likely cycle back to update and determine priorities multiple times, especially as other teams enter the resuscitation.
- Many of us are doing this already. This is a memorable and easily taught structure to what good resuscitationists are doing already.
Recent Related Material
EM:RAP 2019 December - Human Factors in Resuscitation: Team Dynamics