Communication Bundle Research Articles

Health Literacy–Informed Communication to Reduce Discharge Medication Errors in Hospitalized Children

Inadequate communication between caregivers and clinicians at hospital discharge contributes to medication dosing errors in children. Health literacy-informed communication strategies during medication counseling can reduce dosing errors but have not been tested in the pediatric hospital setting. To test a health literacy-informed communication intervention to decrease liquid medication dosing errors compared with standard counseling in hospitalized children. This parallel, randomized clinical trial was performed from June 22, 2021, to August 20, 2022, at a tertiary care, US children's hospital. English- and Spanish-speaking caregivers of hospitalized children 6 years or younger prescribed a new, scheduled liquid medication at discharge were included in the analysis. Permuted block (n = 4) randomization (1:1) to a health literacy-informed discharge medication communication bundle (n = 99) compared with standard counseling (n = 99). A study team member delivered the intervention consisting of a written, pictogram-based medication instruction sheet, teach back (caregivers state information taught), and demonstration of dosing with show back (caregivers show how they would draw the liquid medication in the syringe). Observed dosing errors, assessed using a caregiver-submitted photograph of their child's medication-filled syringe and expressed as the percentage difference from the prescribed dose. Secondary outcomes included caregiver-reported medication knowledge. Outcome measurements were blinded to participant group assignment. Among 198 caregivers randomized (mean [SD] age, 31.4 [6.5] years; 186 women [93.9%]; 36 [18.2%] Hispanic or Latino and 158 [79.8%] White), the primary outcome was available for 151 (76.3%). The observed mean (SD) percentage dosing error was 1.0% (2.2 percentage points) among the intervention group and 3.3% (5.1 percentage points) among the standard counseling group (absolute difference, 2.3 [95% CI, 1.0-3.6] percentage points; P < .001). Twenty-four of 79 caregivers in the intervention group (30.4%) measured an incorrect dose compared with 39 of 72 (54.2%) in the standard counseling group (P = .003). The intervention enhanced caregiver-reported medication knowledge compared with the standard counseling group for medication dose (71 of 76 [93.4%] vs 55 of 69 [79.7%]; P = .03), duration of administration (65 of 76 [85.5%] vs 49 of 69 [71.0%]; P = .04), and correct reporting of 2 or more medication adverse effects (60 of 76 [78.9%] vs 13 of 69 [18.8%]; P < .001). There were no differences in knowledge of medication name, indication, frequency, or storage. A health literacy-informed discharge medication communication bundle reduced home liquid medication administration errors and enhanced caregiver medication knowledge compared with standard counseling. Routine use of these standardized strategies can promote patient safety following hospital discharge. ClinicalTrials.gov Identifier: NCT05143047.

A Trainee-Led Quality Improvement Project Using Change Management Theory to Improve Bedside Rounding.

The coronavirus disease 2019 pandemic disrupted the practice of family-centered rounds. After the height of the pandemic, a trainee-led team identified a low percentage of bedside rounds on general pediatrics resident teams and combined a quality improvement framework and change management theory to increase bedside rounds. Initial efforts focused on a single general pediatrics team with the aim to increase bedside rounds from 18% to 50% within 6 months and sustain improvement for 12 months. A second aim was to increase bedside rounds from 7% to 50% for all general pediatrics resident teams within 6 months of spread. The Model for Improvement informed the identification of 3 primary drivers of bedside rounds: knowledge, culture, and logistics. Twelve plan-do-study-act (PDSA) cycles were implemented. Measures included the percentage of bedside rounds (primary outcome), caregiver attendance (secondary outcome), and nurse attendance and rounding time (balancing measures). For the initial team, 13 522 patient days were analyzed for the primary outcome with the average percentage of weekly bedside rounds increasing from 18% to 89% with 12 months of sustained improvement. The spread of the intervention to all teams revealed an increase in bedside rounding from 7% to 54%. The most significant improvements occurred after PDSA cycle 2, a communication bundle, and PDSA cycle 5, when the project was spread to all teams. This trainee-led initiative reveals the strength of the incorporation of change management theory within a quality improvement framework, resulting in rapid and sustainable increase in bedside rounds.

Communication-Efficient Federated Learning With Gradual Layer Freezing

Federated learning (FL) is a collaborative, privacy-preserving method for training deep neural networks at the edge of the Internet of Things (IoT). Despite the many advantages, existing FL implementations suffer high communication costs that prevent adoption at scale. Specifically, the frequent model updates between the central server and the many end nodes are a source of channel congestion and high energy consumption. This letter tackles this aspect by introducing federated learning with gradual layer freezing (FedGLF), a novel FL scheme that gradually reduces the portion of the model sent back and forth, relieving the communication bundle yet preserving the quality of the training service. The results collected on two image classification tasks learned with different data distributions prove that FedGLF outperforms conventional FL schemes, with data volume savings ranging from 14% to 59% or up to 2.5% higher accuracy.

Building High-Performance Team Dynamics for Rapid Response Events in a US Tertiary Hospital: A Quality Improvement Model for Sustainable Process Change.

Hospital rapid response systems are designed to reduce unmet patient needs and prevent clinical deterioration. Rapid response teams are the principal component of a rapid response system and require teamwork to function optimally; poor communication among team members can result in substandard patient care. The authors describe a process for developing and implementing standardized communication and a teamwork structure for rapid response events (RREs) at a large academic hospital. The multidisciplinary team developed a project charter and key driver diagram, developed a "communication bundle," used quality improvement methodology, monitored adherence to the changes, and reported these data to key stakeholders on a weekly basis. By project end, the team met the goal of having 70% or more of adult RREs include the use of the "communication bundle." The balancing measure demonstrated that the introduction of a formalized communication framework did not significantly increase the duration of RREs.

Applying the Care and Communication Bundle to Promote Palliative Care in a Neuro-Intensive Care Unit: Why and How.

Background: Delivery of palliative care in neurointensive care units (neuro-ICUs) can be inconsistent, often due to absence of formal care triggers. The Care and Communication Bundle (CCB) of Quality Indicators provides a standardized process to deliver effective palliative care services in ICUs, but application of these indicators in this setting has not yet been systemically assessed. Objectives: To evaluate the fit of a CCB in the neuro-ICU through a novel scoring system and identify barriers to adherence. Design: CCB standards for a neuro-ICU were delineated. Assessment of documented indicators and barriers was conducted through electronic medical record retrospective review. Setting/Subjects: A 30-bed neuro-ICU in a large Academic Medical Center in the Southeastern United States. Chart reviews were conducted for 133 critically ill neurology and neurosurgery patients who expired between November 2018 and January 2020. Results: Results demonstrate moderate adherence to CCB standards, including excellent consistency in establishment of patient-centered communication and referral to supportive services (e.g., social work, spiritual support). Identified areas for improvement include documentation of patient and family involvement in care process (i.e., advance directive completion, interdisciplinary team meetings). Conclusions: Application of the CCB in the neuro-ICU is useful for examining adherence to time-based triggers of palliative care standards. The novel scoring system offers opportunities to motivate improvement and reduce variation in palliative care integration.

Strengthening and supporting nurses' communication with mechanically ventilated patients in the intensive care unit: Development of a communication intervention.

Nurse-patient communication in intensive care units is challenged by the fact that patients are voiceless due to intubation and mechanical ventilation. Difficult communication affects nurses negatively, and it requires knowledge and expertise to facilitate communication in this complex and technologically tense setting. Augmentative and alternative communication has been suggested as a way of optimising communication; several approaches can be combined in a multi-component intervention. Also, a communication algorithm has been proposed as a way of providing structure in patient communication. To enhance transparency and avoid poorly reported interventions, this paper describes the process, rationale and reflections behind developing a communication intervention called the ICU-COM. To present the development process of a communication intervention prototype that aims to support and strengthen nurses' communication with mechanically ventilated patients in an intensive care unit. The Medical Research Council's framework for developing complex interventions in health was applied. The approach was target-population centred. The intervention was developed and tailored to four intensive care unit departments at Aarhus University Hospital in Denmark. Intensive care nurses and various experts, namely, speech-language pathologists, graphic designers, a software company, the local Centre for E-learning and nurse specialists were involved in its development. An intervention consisting of: 1) a multi-component communication bundle, 2) delivery of the bundle via a teaching session and 3) initial implementation via nurse communication guides was developed. The communication bundle contained: 1) a communication strategy with a BASIS framework and algorithm, 2) a nurse education programme and 3) low-tech and high-tech communication tools. A systematic approach was applied in the development process. However, the acceptability and feasibility of the intervention is at present unknown.

Handoff Communication between Remote Healthcare Facilities.

Introduction:Handoffs and transitions of care are common weak points in healthcare provider communication as patients move between sites. With no consistent pattern of communication between St. Jude Children’s Research Hospital (St. Jude) and its affiliated clinics, the Affiliate Program Office at St. Jude developed and implemented a standardized communication tool to facilitate patient transitions between different healthcare sites.Methods:Each team of providers created flow diagrams to define the current state of communication when patients were transitioning between remote sites. Fishbone diagrams identified the common barriers to effective communication as a lack of consistent communication and ownership. We developed a communication tool to address these barriers, which was disseminated by secure email. We measured the percent usage of the completed hand-off tool before a patient transitioned, staff experience, and the number of errors.Results:The time to send or receive the communication bundle was <10 minutes. Within 3 months of implementing the SMART bundle at 3 pilot sites, the bundle was used completely in 6 of 8 patient transitions and was associated with somewhat improved staff satisfaction. We identified no adverse events related to the communication bundle.Conclusions:In this small pilot study, we accomplished closed-loop communication between geographically remote healthcare sites by using an electronically transmitted standardized communication bundle.

Structured handoff communication between affiliated health care sites.

182 Background: The affiliate program at St. Jude Children’s Research Hospital (St. Jude) allows more children access to pediatric oncology care closer to the patient’s home. Currently 8 clinics, located throughout the Southeast and the Midwest, are affiliated with St. Jude and contribute 35% of patients enrolled in St. Jude clinical trials. Handoffs and transitions of care are common weak points in health care provider communication as patients move between sites. Failures in communication led to inefficiencies in care, patient dissatisfaction, and near-miss events. Ensuring that the information exchanged during the patient transition is efficient and complete will benefit patient safety and trust. With no consistent pattern of communication between St. Jude and affiliate clinics, we aimed to develop and implement a standardized communication tool to be used with each patient transition between different health care sites. Methods: Each team of providers (St. Jude and affiliate clinics) created individual flow diagrams to define the current state of communication when patients were transitioning between remote sites. Using fishbone diagrams each team identified the barriers to effective communication. Common barriers were incomplete communication and synthesis by the receiver. Results: We developed a communication bundle. Using IPASS methodology (a communication bundle developed for inpatient handoffs between resident physicians) we designed a standardized mnemonic, SMART (S-summary of plan; M-medications/roadmap; A-action plan; R-return visit date; T-transfer confirmation) for a patient transition between different health care sites. The communication bundle was transmitted by secure email. The time to send or receive the communication bundle was &lt; 10 minutes. We measured % usage of the completed tool prior to transition, staff satisfaction, and number of errors. The SMART bundle was used 80% of the time and improved staff satisfaction. No errors have been identified. Conclusions: Closed loop, high-reliability communication can be accomplished between geographically remote health care sites using a standardized communication tool, which is transmitted electronically.

Implementing primary palliative care best practices in critical care with the Care and Communication Bundle

BackgroundClinician–family communication is a central component of medical decision-making in the intensive care unit (ICU) and the quality of this communication has a direct impact on decisions made regarding care...

Standardizing Communications Improves Use of Palliative Care in Patients With Stroke

Patients who have sustained a severe stroke have immediate palliative care needs, and poor communication is a gap in quality that increases length of stay (LOS) and costs, which decreases efficient resource utilization. To standardize communication between families and treatment teams in the intensive care unit (ICU) and demonstrate improvement in LOS and costs, a communication bundle was prospectively implemented in 22 patients and compared against a retrospective control arm of 22 patients. The intervention group demonstrated significant improvement in median ICU and hospital LOS and ICU costs. Standardizing communication significantly improved resource utilization in severe stroke patients.

Impacting the Patient's Experience in a Children's Hospital Using a Communication Bundle Strategy.

The aim of this quality improvement project was to determine whether a communication bundle would impact parents' ratings of nurse-child communication in relation to (a) how often the nurse listened carefully to the child and (b) how often the nurse explained things in a way easy for the child to understand. The Child Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores on the unit lagged behind the hospital's 75th percentile external benchmark established by the National Research Corporation. A convenience sample of the unit's staff participated in the project. The outcome measure was a comparison of Child HCAHPS scores and percentile ranks for the questions pre- and postimplementation of the communication bundle. Following implementation of the communication bundle, the unit's patient satisfaction scores for both questions exceeded the 75th-percentile benchmark. This project enhanced nurse communication at the bedside and the parent's perception of nurse-child communication.

Evidence-Based Review and Discussion Points

Evidence-Based Review and Discussion Points

Early Warning Score Communication Bundle: A Pilot Study.

Unplanned admissions of patients to intensive care units from medical-surgical units often result from failure to recognize clinical deterioration. The early warning score is a clinical decision support tool for nurse surveillance but must be communicated to nurses and implemented appropriately. A communication process including collaboration with experienced intensive care unit nurses may reduce unplanned transfers. To determine the impact of an early warning score communication bundle on medical-surgical transfers to the intensive care unit, rapid response team calls, and morbidity of patients upon intensive care unit transfer. After an early warning score was electronically embedded into medical records, a communication bundle including notification of and telephone collaboration between medical-surgical and intensive care unit nurses was implemented. Data were collected 3 months before and 21 months after implementation. Rapid response team calls increased nonsignificantly during the study period (from 6.47 to 8.29 per 1000 patient-days). Rapid response team calls for patients with early warning scores greater than 4 declined (from 2.04 to 1.77 per 1000 patient-days). Intensive care unit admissions of patients after rapid response team calls significantly declined (P = .03), as did admissions of patients with early warning scores greater than 4 (P = .01), suggesting that earlier intervention for patient deterioration occurred. Documented reassessment response time declined significantly to 28 minutes (P = .002). Electronic surveillance and collaboration with experienced intensive care unit nurses may improve care, control costs, and save lives. Critical care nurses have a role in coaching and guiding less experienced nurses.

Clinical Pearls

About half of adults admitted to intensive care units (ICUs) are patients whose condition has deteriorated while on a medical-surgical unit. Patients’ early warning scores (EWSs) are based on physiological measures and were developed as a decision tool to help bedside nurses identify and take action when a patient decompensates.Fetzer and colleagues created an EWS bundle of interventions, including alerting an experienced ICU nurse, to improve communication and patient outcomes related to patient deterioration. After testing the bundle, they found the following:Findings suggest that use of an electronically embedded EWS and a communication bundle with experienced ICU nurse collaboration can improve patient care and preserve health care costs.See Article, pp 238–242Early movement can improve the muscle weakness commonly experienced by patients in the intensive care unit and prevent potential long-term impairments. Nurse-facilitated mobility improves patient outcomes and decreases length of hospital stay. However, a commonly named barrier to nurse-facilitated mobilization is nurses’ lack of time.To understand time-related barriers, Young and colleagues designed a multidisciplinary team process to directly observe the work performed by nurses and clinical care technicians. They found the following:Direct observation of nursing care activities is a process that could be replicated by other institutions to provide insight in identifying missed opportunities for nurse-facilitated patient mobility.See Article, pp 186–193Pain is a common symptom for many patients in the intensive care unit (ICU). Unrelieved pain can contribute to physical and psychological complications such as hemodynamic instability, infections, anxiety, delirium, and post-ICU syndrome. The complex nature of pain management requires both pharmacological and nonpharmacological interventions.Papathanassoglou and colleagues examined the effects of a multimodal integrative intervention that included relaxation and guided imagery, moderate pressure massage, and music listening. They found that patients receiving the intervention hadAlthough many of the patients had low acuity of illness, the authors suggest use of a multimodal daily intervention to reduce pain and improve pain-related outcomes in critically ill adults.See Article, pp 172–185Patients and families in the critical care setting often experience spiritual distress. Although most nurses do not receive education in how to provide spiritual care to patients, most recognize it as part of holistic nursing practice.Bone and colleagues interviewed nurses in an intensive care unit (ICU) to understand their experiences when making a referral for spiritual care for a dying patient and/or the patient’s family. They found the following 3 categories related to spiritual presence:Nurses considered spiritual care important and valued chaplain support in the holistic care they provide to patients and their families.See Article, pp 212–219

Abstract WP360: Use of a Care and Communication Bundle Can Improve Resource Utilization and Timeliness of Palliative Care for Severe Stroke Patients in the Neuroscience ICU

Background: Severe stroke patients have immediate palliative care (PC) needs and communication between families and clinical teams has been identified as a gap in PC delivery. Delays in care planning can increase length of stay (LOS) and cost of care (COC) which decreases efficient resource utilization. Purpose: The purpose of this quality improvement project is to evaluate whether standardizing the communication process between families and treatment teams using a communication bundle validated in the medical ICU improves LOS, COC, and time to PC consultation in severe stroke patients in a neuroscience ICU. Methods: The Care and Communication Bundle (CCB) was prospectively implemented in 22 consecutive patients from February-April 2017 and compared to a control arm of 22 consecutive patients via retrospective chart review from February-April 2016. Improvement in resource utilization was defined as a decrease in LOS and COC. Patients with a primary diagnosis of ischemic or hemorrhagic stroke, NIHSS score of ≥ 15, and an expected ICU LOS of ≥ 5 days were included. Descriptive statistics were analyzed using Chi Square, Mann-Whitney U , or t- test where appropriate. Significance was set at p &lt;0.05. Results: In the CCB group versus the control group, the median ICU LOS (2 vs 5.5 days, p =0.04), median hospital LOS (4 vs 9 days, p =0.02), and ICU COC ($21,118 vs $68,634, p =&lt;0.01) were significantly lower. Documentation of code status (18 vs 9 patients, p =&lt;0.01), advanced directives (21 vs 6 patients, p =&lt;0.01), and family meetings (20 vs 13 patients, p =0.02) were significantly higher in the CCB group. The CCB group received earlier PC consults (1.5 vs 3.5 days, p =0.07). Conclusions: Standardizing communication between families and treatment teams significantly improved resource utilization and improved timeliness of PC delivery to severe stroke patients. Larger prospective studies of the CCB in severe stroke patients and within other neuroscience ICU populations are needed.

Implementation of a Communication Bundle for High-Risk Patients.

Interventions that facilitate early identification and management of hospitalized pediatric patients who are at risk for deterioration are associated with decreased mortality. In our large pediatric hospital with a history of success in decreasing unrecognized deterioration, patients at higher risk of deterioration are termed "watchers." Because communication errors often contribute to unrecognized deterioration, clear and timely communication of watcher status to all team members and contingency planning was desired. Increase the percentage of eligible watchers with a complete communication, teamwork, and planning bundle within 2 hours of identification from 28% to 80%. Watchers admitted to Hospital Medicine on 2 targeted units were eligible. Stakeholders were educated to facilitate ownership. Daily data analysis enabled real-time failure identification. Automated physician notification provided reminders for timely communication. The percentage of watchers with a complete situation awareness bundle within 2 hours increased from 28% to 81% and was sustained for more than 2 years. There was no change in rates of rapid response team calls or ICU transfers on our intervention units, but these both increased throughout the hospital. Education facilitated modest improvement, with marked improvements and sustainment through use of technology. A novel bundle that included contingency planning and communication expectations was created to improve situation awareness for watchers. Multidisciplinary engagement and use of automated technology facilitated by an electronic health record helped implement and sustain bundle adherence.

Evaluation of a Multifaceted Educational Intervention to Improve Palliative Care in the Intensive Care Unit

Currently, palliative care needs are inconsistently implemented in intensive care units (ICUs). To remedy this problem, a multifaceted educational intervention was delivered to interdisciplinary ICU team members to promote the adoption of the Care and Communication Bundle for patients identified as being at a high risk of death. A preintervention/postintervention evaluation design was used to determine the extent to which the nine quality measures of the Care and Communication Bundle, patient length of stay, and patient mortality were changed after this educational intervention. On the basis of statistical results, documentation of an appropriate decision maker, advance directives, resuscitation status, and social work contact significantly improved after the multifaceted educational intervention to integrate palliative care measures into the ICU.

Rounding and Communication Bundle in Medical Intensive Care Unit: A Quality Improvement Initiative: Identification of Barriers

Rounding and Communication Bundle in Medical Intensive Care Unit: A Quality Improvement Initiative: Identification of Barriers

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Introduction: Each year more than half a million Americans die in or after ICU treatment and many others remain debilitated with severe functional and cognitive impairments. These growing numbers require more innovation within palliative care and have been identified as a healthcare priority. In 2006 after several years of research the care and communication bundle was published with support of many medical organizations. The bundle consists of identifing the medical decision-maker, determining advance directives and code status, distribution of a family information packet, regular pain assessment with optimal pain management, offering of social work and spiritual support and a interdisciplinary family meeting. Research has shown that consistent application of these elements has not occurred. Methods: In April of 2012 a intergrated multidisciplinary team was created to evaluate our compliance with the care and communication bundle. Our team was comprised of critical care physicians, nurse practitioners, physician assistants, nurses, a social worker, and an administrative assistant with data collection knowledge. The project occurred in a 18 bed Neurosurgical ICU in an 800 bed teaching and tertiary care center in New England. Results: The team performed a retrospective chart review over a 5 week period from April 2012-May 2012 to assess compliance with the bundle. There were 151 patients admitted during this period with 30 patients having length of stay >5 days. These charts were reviewed for identification of the medical decision-maker, determining advance directive status, investigation of resuscitation preference, distribution of family information leaflet, regular pain assessment, optimal pain management, the offering of spiritual support and social work, and the offering of a family meeting. The offering of social work support on day 3 was at 50% compliance and the offering of a family meeting on day 5 had 15% compliance. The team focused attention on those 2 elements of the bundle. The remaining elements had a compliance of 90-100%. The data collected was shared with all disciplines involved in care of the ICU patients. A survey of the ICU team was conducted as to barriers for compliance. Our unit social worker identified the lack of timely referrals and the medical providers identified the lack of social work involvement to establish these meetings, and losing track of patient's length of stay as barriers to compliance. Several providers also sighted that family meetings were occurring but there was inadequate documentation to capture these discussions. The administrative assistant for this team created a data sheet to allow tracking of patient's ICU length of stay and compliance with both social work and a family meeting being offered. She sent daily electronic mail to the unit social worker, ICU director, and chairs of the care and communication team to identify patients that were now day 3 and needed a social work consult and patients that were at day 5 and needed a family meeting offered. The medical team would then be asked to consult social services, and either social worker, staff nurse, or medical provider would offer a meeting to the patient and family. The care and communication team developed a standard note both paper and electronic for documentation of the family meeting. Retrospective chart reviews were performed for a 5 week period, 6 and 12 months after the start of these initiatives. Patient's charts with length of stay >5 days were reviewed. Patients' eligible were 58 of the 280 admissions during these time intervals. Social work was offered and involved 100% of the time at both reviews. Family meetings were offered 60% of the time at 6 month interval, and 80% at the 12 month interval. Conclusions: The creation of a intergrated multidisciplinary team improved daily compliance with care and communication bundle.

Suprahyoid neck fascial configuration, especially in the posterior compartment of the parapharyngeal space: A histological study using late‐stage human fetuses

The fascial configuration in the suprahyoid parapharyngeal space was evaluated using semiserial sagittal sections of 15 late-stage human fetal heads. The prevertebral fascia covered the longus colli, longus capitis, and rectus capitis lateralis muscles, but was most evident along the longus colli muscle. The carotid sheath and its extension were located around the internal and external carotid arteries and the lower cranial nerves. The superior cervical ganglion was also inside the sheath. Even near full term, the fetal suprahyoid neck was short, with the jugular foramen and hypoglossal canal located at the posterolateral side of the oropharynx. Thus, the glossopharyngeal and accessory nerves ran across the upper part of the carotid sheath. Fasciae of the stylopharyngeus, styloglossus, and stylohyoideus muscles were attached to and joined the anterosuperior aspect of the carotid sheath. All these neurovascular and muscle sheaths are communicated with the visceral fascia covering the pharynx at multiple sites, and, together, they formed a mesentery-like bundle. This communication bundle was made narrow by the anteriorly protruding longus capitis muscle. The mesentery-like bundle was covered by the posterior marginal fascia of the prestyloid compartment of the parapharyngeal space. The external carotid artery ran on the lateral and posterior sides of the posterior marginal fascia. Consequently, the typical carotid sheath configuration was modified by muscle sheaths from the styloid process, communicated with the visceral fascia and, anteriorly, constituted the posterior margin of the prestyloid space.