Human Factors in Emergency Department eCPR: A Prospective Observational Study of Teamwork, Stress and Environmental Demands

BACKGROUND Extracorporeal cardiopulmonary resuscitation (eCPR) is a high-acuity, low-occurrence (HALO) intervention requiring advanced technical skills and coordinated team performance. This study examined teamwork, provider stress and environmental conditions during Emergency Department (ED) eCPR events, interpreted using Reid and co-authors’ conceptual framework of self, team, environmental and system factors in high-performance resuscitation teams. METHODS We conducted a prospective observational study at two EDs with ethical approval. A pilot phase involving simulation and trauma activations was used to refine research logistics and methods. Recruitment for the eCPR study arm used convenience sampling with eligibility criteria including ED attempts at cannulation for adult cardiac arrest. Patient variables included demographics, Utstein elements and key eCPR timings. During eligible cases up to four providers were pre-consented and enrolled (cannulators, team leaders and defibrillation nurses). Team members were monitored for heart rate, salivary cortisol and psychometric stress-response indices. Global teamwork was assessed using the Mayo High-Performance Team Score (MHPTS). Environmental factors were measured via ambient noise monitoring (dB), team headcounts and observation of workflows. RESULTS Thirteen pilot cases and six eCPR cases (including 18 providers) were observed. Patients had a mean age of 44.7 years (SD 10.0), and five of six arrests presented with a shockable rhythm. Providers demonstrated significant physiological stress, with cortisol levels elevated compared to baseline (p = 0.0023). Team performance scores were consistently high (MHPTS x̄=12; IQR 10–13). Ambient noise peaked at a mean of 93.3 dB (SD 6.4), with overall mean levels of 75.2 dB (SD 7.9). Resuscitation rooms were crowded (headcount x̄=20; IQR 18–29). Despite stress, noise and crowding, team performance remained robust. Observations suggested that predefined roles, crowd-management strategies and regular verbal summaries helped maintain performance. CONCLUSION ED eCPR teams displayed consistently high performance despite substantial provider stress and challenging environmental conditions. Role clarity, crowd control and structured team summaries may help preserve team reliability. Targeted training in these behaviours could further strengthen ED eCPR delivery.