Development of the Huddle Observation Tool for structured case management discussions to improve situation awareness on inpatient clinical wards

Development and Evaluation of a Nurse Practitioner Huddles Toolkit for Long Term Care Homes

Long-term care homes (LTCHs) were disproportionately affected by the coronavirus disease (COVID-19) pandemic, creating stressful circumstances for LTCH employees, residents, and their care partners. Team huddles may improve staff outcomes and enable a supportive climate. Nurse practitioners (NPs) have a multifaceted role in LTCHs, including facilitating implementation of new practices. Informed by a community-based participatory approach to research, this mixed-methods study aimed to develop and evaluate a toolkit for implementing NP-led huddles in an LTCH. The toolkit consists of two sections. Section one describes the huddles' purpose and implementation strategies. Section two contains six scripts to guide huddle discussions. Acceptability of the intervention was evaluated using a quantitative measure (Treatment Acceptability Questionnaire) and through qualitative interviews with huddle participants. Descriptive statistics and manifest content analysis were used to analyse quantitative and qualitative data. The project team rated the toolkit as acceptable. Qualitative findings provided evidence on design quality, limitations, and recommendations for future huddles.

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.

Paediatric early warning systems: not a simple answer to a complex question

Paediatric early warning systems (PEWS) to reduce in-hospital mortality have been a laudable endeavour. Evaluation of their impact has rarely examined the internal validity of the components of PEWS in achieving desired outcomes. We highlight the assumptions made regarding the mode of action of PEWS and, as PEWS become more commonplace, this paper asks whether we really understand their function, process and outcome.

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.

Developing future clinical leaders in patient safety: the Irish experience

Introduction

It is 20 years since the Institute of Medicine advocated a national approach to improve care and patient safety. Patient safety infrastructure has greatly improved in certain countries. In Ireland, patient safety infrastructure is in ongoing development. To contribute to this, the Royal College of Physicians of Ireland/International Society for Quality in Healthcare Scholar in Residence Programme was launched in 2016. This programme aims to improve patient safety and develop a movement of future clinician leaders to drive improvements in patient safety and the quality of care.

Methods

Doctors in postgraduate training complete a year-long immersive mentorship. This involves monthly group meetings with key patient safety opinion makers, one-on-one mentorship, leadership courses, conference attendance and presentations. Each scholar undertakes a quality improvement (QI) project.

Results

A QI project was associated with a decrease in caesarean section rates from 13.7% to 7.6% (p=0.0002) among women in spontaneous labour at term with a cephalic presentation. Other projects are ongoing.

Conclusion

Medical error, patient safety and QI must be addressed comprehensively at both undergraduate and postgraduate level. We believe the Irish mentorship programme will help to change the paradigm and improve patient safety.

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/ ).

A Daily Operational Huddle and a Real-Time Communication Application Improve Efficiency of Laboratory Processes

CONTEXT.—

Clinical laboratory processes that require cooperation among geographically distinct sections often face challenges. We describe these challenges as related to the Gram staining of cerebrospinal fluid, a key test in the management of patients with suspected central nervous system infections, and our attempts to improve quality outcomes.

OBJECTIVE.—

To evaluate multiple tools and strategies for their effectiveness in optimizing the turnaround time of tests sharing a specimen or workflow.

DESIGN.—

Over the course of 5 years, the turnaround time of cerebrospinal fluid Gram stain was studied at one of the largest children's health systems in the US. Baseline data showed suboptimal compliance to targeted turnaround times. A conventional approach to process standardization, and 2 innovative tools that facilitate horizontal integration were applied to the main campus laboratory as follows: a daily huddle and a novel electronic communication application that was interfaced with the laboratory information system. Turnaround time and its variation were assessed. Two other hospital laboratories within the health system that did not undergo these quality interventions served as controls.

RESULTS.—

Standardization of processes reduced the variability of turnaround time but only minimally shortened it. In contrast, an interteam daily huddle that monitored key quality metrics together with the communication application, improved turnaround time significantly and sustainably.

CONCLUSIONS.—

Communication strategies involving a physical or virtual gathering of laboratory representatives encourage horizontal communication and improve turnaround times. These tools are generally applicable and could be used to improve other processes in healthcare, especially those where a workflow is shared between 2 geographically distinct areas of a health system.

Realist Process Evaluation of the implementation and impact of an organisational cultural transformation programme in the Children and Young People's Secure Estate (CYPSE) in England: study protocol

INTRODUCTION

Young people in contact with the youth justice system are more likely to present with complex ongoing needs than young people in the general population. To address this, the Framework for Integrated Care (SECURE STAIRS) is being implemented in the Children and Young People's Secure Estate: a 'whole systems' approach to support secure settings to develop trauma-informed and relationally based environments, supporting staff to provide consistent, therapeutic care. This paper aims to present the protocol for a national cohort study examining the impact and implementation of this cultural transformation programme.

METHODS AND ANALYSIS

A mixed-methods realist evaluation will be conducted. Data collection will take place between August 2018 and December 2020. Eighteen sites will collect routine service activity data and questionnaires completed by young people, parents/guardians and staff. Semi-structured interviews and non-participant observations will be conducted across five qualitative focus sites with young people and staff. An economic evaluation will examine value for money. The results will be triangulated at the analysis stage to gain an in-depth understanding of experiences.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Health Research Authority, Her Majesty's Prison and Probation Service and UCL Ethics Committee. Findings will be disseminated via project reports, site feedback, peer-reviewed journal publications and conference presentations.

Use of huddles among frontline staff in clinical settings: a scoping review protocol

OBJECTIVE

This scoping review aims to provide an overview of the current evidence on huddles in healthcare settings involving frontline staff.

INTRODUCTION

Team-based models are gaining prominence as the preferred method for delivering coordinated, cost-effective, high-quality health care. Huddles are a powerful method for building relationships among frontline staff members. Currently, no reviews have described huddles used among frontline staff in clinical settings. There is therefore a need to identify gaps in the literature on evidence informing this practice for a greater understanding of the resources available for frontline staff to implement huddles.

INCLUSION CRITERIA

This scoping review will consider qualitative studies, experimental and quasi-experimental studies, analytic observational studies and descriptive cross-sectional studies that explore the use of frontline staff huddles to improve quality of care in a clinical setting.

METHODS

An initial limited search of PubMed and CINAHL Plus with Full Text will be performed, followed by analysis of the title, abstract and MeSH used to describe the article. Second, searches of PubMed, EBSCOhost and ProQuest will be conducted, followed by searches in reference lists of all articles that meet the inclusion criteria. Studies published in English from inception to the present will be considered. Retrieved papers will be screened for inclusion by at least two reviewers. Data will be extracted and presented in tabular form and a narrative summary that align with the review's objective.

Workflow disruptions and provider situation awareness in acute care: An observational study with emergency department physicians and nurses

BACKGROUND

The fast-paced and rapidly changing environment of an Emergency Department (ED) requires providers to have a high level of situation awareness (SA). However, acute clinical care also encompasses a multitude of interruption-laden work processes that might degrade SA. It is therefore important to understand how frequent interruptions affect ED provider cognition in general and SA in particular.

OBJECTIVE

We aimed to examine how sources and contents of provider workflow interruptions influence situation awareness of ED physicians and nurses.

METHODS

This prospective, multi-method study combined standardized observations, self-reports of ED providers, and ED administrative data of staffing and patient load. Expert observers identified ED providers' workflow interruptions during 90min observation sessions. Afterwards, each provider reported perceived disruptiveness and situation awareness. Controlling for patient load, patient acuity and staffing, we conducted regression analyses to explore prospective associations between interruptions and provider outcomes.

RESULTS

During 74 observation sessions of overall 110h and 40min, we observed 1205 workflow interruptions (mean rate: 10.9 interruptions/hour). Provider situation awareness was fairly high (M = 7.10; scale 0-10) with no difference between ED physicians and nurses. After controlling for ED workload data, we observed that high rates of interruptions were associated with lower levels of situation awareness (β = -0.27). Further analyses revealed that particularly interruptions by telephone/beeper, technical malfunctions as well as interruptive communication related to completed cases were correlated to low SA.

DISCUSSION

This study in a naturalistic ED setting shows that ED physicians and nurses continuously cope with disruptions and interruptions. Our findings reveal that highly interruptive workflow environments impede providers' situation awareness. Moreover, it sheds light on specific sources and contents of interruptions that influence providers' SA in acute care.

CONCLUSION

Frequent workflow interruptions can degrade ED providers' situation awareness. A deeper understanding of how avoidable and unavoidable interruptions affect provider cognitions with particular focus on social and technology-related disruptions is required. Further emphasis should be placed on the effective application of work re-design in this context to foster safe and efficient patient care.

Improving Pediatric Administrative Disaster Preparedness Through Simulated Disaster Huddles

Members of an emergency department (ED) staff need to be prepared for mass casualty incidents (MCIs) at all times. Didactic sessions, drills, and functional exercises have shown to be effective, but it is challenging to find time and resources for appropriate training. We conducted brief, task-specific drills (deemed "disaster huddles") in a pediatric ED (PED) to examine if such an approach could be an alternative or supplement to traditional MCI training paradigms. Over the course of the study, we observed an improving trend in the overall score for administrative disaster preparedness. Disaster huddles may be an effective way to improve administrative disaster preparedness in the PED. Low-effort, low-time commitment education could be an attractive way for further disaster preparedness efforts. Further studies are indicated to show a potential impact on lasting behavior and patient outcomes.

Can Teamwork Promote Safety in Organizations?

In this review, we conceptualize teamwork as the linchpin driving safety performance throughout an organization. Safety is promoted by teams through various mechanisms that interact in a complex and dynamic process. We press pause on this dynamic process to organize a discussion highlighting the critical role played by teamwork factors in the engagement of safe and unsafe behavior, identifying five team-level emergent states that enable effective teamwork and safety: psychological safety, team trust, collective efficacy, shared mental models, and situation awareness. Additionally, we consider foundational conditions that support team-driven safety, the development of safety culture, and the importance of team safety climate in shaping performance. We discuss leveraging teams to generate safety and identify directions for future research investigating the relationship between teamwork and safety. Overall, we submit that researchers and practitioners would benefit from taking a systems perspective of safety by integrating principles of team science to better understand and promote safety in organizations.

Developing the evidence base for evaluating dementia training in NHS hospitals (DEMTRAIN): a mixed-methods study protocol

INTRODUCTION

Around 70% of acute hospital beds in the UK are occupied by older people, approximately 40% of whom have dementia. Improving the quality of care in hospitals is a key priority within national dementia strategies. Limited research has been conducted to evaluate dementia training packages for staff, and evaluation of training often focuses on immediate, on-the-day training feedback and effects.

OBJECTIVES

Our study aims to answer two research questions: (1) How do variations in content, implementation and intensity of staff dementia training in acute hospitals in England relate to health service outcome/process measures and staff outcomes? and (2) What components of staff dementia training are most strongly related to improved patient and staff outcomes?

METHODS AND ANALYSIS

Using the principles of programme theory, a mixed-method study will be used to identify mechanisms and the interactions between them, as well as facilitators and barriers to dementia training in hospitals. We will use existing data, such as Hospital Episode Statistics, alongside two surveys (at hospital and staff level).We will recruit up to 193 acute hospitals in England to participate in the hospital level survey. We aim to recruit up to 30 staff members per hospital, from a random sample of 24 hospitals. In addition, we will explore the cost-effectiveness of dementia training packages and carry out an in-depth case study of up to six hospitals.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Faculty of Health and Medicine Research Ethics Committee (FHMREC 17056) and Health Research Authority (Integrated Research Approval System (IRAS) ID 242166: REC reference 18/HRA/1198). We plan to develop both standard (eg, academic publications, presentations at conferences) and innovative (eg, citizen scientist web portals, online fora, links with hospitals and third sector organisations) means of ensuring the study findings are accessible and disseminated regionally, nationally and internationally.

Assessing risks to paediatric patients: conversation analysis of situation awareness in huddle meetings in England

OBJECTIVES

To analyse the language and conversation used in huddles to gain a deeper understanding of exactly how huddles proceed in practice and to examine the methods by which staff members identify at-risk patients.

SETTING

Paediatric wards in four English hospitals, which were part of a 12-hospital cohort participating in the Situation Awareness for Everyone programme. Wards varied by geographical region and type of hospital.

PARTICIPANTS

Paediatric staff on wards in four English hospitals.

DESIGN

Ethnomethodology and conversation analysis of recorded safety huddles.

METHODS

This study represents the first analysis of huddle interaction. All huddle meetings taking place on four wards across four different hospitals were audio recorded and transcribed. The research question examined was: how are staff identifying at-risk patients in huddles? The ethnomethodological conversation analytic approach was used to analyse the transcripts.

RESULTS

Huddlers made use of categories that allowed them to efficiently identify patients for each other as needing increased attention. Lexicon included the use of 'no concerns', 'the one to watch', 'watcher' and 'acute concerns'. Huddlers used the meetings to go beyond standardised indicators of risk to identify relative risk and movement in patients towards deterioration, relative to the last huddle meeting and to their usual practices. An implicit category, termed here 'pre-concerns', was used by staff to identify such in-between states. Sequential analysis also highlighted the conversational rights that were held implicitly by staff in different clinical roles.

CONCLUSION

Practical implications and recommendations for huddlers are considered. These included that for increased situation awareness, it is recommended that all staff are active in the huddle conversation and not only the most senior team members.