A novel briefing checklist at shift handoff in an emergency department improves situational awareness and safety event identification

Improving clinician agreement and comfort through the development of a pediatric behavioral health huddle tool

BACKGROUND

Hospitalized pediatric patients with behavioral health (BH) diagnoses awaiting transfer can exhibit behaviors that may lead to workplace violence such as aggression. Workplace violence can lead to discomfort in caring for these patients. Huddles can be used as a tool to identify potential for violence, to help address workplace violence, and improve clinician situational awareness.

METHODS

Utilizing QI methodology, a BH specific huddle tool was created and implemented on an Acute Care floor that identified key components such as triggers and behavioral stability. Mixed methods were used to study the intervention including focus groups, surveys and measurement of agreement (surrogate for situational awareness). The aims of this quality improvement (QI) project were to 1) improve situational awareness by increasing agreement between team members 2) improve the overall comfort of the clinical team caring for BH patients by 10%.

RESULTS

Agreement between clinicians on patient stability increased by 20%. Comfort in caring for BH patients increased by 4%. Providers reported the tool increased their understanding (89%) and communication (81%) regarding plan of care.

APPLICATION TO PRACTICE

Standardized huddle tool can be utilized to increase situational awareness among team members caring for patients with behavioral health diagnoses and may help to address workplace violence.

Assessing the Value of Huddle Implementation in the Perioperative Setting

Communication is essential for safe, effective patient care. In perioperative services, where interdisciplinary teamwork is crucial, communication breakdowns may lead to increased errors, decreased staff member satisfaction, and poor team performance. This process improvement project focused on instituting perioperative huddles for two months and measuring the effect that they had on staff members' satisfaction, engagement, and communication effectiveness. We used validated, Likert-style survey tools to gauge participants' satisfaction, level of engagement, communication practices, and opinions about the value of huddles before and after implementation, in addition to an open-ended descriptive question in the postsurvey. Sixty-one participants completed the presurvey and 24 participants completed the postsurvey. Scores across all categories increased post huddle implementation. Benefits of the huddles noted by participants included timely and consistent messaging, sharing essential information, and increased feelings of connection between perioperative leaders and staff members.

Implementation of ED I-PASS as a Standardized Handoff Tool in the Pediatric Emergency Department

INTRODUCTION

Communication, failures during patient handoffs are a significant cause of medical error. There is a paucity of data on standardized handoff tools for intershift transitions of care in pediatric emergency medicine (PEM). The purpose of this quality improvement (QI) initiative was to improve handoffs between PEM attending physicians (i.e., supervising physicians ultimately responsible for patient care) through the implementation of a modified I-PASS tool (ED I-PASS). Our aims were to: (1) increase the proportion of physicians using ED I-PASS by two-thirds and (2) decrease the proportion reporting information loss during shift change by one-third, over a 6-month period.

METHODS

After literature and stakeholder review, Expected Disposition, Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver (ED I-PASS) was implemented using iterative Plan-Do-Study-Act cycles, incorporating: trained "super-users"; print and electronic cognitive support tools; direct observation; and general and targeted feedback. Implementation occurred from September to April of 2021, during the height of the COVID-19 pandemic, when patient volumes were significantly lower than prepandemic levels. Data from observed handoffs were collected for process outcomes. Surveys regarding handoff practices were distributed before and after ED I-PASS implementation.

RESULTS

82.8% of participants completed follow-up surveys, and 69.6% of PEM physicians were observed performing a handoff. Use of ED I-PASS increased from 7.1% to 87.5% ( p < .001) and the reported perceived loss of important patient information during transitions of care decreased 50%, from 75.0% to 37.5% ( p = .02). Most (76.0%) participants reported satisfaction with ED I-PASS, despite half citing a perceived increase in handoff length. 54.2% reported a concurrent increase in written handoff documentation during the intervention.

CONCLUSION

ED I-PASS can be successfully implemented among attending physicians in the pediatric emergency department setting. Its use resulted in significant decreases in reported perceived loss of patient information during intershift handoffs.

A multidisciplinary safety briefing for acutely ill and deteriorating patients: A quality improvement project

BACKGROUND

Safety briefings can help promoting situational awareness, interprofessional communication and improve patient safety.

LOCAL PROBLEM

A clinical survey highlighted that 90% of the participants including the medical team and the critical care outreach team nurses perceived the meeting for escalating acutely ill and deteriorating patients during the out-of-hours period (20.00 to 08.00) to have unconstructive and unwelcoming atmosphere with belittling, hostility and unhelpful criticisms. The participants reported that the communication across teams lacked in structure and clear information given; but staff also self-reported lacking confidence in communicating key issues.

METHOD

A quality improvement project with Plan-Do-Study-Act was adopted to design and implement a dedicated multidisciplinary safety briefing with a structured format.

RESULTS

The multidisciplinary safety briefing was to 90% of clinicians, and it took a median of 10 min to complete. Delayed referrals to the critical care outreach team were reduced by 46%. Positive changes included increased situational awareness and clearer communication across teams. Barriers identified were variable usage and need for face-to-face presence. Considering all the findings and the time constraint during the SARS-CoV-2 pandemic, we changed to a telephonic safety briefing directly to the team leaders.

CONCLUSION

A structured multidisciplinary safety briefing can improve patient safety and support management of deteriorating and acutely ill patients on the wards during the out-of-hours period.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

Patient safety is the foundation of high-quality health care and remains a critical priority for all clinicians caring for children. There are numerous aspects of pediatric care that increase the risk of patient harm, including but not limited to risk from medication errors attributable to weight-dependent dosing and need for appropriate equipment and training. Of note, the majority of children who are ill and injured are brought to community hospital emergency departments. It is, therefore, imperative that all emergency departments practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This technical report outlined the challenges and resources necessary to minimize pediatric medical errors and to provide safe medical care for children of all ages in emergency care settings.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

This is a revision of the previous American Academy of Pediatrics policy statement titled "Patient Safety in the Emergency Care Setting," and is the first joint policy statement by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association to address pediatric patient safety in the emergency care setting. Caring for children in the emergency setting can be prone to medical errors because of a number of environmental and human factors. The emergency department (ED) has frequent workflow interruptions, multiple care transitions, and barriers to effective communication. In addition, the high volume of patients, high-decision density under time pressure, diagnostic uncertainty, and limited knowledge of patients' history and preexisting conditions make the safe care of critically ill and injured patients even more challenging. It is critical that all EDs, including general EDs who care for the majority of ill and injured children, understand the unique safety issues related to children. Furthermore, it is imperative that all EDs practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This policy statement outlines the recommendations necessary for EDs to minimize pediatric medical errors and to provide safe care for children of all ages.

Situation awareness and the mitigation of risk associated with patient deterioration: A meta-narrative review of theories and models and their relevance to nursing practice

BACKGROUND

Accurate situation awareness has been identified as a critical component of effective deteriorating patient response systems and an essential patient safety skill for nursing practice. However, situation awareness has been defined and theorised from multiple perspectives to explain how individuals, teams and systems maintain awareness in dynamic task environments.

AIM

Our aim was to critically analyse the different approaches taken to the study of situation awareness in healthcare and explore the implications for nursing practice and research as it relates to clinical deterioration in ward contexts.

METHODS

We undertook a meta-narrative review of the healthcare literature to capture how situation awareness has been defined, theorised and studied in healthcare. Following an initial scoping review, we conducted an extensive search of ten electronic databases and included any theoretical, empirical or critical papers with a primary focus on situation awareness in an inpatient hospital setting. Included papers were collaboratively categorised in accordance with their theoretical framing, research tradition and paradigm with a narrative review presented.

RESULTS

A total of 120 papers were included in this review. Three overarching narratives reflecting philosophical, patient safety and solution focussed framings of situation awareness and seven meta-narratives were identified as follows: individual, team and systems perspectives of situation awareness (meta-narratives 1-3), situation awareness and patient safety (meta-narrative 4), communication tools, technologies and education to support situation awareness (meta-narratives 5-7). We identified a concentration of literature from anaesthesia and operating rooms and a body of research largely located within a cognitive engineering tradition and a positivist research paradigm. Endsley's situation awareness model was applied in over 80% of the papers reviewed. A minority of papers drew on alternative situation awareness theories including constructivist, collaborative and distributed perspectives.

CONCLUSIONS

Nurses have a critical role in identifying and escalating the care of deteriorating patients. There is a need to build on prior studies and reflect on the reality of nurse's work and the constraints imposed on situation awareness by the demands of busy inpatient wards. We suggest that this will require an analysis that complements but goes beyond the dominant cognitive engineering tradition to reflect the complex socio-cultural reality of ward-based teams and to explore how situation awareness emerges in increasingly complex, technologically enabled distributed healthcare systems.

Huddles and their effectiveness at the frontlines of clinical care: a scoping review

BACKGROUND

Brief, stand-up meetings known as huddles may improve clinical care, but knowledge about huddle implementation and effectiveness at the frontlines is fragmented and setting specific. This work provides a comprehensive overview of huddles used in diverse health care settings, examines the empirical support for huddle effectiveness, and identifies knowledge gaps and opportunities for future research.

METHODS

A scoping review was completed by searching the databases PubMed, EBSCOhost, ProQuest, and OvidSP for studies published in English from inception to May 31, 2019. Eligible studies described huddles that (1) took place in a clinical or medical setting providing health care patient services, (2) included frontline staff members, (3) were used to improve care quality, and (4) were studied empirically. Two reviewers independently screened abstracts and full texts; seven reviewers independently abstracted data from full texts.

RESULTS

Of 2,185 identified studies, 158 met inclusion criteria. The majority (67.7%) of studies described huddles used to improve team communication, collaboration, and/or coordination. Huddles positively impacted team process outcomes in 67.7% of studies, including improvements in efficiency, process-based functioning, and communication across clinical roles (64.4%); situational awareness and staff perceptions of safety and safety climate (44.6%); and staff satisfaction and engagement (29.7%). Almost half of studies (44.3%) reported huddles positively impacting clinical care outcomes such as patients receiving timely and/or evidence-based assessments and care (31.4%); decreased medical errors and adverse drug events (24.3%); and decreased rates of other negative outcomes (20.0%).

DISCUSSION

Huddles involving frontline staff are an increasingly prevalent practice across diverse health care settings. Huddles are generally interdisciplinary and aimed at improving team communication, collaboration, and/or coordination. Data from the scoping review point to the effectiveness of huddles at improving work and team process outcomes and indicate the positive impact of huddles can extend beyond processes to include improvements in clinical outcomes.

STUDY REGISTRATION

This scoping review was registered with the Open Science Framework on 18 January 2019 ( https://osf.io/bdj2x/ ).

Studying Institutional Situational Awareness Through Anonymous Incident Reporting

BACKGROUND AND OBJECTIVES

The efficacy of anonymous incident reporting (AIR) is critical to creating a culture of safety. Prior studies have sought to establish AIR in a similar manner as aviation, nuclear power, and other industries. However, health care presents unique challenges that differ greatly from these industries. We present a straightforward method using statistical process control to study the progression and efficacy of AIR.

METHODS

This study represents a retrospective review of all anonymous incident reports and surgical critical events from 2012 to 2017 at a single-institution, 500-bed, university-based, metropolitan Veterans Affairs Administration Medical Center located in Texas. This work was approved by the Veterans Administration Quality Board and deemed to be an appropriate quality improvement project. This project did not require institutional review board approval.

RESULTS

There was an exponential increase in AIRs in the first 15 months from 1 report per month to 168 reports in the ninth month (1425% increase). The results then plateaued over time (first year: 1017, second year: 1634, and third year: 1938-common-cause variation). A logarithmic regression was performed for progression of AIRs per month yielding the equation y = -7E-13ln(x) + 142.92, Pearson Correlation Coefficient = 0.55, where y represents number of reports and x time by month. The highest number of Critical Incident Tracking Notification System (CITNS) reports was observed early in the self-reporting process and decreased over time (first year: 5, second year: 2, third year: 1, fourth year: 1, and fifth year: 0). The numbers of AIR and CITNS reports were found to be inversely related with a Pearson correlation coefficient of -0.4.

CONCLUSIONS

Statistical process control can be applied to an institution's AIR program to study progression and situational awareness.

The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS

BACKGROUND AND OBJECTIVES

Despite the American College of Emergency Physicians and American Academy of Pediatrics recommendations for standardised handoffs in the emergency department (ED), few EDs have an established tool. Our aim was to improve the quality of handoffs in the ED by establishing compliance with the I-PASS handoff tool.

METHODS

This is a quality improvement (QI) initiative to standardise handoffs in a large academic paediatric ED. Following review of the literature and focus groups with key stakeholders, I-PASS was selected and modified to fit departmental needs. Implementation throughPlan-Do-Study-Act cycles included the development of educational materials, reminders and real-time feedback. Required use of I-PASS during designated team sign-out began in June 2016. Compliance with the handoff tool and handoff deficiencies was measured through observations by faculty trained in I-PASS. As a balancing measure, time to complete handoff was monitored and compared with preintervention data.

RESULTS

Compliance with I-PASS reached 80% within 6 months, 100% within 7 months and sustained at 100% during the remainder of the study period. The average percent of omissions of crucial information per handoff declined to 8.3%, which was a 53% decrease. Average percentage of tangential information and miscommunications per handoff did not show a decline. The average handoff took 20 min, which did not differ from the preintervention time. Survey results demonstrated a perceived improvement in patient safety through closed-loop communication, clear action lists and contingency planning and proper patient acuity identification.

CONCLUSIONS

I-PASS is applicable in the ED and can be successfully implemented through QI methodology contributing to an overall culture of safety.

Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness

Aim

Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation.

Design and implementation

We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including ‘VITAL’ (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, ‘STOP’ (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and ‘STOP’ (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme.

Results

The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001).

Conclusion

The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness.

Innovating Pediatric Emergency Care and Learning Through Interprofessional Briefing and Workplace-Based Assessment: A Qualitative Study

BACKGROUND

Managing pediatric emergencies can be both clinically and educationally challenging with little existing research on how to improve resident involvement. Moreover, nursing input is frequently ignored. We report here on an innovation using interprofessional briefing (iB) and workplace-based assessment (iWBA) to improve the delivery of care, the involvement of residents, and their assessment.

METHODS

Over a period of 3 months, we implement an innovation using iB and iWBA for residents providing emergency pediatric care. A constructivist thematic analysis approach was used to collect and analyze data from 4 focus groups (N = 18) with nurses (4), supervisors (5), and 2 groups of residents (4 + 5).

RESULTS

Residents, supervisors, and nurses all felt that iB had positive impacts on learning, teamwork, and patient care. Moreover, when used, iB seemed to play an important role in enhancing the impact of iWBA. Although iB and iWBA seemed to be accepted and participants described important impacts on emergency department culture, conducting of both iB and iWBA could be sometimes challenging as opposed to iB alone mainly because of time constraints.

CONCLUSIONS

Interprofessional briefing and iWBA are promising approaches for not only resident involvement and learning during pediatric emergencies but also enhancing team function and patient care. Nursing involvement was pivotal in the success of the innovation enhancing both care and resident learning.

Critical Communication: A Cross-sectional Study of Signout at the Prehospital and Hospital Interface

Introduction Miscommunication during patient handoff contributes to an estimated 80% of serious medical errors and, consequently, plays a key role in the estimated five million excess deaths annually from poor quality of care in low- and middle-income countries (LMICs). Objective The objective of this study was to assess signout communication during patient handoffs between prehospital personnel and hospital staff. Methods This is a cross-sectional study, with a convenience sample of 931 interfacility transfers for pregnant women across four states from November 7 to December 13, 2016. A complete signout, as defined for this study, contains all necessary signout elements for patient care exchanged verbally or in written form between an emergency medical technician (EMT) and a physician or nurse. Results Enrollment of 786 cases from 931 interfacility transfers resulted in 1572 opportunities for signout. EMTs and a physician or nurse signed out in 1549 cases (98.5%). Signout contained all elements in 135 cases (8.6%). The mean percentage of signout elements included was 45.2% (95% CI, 43.9-46.6). Physician involvement was correlated with a higher mean percent (63.4% [95% CI, 62-64.8]) compared to nurse involvement (23.6% [95% CI, 22.5-24.8]). With respect to the frequency of signout communication, 63.1% of EMTs reported often or always giving signout, and 60.5% reported often or always giving signout; they reported feeling moderately to very comfortable with signout (73.7%) and 34.1% requested further training. Conclusions Physicians, nurses, and the EMTs conducted signout 99% of the time but often fell short of including all elements required for optimal patient care. Interventions aimed at improving the quality of patient care must include strengthening signout communication.

Development and implementation of a standardised emergency department intershift handover tool to improve physician communication

BACKGROUND

Structured handover can reduce communication breakdowns and potential medical errors. In our emergency department (ED) we identified a safety risk due to variation in quality and content of overnight handovers between physicians.

AIM

Our goal was to develop and implement a standardised ED-specific handover tool using quality improvement (QI) methodology. We aimed to increase the proportion of patients having adequate handover information conveyed at overnight shift change from a baseline of 50%-75% in 4 months.

METHODS

We used published best practices, stakeholder input and local data to develop a tool customised for intershift ED handovers. Implementation methods included education, cognitive aids, policy change and plan-do-study-act cycles informed by end-user feedback. We monitored progress using direct observation convenience sampling.

MEASURES

Our outcome measure was proportion of adequate patient handovers (defined as >50% of handover components communicated per patient) per overnight handover session. Tool utilisation characteristics were used for process measurement, and time metrics for balancing measures. We report changes using statistical process control charts and descriptive statistics.

RESULTS

We observed 49 overnight handover sessions from 2017 to 2019, evaluating handovers of 850 patients. Our improvement target was met in 10 months (median=76.1%) and proportion of adequate handovers continued to improve to median=83.0% at the postimprovement audit. Written communication of handover information increased from a median of 19.2% to 68.7%. Handover time increased by median=31 s per patient. End-users subjectively reported improved communication quality and value for resident education.

CONCLUSIONS

We achieved sustained improvements in the amount of information communicated during physician ED handovers using established QI methodologies. Engaging stakeholders in handover tool customisation for local context was an important success factor. We believe this approach can be easily adopted by any ED.

Optimising paediatric afferent component early warning systems: a hermeneutic systematic literature review and model development

OBJECTIVE

To identify the core components of successful early warning systems for detecting and initiating action in response to clinical deterioration in paediatric inpatients.

METHODS

A hermeneutic systematic literature review informed by translational mobilisation theory and normalisation process theory was used to synthesise 82 studies of paediatric and adult early warning systems and interventions to support the detection of clinical deterioration and escalation of care. This method, which is designed to develop understanding, enabled the development of a propositional model of an optimal afferent component early warning system.

RESULTS

Detecting deterioration and initiating action in response to clinical deterioration in paediatric inpatients involves several challenges, and the potential failure points in early warning systems are well documented. Track and trigger tools (TTT) are commonly used and have value in supporting key mechanisms of action but depend on certain preconditions for successful integration into practice. Several supplementary interventions have been proposed to improve the effectiveness of early warning systems but there is limited evidence to recommend their wider use, due to the weight and quality of the evidence; the extent to which systems are conditioned by the local clinical context; and the need to attend to system component relationships, which do not work in isolation. While it was not possible to make empirical recommendations for practice, the review methodology generated theoretical inferences about the core components of an optimal system for early warning systems. These are presented as a propositional model conceptualised as three subsystems: detection, planning and action.

CONCLUSIONS

There is a growing consensus of the need to think beyond TTTs in improving action to detect and respond to clinical deterioration. Clinical teams wishing to improve early warning systems can use the model to consider systematically the constellation of factors necessary to support detection, planning and action and consider how these arrangements can be implemented in their local context.

PROSPERO REGISTRATION NUMBER

CRD42015015326.

Improving the quality of communication during handover in a Paediatric Emergency Department: a qualitative pilot study

Introduction

There is a dearth of literature that specifically addresses the handover reporting process among healthcare staff working in children's Emergency Department (ED). Widespread gaps in service provision, such as gaps in communication in handover reports to ambulance staff have been noted in the general literature on the topic. There are also improvements observed in handover when a structured mnemonic was encouraged. Structured reports improve communication, safety and may reduce medication errors. Thus, the improvement of handover reporting in children's ED has important implications for children's healthcare practice. However, little is known about communication processes during handover reports in Italian children's ED or its consequences for errors or risks.

Methods

A qualitative description methodology was used. Semi-structured interviews were used to collect data from five children's ED nurses. Thematic content analysis was used to identify common themes.

Results

Emergent themes were: interpersonal influences on handover; structural issues; and local contextual factors.

Conclusions

The findings of this pilot study prompted the need for a standardized tool that improves communication during handover. As such, standardizing the communication process during handover could be effectively resolved by using a mnemonic tool adapted for handover in a paediatric emergency department.

Do safety briefings improve patient safety in the acute hospital setting? A systematic review

AIMS

To synthesize current knowledge about the impact of safety briefings as an intervention to improve patient safety.

BACKGROUND

Improving safety in health care remains an ongoing challenge. There is a lack of evidence underpinning safety enhancing interventions.

DESIGN

Mixed method multi-level synthesis.

DATA SOURCES

Four health literature databases were searched (Cinahl, Medline, Scopus and Health Business Elite) from January 2002 - March 2017.

REVIEW METHODS

Thomas and Harden approach to mixed method synthesis.

RESULTS

Following quality appraisal, 12 studies were included. There was significant heterogeneity in study aims, measures, and outcomes. Findings showed that safety briefings achieved beneficial outcomes and can improve safety culture. Outcomes included improved risk identification, reduced falls, enhanced relationships, increased incident reporting, ability to voice concerns, and reduced length of stay.

CONCLUSION

Healthcare leaders should embrace the potential of safety briefings by promoting their effective use whilst allowing for local adaptation.

Handover of Patients From Prehospital Emergency Services to Emergency Departments: A Qualitative Analysis Based on Experiences of Nurses

BACKGROUND

During the transfer of patients, both ambulance and hospital emergency service professionals need to exchange necessary, precise, and complete information for an effective handover. Some factors threaten a quality handover such as excessive caseload, patients with multiple comorbidities, limited past medical history, and frequent interruptions.

PURPOSE

To explore the viewpoint of nurses on their experience of patient handovers, describing the essential aspects of the process and areas for improvement, and establishing standardized elements for an effective handover.

METHODS

A qualitative research method was used.

RESULTS

Nurses identified the need to standardize the patient transfer process by a written record to support the verbal handover and to transmit patient information adequately, in a timely manner, and in a space free of interruptions, in order to increase patient safety.

CONCLUSIONS

An organized method does not exist. The quality of handovers could be enhanced by improvements in communication and standardizing the process.

Informing Leadership Models: Nursing and Organizational Characteristics of Neonatal Intensive Care Units in Freestanding Children's Hospitals

BACKGROUND

Neonatal intensive care units (NICUs) located in freestanding children's hospitals may exhibit significant variation in nursing and organizational characteristics, which can serve as opportunities for collaboration to understand optimal staffing models and linkages to patient outcomes.

OBJECTIVES

Adopting methods used by Hickey et al in pediatric cardiovascular critical care, the purpose of this study was to provide a foundational description of the nursing and organizational characteristics for NICUs located in freestanding children's hospitals in the United States.

METHODS

Clinical nurse leaders in NICUs located in freestanding children's hospitals were invited to participate in an electronic cross-sectional survey. Descriptive analyses were used to summarize nursing and organizational characteristics.

RESULTS

The response rate was 30% (13/43), with 69.2% of NICUs classified as level III/IV and 30.8% classified as level II/III. Licensed bed capacity varied significantly (range, 24-167), as did the proportion of full-time equivalent nurses (range, 71.78-252.3). Approximately three-quarters of staff nurses held baccalaureate degrees or higher. A quarter of nurses had 16 or more years (26.3%) of experience, and 36.9% of nurses had 11 or more years of nursing experience. Nearly one-third (29.2%) had 5 or less years of total nursing experience. Few nurses (10.6%) held neonatal specialty certification. All units had nurse educators, national and unit-based quality metrics, and procedural checklists.

CONCLUSION

This study identified (1) variation in staffing models signaling an opportunity for collaboration, (2) the need to establish ongoing processes for sites to participate in future collaborative efforts, and (3) survey modifications necessary to ensure a more comprehensive understanding of nursing and organizational characteristics in freestanding children's hospital NICUs.

Waterfalls and Handoffs: A Novel Physician Staffing Model to Decrease Handoffs in a Pediatric Emergency Department

STUDY OBJECTIVE

Patient handoffs at shift change in the emergency department (ED) are a well-known risk point for patient safety. Numerous methods have been implemented and studied to improve the quality of handoffs to mitigate this risk. However, few have investigated processes designed to decrease the number of handoffs. Our objective is to evaluate a novel attending physician staffing model in an academic pediatric ED that was designed to decrease patient handoffs.

METHODS

A multidisciplinary team met in August 2012 to redesign the attending physician staffing model. The team sought to decrease patient handoffs, optimize provider efficiency, and balance workload without increasing total attending physician hours. The original model required multiple handoffs at shift change. This was replaced with overlapping "waterfall" shifts. This was a retrospective quality improvement study of a process change that evaluated the percentage of intradepartmental handoffs before and after implementation of a new novel attending physician staffing model. In addition, surveys were conducted among attending physicians and charge nurses to inquire about perceived impacts of the change.

RESULTS

A total of 43,835 patient encounters were analyzed. Immediately after implementation of the new model, there was a 25% reduction in the proportion of encounters with patient handoffs, from 7.9% to 5.9%. A survey of physicians and charge nurses demonstrated improved perceptions of patient safety, ED flow, and job satisfaction.

CONCLUSION

This new emergency physician staffing model with overlapping shifts decreased the proportion of patient handoffs. This innovative system can be implemented and scaled to suit EDs that have more than single-physician coverage.

Implementing standardized, inter-unit communication in an international setting: handoff of patients from emergency medicine to internal medicine

Standardized handoffs may reduce communication errors, but research on handoff in community and international settings is lacking. Our study at a community hospital in the United Arab Emirates characterizes existing handoff practices for admitted patients from emergency medicine (EM) to internal medicine (IM), develops a standardized handoff tool, and assesses its impact on communication and physician perceptions. EM physicians completed a survey regarding handoff practices and expectations. Trained observers utilized a checklist based on the Systems Engineering Initiative for Patient Safety model to observe 40 handoffs. EM and IM physicians collaboratively developed a written tool encouraging bedside handoff of admitted patients. After the intervention, surveys of EM physicians and 40 observations were subsequently repeated. 77.5% of initial observed handoffs occurred face-to-face, with 42.5% at bedside, and in four different languages. Most survey respondents considered face-to-face handoff ideal. Respondents noted 9-13 patients suffering harm due to handoff in the prior month. After handoff tool implementation, 97.5% of observed handoffs occurred face-to-face (versus 77.5%, p = 0.014), with 82.5% at bedside (versus 42.5%, p < 0.001), and all in English. Handoff was streamlined from 7 possible pathways to 3. Most post-intervention survey respondents reported improved workflow (77.8%) and safety (83.3%); none reported patient harm. Respondents and observers noted reduced inefficiency (p < 0.05). Our standardized tool increased face-to-face and bedside handoff, positively impacted workflow, and increased perceptions of safety by EM physicians in an international, non-academic setting. Our three-step approach can be applied towards developing standardized, context-specific inter-specialty handoff in a variety of settings.

A Simulation-based Approach to Measuring Team Situational Awareness in Emergency Medicine: A Multicenter, Observational Study

OBJECTIVES

Team situational awareness (TSA) is critical for effective teamwork and supports dynamic decision making in unpredictable, time-pressured situations. Simulation provides a platform for developing and assessing TSA, but these efforts are limited by suboptimal measurement approaches. The objective of this study was to develop and evaluate a novel approach to TSA measurement in interprofessional emergency medicine (EM) teams.

METHODS

We performed a multicenter, prospective, simulation-based observational study to evaluate an approach to TSA measurement. Interprofessional emergency medical teams, consisting of EM resident physicians, nurses, and medical students, were recruited from the University of Washington (Seattle, WA) and Wayne State University (Detroit, MI). Each team completed a simulated emergency resuscitation scenario. Immediately following the simulation, team members completed a TSA measure, a team perception of shared understanding measure, and a team leader effectiveness measure. Subject matter expert reviews and pilot testing of the TSA measure provided evidence of content and response process validity. Simulations were recorded and independently coded for team performance using a previously validated measure. The relationships between the TSA measure and other variables (team clinical performance, team perception of shared understanding, team leader effectiveness, and team experience) were explored. The TSA agreement metric was indexed by averaging the pairwise agreement for each dyad on a team and then averaging across dyads to yield agreement at the team level. For the team perception of shared understanding and team leadership effectiveness measures, individual team member scores were aggregated within a team to create a single team score. We computed descriptive statistics for all outcomes. We calculated Pearson's product-moment correlations to determine bivariate correlations between outcome variables with two-tailed significance testing (p < 0.05).

RESULTS

A total of 123 participants were recruited and formed three-person teams (n = 41 teams). All teams completed the assessment scenario and postsimulation measures. TSA agreement ranged from 0.19 to 0.9 and had a mean (±SD) of 0.61 (±0.17). TSA correlated with team clinical performance (p < 0.05) but did not correlate with team perception of shared understanding, team leader effectiveness, or team experience.

CONCLUSIONS

Team situational awareness supports adaptive teams and is critical for high reliability organizations such as healthcare systems. Simulation can provide a platform for research aimed at understanding and measuring TSA. This study provides a feasible method for simulation-based assessment of TSA in interdisciplinary teams that addresses prior measure limitations and is appropriate for use in highly dynamic, uncertain situations commonly encountered in emergency department systems. Future research is needed to understand the development of and interactions between individual-, team-, and system (distributed)-level cognitive processes.

Evaluating Situation Awareness: An Integrative Review

Situation awareness (SA) refers to the conscious awareness of the current situation in relation to one’s environment. In nursing, loss or failure to achieve high levels of SA is linked with adverse patient outcomes. The purpose of this integrative review is to examine various instruments and techniques used to measure SA among nurses across academic and clinical settings. Computerized database and ancestry search strategies resulted in 40 empirical research reports. Of the reports included in the review, 24 measured SA among teams that included nurses and 16 measured SA solely in nurses. Methods used to evaluate SA included direct and indirect methods. Direct methods included the Situation Awareness Global Assessment Technique and questionnaires. Indirect methods included observer rating instruments and performance outcome measures. To have a better understanding of how nurses’ make decisions in complex work environments, reliable and valid measures of SA is crucial.

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings

Handoffs represent a critical transition point in patient care that play a key role in patient safety. Our quality improvement project was a descriptive observational study aimed at standardizing pediatric hospitalist handoffs via implementation of a handoff checklist, with the goal of improving handoff quality and physician satisfaction within six months. The handoff checklist was quickly adapted by hospitalists, with median compliance rate of 83% during the study. Handoff quality was assessed by trained observers using the validated Handoff Clinical Evaluation Exercise (CEX) tool at multiple time periods pre- and post-implementation (at 2, 6, 12, and 24 months). Handoff quality improved during our study, with a significant decrease in the percentage of "unsatisfactory" handoffs from 9% to 0% (p-value 0.004), an effect which was sustained after initial project completion. The cumulative time required for verbal handoffs for different attending physicians paralleled patient census. However, our project identified wasted down time between individual physician handoffs, and an intervention to change shift times led to a decrease in the average total handoff process time from 86 minutes to 60 minutes, p-value <0.001. An average of 7.4 patient care items was identified during handoffs. A physician perception survey revealed improved situational awareness, efficiency, patient safety, and physician satisfaction as a result of our handoff improvement project. In conclusion, implementation of a checklist and standardized handoff process for pediatric hospitalists improved handoff efficiency and quality, as well as physician satisfaction.

Practicing handoffs early: Applying a clinical framework in the anatomy laboratory

The anatomy laboratory provides an ideal environment for the integration of clinical contexts as the willed-donor is often regarded as a student's "first patient." This study evaluated an innovative approach to peer teaching in the anatomy laboratory using a clinical handoff context. The authors introduced the "Situation, Background, Assessment, Recommendation" (SBAR) handoff framework within the anatomy laboratory. Study participants included 147 second-year medical students completing the head and neck portion of an anatomy course. The authors used mixed methods to evaluate the impact of the anatomic SBAR on the student anatomy laboratory experience. Qualitative analysis of student evaluations revealed three themes which emerged from students' summaries of their anatomic handoff experiences: Learning-by-teaching; Acquiescing to doing more with less; and Distrust of the peer handoff process. All the themes demonstrated that the anatomic handoff encouraged students' focus on the knowledge preparation and reflection. Closed question analysis suggested that that students' perceptions of handoff usefulness were tied to deeper learning strategies. The handoff provided a mechanism for promoting students' focus on anatomical relationships and facilitated students' learning of transferable clinical skills. Together, these results suggest that the introduction of a handoff process in anatomy education provided both a mechanism for learning anatomy and a unique opportunity for early exposure to an essential clinical skill. This clinical and basic science integration may serve as a vertical integration thread which can be woven throughout undergraduate medical education. Future study will focus on exploring the long-term impacts and learning outcomes of this integration. Anat Sci Educ 9: 476-487. © 2016 American Association of Anatomists.

Cross-checking to reduce adverse events resulting from medical errors in the emergency department: study protocol of the CHARMED cluster randomized study

BACKGROUND

Medical errors and preventable adverse events are a major cause of concern, especially in the emergency department (ED) where its prevalence has been reported to be roughly of 5-10% of visits. Due to a short length of stay, emergency patients are often managed by a sole physician - in contrast with other specialties where they can benefit from multiples handover, ward rounds and staff meetings. As some studies report that the rate and severity of errors may decrease when there is more than one physician involved in the management in different settings, we sought to assess the impact of regular systematic cross-checkings between physicians in the ED.

DESIGN

The CHARMED (Cross-checking to reduce adverse events resulting from medical errors in the emergency department) study is a multicenter cluster randomized study that aim to evaluate the reduction of the rate of severe medical errors with implementation of systematic cross checkings between emergency physician, compared to a control period with usual care. This study will evaluate the effect of this intervention on the rate of severe medical errors (i.e. preventable adverse events or near miss) using a previously described two-level chart abstraction. We made the hypothesis that implementing frequent and systematic cross checking will reduce the rate of severe medical errors from 10 to 6% - 1584 patients will be included, 140 for each period in each center.

DISCUSSION

The CHARMED study will be the largest study that analyse unselected ED charts for medical errors. This could provide evidence that frequent systematic cross-checking will reduce the incidence of severe medical errors.

TRIAL REGISTRATION

Clinical Trials, NCT02356926.

Can emergent treatments result in more severe errors?: An analysis of a large institutional near-miss incident reporting database

PURPOSE

Emergent radiation treatments may be subject to more errors because of the compressed time frame. Few data exist on the magnitude of this problem or how to guide safety improvement interventions. The purpose of this study is to examine patterns of near-miss events in emergent treatments using a large institutional incident reporting system.

METHODS AND MATERIALS

Events in the incident reporting database from February 2012 to October 2013 were reviewed prospectively by a multidisciplinary team to identify emergent treatments. Reports were scored for potential near-miss risk index (NMRI) on a 0 to 4 scale. Workflow steps of where events originated and were detected were analyzed. Events were categorized by use of the causal factor system from the Radiation Oncology Incident Learning System. Mann-Whitney U tests were used to compare mean NMRI score, and Fisher exact tests were performed to compare the proportion of high-risk events between emergent and nonemergent treatments and between emergent treatments on weekdays and weekends or holidays.

RESULTS

Over the study period, approximately 1600 patients were treated, 190 of them emergently. Seventy-one incident reports were submitted for 55 unique patients. Fewer events were reported for emergent treatments than for nonemergent treatments (0.37 events per new treatment vs 0.86; P < .01). Mean risk index for emergent reports was 1.90 versus 1.48 for nonemergent reports (P < .01). Rate of NMRI 4 was 10% for emergent treatments versus 4% for nonemergent treatments (P < .01). Emergent treatments started on a weekend or holiday had a higher proportion of critical near-miss events than emergent treatments started during the week (37% vs 7.9%, P = .034).

CONCLUSIONS

In this study, fewer near-miss incidents were reported per treatment course for emergent treatments. This may be attributable to reporting bias. More importantly, when emergent near misses occur, they are of greater severity.