Approximately 180,000 patients die annually in the

PRACTICE IMPROVEMENT SITUATION, BACKGROUND, ASSESSMENT, AND RECOMMENDATION GUIDED HUDDLES IMPROVE COMMUNICATION AND TEAMWORK IN THE EMERGENCY DEPARTMENT Authors: Heather A. Martin, DNP, RN, PNP-BC, and Susan M. Ciurzynski, PhD, RN, PNP-BC, Rochester, NY Earn Up to 8.0 CE Hours. See page 545. Problem: Thousands of people die annually in hospitals because of poor communication and teamwork between health care team members. Standardized tools and strategies help increase the amount and quality of communication. Two structured communication methods include implementing huddles and the use of the situation, background, assessment, and recommendation (SBAR) communication framework. Methods: To improve communication among nurse practitioners and registered nurses within a pediatric emergency department, a performance-improvement project with the structured processes of a joint patient evaluation and huddle was implemented. Data were gathered from 32 nurses and 2 nurse practitioners using structured observation and pre- and post-implementation surveys. The following outcomes were measured: presence or absence of joint patient evaluation and SBAR-guided huddle, verbalization of treatment plan, communication, teamwork, and nurse satisfaction. Results: Eighty-three percent of patient encounters included a joint evaluation. A huddle structured with SBAR was conducted 86% of the time. Registered nurses and nurse practitioners verbalized patients treatment plans in 89% of cases and 97% of cases, respectively. Improved teamwork, communication, and nursing satisfaction scores were demonstrated among the nurse practitioners and registered nurses. Implications for practice: This project showed the feasibility of a simple and inexpensive joint nurse practitioner registered nurse patient evaluation followed by a structured huddle, which improved communication, teamwork, and nurse satisfaction scores. This performance-improvement project has the potential to enhance efficiency by reducing redundancy, as well as to improve patient safety through the use of structured communication techniques. Keywords: Communication; Teamwork; Emergency department; Huddle; SBAR Approximately 180,000 patients die annually in the United States because of adverse medical events. 1 Most of these events are related to miscommunication among health care teams. 2 Effective face-to-face communica- Heather A. Martin, Member, Genesee Valley, is Emergency Medicine Quality Assurance Coordinator and Pediatric Emergency Medicine Nurse Practitioner, University of Rochester Medical Center, Rochester, NY. Susan M. Ciurzynski is Associate Professor of Clinical Nursing, University of Rochester School of Nursing, Rochester, NY. For correspondence, write: Heather A. Martin, DNP, RN, PNP-BC, University of Rochester Medical Center, 601 Elmwood Ave, Box 655, Rochester, NY 14642; E-mail: heather_martin@urmc.rochester.edu. J Emerg Nurs 2015;41:484-8 Available online 2 July 2015. 0099-1767 Copyright 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.05.017 tion between professionals is crucial for successful teamwork and essential to high-quality patient care. 3 Processes to improve communication among ED staff should be standardized as much as possible to improve the efficiency of the emergency department by minimizing the time it takes to carry out a patient s treatment plan. Teams that jointly evaluate a patient, obtain the patient s history together, and perform a physical examination conjointly are able to reduce redundancy, save time, and increase patient and staff satisfaction. 4 Furthermore, well-functioning, patientfocused teams have been associated with increased productivity, increased quality of care, decreased costs, and improved patient outcomes. 3 In addition, nursing satisfaction improves when nurses are allowed to participate in the team as part of collaboration related to patient care decisions. 5 The Institute of Healthcare Improvement 6 and Team- STEPPS 7 recommend standardizing communication strategies (eg, huddles) to increase the amount and quality of communication, as well as to prevent adverse patient outcomes. Specifically, 484 JOURNAL OF EMERGENCY NURSING VOLUME 41 ISSUE 6 November 2015

Martin and Ciurzynski/PRACTICE IMPROVEMENT the use of the situation, background, assessment, and recommendation (SBAR) framework has been implemented across the US as a best practice in delivering information in a rapid transmission, 6 which is often necessary in a busy ED setting. With the goal to improve communication, teamwork, and nurse (registered nurse [RN]) job satisfaction in our pediatric emergency department, a performance-improvement (PI) project was instituted in which the nurse practitioner (NP) provider and RN conducted a joint history and physical assessment, followed by a huddle standardized with the SBAR framework. The purpose of this article is to describe the findings of this PI project, including the feasibility of initiating this approach and association with teamwork, communication, and nurse satisfaction scores. Methods ETHICS Permission to conduct this project was obtained from the medical center s nursing and medical leadership teams. In addition, approval as exempt status was received from the medical center s institutional review board. SETTING The PI project took place in an academic medical center s pediatric emergency department located in western New York State during the autumn and winter months of 2013 2014. This pediatric emergency department provides care to approximately 30,000 children annually and is the Level ITraumaCenterforthearea.ThesampleconsistedofRNswho were employed full time and part time in the pediatric emergency department, along with 2 board-certified pediatric NPs. Because the project was a department PI initiative, all RNs and NPs were included in this intervention. PROCESS Staff Education Before the start of the practice change, a 1-hour educational in-service was developed and presented to pediatric ED nursing staff (N = 33). The education highlighted the importance of effective communication among team members and the outcomes hypothesized from implementing structured communication techniques. A verbal, step-by-step scenario of an NP and RN entering a patient room together to obtain the history and perform the physical examination, followed by a demonstration of a huddle structured with the SBAR framework, was provided. NP-RN Joint Evaluation After staff education, the NPs and RNs began the process of conducting joint, simultaneous patient evaluations of eligible patients. Eligible patients were defined as those who did not require immediate lifesaving treatment or resuscitation. The current practice of an NP and RN being assigned to care for patients based on their workload and availability did not change. For this PI project, it was emphasized that once an NP and RN were identified as assigned to care for the same patient, they coordinated a time when both were available to go into the examination room together. Once the NP and RN were in the room, the patient or family member was asked to relay the reason for coming to the hospital and precipitating symptoms. After the NP and RN team heard the patient s history, they performed a physical examination together. By doing this, the NP and RN were able to assess and discuss their findings concurrently. Huddles Structured With SBAR After the joint evaluation, the NP and RN were asked to huddle to discuss the patient s history and physical findings using the SBAR format. This huddle could have been completed within the examination room with the patient present or outside the room in a private, quiet area where the plan could be discussed. The option of stepping out of the patient s room was given to the team members in case there were sensitive issues that needed to be discussed, such as concerns of potential child abuse. At any time, a team member could speak up and disagree with what was being said or include additional information considered important to properly care for the patient. By following the SBAR format, the team members could communicate in a concise and anticipated method. The final element of the huddle included the recommendation of the treatment plan. Together, the NP and RN determined a plan of care for the patient and negotiated who was going to be responsible for each part of the plan, based on their scope of practice. METHODS OF EVALUATION Design The PI project was evaluated by using a structured observational audit with the Huddle, SBAR, and Communication Observation Tool (HSCOT) and self-administered pre- November 2015 VOLUME 41 ISSUE 6 WWW.JENONLINE.ORG 485

PRACTICE IMPROVEMENT/Martin and Ciurzynski and post-test survey using the Collaboration and Satisfaction About Care Decisions PEDS ED (CSACD) survey. 8 Measures and Data Analysis Outcomes measured in this project included NP/RN teamwork and communication, RN job satisfaction, and effectiveness of the huddle in creating a clear treatment plan, as well as feasibility of both the joint evaluation and the SBAR-guided huddle. Data were analyzed using SPSS software, version 20 (IBM, Armonk, NY). Data obtained from the HSCOT instrument (N = 36), including perception of the joint evaluation and huddle, and the CSACD survey were analyzed using descriptive statistics. Huddle, SBAR, and Communication To assess teamwork, communication, and the feasibility of the joint evaluation and huddle conducted using the SBAR framework, the project manager observed the NP and RN performing these components. The observer determined if a joint evaluation took place and rated the quality and effectiveness of the SBAR-guided huddle using a structured list of criteria. Data were collected using the HSCOT instrument, which was developed for this project based on The Joint Commission Hand-Off Communication Audit Tool. 9 This audit tool was originally created as a method to measure the effectiveness of using the SBAR framework during the handoff of a patient from one unit to the next or between providers. The revised tool was reviewed by an expert panel including 3 doctoral prepared nurses and an associate director of nursing for the organization. Collaboration and Satisfaction About Care Decisions All NPs and RNs were asked to complete the CSACD survey 8 to measure the perceived amount of collaboration (including teamwork and communication) and satisfaction in the pediatric emergency department. The CSACD survey contains 9 items and 2 subscales representing collaboration and satisfaction with care decisions. In this self-administered questionnaire, the participants rate their level of agreement on a 7-point Likert scale (1, strongly disagree, to 7, strongly agree), which was scored by taking a mean of all responses. Data were collected at baseline (immediately after the educational in-service, N = 33) and at the end of each patient encounter following the NP/RN joint evaluation and huddle that the project manager (pediatric emergency NP) observed (N = 64). Some RNs and NPs participated in multiple patient encounters during this project and were allowed to complete a CSACD survey for each encounter. Results SAMPLE AND DEMOGRAPHIC DATA Of the 32 subjects who participated in the PI project, 30 (94%) were women. The age distribution of the sample was 25 to 62 years, with a mean of 37 years (SD, 10.5 years). The majority of the subjects (84%) recognized their race as being white. All but 1 subject identified their ethnicity as being non-hispanic or non-latino. The average number of years the subjects had been an RN was 11.5 years, with an average of 4.8 years working in the pediatric emergency department. The majority of the RNs (69%) were employed full time, 25% were employed part time, and 6% were per-diem staff. The educational preparation of the RNs included an associate s degree is 22%, bachelor s degree in 56%, master s degree in nursing in 12%, and master s degree in another field in 9%. For the NP subjects (n = 2), the average length they had been an NP and within the pediatric emergency department was 6 years. CSACD SURVEY RELIABILITY Psychometric testing of the CSACD instrument among the current sample was found to have a high level of reliability (Cronbach α = 0.97; inter-item correlations ranged from 0.81 to 0.93). NP AND RN JOINT EVALUATIONS Joint patient evaluations took place in the majority of patient encounters (83%) with minimal interruptions noted. Of the 36 patient encounters observed, 30 (83%) had a joint patient evaluation and 31 (86.1%) had a huddle conducted. For the 6 encounters (16.7%) that did not have a joint evaluation, the following reasons were provided: immediate acuity of the patient and too busy caring for other patients. The RNs rated their experience with the joint evaluation slightly higher than the NPs. Specifically, 83% of the RNs reported they had a great experience with the joint evaluation. In comparison, the NPs rated the joint evaluation as being great 78% of the time and poor in 22% of the encounters. When the project manager inquired about the lower scoring of the patient encounters by the NPs, the reason given was that they wanted more input from and interaction by the RN than what were provided. STRUCTURED HUDDLE BASED ON SBAR FRAMEWORK On the basis of the observations conducted, 86% of the 36 patient encounters had a structured huddle after the joint patient evaluation. In 1 encounter this huddle occurred when there was no joint evaluation. Of the huddles that 486 JOURNAL OF EMERGENCY NURSING VOLUME 41 ISSUE 6 November 2015

Martin and Ciurzynski/PRACTICE IMPROVEMENT were completed, 7 (23%) were interrupted. Interruptions occurred when the RN conducting the joint evaluation with the NP was also responsible for managing the unit. COMMUNICATION AND TEAMWORK After implementation of the joint evaluation and huddle, there was an improvement in the mean communication score between the NP and RN. Specifically, the mean increased from 5.68 (SD, 1.11) at baseline to 6.59 (SD, 1.12) after the intervention. Perceptions of teamwork improved between the NP and RN after implementation of this project. Specifically, the mean (SD) increased from 5.47 (SD, 1.08) at baseline to 6.46 (1.13) after the intervention. RN JOB SATISFACTION There was an improvement in satisfaction of the RN after the implementation of this project from a baseline mean of 5.17 (SD, 1.09) to a post-intervention mean of 6.45 (SD, 0.72). In addition, most of the RNs rated their perception of the joint evaluation and huddle as satisfactory (83% and 86%, respectively). One comment shared by an RN was as follows: I appreciated working directly with the NP and being able to participate in the decision making. PATIENT TREATMENT PLAN In 86% of the patient encounters observed, both the NP and RN verbalized the next steps in the treatment plan and what role each team member had in determining what diagnostic tests needed to be completed, what medications should be ordered, and what consultations needed to be completed. Of the4cases(11%)inwhichthenpandrndidnotknowthe next steps in the treatment plan, a huddle did not take place where this information would have been discussed. Discussion Throughout this PI project, we emphasized the need for the RN and NP to evaluate the patient together and to summarize this evaluation by using a structured process (ie, huddle) and structured tool (ie, SBAR) to improve communication. We found that there was an improvement in NP and RN communication with the addition of a joint patient evaluation followed by a structured huddle. Our findings are consistent with previous research that also showed that consistent, structured techniques improve perception of communication among team members. 3 Interestingly, in 1 case in which the NP and RN did not conduct a joint evaluation and huddle at the bedside, the NP and RN came together outside the room and conducted the recommendation portion of the huddle to determine the treatment plan for the patient. This effort was applauded and showed that, in certain cases in which a joint patient evaluation may not be entirely feasible, it should be feasible for the NP and RN to at least huddle and discuss the assessment and treatment plan based on the SBAR framework. This finding may be explained by the fact that the RN and NP recognize that for an effective treatment plan to take place, they must communicate face to face and a huddle is a method by which they are able to achieve this interaction. It can therefore be concluded that the huddle was imperative to the determination and undertaking of the patient treatment plan in the current project. Our finding of increased teamwork scores was not surprising, based on empirical evidence that emphasizes the importance of collaboration among members of a team. By increasing communication, collaboration, and coordination of patient care, along with the ability to express ideas among team members, teamwork among medical staff members can be improved. 10 The RNs and NPs in this project were given the tools needed to increase communication and the ability to coordinate patient care, which was associated with an increase in teamwork. With the application of the joint patient evaluation, satisfaction among pediatric emergency nurses improved. This finding may be attributed to staff feeling that their skills and knowledgewereofgreatervalueastheycontributedtothe treatment plan. The inclusion of the RN with the NP during the joint patient evaluation allowed the RN to add his or her input to the assessment and the recommended treatment plan. This explanation is supported by the literature, in which authors have concluded that increased communication and teamwork lead to an increase in nursing satisfaction. 6 Before this project, it was common for the RN to assess the patient on his or her own, followed by the NP repeating the same examination. At the completion of the NP examination, a treatment plan would be formed based on the NP examination alone, without input from the RN regarding his or her assessment and recommendations for treatment. As a result, staff members were not working in teams but rather in parallel silos. Having a joint evaluation conducted by the NP and RN not only improved communication and teamwork within the team but also reduced the redundancy of the patient telling his or her story multiple times. On the basis of this project s findings, it would be important for future studies to explore factors surrounding RN contributions in patient treatment plans. Itisimportanttonotethatthere was a high success rate with this project that might be attributed to the RN and NP staff being a highly motivated group that was invested in creating change to improve their work environment. With other groups of providers who rotate through the pediatric emergency November 2015 VOLUME 41 ISSUE 6 WWW.JENONLINE.ORG 487

PRACTICE IMPROVEMENT/Martin and Ciurzynski department and do not consider this unit their home, there may be less inclination to perform a joint evaluation and huddle with the nursing staff. This interpretation is supported by literature stating that colleagues from within their respective professional groups are closely connected and communication is improved within these groups. 11 The high success rate may also be attributed to the baseline data being obtained immediately after the 1-hour educational in-service. The CSACD survey was distributed immediately after the education because of the convenience of having all staff members present for a training session. In the future, the survey should be distributed before any education to minimize undue influence. From the findings of this PI project and on the basis of support from the literature, we conclude that it would be feasible to implement the standard practice of joint patient evaluations between the RN and NP in the pediatric emergency department for non critically ill patients. In the future, this should be a practicable project to implement within an emergency department with similar demographic characteristics and a similar organizational structure. The implementation of this project is relatively inexpensive and simple. In 2009 medical errors specifically related to poor communication and teamwork resulted in the spending of over $1 billion, with a median cost of $939 per error. 12 Thus, improved communication and teamwork among medical teams can lead to enhanced patient safety, as well as cost savings to the institution. Future research and quality-improvement assessment should evaluate the comparison of cost to potential value of this PI intervention. For example, it would be wise to analyze if ED length of stay is reduced by the application of joint patient evaluations and huddles structured with SBAR. Conclusions Communication occurs in complex environments, such as the emergency department, where information needs to be relayed in a short period. To accomplish this, it is optimal to use structured communication techniques, such as huddles and the SBAR framework, to promote improved communication between staff members. This PI project showed that a joint patient evaluation followed by a structured huddle can improve communication, teamwork, and nursing satisfaction between NPs and RNs within a pediatric emergency department. Since the conclusion of this PI project, the NPs and RNs have continued to jointly evaluate the patients, as well as huddle to discuss the proposed treatment plan, because of the high success rate discovered with this initiative. The joint evaluation followed byahuddlewasfoundtobeafeasibleandeffectivemeasureto undertake to determine a patient s treatment plan that could potentially increase patient safety in the emergency department. Acknowledgment We thank Mary G. Carey, PhD, RN, CNS, FAHA, M. Colleen Davis, MD, MPH, FAAP, FACEP, Teresa Glessner, DNP, RN, ACNP-BC, NEA-BC, CCRN, and Anne Swantz, MS, RN, CPNP-BC, for their guidance and support throughout this entire project. We also recognize Marcy Noble, RN, BSN, CPEN, and the entire nursing staff of the pediatric emergency department for their participation and enthusiasm in making this project a success. REFERENCES 1. Levinson DR. Adverse events in hospitals: Medicare s responses to alleged serious events. Report No. 0EI-01-08-00590. Washington, DC: US Department of Health and Human Services, Office of the Inspector General. http://psnet.ahrq.gov/resource.aspx?resourceid=23433. Published October 2011. Accessed February 9, 2015. 2. The Joint Commission. Sentinel event data. Root causes by event type. 2004-2Q 2014. http://www.jointcommission.org/assets/1/18/root_causes_by_ Event_Type. Accessed February 9, 2015. 3. Leonard M, Frankel A. Role of effective teamwork and communication in delivering safe, high-quality care. Mt Sinai J Med. 2011;78:820-826. 4. Mazzocato P, Forsberg H, Schwartz U. Team behaviors in emergency care: a qualitative study using behavior analysis of what makes teams work. Scand J Trauma Resusc Emerg Med. 2011;19:70-76. 5. Ajeibe D, McNeese-Smith D, Phillips L, Leach L. Effect of nursephysician teamwork in the emergency department nurse-physician perception of job satisfaction. J Nurs Care. 2014;3:1-8. 6. Institute for Healthcare Improvement. Balance supply and demand on a daily, weekly, and long-term basis: use regular huddles and staff meetings to plan production and to optimize team communication. http://www.ihi.org/ resources/pages/changes/useregularhuddlesandstaffmeetingstoplan ProductionandtoOptimizeTeamCommunication.aspx. Published April 27, 2011. Accessed October 1, 2012. 7. Agency for Healthcare Research & Quality. TeamSTEPPS: national implementation. http://teamstepps.ahrq.gov. Accessed October 1, 2012. 8. Baggs J. Development of an instrument to measure collaboration and satisfaction about care decisions. J Adv Nurs. 1994;20(1):176-182. 9. Joint Commission Center for Transforming Healthcare. Facts about the Hand-off Communications Project. http://www.centerfortransforminghealthcare.org/ projects/detail.aspx?project=1. Published October 2013. Accessed March 1, 2014. 10. Lown B, Manning C. The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. Acad Med. 2010;85(6):1073-1081. 11. Creswick N, Westbrook J, Braithwaite J. Understanding communication networks in the emergency department. BMC Health Serv Res. 2009;9:247. 12. David G, Gunnarsson C, Waters H, Horblyuk R, Kaplan H. Economic measurement of medical errors using a hospital claims database. Value Health. 2013;16(2):305-310. 488 JOURNAL OF EMERGENCY NURSING VOLUME 41 ISSUE 6 November 2015