Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy

What every intensivist should know about..Patient safety huddles in the ICU

Patient safety huddles are brief, multidisciplinary conversations that focus on a specific topic or event. Huddles have been shown to improve communication among healthcare providers in a variety of settings, including the intensive care unit (ICU). This paper presents key features of patient safety huddles and describes the ways in which huddle techniques may be particularly relevant to the practice of critical care.

Let's Talk Safety - Data from the Neonatal Intensive Care Unit Safety and Bed Capacity Huddles

BACKGROUND

Huddles are brief team meetings designed to communicate essential information. Safety huddles provide a forum to identify and review patient safety events. In a just culture, everyone is accountable for patient safety.

PURPOSE

The purpose of this project is to discuss safety issues/events at the twice daily bed capacity huddles in a Level IV Neonatal Intensive Care Unit (NICU) utilizing a just culture model. Having daily discussions of patient safety and the escalation process for follow-up promotes a just culture. The aims are to improve the unit's culture of safety and learn from patient safety issues.

METHODS

A just culture model was adopted to promote discussion of safety events during the huddles. A structured checklist of safety events was utilized along with a script of ground rules. Twice a day, a multidisciplinary group gathers to huddle. Nurse leaders facilitate the discussion, track the results, and provide follow-up.

RESULTS

The structured safety huddle began in May of 2020 and continues twice daily. All required staff attend. The escalation process is defined and has prevented recurrence of some safety issues. The NICU experienced a 14% increase in favorable results on the Agency for Healthcare Research and Quality (AHRQ) culture of safety survey since the inception of the structured safety huddles.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Safety huddle discussions have impacted the culture of safety on this unit. Tracking of discussions can help to identify trends, improve processes, and impact patient safety.

Enhancing safety culture in radiology: Key practices and recommendations for sustainable excellence

OBJECTIVES

This review aims to explore and thematically synthesize the existing literature on safety culture within the context of radiology. The primary objective is to identify key practices that effectively strengthen safety culture, highlighting the pivotal roles of leadership, effective teamwork, and interprofessional collaboration in these efforts. The review intends to showcase actionable recommendations that are particularly relevant to the radiology setting.

KEY FINDINGS

The study highlights that effective leadership is fundamental in establishing and nurturing a safety-first approach within radiology departments. Key practices for promoting a safety culture include safety huddles, leadership walkarounds, quality learning boards, intentional patient rounding (frequent patient-care provider interactions), morbidity and mortality meetings, and multidisciplinary team rounds. These practices have been found to facilitate open communication and transparency, which are crucial elements in creating a sustainable safety culture. Additionally, the study underscores the significant role of radiology managers in driving these safety initiatives and acting as facilitators for a culture of safety, focused on long-term excellence and continuous improvement.

CONCLUSION

The study concludes that a multifaceted and comprehensive approach is vital for fostering a safety culture in radiology departments, with a focus on sustainable excellence in patient care. The leadership role is critical in this process, with radiology managers being instrumental in implementing and maintaining effective safety practices.

IMPLICATIONS FOR PRACTICE

This study provides best practices for sustainable safety culture in radiology departments. It advocates for healthcare managers to adopt and integrate these identified practices into their operational strategies. Continuous professional development, focusing on safety and quality in patient care, and fostering a collaborative environment for open discussion and learning from safety incidents are essential for the continued advancement and excellence of healthcare services.

Stakeholder-Engaged Development of a Theory-Driven, Feasible, and Acceptable Approach to Concussion Education

Concussion education is widely mandated and largely ineffective. Recent consensus guidance on concussion education asserts the importance of (1) theory-driven programming that targets the team as a system and (2) working with end users throughout the development process, and considering issues such as feasibility, acceptability, and sustainability. Consistent with this guidance, and in collaboration with youth sport stakeholders in two regions of the United States, we developed a novel approach to concussion education: Pre-game safety huddles. Safety huddles have the following two core components: (1) athletes, coaches, and other stakeholders come together before the start of each game and (2) opinion leaders (coaches, referees) affirm the importance of care seeking for suspected concussion. The aim of this article is to provide an overview of the collaborative process through which we refined the safety huddle concept into an acceptable and feasible intervention with potential for sustainable implementation in diverse youth sports settings with minimal resource demands. In describing our process and discussing challenges and opportunities, we hope to provide an example for others seeking to develop and implement injury prevention interventions in youth sports settings.

Patient safety culture assessment before and after safety huddle implementation

OBJECTIVE

To identify whether safety huddle implementation enabled a change in patient safety culture.

METHOD

Quasi-experimental research that assessed patient safety culture before and after safety huddle implementation.

RESULTS.

The study revealed that 53.98% completed the two safety culture assessments, with 60.1% adherence from the nursing team, with a statistically significant difference in the second assessment regarding perception of patient safety and adverse events notified (p < 0.00). Regarding good practice indicators, a statistically significant difference (p < 0.00) was observed in item 43 and improvement in almost all dimensions in the second safety culture assessment. The huddles totaled 105 days, with 100% adherence from the nursing team. Regarding checklist items, all presented satisfactory responses (above 50%).

CONCLUSION

Safety huddles proved to be an effective tool for communication between healthcare professionals and managers, demonstrating positive impacts on good practice indicators and most safety culture dimensions.

Clinical Informatics Team Members' Perspectives on Health Information Technology Safety After Experiential Learning and Safety Process Development: Qualitative Descriptive Study

BACKGROUND

Although intended to support improvement, the rapid adoption and evolution of technologies in health care can also bring about unintended consequences related to safety. In this project, an embedded researcher with expertise in patient safety and clinical education worked with a clinical informatics team to examine safety and harm related to health information technologies (HITs) in primary and community care settings. The clinical informatics team participated in learning activities around relevant topics (eg, human factors, high reliability organizations, and sociotechnical systems) and cocreated a process to address safety events related to technology (ie, safety huddles and sociotechnical analysis of safety events).

OBJECTIVE

This study aimed to explore clinical informaticians' experiences of incorporating safety practices into their work.

METHODS

We used a qualitative descriptive design and conducted web-based focus groups with clinical informaticians. Thematic analysis was used to analyze the data.

RESULTS

A total of 10 informants participated. Barriers to addressing safety and harm in their context included limited prior knowledge of HIT safety, previous assumptions and perspectives, competing priorities and organizational barriers, difficulty with the reporting system and processes, and a limited number of reports for learning. Enablers to promoting safety and mitigating harm included participating in learning sessions, gaining experience analyzing reported events, participating in safety huddles, and role modeling and leadership from the embedded researcher. Individual outcomes included increased ownership and interest in HIT safety, the development of a sociotechnical systems perspective, thinking differently about safety, and increased consideration for user perspectives. Team outcomes included enhanced communication within the team, using safety events to inform future work and strategic planning, and an overall promotion of a culture of safety.

CONCLUSIONS

As HITs are integrated into care delivery, it is important for clinical informaticians to recognize the risks related to safety. Experiential learning activities, including reviewing safety event reports and participating in safety huddles, were identified as particularly impactful. An HIT safety learning initiative is a feasible approach for clinical informaticians to become more knowledgeable and engaged in HIT safety issues in their work.

Conceptualizations of interprofessional communication in intensive care units: findings from a scoping review

BACKGROUND

Clinical errors in intensive care units (ICUs) are consistently attributed to communication errors. Despite its importance for patient safety and quality in critical care settings, few studies consider interprofessional communication as more than the basic exchange of information.

METHODS

We conducted a scoping review of interprofessional communication in ICUs to (1) characterize how communication is defined and measured and (2) identify contributions the field of health communication can make to team communication in ICUs. Through a series of queries in PubMed and Communication and Mass Media Complete databases, we identified and compared persistent gaps in how communication is framed and theorized in 28 publications from health services and 6 from social science outlets. We identified research priorities and suggested strategies for discussing communication more holistically in future health services research.

RESULTS

34 articles published from 1999 to 2021 were included. Six explicitly defined communication. Six were published in social science journals, but none were authored by a communication studies scholar. Half of the articles addressed communication as a transaction focused on information transfer, and the other half addressed communication as a process.

CONCLUSIONS

Methodological implications are identified with the intent to encourage future interdisciplinary collaboration for studying communication in ICUs. We discuss the importance of (1) using language to describe communication that facilitates interdisciplinary engagement, (2) prioritizing communication as a process and using qualitative methods to provide insight, and (3) engaging health communication theories and experts to assist in developing more fruitful research questions and designs.

A new practical approach using TeamSTEPPS strategies and tools: - an educational design

BACKGROUND

Teamwork has played a critical role in ensuring patients' safety and preventing human errors in surgery. With advancements in educational technologies, including virtual reality, it is necessary to develop new teaching methods for interpersonal teamwork based on local needs assessments in countries with indigenous cultures. This study aimed to design and develop a new method of teaching teamwork in cesarean section surgery using virtual reality; we further evaluated the effects of this method on healthcare professionals' knowledge and attitudes about teamwork.

METHODS

This study was designed using the ADDIE instructional design model. The TeamSTEPPS Learning Benchmarks questionnaire was used to assess the educational needs of 85 participants who were members of the cesarean section surgery team. A specialized panel analyzed the extracted needs, and the scenario was compiled during the design stage. Finally, four virtual reality contents were created using 360-video H.265 format, which were prepared from specified scenarios in the development of the educational program. The TeamSTEPPS Learning Benchmarks questionnaire was used to measure knowledge, and the T-TAQ was used to measure the participants' attitudes.

RESULTS

Six micro- skills were identified as training needs, including briefing, debriefing, cross-monitoring, I'M SAFE checklist, call-out and check-back, and two-challenge rule. Intervention results showed that the virtual reality content improved teamwork competencies in an interprofessional team performing cesarean section surgery. A significant increase was observed in the mean score of knowledge and attitude after the intervention.

CONCLUSION

Through addressing the need for teamwork training, utilizing the TeamSTEPPS strategy, and incorporating new educational technologies like virtual reality, the collaboration among surgical team members can be enhanced.

Investigating safe nursing care and medication safety competence in nursing students: a multicenter cross-sectional study in Iran

BACKGROUND

Medication safety competence is very important as one of the clinical skills among nursing students to provide safe nursing care. The lack of medication safety competence in nursing students leads to occurrence of medication errors subsequently jeopardizing patient safety. Thus, the present study was conducted to investigate safe nursing care and medication safety competence among nursing students in the south of Iran.

METHODS

A descriptive cross-sectional multicenter study was conducted from September to December 2022. The research population included nursing students of three universities of medical sciences in Fars Province, Southern Iran. A total of 310 nursing students who were selected through convenience sampling participated in the study. The data collection instruments consisted of a demographics survey, Medication Safety Competence Scale (MSCS), and a Safe Nursing Care Scale (SNCS). The collected data were analyzed using descriptive statistics (absolute and relative frequency, mean and standard deviation) and inferential statistics (Independent t-test, Analysis of variance and Pearson correlation coefficient). The data were analyzed in SPSS 23 and the level of significance was considered 0.05.

RESULTS

The mean age of the participants was 22.53 ± 1.69 years. The total mean scores for medication safety competence and safe nursing care were found to be 111.97 ± 11.85 and 105.12 ± 11.64, respectively. There was a statistically significant positive correlation between safe nursing care and medication safety competence (r = 0.084, P < 0.001).

CONCLUSION

The mean scores of nursing students' medication safety competence and safe nursing care were at an average level. To maintain patient safety, nursing instructors and managers are recommended to employ appropriate strategies to improve medication safety competence and safe nursing care in nursing students.

Debriefing Methods for Simulation in Healthcare: A Systematic Review

ABSTRACT

Debriefing is a critical component in most simulation experiences. With the growing number of debriefing concepts, approaches, and tools, we need to understand how to debrief most effectively because there is little empiric evidence to guide us in their use. This systematic review explores the current literature on debriefing in healthcare simulation education to understand the evidence behind practice and clarify gaps in the literature. The PICO question for this review was defined as "In healthcare providers [P], does the use of one debriefing or feedback intervention [I], compared to a different debriefing or feedback intervention [C], improve educational and clinical outcomes [O] in simulation-based education?" We included 70 studies in our final review and found that our current debriefing strategies, frameworks, and techniques are not based on robust empirical evidence. Based on this, we highlight future research needs.

Impacts of Huddle Intervention on the Patient Safety Culture of Medical Team Members in Medical Ward: One-Group Pretest-Posttest Design

Objective

A huddle is a short, regular meetings to discuss existing or emerging patient safety issues. Hospital administrators can encourage healthcare staff to voluntarily examine the potential occurrence and severity of risks, thereby enhancing awareness of patient safety. The purpose of this study is to explore the effects of huddle intervention on patient safety culture among medical team members and related factors.

Methods

We used a one-group pretest-posttest research design and convenience sampled 109 members of the general internal medicine ward team members from a medical center in central Taiwan. They participated 2 times per week in 15-min huddles from 08:15 to 08:30 in the morning, which lasted for a total of 4 weeks. The process was based on submitted ideas, approved ideas, research ideas and standardization, and data on the safety attitudes questionnaire (SAQ) were collected during the huddles' intervention pretest and posttest.

Results

After the huddle intervention, we found significantly improved scores for safety attitude, teamwork climate (76.49±16.13 vs 83.26±13.39, p < 0.001), safety climate (75.07±16.07 vs 82.63±13.72, p < 0.001), job satisfaction (73.67±19.84 vs 83.39±17.21, p < 0.001), perceptions of management (77.87±19.99 vs 84.86±16.03, p < 0.001) and working conditions (78.96±18.16 vs 86.18±14.90, p < 0.001). Correlation analyses on the differences between pretest and posttest showed that age had a significant correlation with safety climate (r = 0.22, p = 0.022) and working conditions (r = 0.20, p = 0.035). The number of times to participate in a huddle had a significant correlation with teamwork climate (r = 0.33, p =<.001), safety climate (r = 0.30, p = 0.002), job satisfaction (r = 0.19, p = 0.043), and work conditions (r = 0.28, p = 0.003).

Conclusion

Huddles improve clinical team members' understanding of different dimensions and relate factors of safety attitudes. Implementation of the huddles involved standardized process will help hospital administrators understand the steps to parallel expansion to other wards.

Nurse practitioner led implementation of huddles for staff in long term care homes during the COVID-19 pandemic

BACKGROUND

Staff working in long-term care (LTC) homes during COVID-19 frequently reported a lack of communication, collaboration, and teamwork, all of which are associated with staff dissatisfaction, health concerns, lack of support and moral distress. Our study introduced regular huddles to support LTC staff during COVID-19, led by a Nurse Practitioner (NP). The objectives were to evaluate the process of huddle implementation and to examine differences in outcomes between categories of staff (direct care staff, allied care and support staff, and management) who attended huddles and those who did not.

METHODS

All staff and management at one LTC home (< 150 beds) in Ontario, Canada were included in this pre-experimental design study. The process evaluation used a huddle observation tool and focused on the dose (duration, frequency) and fidelity (NP's adherence to the huddle guide) of implementation. The staff attending and non-attending huddles were compared on outcomes measured at post-test: job satisfaction, physical and mental health, perception of support received, and levels of moral distress. The outcomes were assessed with validated measures and compared between categories of staff using Bayesian models.

RESULTS

A total of 42 staff enrolled in the study (20 attending and 22 non-attending huddles). Forty-eight huddles were implemented by the NP over 15 weeks and lasted 15 min on average. Huddles were most commonly attended by direct care staff, followed by allied care/support, and management staff. All huddles adhered to the huddle guide as designed by the research team. Topics most often addressed during the huddles were related to resident care (46%) and staff well-being (34%). Differences were found between staff attending and non-attending huddles: direct care staff attending huddles reported lower levels of overall moral distress, and allied care and support staff attending huddles perceived higher levels of support from the NP.

CONCLUSIONS

NP-led huddles in LTC homes may positively influence staff outcomes. The process evaluation provided some understanding of why the huddles may have been beneficial: the NP addressed resident care issues which were important to staff, encouraged a collaborative approach to solving issues on the unit, and discussed their well-being.

TRIAL REGISTRATION NUMBER

NCT05387213, registered on 24/05/2022.

[Impact of the "daily huddle" on the safety of pediatric hospitalized patients]

INTRODUCTION

In 2017, the Joint Commission proposed daily meetings called "huddle" as an indicator of quality of care. They are brief daily meetings of the multidisciplinary team, where security problems of the last 24h are shared and risks are anticipated. The objectives were to describe the most frequent safety events in Pediatric wards, implement improvements in patient safety, improve team communication, implement international safety protocols, and measure the satisfaction of the staff involved.

MATERIAL AND METHODS

Prospective, longitudinal and analytical design (June 2020-February 2022), with previous educational intervention. Safety incidents, data related to unequivocal identification, allergy and pain records, data from the Scale for the Early Detection of Deficiencies (SAPI) and the Scale for the Secure Transmission of Information (SBAR) were collected. The degree of satisfaction of the professionals was evaluated.

RESULTS

Three hundred forty-eight security incidents were recorded. Medication prescription or administration errors stood out (n=103). Drug prescription or administration errors stood out (n=103), especially those related to high-risk medication: acetaminophen (n=14) (×10 doses of acetaminophen; n=6), insulin (n=6), potassium (n=5) and morphic (n=5). An improvement was observed in the pain record; 5% versus 80% (P<.01), in the SAPI registry 5% versus 70% (P<.01), in SBAER scale 40% vs 100% (P<.01), in unequivocal identification of the patient 80% versus 100%; (P<.01) and in the application of analgesic techniques 60% versus 85% (P=.01). In the survey of professionals, a degree of satisfaction of 8 (7-9.5)/10 was obtained.

CONCLUSIONS

Huddles made it possible to learn about security events in our environment and increase the safety of hospitalized patients, and improved communication and the relationship of the multidisciplinary team.

Emergency nurse and physician perceptions of barriers and facilitators to optimal nutrition in the emergency department: A national cross-sectional survey

INTRODUCTION

Optimal nutritional support is becoming increasingly important in Emergency Departments (EDs) as over half of patients presenting to ED are reported to be malnourished or at risk of malnutrition. Few studies have examined the barriers and facilitators to nutritional support in ED.

AIM

To identify barriers and facilitators to providing optimal nutritional support in the ED from nurse and physician perspectives.

METHODS

A cross-sectional 31-item electronic survey was developed, validated, and distributed nationally in August 2021 in China.

RESULTS

A total of 1766 eligible respondents completed the survey, including 846 ED nurses and 920 ED physicians from 155 hospitals. Barriers to optimal nutrition were moderate (2.72/5 ± 0.88); the most common barrier was lack of multidisciplinary team-work support. Facilitators to support optimal nutrition were moderately high (3.58/5 ± 1.08); the most common facilitator was technical/professional support and organizational management. Respondents who received recent nutrition training and those with higher levels of nutrition knowledge (self-rated) perceived fewer barriers overall to optimal nutrition in ED (P < 0.01).

CONCLUSION

Context specific barriers and facilitators both hinder and support optimal nutrition in ED. Further research is required to develop tailored interventions to address specific barriers to optimal nutrition and enhance facilitators in the ED context.

Identifying self-presentation components among nursing students with unsafe clinical practice: a qualitative study

BACKGROUND

Maintaining patient safety is a practical standard that is a priority in nursing education. One of the main roles of clinical instructors is to evaluate students and identify if students exhibit unsafe clinical practice early to support their remediation. This study was conducted to identify self-presentation components among nursing students with unsafe clinical practice.

METHODS

This qualitative study was conducted with 18 faculty members, nursing students, and supervisors of medical centers. Data collection was done through purposive sampling and semi-structured interviews. Data analysis was done using conventional qualitative content analysis using MAXQDA10 software.

RESULTS

One main category labelled self-presentation emerged from the data along with three subcategories of defensive/protective behaviors, assertive behaviors, and aggressive behaviors.

CONCLUSION

In various clinical situations, students use defensive, assertive, and aggressive tactics to maintain their professional identity and present a positive image of themselves when they make a mistake or predict that they will be evaluated on their performance. Therefore, it seems that the first vital step to preventing unsafe behaviors and reporting medical errors is to create appropriate structures for identification, learning, guidance, and evaluation based on progress and fostering a growth mindset among students and clinical educators.

Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings

BACKGROUND

Debriefings help teams learn quickly and treat patients safely. However, many clinicians and educators report to struggle with leading debriefings. Little empirical knowledge on optimal debriefing processes is available. The aim of the study was to evaluate the potential of specific types of debriefer communication to trigger participants' reflection in debriefings.

METHODS

In this prospective observational, microanalytic interaction analysis study, we observed clinicians while they participated in healthcare team debriefings following three high-risk anaesthetic scenarios during simulation-based team training. Using the video-recorded debriefings and INTERACT coding software, we applied timed, event-based coding with DE-CODE, a coding scheme for assessing debriefing interactions. We used lag sequential analysis to explore the relationship between what debriefers and participants said. We hypothesised that combining advocacy (ie, stating an observation followed by an opinion) with an open-ended question would be associated with participants' verbalisation of a mental model as a particular form of reflection.

RESULTS

The 50 debriefings with overall 114 participants had a mean duration of 49.35 min (SD=8.89 min) and included 18 486 behavioural transitions. We detected significant behavioural linkages from debriefers' observation to debriefers' opinion (z=9.85, p<0.001), from opinion to debriefers' open-ended question (z=9.52, p<0.001) and from open-ended question to participants' mental model (z=7.41, p<0.001), supporting our hypothesis. Furthermore, participants shared mental models after debriefers paraphrased their statements and asked specific questions but not after debriefers appreciated their actions without asking any follow-up questions. Participants also triggered reflection among themselves, particularly by sharing personal anecdotes.

CONCLUSION

When debriefers pair their observations and opinions with open-ended questions, paraphrase participants' statements and ask specific questions, they help participants reflect during debriefings.

Difference in prioritization of patient safety interventions between experts and patient safety managers in Japan

Although a variety of patient safety interventions have been implemented, prioritizing them in a limited resource environment is important. The intervention priorities of patient safety managers may differ from those of patient safety experts. This study aimed to clarify the difference in prioritization of interventions between experts and safety managers to better identify interventions that should be promoted in Japan. We performed a secondary data analysis of two surveys: the Delphi survey for Japanese experts and a nationwide questionnaire survey for safety managers in hospitals. Regarding the 32 interventions constituting 14 organizational-level and 18 clinical-level interventions examined in the previous studies, we assessed three correlations to examine the difference in prioritization between experts and safety managers: correlations between experts and safety managers in the three perspectives (contribution, dissemination, and priority), those between priorities of experts and safety managers at the clinical and organizational level, and those among the three perspectives in experts and safety managers. Contribution (r = 0.768) and dissemination (r = 0.689) of patient safety interventions evaluated by experts and safety managers were positively correlated, but priorities were not. Interventions with priorities that differed between experts and safety managers were identified. In experts, there was no significant correlation between contribution and priority or between dissemination and priority. For safety managers, contributions (r = 0.812) and dissemination (r = 0.691) were positively correlated with priority. Our results suggest that patient safety managers evaluated future priority based on past contributions and current dissemination, whereas experts evaluated future priority based on other factors, such as expected impacts in the future, as mentioned in the previous study. In health policymaking, promotion of patient safety interventions that were given high priority by experts, but low priority by safety managers, should be considered with possible incentives.

Employee Engagement in Quality Improvement and Patient Sociodemographic Characteristics in Federally Qualified Health Centers

Quality improvement (QI) work is critical, particularly in federally qualified health centers (FQHCs) that treat underserved populations. In a national sample of 45 FQHCs, we examined how patients' sociodemographic characteristics were associated with employee engagement in QI, via innovation contests that solicited ideas for improving care and offered opportunities to vote on ideas. We posited that patients' sociodemographic characteristics influence the complexity and intensity of clinical work and thus employees' capacity to engage in QI. Regression results indicated that the percentage of patients living in poverty was negatively associated with employee participation in idea submission and voting. Moreover, the percentage of Hispanic patients was negatively associated with participation in voting. The percentage of Black patients, however, was not associated with either outcome. FQHCs that serve a higher share of low income and/or Hispanic patients may face resource and personnel constraints that reduce employees' capacity to contribute to QI efforts.

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.

Making Every Meeting Count: A Qualitative Investigation of Multiteam Meeting Events and Their Role in Supporting Coordinated Cancer Care Delivery

PURPOSE

This research considers how cross-disciplinary cancer care meetings can facilitate coordination within the multiteam systems (MTSs) that provide inpatient hospital care. We conducted a series of interviews and observations with members of a single cancer care MTS to address the following research questions: (1) what are the key characteristics of MTS cancer care meetings (with regard to composition, focus, and structure)? and (2) how is cross-team coordination acknowledged and addressed during these meetings?

METHODS

In this single-site case study of a MTS operating to provide gynecologic oncology care within a teaching hospital, two types of meetings, called rounds and huddles, were held consistently. We used qualitative methods, including interviews with health care professional subject matter experts and 30 hours of observations of cancer care meetings, and analyzed the data in three stages of qualitative coding.

RESULTS

Our analyses resulted in a thematic framework detailing key processes, and subprocesses, identified as central to the activities of observed cancer care meetings. Key processes include information sharing, gaining clarity, strategizing, and pedagogy. Discussions and explanations of this framework showcase the ways in which MTS meetings can bolster cross-team coordination and facilitate MTS activities.

CONCLUSION

Inpatient cancer care meetings provide opportunities to facilitate MTS coordination in several ways, yet doing so does not come without challenges. Considering these results together with insights from meeting science and MTS research, this article concludes by putting forward practical recommendations for leveraging opportunities and overcoming challenges to use cancer care meetings as tools to support cross-team coordination.

Engineering a Clinical Microsystem to Decrease Workplace Violence for Medically and Psychiatrically Concurrently Decompensated Patients

BACKGROUND

Hospitalized medical patients with concurrently decompensated psychiatric and medical conditions experience worse clinical outcomes. Health care providers caring for this patient population are at increased risk of workplace violence. The authors sought to understand the effects of a clinical microsystem specifically designed to care for patients too psychiatrically ill for medical units and too medically ill for psychiatry units.

METHODS

The research team performed a quality improvement study in which a medicine-psychiatry co-managed clinical microsystem incorporating high performance teamwork principles was engineered in an urban academic medical center to improve patient and staff safety, as well as operational outcomes. Poisson regression was performed to determine differences between workplace violence events, falls, 30-day emergency department (ED) revisits, and hospital readmissions, comparing the baseline period to the intervention period.

RESULTS

There were 321 patients discharged in the baseline period and 310 during the intervention period. Workplace violence events decreased by 65.6% (incidence rate ratio [IRR] 0.34, 95% confidence interval [CI] 0.20-0.57, p < 0.001) after implementation of the clinical microsystem when compared to the baseline period. The rate of ED utilization at 30 days postdischarge also decreased from 30.6% at baseline to 21.0% postintervention (adjusted odds ratio [aOR] 0.60, 95% CI 0.42-0.87, p = 0.006). No differences were detected in falls and 30-day readmissions.

CONCLUSION

For patients with concurrently decompensated medical and psychiatric conditions, the incidence of workplace violence and postdischarge ED utilization can be improved by creating a clinical microsystem that integrates changes to both the physical environment and teamwork processes.

Patient safety and staff psychological safety: A mixed methods study on aspects of teamwork in the operating room

Objectives

To predict the amount of teamwork that takes place throughout a surgery, based on performing a preoperative safety standards (surgical safety checklist and surgical count) and to explore factors affecting patient safety and staff psychological safety during a surgery, based on interprofessional teamwork.

Methods

This mixed methods study included quantitative and qualitative analyses. Quantitative data included 2,184 direct observations of surgical cases with regard to the performance of safety standards during surgeries in 29 hospitals, analyzed using multivariate binary logistic regressions. Qualitative data were obtained from an analysis of 25 semi-structured interviews with operating room (OR) clinicians and risk managers, using an inductive thematic analysis approach.

Results

Analysis of the OR observations revealed that a lack of teamwork in the preoperative "sign-in" phase doubled the chances of there being a lack of teamwork during surgery [odds ratio = 1.972, 95% confidence interval (CI) 1.741, 2.233, p < 0.001] and during the "time-out" phase (odds ratio = 2.142, 95% CI 1.879, 2.441, p < 0.001). Consistent presence of staff during surgery significantly increased teamwork, by 21% for physicians and 24% for nurses (p < 0.05), but staff turnover significantly decreased teamwork, by 73% for physicians (p < 0.05). Interview data indicated that patient safety and staff psychological safety are related to a perception of a collaborative team role among OR staff, with mutual commitment and effective interprofessional communication.

Conclusions

Healthcare organizations should consider the key finding of this study when trying to identify factors that affect teamwork during a surgery. Effective preoperative teamwork positively affects intraoperative teamwork, as does the presence of more clinicians participating in a surgery, with no turnover. Other factors include working in a fixed, designated team, led by a surgeon, which functions with effective interprofessional communication that promotes patient safety and staff psychological safety.

HeartWatch: Implementing a Pediatric Heart Center Program to Prevent Cardiac Arrests Outside the ICU

Pediatric patients with cardiovascular disease are at increased risk of cardiopulmonary arrest. Despite utilization of Cardiac Pediatric Early Warning Scores to identify patients at risk of decompensation, our institution had a twofold increase in cardiac arrests (CAs) in the acute care cardiology unit (ACCU) over 2 years. Through a quality improvement initiative, we developed a watcher program, HeartWatch, to reduce the CA arrest rate in the ACCU by 50% over the first year of implementation.

METHODS

HeartWatch aims to identify patients not adequately captured by Cardiac Pediatric Early Warning Scores who are at high risk for sudden decompensation. Inclusion criteria were developed and evaluated during pilot and implemented phases (April 2020-April 2021) and then monitored in a sustained phase through June 2022. Our primary outcome was the reduction in the out-of-ICU CA rate.

RESULTS

During the 13 months, we enrolled 169 patients, and the CA rate decreased from 0.7 to 0.33 per 1,000 patient days, a 53% reduction. The CA rate further decreased to 0.28 events per 1,000 patient days, a 60% reduction, by June 2022. The most common indications for HeartWatch inclusion were high-risk single-ventricle patients (31%) and patients with diminished ventricular function (20%).

CONCLUSIONS

Implementation of HeartWatch was associated with a meaningful reduction in CA in the ACCU. Creating shared mental models for high-risk patients is essential for patient safety. Future work will optimize local processes that focus on the sustainability of our gains. We will also evaluate opportunities to adapt and implement a similar framework in other institutions to assess reproducibility.

The Effect of a System-Level Tiered Huddle System on Reporting Patient Safety Events: An Interrupted Time Series Analysis

BACKGROUND

The objective of this research was to evaluate the effect of implementing a system-level tiered huddle system (THS) on the reporting of patient safety events into the official event reporting system.

METHODS

A quasi-experimental study using interrupted time series was conducted to assess the impact and changes to trends in the reporting of patient safety events pre- (February-July 2020; six months) and post- (September 2020-February 2021; six months) THS implementation within one health care system (238 clinics and 4 hospitals). The severity of harm was analyzed in July 2021 using a modified Agency for Healthcare Research and Quality (AHRQ) harm score classification. The primary outcome measure was the number of patient safety events reported per month. Secondary outcomes included the number of patient safety events reported per month by each AHRQ harm score classification.

RESULTS

The system-level THS implementation led to a significant and immediate increase in the total number of patient safety events reported per month (777.73, 95% confidence interval [CI] 310.78-1,244.68, p = 0.004). Similar significant increases were seen for reported numbers of unsafe conditions, near misses, no-harm events that reached patients, and temporary harm (p < 0.05 for each). Reporting of events with permanent harm and deaths also increased but was not statistically significant, likely due to the small number of reported events involving actual harm.

CONCLUSION

These findings suggest that system-level THS implementation may increase reporting of patient safety events in the official event reporting system.

Protocol for a stepped wedge cluster randomized quality improvement project to evaluate the impact of medical safety huddles on patient safety

Introduction

Physician engagement is crucial for furthering patient safety and quality improvement within healthcare organizations. Medical Safety Huddles, which are physician-specific huddles, is a novel way to engage physicians with patient safety and may reduce adverse events experienced by patients. We plan to conduct a multi-center quality improvement (QI) initiative to implement and evaluate Medical Safety Huddles. The primary objective is to determine the impact of the huddles on adverse events experienced by patients. Secondary objectives include assessing the impact of the huddles on patient safety culture and physician engagement, and a process evaluation to assess the fidelity of implementation.

Methods

This stepped wedge cluster randomized study will be conducted at four academic inpatient hospitals over 19 months. Each site will adapt Medical Safety Huddles to its own practice context to best engage physicians. We will review randomly selected patient charts for adverse events. Generalized linear mixed effects regression will be used to estimate the overall intervention effect on adverse events. Process measures such as physician attendance rates and number of safety issues raised per huddle will be tracked to monitor implementation adherence.

Conclusion

Medical Safety Huddles may help healthcare organizations and medical leaders to better engage physicians with patient safety. The project results will assess the fidelity of implementation and determine the impact of Medical Safety Huddles on patient safety.

Improving Discharge Safety in a Pediatric Emergency Department

BACKGROUND AND OBJECTIVES

Discharge from the emergency department (ED) involves a complex series of steps to ensure a safe transition to home and follow-up care. Preventable, discharge-related serious safety events (SSEs) in our ED highlighted local vulnerabilities. We aimed to improve ED discharge by implementing a standardized discharge process with emphasis on multidisciplinary communication and family engagement.

METHODS

At a tertiary children's hospital, we used the model for improvement to revise discharge care. Interventions included a new discharge checklist, a provider huddle emphasizing discharge vital signs, and a scripted discharge review of instructions with families. We used statistical process control to evaluate performance. Primary outcomes included elimination of preventable, discharge-related SSEs and Press Ganey survey results assessing caregiver information for care of child at home. A secondary outcome was number of days between preventable low-level (near-miss, no or minimal harm) events. Process measures included discharge checklist adoption and vital sign acquisition. Balancing measures were length of stay (LOS) and return rates.

RESULTS

Over the study period, there were no preventable SSEs and low-level event frequency improved to a peak of &gt;150 days between events. Press Ganey responses regarding quality of discharge information did not change (62%). Checklist use was rapidly adopted, reaching 94%. Vital sign acquisition increased from 67% to 83%. There was no change in the balancing measures of median LOS or return visit rates.

CONCLUSIONS

The development and implementation of a standardized discharge process led to the elimination of reported discharge-related events, without increasing LOS or return visits.

The Effectiveness of Multidisciplinary Team Huddles in Healthcare Hospital-Based Setting

Objective

Huddles are short, regular debriefings that are designed to provide frontline staff and bedside caregivers environments to share problems and identify solutions. Daily huddle implementation could improve medical safety work, problem identification and improvement, situation awareness and teamwork enhancement, the collaboration and communication between professionals and departments, and patient safety. This study aimed evaluated the effectiveness of a hospital-based huddle at a general medical ward in Taiwan.

Methods

A Continuous Integration team was conducted by combining multidisciplinary frontline staff to huddle at a 74-bed general medical ward. Team Huddles started twice a week. A physical huddle run board was created, which contained four parts, including idea submitted, idea approved, working on an idea and standardizing. Problems were submitted to the board to be identified, and the solutions were evaluated through huddle discussion. We divided the problems into two groups: quick hits (resolved within 24-48hrs) and complex issues (resolved >48hrs). An anonymous questionnaire was designed to evaluate the huddle response.

Results

A total of 44 huddles occurred from September 9th, 2020, to September 30th, 2021, and 81 issues were identified and resolved. The majority issues were policy documentation (n=23; 28.4%). Sixty-seven (82.7%) issues were defined as quick hits, and the other fourteen (17.3%) issues were complex. The mean hours to the resolution of quick hits was 5.17 hours, median 3.5 hours, and range from 0.01-15.4 hours. The mean days to resolve completion issues were 19.73 days, median 7.5 days, and range 3.57-26.14 days. An overwhelming 92.9% of staff responded that huddles help to expedite the process to reach treatment goals, reduce clinical mistakes, near misses, reduce patient incidences, and help teamwork enhancement, with rating of 4.52 (on a 5-point Likert scale).

Conclusion

Implementing of multidisciplinary team huddle improved the accountability of issue identification, problem-solving and teamwork enhancement.

Understanding teamwork in rapidly deployed interprofessional teams in intensive and acute care: A systematic review of reviews

The rapid increase of acute and intensive care capacities in hospitals needed during the response to COVID-19 created an urgent demand for skilled healthcare staff across the globe. To upscale capacity, many hospitals chose to increase their teams in these departments with rapidly re-deployed inter-professional healthcare personnel, many of whom had no prior experience of working in a high-risk environment and were neither prepared nor trained for work on such wards. This systematic review of reviews examines the current evidence base for successful teamwork in rapidly deployed interprofessional teams in intensive and acute care settings, by assessing systematic reviews of empirical studies to inform future deployments and support of rapidly formed clinical teams. This study identified 18 systematic reviews for further analysis. Utilising an integrative narrative synthesis process supported by thematic coding and graphical network analysis, 13 themes were found to dominate the literature on teams and teamwork in inter-professional and inter-disciplinary teams. This approach was chosen to make the selection process more transparent and enable the thematic clusters in the reviewed papers to be presented visually and codifying four factors that structure the literature on inter-professional teams (i.e., team-internal procedures and dynamics, communicative processes, organisational and team extrinsic influences on teams, and lastly patient and staff outcomes). Practically, the findings suggest that managers and team leaders in fluid and ad-hoc inter-professional healthcare teams in an intensive care environment need to pay attention to reducing pre-existing occupational identities and power-dynamics by emphasizing skill mix, establishing combined workspaces and break areas, clarifying roles and responsibilities, facilitating formal information exchange and developing informal opportunities for communication. The results may guide the further analysis of factors that affect the performance of inter-professional teams in emergency and crisis deployment.

Implementation of a Virtual Huddle to Support Patient Care During the COVID-19 Pandemic

BACKGROUND

During a surge of COVID-19 cases, the volume of acute care patients with hypoxemic respiratory failure placed a high burden of responsibility on internal medicine, pulmonary and critical care medicine, and clinical pharmacy services.

OBSERVATIONS

We describe the COVID-19 Tele-Huddle Program, a novel approach to communication between key stakeholders in COVID-19 patient care through a daily video conferencing huddle. The program was implemented during a 4-week surge in COVID-19 cases at a large, academic medical center in Houston, Texas. Data collected during the COVID-19 Tele-Huddle Program included the type and number of interventions implemented, number of patients discussed, and COVID-19 therapies provided. In addition, hospital medicine team members completed a user-experience survey.

CONCLUSIONS

A multidisciplinary consultation service using video conferencing can support the care of patients with high disease severity without overwhelming existing inpatient medical, intensive care, and pharmacy services.

“Debriefing and Organizational Lessons Learned” (DOLL): A Qualitative Study to Develop a Classification Framework for Reporting Clinical Debriefing Results

Background

The COVID-19 crisis has radically affected our healthcare institutions. Debriefings in clinical settings provide a time for the clinicians to reflect on the successes (pluses) and difficulties (deltas) encountered. Debriefings tend to be well-received if included in the broader management of the unit. The goal of this study was to develop a framework to categorize these debriefings and to assess its worthiness.

Methods

A qualitative approach based on a grounded theory research method was adopted resulting in the “Debriefing and Organizational Lessons Learned” (DOLL) framework. Debriefings were conducted within two Emergency Departments of a Belgian University Hospital during an 8-week period. In the first step, three researchers used debriefing transcripts to inductively develop a tentative framework. During the second step, these three researchers conducted independent categorizations of the debriefings using the developed framework. In step 3, the team analyzed the data to understand the utility of the framework. Chi-square was conducted to examine the associations between the item types (pluses and deltas) and the framework's dimensions.

Results

The DOLL is composed of seven dimensions and 13 subdimensions. Applied to 163 debriefings, the model identified 339 items, including 97 pluses and 242 deltas. Results revealed that there was an association between the frequency of pluses and deltas and the dimensions (p &lt; 0.001). The deltas were mainly related to the work environment (equipment and maintenance) (p &lt; 0.001) while the pluses identified tended to be related to the organization of the unit (communication and roles) (p &lt; 0.001). With leadership's support and subsequent actions, clinicians were more enthusiastic about participating and the researchers anecdotally detected a switch toward a more positive organizational learning approach.

Conclusion

The framework increases the potential value of clinical debriefings because it organizes results into actionable areas. Indeed, leadership found the DOLL to be a useful management tool. Further research is needed to investigate how DOLL may work in non-crisis circumstances and further apply the DOLL into incident reporting and risk management process of the unit.

The impact of huddles on a multidisciplinary healthcare teams' work engagement, teamwork and job satisfaction: A systematic review

BACKGROUND

Job satisfaction and retention of healthcare staff remains an ongoing issue in many health systems. Huddles have been endorsed as a mechanism to improve patient safety by improving teamwork, collaboration, and communication in teams.

AIM

This study aims to synthesises the literature to investigate the impact of huddles on job satisfaction, teamwork, and work engagement in multidisciplinary healthcare teams.

METHODS

Five academic databases were searched to conduct a systematic review of peer-reviewed literature published from January 2000 to January 2020. Articles were included if they (1) featured a daily huddle, were conducted in a healthcare setting, and involved a multidisciplinary team and (2) measured variables including job satisfaction, work engagement, or teamwork. Results were reported in accordance with the systematic synthesis without meta-analysis and preferred reporting items for systematic reviews and meta-analysis guidelines. We identified 445 articles of which 12 met the eligibility criteria and are included in this review.

RESULTS

All 12 included studies found a predominantly positive impact on teamwork and job satisfaction. None of the studies discussed or reported evidence of the impact of huddles on work engagement. This review highlights the value of a daily multidisciplinary healthcare team huddle in improving job satisfaction and teamwork for the healthcare staff involved. However, there is a dearth of high-quality, peer-reviewed evidence regarding the direct impact of huddles on job satisfaction, teamwork and in particular on work engagement. Further research-particularly controlled studies on adoption, implementation and outcomes for healthcare team culture-is needed to further assess this intervention.

Improving Knowledge of Active Safety and QI Projects Amongst Practitioners in a Pediatric ICU

Introduction

The success of quality improvement (QI) projects depends on many factors, with communication and knowledge of project-specific practice change being fundamental. This project aimed to improve the knowledge of active safety and QI projects.

Methods

Two interventions were trialed to improve knowledge: paired email and meeting announcements followed by a daily huddle to review ongoing projects. Knowledge, measured as the ability to recall a project and its practice change, was the primary outcome. The frequency and duration of the Huddle were process and balancing measures, respectively.

Results

Seven days after a meeting/email announcement, 3 of 13 (23%) faculty and fellows recalled the announced practice change. Investigators then tested the effects of the Huddle by assessing practitioners' knowledge of safety and QI project-related practice changes on the first and last day of a service week. The average percentage of items recalled increased from the beginning to end of a service week by 33% [46% to 79%, 95% confidence interval (CI) 12-53] for faculty and 27% (51% to 77%, 95% CI 13-40) for fellows. The Huddle occurred in four of seven (interquartile range 2-5) days/wk with a mean duration of 4.5 (SD 2) minutes. Follow-up assessment 2 years after Huddle implementation demonstrate sustained increase in item recall [faculty +36% (95% CI +13% to 40%); fellows +35% (95% CI +23% to 47%)].

Conclusions

A daily huddle to discuss safety and QI project-related practice change is an effective and time-efficient communication method to increase knowledge of active projects.

Creating a Process for the Implementation of Tiered Huddles in a Veterans Affairs Medical Center

Introduction

In 2019, the Veteran’s Health Administration began its journey in pursuit of becoming an enterprise-wide High Reliability Organization (HRO). Improving the delivery of safe, high quality patient care is a central focus of HROs. Requisite to meeting this goal is the timely identification and resolution of problems. This is best achieved by empowering and engaging both clinical and non-clinical staff across the healthcare organization through the promotion of robust collaboration and communication between various disciplines. Improved care coordination and increased accountability are two important subsequent outcomes. One method for accomplishing this is through the implementation of tiered huddles.

Materials and Methods

An extensive review of the current literature from 2013 until June 2021 was conducted for evidence highlighting the experiences of other healthcare organizations during implementation of huddles. Following the review, a tiered huddle proposal was developed and presented to the executive leadership team of a healthcare system for approval. Pilot testing of the tiered huddle implementation plan began in October 2021 over a 12-week period with three services. On average, the pilot services had between three to four tiers from frontline staff to the executive level of leadership.

Results

Over the 12-week period, out of the possible 120 tiered huddles that could have been conducted, 68% (n = 81) were completed. Of the tiered huddles conducted, 99% (n = 80) started and ended on time. During the pilot test, seven issues were identified by frontline staff: coordination of pre-procedural coronavirus testing, equipment/computer issues, rooms out of service, staffing levels, and lack of responsiveness from other departments. Issues related to staffing, unresponsiveness from other departments, and equipment concerns required elevation to a higher-level tier with no issues remaining open. Delays in patient care, or prolongation of shift hours for staff because of tiered huddles, was low at 2.5% (n = 2). For the duration of the pilot test, a total of 75 minutes accounted for shifts being extended among five staff members.

Conclusions

The success of this initiative demonstrates the importance of thoughtfully creating a robust process when planning for the implementation of tiered huddles. The findings from this initiative will be of immense value with the implementation of tiered huddles across our healthcare system. We believe that this approach can be used by other healthcare institutions along their journey to improving patient safety and quality.

Effect of Daily Multidisciplinary Team Reflection in Ambulatory Care: A Qualitative Analysis

Purpose

Participants and Methods

Results

Conclusion

Work interruptions and missed nursing care: A necessary evil or an opportunity? The role of nurses' sense of controllability

AIM

To explore nurses' experiences with work interruptions (WIs) through the lens of missed nursing care (MNC).

DESIGN

A qualitative descriptive design.

METHODS

Eleven small focus groups involving 34 nurses (three nurses per group on average) from acute-care hospital wards were conducted. Nurses shared their experiences with WIs (sources, reactions and decisions) from the MNC perspective. Data analysis was conducted via content analysis.

RESULTS

A preponderant theme emerged-the dynamic of controllability. Nurses who perceived a sense of controllability felt that they could decide whether to accept or reject the WI, regardless of WI type, and emotions of anger emerged. Conversely, nurses who did not perceive sense of controllability attended the secondary task: MNC occurred, and distress emotions emerged. Results emphasized that nurses are active agents prioritizing whether to omit or complete care in the face of WIs. Controllability, accompanied by active negative emotions, perpetuate a prioritization process that makes it less probable that MNC occurs.

Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the Huddle Up for Safer Healthcare (HUSH) project

Background

The Patient Safety Huddle (PSH) is a brief multidisciplinary daily meeting held to discuss threats to patient safety and actions to mitigate risk. Despite growing interest and application of huddles as a mechanism for improving safety, evidence of their impact remains limited. There is also variation in how huddles are conceived and implemented with insufficient focus on their fidelity (the extent to which delivered as planned) and potential ways in which they might influence outcomes. The Huddle Up for Safer Healthcare (HUSH) project attempted to scale up the implementation of patient safety huddles (PSHs) in five hospitals – 92 wards - across three UK NHS Trusts. This paper aims to assess their fidelity, time to embed, and impact on teamwork and safety culture.

Methods

A multi-method Developmental Evaluation was conducted. The Stages of Implementation Checklist (SIC) was used to determine time taken to embed PSHs. Observations were used to check embedded status and fidelity of PSH. A Teamwork and Safety Climate survey (TSC) was administered at two time-points: pre- and post-embedding. Changes in TSC scores were calculated for Trusts, job role and clinical speciality.

Results

Observations confirmed PSHs were embedded in 64 wards. Mean fidelity score was 4.9/9. PSHs frequently demonstrated a ‘fear free’ space while Statistical Process Control charts and historical harms were routinely omitted. Analysis showed a positive change for the majority (26/27) of TSC questions and the overall safety grade of the ward.

Conclusions

PSHs are feasible and effective for improving teamwork and safety culture, especially for nurses. PSH fidelity criteria may need adjusting to include factors deemed most useful by frontline staff. Future work should examine inter-disciplinary and role-based differences in TSC outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07080-1.

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/ ).

The Surgical Safety Huddle: Novel Quality Improvement Patient Safety Initiative

Background: Acutely deteriorating patients are entitled to the best possible care which includes early recognition and timely appropriate intervention to reduce adverse events, unnecessary admissions to intensive care and/or cardiac arrest. Aim: To reduce the number of poor outcomes for surgical patients with a National Early Warning Score (NEWS) score ≥7 in our institution by 50%. A poor outcome was defined as: 1. Cardiac arrest 2. NEWS >7 not improving after 72 hours 3. Transfer to ICU >6 hours Methods: Surgical inpatients from a variety of surgical specialties (general, vascular, breast, colorectal, hepatobiliary, and plastic surgery) in a large university teaching hospital were included. Quality improvement tools were used to generate regular dialogue with the clinical teams, resulting in the concept of the surgical safety huddle being proposed. Deteriorating patients were highlighted at the daily huddle and a plan of early intervention was implemented. An incremental approach with continuous PDSA [Plan- Do-Study-Act] cycles and subsequent feedback was adopted on the surgical ward to develop the huddle. Poor patient outcomes were analysed prospectively via chart reviews. Results: Prior to the introduction of the “surgical huddle” 110 patients with NEWS >7 were audited. Twenty-eight of these patients had a poor outcome at 72 hours (25%). Following the introduction of the surgical huddle supported by the deteriorating patient team, 64 patients with NEWS >7 were reviewed. Three of these patients had a poor outcome at 72 hours (4.7%). The introduction of the surgical huddle increased the interval between cardiac arrests more than sixfold on the surgical ward. Discussion: The introduction of the surgical safety huddle supported by the deteriorating patient response team reduced the number of cardiac arrests and poor outcomes in a surgical inpatient cohort.

Situational Awareness Huddles in a Pediatric Cardiac Intensive Care Unit During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has created challenges for provider teams working in intensive care units, including rapidly changing patient care regulations, staffing considerations, and preservation of personal protective equipment. The need for enhanced respiratory precautions for infected patients and patients under investigation has necessitated a new process for interventions and resuscitation.

LOCAL PROBLEM

Along with changing regulations and equipment, significant staff anxiety surrounded caring for infected patients and preparing for emergency situations.

METHODS

A huddle process was implemented in the pediatric cardiac intensive care unit for acutely ill patients who required enhanced respiratory precautions and were at risk of imminent decompensation, or who required a bedside procedure. During a huddle, the multidisciplinary team used process maps displayed in patient rooms; the huddle process created a situational awareness of events among these teams.

INTERVENTION

After implementation of huddles, a survey was distributed to cardiac intensive care unit staff in order to understand their satisfaction with the huddle process.

RESULTS

A total of 36 staff responded to the survey. They thought the huddles helped them to prepare for resuscitation scenarios, helped limit the number of personnel responding to an emergency, and reduced their anxiety surrounding caring for these patients. Staff suggested generalizing this huddle process to all patients at acute risk for decompensation in the cardiac intensive care unit.

CONCLUSIONS

A novel huddle process created situational awareness among staff caring for patients requiring enhanced respiratory isolation because of COVID-19. Multidisciplinary huddles allowed staff from various disciplines to apply a process map for interventions and resuscitations among critically ill children with heart disease.

How to do no harm: empowering local leaders to make care safer in low-resource settings

In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a 'portfolio' approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous challenges in delivering safe care but, if given sufficient support, they are nevertheless in a position to bring about major improvements. Skills in improving safety and quality should be recognised as equivalent to any other form of (sub)specialty training and as an essential element of any senior clinical or management role. National professional organisations need to promote appropriate education and provide coaching, mentorship and support to local leaders.

[Safety-II in daily clinical practice]

BACKGROUND

Providing patient safety is a central matter in health care requiring complex treatment processes containing many risks. In hospital care, adverse events and patient harm occur frequently. In this context, the safety sciences investigate causes and contributing factors of such events as well as improvement measures. With Safety-I and Safety-II, two complementary approaches come into play. While Safety-I aims to minimize adverse events, the Safety-II approach focuses on understanding the system as a whole whose normal operations can result in both desired and adverse events. With the implementation of the Critical Incident Report System (CIRS), the Safety-I approach (with a focus on errors and correction of negative consequences for patient safety) has become an integral part of the university hospital chosen for this study. The subject matter of this study is to determine if and how the Safety-II approach (focussing on normal operation and the understanding of positive effects for patient safety) is already in use and what measurements can support its integration in daily clinical practice.

METHOD

Through observation, the structures of daily feedback meetings (huddles) from six different hospital departments have been gathered to determine if they can be considered as potential starting points for the implementation of the Safety-II approach. The following expert interviews (n=7) discussed four potentials of the Safety-II approach using the Resilient Assessment Grid (RAG). Finally, a focus group discussed which measurements are central for the integration of the Safety-II approach in daily clinical practice.

RESULTS

The study shows that department teams partially follow the Safety-II approach. During team huddles, positive experiences are already exchanged. The expert interviews revealed that the RAG potentials respond, learn and anticipate have already been realized satisfactorily while the potential monitor fell behind. The focus groups regard the Safety-II approach more as a matter of corporate culture and less as a paradigm shift which is needed to be integrated into day-to-day business.

DISCUSSION

Successfully establishing the Safety-II approach requires a focus not just on unwanted occurrences. It is also necessary to focus on the often not directly apparent desired occurrences, which ensure patient safety, and to systematically reflect on them in order to contribute to the development of the organizational culture. Having a better understanding of how the system of daily clinical practice with all its subsystems works will make it possible to proactively counteract unwanted occurrences, for example through regular feedback sessions and debriefings, and to increase patient safety.

Long-Term Acute Care Hospitals Extend ICU Capacity for COVID-19 Response and Recovery

The COVID-19 pandemic has presented novel challenges for the entire health-care continuum, requiring transformative changes to hospital and post-acute care, including clinical, administrative, and physical modifications to current standards of operations. Innovative use and adaptation of long-term acute care hospitals (LTACHs) can safely and effectively care for patients during the ongoing COVID-19 pandemic. A framework for the rapid changes, including increasing collaboration with external health-care organizations, creating new methods for enhanced communication, and modifying processes focused on patient safety and clinical outcomes, is described for a network of 94 LTACHs. When managed and modified correctly, LTACHs can play a vital role in managing the national health-care pandemic crisis.

Responding to COVID-19: Lessons Learned from a Senior Living and Social Service Organization

This case study analyzes one senior living and social service organization’s coronavirus (COVID-19) crisis response. We conducted interviews with n = 14 department managers to explore the organization’s pivot to remote work and service provision. We used the Pearson and Mitroff Crisis Management Framework to organize themes. A pre-existing culture of teamwork, willingness to adapt and adopt new approaches, and responsiveness to new policies and procedures facilitated the COVID-19 crisis response. However, low levels of digital literacy among staff, decreased job satisfaction due to no face-to-face interaction between care recipient and service provider, and lack of proactive policies for crisis response, which decreased the speed of enacting remote service provision, were obstacles in effective crisis response. Lessons learned from this case study highlight the need for pre-emptive policy creation on remote service provision and work from home policies, as well as training considerations for senior living and social service organizations.

Are Huddles the Missing PEACE of the Puzzle in Implementing Clinical Innovation for the Eating Disorder and Autism Comorbidity?

Huddles are brief, time-limited, focused meetings to help organize and support clinical teams. Huddles have demonstrated their value and transferable benefits across a range of settings. Based on their transferable nature, their potential could be unacknowledged as a clinical implementation technique, particularly in specific subgroups of patients with anorexia who need a higher level of care. An innovative clinical pathway aimed at supporting autistic patients with eating disorders (PEACE Pathway) evaluated the use of weekly PEACE huddles for the multidisciplinary team as part of the implementation process across a 12-months period. A total of 283 responses evaluated the huddle as useful on average 84/100. Using content analysis, several perceived benefits were found of the huddles which were in line with the underpinnings of traditional huddles, suggesting that huddles are transferable as implementation techniques, as evidence by a team providing higher-level care for eating disorders.

Teamworking in endoscopy: a human factors toolkit for the COVID-19 era

BACKGROUND

Endoscopy services have had to rapidly adapt their working practices in response to COVID-19. As recovery of endoscopy services proceeds, our workforce faces numerous challenges that can impair effective teamworking. We designed and developed a novel toolkit to support teamworking in endoscopy during the pandemic.

METHODS

A human factors model was developed to understand the impact of COVID-19 on endoscopy teams. From this, we identified a set of key teamworking goals, which informed the development of a toolkit to support several team processes. The toolkit was refined following expert input and refinement over a 6-week period.

RESULTS

The toolkit consists of four cognitive aids that can be used to support team huddles, briefings, and debriefs, alongside techniques to optimize endoscopic nontechnical skills across the patient-procedure pathway. We describe the processes that local endoscopy units can employ to implement this toolkit.

CONCLUSION

A toolkit of cognitive aids, based on human factors principles, may be useful in supporting teams, helping them adapt to working safely in the era of COVID-19.