Patient Safety / Quality

Huddle up for patient safety

You have received report on your patients and are starting your shift on a busy medical-surgical unit. To help control your workflow and manage your time more effectively, you begin to organize your thoughts and prioritize your tasks.

Within minutes, the dialysis center calls, requesting one of your patients be sent there for treatment. Another patient rings for assistance to walk to the bathroom. An elderly patient with dementia is trying to get out of bed. Another patient is requesting pain medication. Your attempt to prioritize your tasks goes up in smoke before your day even gets rolling.

In acute-care settings, scenarios like this are common. Chaos erupts within what had been a manageable and relatively orderly shift. In a matter of minutes, the workflow of nursing care delivery changes.

This was happening frequently on 6 Tower (6T)—a 30-bed, high-acuity, medical-surgical unit at Lehigh Valley Hospital (LVH). At this Magnet®-recognized academic community hospital in Allentown, Pennsylvania, all patient rooms on 6T are private, arranged in a long corridor. No central nurses’ station exists.

Although staff and patient surveys had yielded objective, positive data associated with teamwork, all too often we found ourselves working in silos, trying to master our own work assignments. We weren’t aware when our coworkers were overwhelmed and needed assistance—or when coworkers were available to give us support when we needed a hand.

This article describes how the 6T staff implemented safety huddles to heighten awareness of individual staff and patient needs that could be anticipated at the beginning of, or throughout, the shift.


Developing our huddle process

The huddle concept in nursing isn’t new. After we presented our huddle process in a poster at a national conference, we got feedback that many other organizations have “been there and done that.” They reported their huddles had gone by the wayside and no longer were part of their daily practice.

But on our unit, we started using huddles more than 5 years ago—and still do. Staff members have firmly embraced the process and believe it has had positive effects on patient outcomes and staff satisfaction.

The first step in developing our huddle process was a literature search. We focused on three concepts—the huddle itself, after-action review (AAR), and crew resource management (CRM).

The literature describes huddles in various formats and for various purposes. One article discussed periodic meetings of interdisciplinary coworkers to address departmental patient-care problems and to resolve them quickly. Another described a daily morning staff huddle initiated by the unit manager to communicate expectations and general information.

Other literature on huddles was more pertinent to our goals of controlling workflow and affecting patient outcomes. The Institute for Healthcare Improvement’s “change idea” (use of huddles and meetings) discusses how a team can use huddles to improve communication or supply and demand. For instance, staff members working on an inpatient surgical unit at Children’s Hospital Boston found that 5- to 10-minute briefings several times daily enhanced communication among staff and promoted a sense of teamwork that benefits both staff and patients.

AARs and CRM

AARs and CRMs are concepts formulated outside the healthcare arena.

  • An AAR is a discussion of an event in which those involved explore what happened and why, identify what went well, and explore opportunities for improvement.
  • A CRM is designed to help individuals think and act as a team to improve safety.

Merging strategies from AAR and CRM, safety huddles have been initiated in healthcare settings to enhance teamwork and promote more effective communication. Effective communication is crucial to seamless work processes. For example, after a patient fall or other event, our staff gathers the team together for a post-fall huddle (an AAR) to discuss the situation and circumstances surrounding the fall. In this debriefing, team members assess how they could have prevented the fall, how to learn from it, and how to improve practice to prevent falls. We’ve found these huddles to be enlightening, with every staff member giving input.

Our post-fall huddles prompted us to take the idea one step further—holding proactive huddles to help prevent patient safety issues and staff concerns. We recognized the opportunity to design and implement a process that gathers the team together to talk about the game plan, both at the beginning of and throughout the shift, as needed.

Planned and scheduled huddles

Our unit has a strong shared governance model with multiple councils. The practice council was charged to design the huddle process. Other councils became involved in various aspects of the initiative. For example, the education council planned and implemented staff education and the quality council focused on outcomes.

We hold planned huddles at 8:00 AM for the 7:00 AM–7:30 PM shift, and at 8:00 PM for the 7:00 PM–7:30 AM shift. Attendance is mandatory. As 8:00 AM and 8:00 PM approach, staff members are expected to report to the designated area so the huddle can begin on time. The huddle lasts 5 to 10 minutes. The charge nurse facilitates the huddle and ensures adherence to the standard process in a timely manner.

Every unit staff member on duty is included in the huddle, and their input is valued. Participants include direct-care registered nurses (RNs), clerical staff, nonlicensed assistive personnel, charge nurse, unit educator, and unit manager.

Although huddles work best when all unit staff members attend, we realize patient safety takes priority, such as during a critical patient situation. At those rare times, the charge nurse reports for the staff member who’s unable to attend the huddle.

Huddles are held in a central, open space on the unit. This allows staff members to see the full length of the unit’s two hallways and to stay close and readily available to patients.

Huddle sheet
We use a template called a huddle sheet to promote the systematic, concise format designed by our practice council and revised several times. The most recent update incorporated attention to nurse-sensitive indicators. (See the Huddle sheet below.)

Huddle sheet

 

During the huddle, every RN reviews items on the sheet in consecutive order as they relate to each assigned patient. They review indwelling urinary (Foley) catheters first, including the number of patients with catheters, whether an order exists for each catheter, and the medical necessity of the catheter. If no acceptable reason exists for keeping the catheter in place, the RN is encouraged to advocate for its removal. During each RN’s dialogue, unlicensed assistive personnel contribute their knowledge of the patient, as appropriate.

Next, we address issues that could affect patient safety, such as heparin and insulin drips, restraints, and patients undergoing the alcohol withdrawal protocol. We announce which patients are at risk for falls and pressure ulcers, as well as associated interventions and their effectiveness. As appropriate, team members coach the assigned nurse to consider further interventions. For example, if a patient has a fall precaution sign posted and a bed check alarm in place but keeps trying to get out of bed, we may suggest the nurse consider a safety bed or partner with family members to keep their loved one safe.

Finally, we review factors affecting our workload, such as the number of patients who require total assistance or complex treatments, are being discharged, or are undergoing procedures off the unit. This gives us the “pulse” of the unit. If necessary, we can make adjustments proactively to ensure patient safety.

The clerical staff member screens phone calls, records vital information (such as anticipated discharges), and reports the hospital census and capacity flow, particularly involving the emergency department. Occasionally, the unit manager attends the huddle to communicate operational high-priority issues. See the box below for a case study of a planned and scheduled huddle.

Planned and scheduled huddle: Case study

Mrs. W, age 80, is admitted to the medical-surgical unit at 4:40 AM with a diagnosis of sepsis and urinary tract infection. At that time, the only available room is at the end of the hallway, at the most distant point from the staff members’ gathering area.

Mrs. W is extremely confused and agitated, pulls at her invasive lines, and calls out for her mother. Her bed check alarm sounds continuously. This requires her nurse and the unlicensed assistive staff member on night shift to spend a great deal of time in her room.

After change-of-shift bedside report, the day-shift nurse, Donna, and an unlicensed staff member are in Mrs. W’s room until the start of the 8:00 AM huddle. All unit nurses report patients who have indwelling urinary catheters; are at risk for safety problems, pressure ulcers, or falls; are potential discharges; or require complete care and off-unit procedures.

Staff members don’t intervene or challenge Donna until she reports on Mrs. W. Within minutes, the team collaboratively develops a revised plan of action, which includes moving Mrs. W closer to the central staff work area after the imminent discharge of another patient; putting her in a low-rise bed; outlining the bed with floor mats; contacting a family member to ask if they’re able to partner with staff to keep the patient safe; collaborating with the unit-based pharmacist to check for medications that may be affecting Mrs. W’s behavior; and placing mitts on her hands. This huddle leads to improved patient safety and more efficient care delivery.

Unplanned impromptu huddles

Any staff member can call an impromptu huddle at any time. Often, the charge nurse calls one based on her awareness of what each nurse is experiencing. As with planned huddles, all staff members are expected to attend the huddle to “stop the madness” and create a new game plan. Impromptu huddles normally are held in the same centralized location as planned huddles. However, post-fall huddles commonly are held in the patient’s room because of the need to stay with and observe the patient and assess the environment at the time of the fall.

Unlike a planned huddle, unplanned huddles don’t involve a standard template. Instead, the charge nurse reports the unit’s current situation and the need to take action to resolve the specific problem. Taking a moment to step outside the individual’s immediate landscape and take a deep, cleansing breath helps staff refocus and reprioritize. The ability to think out loud, brainstorm, and hear input from all staff members promotes collaborative solutions. See the box below for a case study of an impromptu huddle.

Unplanned impromptu huddle: Case study

It’s 9:45 AM on a Saturday; two of the unit’s 30 beds are empty. Earlier, at the 8:00 AM scheduled huddle, the charge nurse had shared that patients had been assigned to both empty beds—one patient from the emergency department and the other a transfer from the intensive care unit (ICU).

All nurses are performing morning assessments and medication administration. One has a patient in respiratory distress due to fluid overload; another is dealing with an angry patient who calls out continuously and tries to get out of bed, which he shouldn’t be doing. A rounding physician is ordering STAT blood work. Because the GI diagnostic and testing area is closed on Saturdays, another physician is planning a bedside colonoscopy and requests a nurse’s assistance. Calls to all nurses’ wireless phones are constant, interrupting concentration and work flow. Many patients require complete assistance with bathing, positioning, and feeding. Patient call bells are sounding continuously.

To help the unit deal with the chaos, the charge nurse calls an impromptu huddle. All team members and the two physicians gather, take a deep breath, and verbalize their patients’ and their own needs. The charge nurse instructs the clerical staff to hold all phone calls to the nurses’ wireless phones for the next hour. Then she states she will call the house supervisor to obtain an available nurse from elsewhere in the hospital to assist with the bedside colonoscopy. She assigns one unlicensed assistive staff member to complete all STAT phlebotomies and assigns the other two unlicensed personnel to answer call lights and perform other prioritized duties for the entire unit. The group reaches a consensus on postponing bathing patients until later in the day. The nurse with the least-urgent patient needs agrees to oversee transfer of the patient with respiratory distress to the ICU.

After this 10-minute huddle, all staff members disperse to start their assignments, knowing others are aware of their needs and a plan is in place. The stress level decreases and within an hour, unit activities become less chaotic, proactive, and better planned.

Measurement and impact

Evaluation focuses on quantifiable metrics that the huddle process affects. These include nurse-sensitive clinical indicators and staff satisfaction. The bar graphs below show continuous improvements in patient falls, pressure ulcers, and catheter-associated urinary tract infections since our huddles were implemented.

LVHN 6 Tower Nurse-Sensitive Indicator Bar Graphs

 

In our organization, employee satisfaction surveys are done every 2 years. The following statements were chosen as metrics associated with huddles.

  • “My department operates at 100% efficiency.”
  • “I feel safe raising issues of concern regarding quality, productivity, or safety with my peers, my supervisor, other departments, and higher levels of management.”
  • “My coworkers consistently look for more efficient and effective ways of getting the job done.”

Scores for two of these three questions have improved since huddle implementation. Also, informal qualitative comments from our staff about huddles have been extremely positive.

Lessons learned
Initially, it was a struggle to get everyone to stop what they were doing and gather for huddles. Some viewed the huddle as yet another task—one that took them away from patients. We often had to phone or look for staff members to remind them of the huddle; this delayed the process and wasted the time of those who were prompt.

Because we knew it was important for everyone to be present and engaged in the huddle process, team members held one another accountable. We did this through gentle reminders, such as the charge nurse calling out, “Five minutes till huddle” to reinforce the need to avoid starting a task that would prevent attendance. Also, huddle attendance and participation were added to staff member orientation and identified as competency expectations.

Almost immediately after we implemented huddles, staff recognized the benefits. Before long, they began to look forward to the few minutes of calmness the huddle provided, because it allowed them to collect their thoughts and muster the energy to face the challenges of their shift.

When planning our huddle process, we had to determine the best time to schedule them. For several years, we’d been committed to hourly rounding. Starting huddles 1 hour after the beginning of the shift allows all staff members to complete an initial rounding process for all assigned patients. Thus, we’re familiar with our patients’ needs when the huddle occurs and can communicate identified issues early during our shifts. Also, completing rounds on all patients immediately before the huddle helps us feel comfortable leaving our designated work area because we know all patient needs have been addressed.

Our original huddle design included only 6T staff members. But as the huddle process has evolved, it has grown to include interprofessional team members, such as physicians, pharmacists, and chaplains. These individuals requested to attend after observing huddles, expressing a desire to be involved for the patients’ benefit.

Our huddles have had a positive impact on our work flow, enhancing satisfaction through camaraderie and “esprit de corps.” Most importantly, we believe huddles offer an added action within our total repertoire of actions aimed at improving clinical quality outcomes and patient safety.

Selected references

Agency for Healthcare Research and Quality. About TeamSTEPPS. http://teamstepps.ahrq.gov/about-2cl_3.htm.

Decreasing infections, reducing falls, maximizing prevention, improving care: a formula for success for 6 hospitals earning ANA’s award for nursing quality. Colo Nurse. 2013;113(2):7.

Institute for Healthcare Improvement. Use regular huddles and staff meetings to plan production and to optimize team communication. www.ihi.org/resources/Pages/Changes/UseRegularHuddlesandStaffMeetingstoPlanProductionandtoOptimizeTeamCommunication.aspx

Sculli G, Sine D. Soaring to Success: Taking Crew Resource Management from the Cockpit to the Nursing Unit. Danvers, MA; HCPro, Inc: 2011.

Maryann Lubinensky is a clinical nurse on the 6 Tower medical-surgical unit at Lehigh Valley Health Network In Allentown, Pennsylvania. Roseanne Kratzer and Jaclyn Bergstol were clinical staff nurses on the 6T medical-surgical unit when this article was written.

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