Interdisciplinary Huddle Research Articles

Assessing the implementation of nurse practitioner-led huddles in long-term care using the Consolidated Framework for Implementation Research (CFIR)

BackgroundThe COVID-19 pandemic created major challenges in long-term care (LTC) homes across Canada and globally. A nurse practitioner-led interdisciplinary huddle intervention was developed to support staff wellbeing in two LTC homes in Ontario, Canada. The objective of this study was to identify the constructs strongly influencing the process of implementation of huddles across both sites, capturing the overall barriers and facilitators and the intervention’s intrinsic properties.MethodsNineteen participants were interviewed about their experiences, pre-, post-, and during huddle implementation. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. CFIR rating rules and a cross-comparison analysis was used to identify differentiating factors between sites. A novel extension to the CFIR analysis process was designed to assess commonly influential factors across both sites.ResultsNineteen of twenty selected CFIR constructs were coded in interviews from both sites. Five constructs were determined to be strongly influential across both implementation sites and a detailed description is provided: evidence strength and quality; needs and resources of those served by the organization; leadership engagement; relative priority; and champions. A summary of ratings and an illustrative quote are provided for each construct.ConclusionSuccessful huddles require long-term care leaders to consider their involvement, the inclusion all team members to help build relationships and foster cohesion, and the integration of nurse practitioners as full-time staff members within LTC homes to support staff and facilitate initiatives for wellbeing. This research provides an example of a novel approach using the CFIR methodology, extending its use to identify significant factors for implementation when it is not possible to compare differences in success.

Piloting an Electronic Sepsis Alerting System to Reduce Inpatient Sepsis-related Serious Safety Events.

Background: Electronic surveillance systems that enable continuous patient screening for emerging signs of sepsis may improve sepsis recognition and patient outcomes. Objectives: An electronic sepsis alerting system was piloted on Pediatric Medicine units at a tertiary care hospital. The pilot served to refine the system and accompanying workflow before hospital-wide implementation, aiming to reduce inpatient serious safety events related to delayed sepsis recognition. Methods: The multitiered intervention included (1) an electronic sepsis screening and alerting system; (2) an interdisciplinary huddle workflow; (3) risk stratification nomenclature (continue routine care, sepsis watch, code sepsis) to reconcile alerts; and (4) streamlined documentation and ordering tools. Iterative changes were made to the tools and workflow using plan, do, study, act cycle methodology. Measures of clinician adherence to the workflow were tracked monthly during the pilot (% alerts reconciled, % alerts with documented huddle note). Alert to huddle time and huddle to reconciliation time (target: 10 minutes) served as outcome measures for the pilot. The frequency of consults to the hospital’s critical care response team for the indication of query sepsis was monitored as a balancing measure. Alert frequency, rate of corresponding clinical concern for sepsis, and missed sepsis cases were tracked as measures of screening tool utility. Results: During the 3-month pilot, 86% of alerts were reconciled and 67% had a documented huddle note. The median alert to huddle time decreased from 9 to 3 minutes over the course of the pilot. The median huddle to reconciliation time decreased from 14 to 8 minutes. The frequency of CCRT consults during the pilot was 1 per month, which was increased slightly from the baseline frequency of 0.67 consults per month over the previous year. An alert was triggered for 4.1% of opportunities (average 2.2 alerts per day). Of the alerts reconciled, 29% indicated a concern for sepsis. There were four instances of clinical concern for sepsis where no alert was triggered. The sepsis huddle workflow was followed in three of these instances. Conclusions/implications: Pilot results suggest clinician adherence to a new streamlined approach to care for inpatients at risk for sepsis. Involving clinicians in system design and embedding electronic tools within existing care processes supported workflow uptake. Future efforts will focus on optimizing the alerting system’s clinical accuracy and examining its impact on clinical outcomes.

Influencing a Culture of Quality and Safety Through Huddles.

Literature shows that interdisciplinary huddles help promote clear communication and proactive reporting of potential errors. High reliability organization (HRO) and just culture models were implemented, yet fragmented team communication about patient safety remained. Huddles were implemented to identify and address patient safety issues. A pre/postintervention design was used. Near-miss and actual event safety metrics, patient satisfaction, and employee satisfaction/work group perceptions were measured at 3 time points over 1 year. Daily interdisciplinary huddles were implemented to improve communication, reduce errors, and improve patient and employee satisfaction. Near-miss reporting increased across time points. Patient satisfaction with how the staff worked together to provide care significantly increased over time. Employee satisfaction and perception of work group communication, collaboration, and psychological safety scores improved, however, were not statistically significant. Implementing huddles demonstrated improved outcomes in patient safety, patient satisfaction, and employee satisfaction/work group perceptions.

Impact of Pediatric Intensive Care Unit Preadmission Huddle on Perceptions of Interprofessional Communication About Patient Safety.

Preadmission discussions in the study institution's pediatric intensive care unit are not standardized and admission plans were thought to be disjointed, leading to a perceived lack of organization and preparation for the arrival of a critically ill child. To evaluate the impact of a new, formalized preadmission pediatric intensive care unit interdisciplinary huddle on clinician perceptions of interprofessional communication. The hypothesis was that preadmission huddles would improve unit clinicians' perceptions of interprofessional communication. Interprofessional pediatric intensive care unit clinicians (physicians, advanced practice providers, nurses, and respiratory therapists) completed surveys before and 7 months after preadmission interdisciplinary huddle implementation. Huddle compliance and perceptions of interprofessional communication in the unit were evaluated. Of 265 eligible pediatric intensive care unit admissions, 69 huddles (26.0%) occurred. The postintervention survey revealed increased odds (odds ratio [95% CI]) of responding "strongly agree" or "agree" to questions about the opportunity to "communicate effectively with health care team members" (2.42 [1.10-5.34]), "respond to feedback from health care team members" (2.54 [1.23-5.24]), and "convey knowledge to other health care team members" (2.71 [1.31-5.61]) before an admission. This study introduced a formalized huddle that improved pediatric intensive care unit clinicians' perceived communication with other health care team members in the preadmission period. Future studies are needed to determine if this perceived improvement in communication significantly affects health care outcomes of critically ill children or if these results are generalizable to other pediatric intensive care unit settings.

Resident integration with inpatient clinical documentation improvement: a quality improvement project

BackgroundClinical documentation improvement (CDI) is an increasing part of health system quality and patient care with clinical documentation integrity specialists (CDIS) expanding into daily physician workflow. This integration can be...

Non-COVID co-morbidity: potential indirect consequences of the SARS-CoV-2 pandemic in a neonatal intensive care unit

Non-COVID co-morbidity: potential indirect consequences of the SARS-CoV-2 pandemic in a neonatal intensive care unit

Huddle Up! A Comprehensive Approach to Improving Interdisciplinary Huddle in a VA Geriatric Primary Care Clinic

Spending time in brief meetings or “huddles” is associated with greater job satisfaction and less burnout, especially when team members have mutually agreed upon goals and can participate in decision-making. However, huddles are often unproductive and may have opposite the intended effect if not tailored to the specific team involved. We sent a survey to all members of our VA Geriatric primary care team (including geriatric medicine fellows, social work, psychology, audiology, pharmacy, faculty and support staff) asking them to rate our huddle’s impact on their stress level, efficiency, learning, preparedness and feeling supported at work. Responders indicated if they received needed information and if they understood what information was needed from them. We then held a team meeting to establish mutually agreed upon goals, expectations and organization of huddle, which were then reinforced with visual and timer reminders. After 6 weeks utilizing the new format, we administered a post intervention survey assessing the impact of the change. The initial survey revealed that the geriatric medicine fellows had worse ratings than other trainees, staff, and faculty. Fellows were more likely to say that they did not know what information was needed from them; and they did not receive information needed from others. The follow up survey showed improvement in all scores among geriatrics medicine fellows and allied health professionals, including 100% of respondents indicating they receive needed information. Overall, comments regarding the intervention were positive, demonstrating that a structured, organized huddle tailored to a specific team, can be beneficial.

Team-Based Communication Increases Adherence to Suggested Decision-to-Incision Times in an Urban County Hospital [8A

INTRODUCTION: Decision-to-Incision (DTI) research has investigated maternal and neonatal outcomes, while literature on decreasing DTI times remains sparse. Here we describe a quality improvement project, led by first-year medical students, aimed at reducing DTI times at a county hospital using a worksheet to guide communication during interdisciplinary huddles before each unplanned cesarean. METHODS: In 2017, medical students at Zuckerberg San Francisco General Hospital implemented a grading system to standardize the urgency of unplanned cesareans and interdisciplinary DTI huddles to assign target incision times for cesareans. Our initial intervention provided checklists for each team member. Following interviews with staff, we developed a printed communication tool to facilitate discussion around urgency, potential delays, and target incision time. Using worksheet and medical record data, we analyzed use of the DTI communication tool and DTI times pre-intervention (June-August 2016), post-checklist implementation (February-August 2017) and post-communication tool implementation (March-August 2018). RESULTS: Use of the DTI workflow in unplanned cesareans more than doubled from 20.2% to 47.7% after switching from checklists (n=74) to the communication tool (n=86). Mean DTI time decreased from 93 to 82 minutes during the same time period. Following implementation of the tool, 52.5% of unplanned cesareans occurred within five minutes of the suggested DTI times for each grade, and we observed a significant effect of urgency grade on DTI time [F(2,47)=11.3, P<.001]. CONCLUSION: The grading system adequately stratified the urgency of cesareans, while the communication tool streamlined discussion of potential delays. Guided interdisciplinary communication, not just checklists, facilitates team-based interactions critical to decreasing DTI times.

Building Behavioral Health Homes: Clinician and Staff Perspectives on Creating Integrated Care Teams.

Adults with serious mental illness and substance use disorders have elevated risk of mortality and higher healthcare costs compared to the general population. As these disparities have been linked to poor management of co-occurring chronic conditions in primary care, the behavioral health setting may be a preferred setting for routine medical screening and treatment. This qualitative study describes early stages of integrating care teams in emerging medical homes based in mental health and addiction treatment settings. Clinicians and staff from ten agencies engaged in the Behavioral Health Home Learning Collaborative participated in qualitative interviews exploring local definitions of "behavioral health home" and initial barriers and facilitators to integration. Facilitators included clear staff roles, flexible scheduling, and interdisciplinary huddles and staff trainings. Challenges included workforce, limited use of electronic health records, and differing professional cultures. Participants advocated for new workflows and payment structures to accommodate scheduling demands and holistic case management.

Introduction of a Horizontal and Vertical Split Flow Model of Emergency Department Patients as a Response to Overcrowding

IntroductionED overcrowding is an issue that is affecting every emergency department and every hospital. The inability to maintain patient flow into and out of the emergency department paralyzes the ability to provide effective and timely patient care. Many solutions have been proposed on how to mitigate the effects of ED overcrowding. Solutions involve either hospital-wide initiatives or ED-based solutions. In this article, the authors seek to describe and provide metrics for a patient flow methodology that targets ESI 3 patients in a vertical flow model. MethodsIn the Stanford Emergency Department, a vertical flow model was created from existing ED space by removing fold-down horizontal stretchers and replacing them with multiple chairs that allowed for assessment and medical management in an upright sitting position. The model was launched and sustained through frequent interdisciplinary huddles, detailed inclusion and exclusion criteria, scripted text on how to promote the flow model to patients, and close analytics of metrics. Metrics for success included patient length of stay (LOS) for those triaged to the vertical flow area compared with ESI 3 patients triaged to the traditional emergency department as a comparison group. The secondary outcome is the total number of patients seen in the vertical flow area. This was a 6-month—September 2014, to February 2015—retrospective pre- and postintervention study that examined LOS as a marker for effective launch and implementation of a vertical patient workflow model. ResultsThe patients triaged to the vertical flow area in the study period tended to be younger than in the control period (43 years versus 52 years, P = 0.00). There was a significant decrease in our primary end point: the total LOS for ESI 3 patients triaged to the vertical flow area (270 minutes versus 384 minutes, P = 0.00). ConclusionImplementation of a vertical patient flow strategy can decrease LOS for the vertical ESI 3 patients based upon the inclusion and exclusion criteria. Furthermore, this is accomplished with minimal financial investment within the physical constraints of an existing emergency department.Image 1

Implementing Huddles Improves Care Coordination in an Academic Health Center.

To determine whether routinely scheduled, organized interdisciplinary huddles result in decreased length of stay and readmissions. The study was conducted in an academic health center (AHC) that also fills a community hospital need for a diverse inner-city population. Results are applicable in other care settings. Daily interdisciplinary huddles were piloted on 5 medical/surgical units. The 2015 readmission and length of stay data were compared with the 2013 baseline. There was a mean readmission reduction of 0.56%. A paired t test comparing the 2013 and 2015 readmission rates of the 5 units was significant (p < .05). There was a 0.42-day increase in the mean LOS between the 2013 baseline and the 2015 follow-up. A paired t test comparing 2013 and 2015 readmission rates of the 5 units was not significant at the .05 level. Daily interdisciplinary sessions can result in reduced readmissions. Long-lasting positive outcomes related to enhanced communication are possible. Requirements for success include consistency in the standard huddle content reviewed. Data should be followed closely throughout an extended period of time to identify trends and support sustainment. Creative means to obtain input from services that cover multiple units and not be able to attend huddles may be necessary. Staff turnover will impact success. Variation in physician engagement can be addressed by frequent communication on the "why" behind the significance of the huddles, as well as sharing of change data highlighting success stories.

Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion

ABSTRACTObjective: To determine if a lean intervention improved emergency department (ED) throughput and reduced ED boarding by improving patient discharge efficiency from a tertiary care children’s hospital.Methods: The study was conducted at a tertiary care children’s hospital to study the impact lean that changes made to an inpatient pediatric service line had on ED efficiency. Discharge times from the general pediatrics’ service were compared to patients discharged from all other pediatric subspecialty services. The intervention was multifaceted. First, team staffing reconfiguration permitted all discharge work to be done at the patient’s bedside using a new discharge checklist. The intervention also incorporated an afternoon interdisciplinary huddle to work on the following day’s discharges. Retrospectively, we determined the impact this had on median times of discharge order entry, patient discharge, and percent of patients discharged before noon. As a marker of ED throughput, we determined median hour of day that admitted patients left the ED to move to their hospital bed. As marker of ED congestion we determined median boarding times.Results: For the general pediatrics service line, the median discharge order entry time decreased from 1:43pm to 11:28am (p < 0.0001) and the median time of discharge decreased from 3:25pm to 2:25pm (p < 0.0001). The percent of patients discharged before noon increased from 14.0% to 26.0% (p < 0.0001). The discharge metrics remained unchanged for the pediatric subspecialty services group. Median ED boarding time decreased by 49 minutes (p < 0.0001). As a result, the median time of day admitted patients were discharged from the ED was advanced from 5 PM to 4 PM.Conclusion: Lean principles implemented by one hospital service line improved patient discharge times enhanced patient ED throughput, and reduced ED boarding times.

Systematic identification and management of barriers to vascular surgery patient discharge time of day

ObjectiveLength of stay fails to completely capture the clinical and economic effects of patient progression through the phases of inpatient care, such as admission, room placement, procedures, and discharge. Delayed hospital throughput has been linked to increased time spent in the emergency department and postanesthesia care unit, delayed time to treatment, increased in-hospital mortality, decreased patient satisfaction, and lost hospital revenue. We identified barriers to vascular surgery inpatient care progression and instituted defined measures to positively impact standardized metrics. MethodsThe study was divided into three periods: preintervention, “wash-in,” and postintervention. During the preintervention phase, barriers to patient flow were quantified by an interdisciplinary team. Suboptimal provider communication emerged as the key barrier. An enhanced communication intervention consisting of face-to-face and mobile application-based education on key patient flow metrics, explicit discussion of individual patient barriers to progression at rounds and interdisciplinary huddles, and communication of projected discharge and potential barriers via e-mail was developed with input from all stakeholders. Following a 4-week wash-in implementation phase, data collection was repeated. ResultsThe pre- and postintervention patient cohorts accounted for 244.3 and 238.1 inpatient days, respectively. Both groups had similar baseline demographic, clinical characteristics, and procedures performed during hospitalization. The postintervention group was discharged 78 minutes earlier (14:00:32 vs 15:18:37; P = .03) with a trend toward increased discharge by noon (94% vs 88%; P = .09). Readmission rates did not differ (P = .44). ConclusionsImplementation of a focused, interdisciplinary, frontline provider-driven, enhanced communication program can be feasibly incorporated into existing specialty surgical workflow. The program resulted in improved timeliness of discharge and projected cost savings, without increasing readmission rates.

A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk

BackgroundSituation awareness (SA)—the perception of data elements, comprehension of their meaning and projection of their status in the near future—has been associated with human performance in high-risk environments, including aviation...