BACKGROUND AND OBJECTIVES: Improved situation awareness may prevent unplanned ICU transfers. Transfers with serious safety issues may be classified as unrecognized situation awareness failure events (UNSAFE) and are associated with intubation, vasopressors, or >3 fluid boluses within 1 hour before or after ICU arrival. Our aim was to decrease the proportion of unplanned ICU transfers that met UNSAFE criteria by 50% in 1 year.
METHODS: We adapted a previously described huddle-based intervention. In May 2015, we started a daily safety brief with hospital-wide representation; concurrently, nurses and residents separately identified watcher patients (ie, patients at risk for UNSAFE transfers) to be reported in the daily safety brief. Watcher patients frequently differed between the groups, so in July 2015, we started twice-daily watcher huddles on a pilot floor. During these huddles, nurses and residents jointly identified watcher patients on the basis of defined criteria and deployed mitigation plans. By March 2016, we implemented these huddles hospital-wide. We reviewed the electronic medical record to categorize all unplanned ICU transfers as safe or UNSAFE. Our outcome was the proportion of unplanned ICU transfers that met UNSAFE criteria.
RESULTS: In the 16-month pre-intervention period, 49 of the 322 unplanned ICU transfers were UNSAFE (median 15.5%); in the 12-month post-intervention period, 13 of the 329 unplanned ICU transfers were UNSAFE (median 3%). These findings represent an 81% reduction in the proportion of UNSAFE transfers.
CONCLUSIONS: Watcher huddles incorporated into the daily inpatient routine can significantly decrease UNSAFE transfers.
Adverse events occur fairly frequently in health care, but some may be preventable if warning signs are detected early.1 Particularly serious are “failure to rescue” events that develop under the watch of health care providers; the Agency for Healthcare Research and Quality suggests the incidence of these events may reflect the quality of monitoring, the effectiveness of actions taken once early complications are recognized, or both.2 The importance of an inpatient team’s ability to promptly recognize when their patients are worsening is supported by the observation in adult literature that ICU patients admitted from inpatient noncritical care floors have significantly higher mortality than ICU patients admitted from the emergency department or operating room.3
This idea of early recognition is embedded in situation awareness, which is defined as “the perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future.”4 It was initially used by the US military in which understanding environmental factors that affected outcomes was particularly crucial. In a clinical setting, identifying patients at risk for decompensation and enacting plans to prevent adverse events is expected to improve situation awareness.5
To reduce failure to rescue events attributable to poor situation awareness, we referenced an existing huddle-based model at Cincinnati Children’s Hospital that decreased unrecognized situation awareness failure events (UNSAFE) transfers, those from an inpatient noncritical care floor to the ICU where the patient received intubation, vasopressors, or >3 fluid boluses within 1 hour before or after transfer.4 In the model, a stepwise approach is used that includes proactive risk identification by nurses, unit-based huddles between charge nurses and physicians, and a 3-times daily all-inclusive inpatient huddle. After finding an initial but unsustained decrease in UNSAFE transfers, the improvement team added a “robust plan bundle” to the model that described treatment and escalation plans if the predicted outcome was not achieved by a defined deadline.5
Our goal in this quality initiative was to decrease the proportion of unplanned ICU transfers that met UNSAFE criteria by 50% (ie, from a baseline of 15.5%) in 1 year.
Setting and Context
Le Bonheur Children’s Hospital is a 255-bed tertiary freestanding children’s hospital with 6 inpatient noncritical care floors. Most nonsurgical general pediatric and subspecialty patients are cared for by 4 floor-based pediatric resident teams; the remaining patients are cared for by a nonacademic hospitalist service and surgical resident teams. Nighttime coverage for all nonsurgical patients is provided by a single pediatric resident night team of 2 supervising residents and 3 to 4 interns.
Our improvement team, the Situation Awareness Committee, was composed of representatives from hospital administration, risk management, nursing clinical directors, pediatric chief residents, and the hospitalist service. We chose to adapt the model from Cincinnati Children’s Hospital for several reasons, primarily because of its focus on promoting safety by improving situation awareness. Our initiative followed a sentinel failure to rescue event, the unexpected death of a patient on an inpatient noncritical care floor that was judged to be preventable had signs of deterioration been recognized and addressed in a timely manner. Pediatric residents use the I-PASS method for handoff, so this initiative built on an established watcher concept as an indicator of heightened concern and illness severity.6 Although 2 of our 4 teams cover multiple (ie, 2 instead of 1) floors, the relative co-location of residents and nurses was conducive to trialing and refining a huddle-based intervention. Importantly, we had full engagement of hospital administration and residency program leadership; the chief medical officer chaired the Situation Awareness Committee, and the pediatric residency program director, a practicing pediatric intensivist, mentored this initiative and served as our faculty liaison.
The process had 2 phases: implementation of a hospital-wide daily safety brief in May 2015, followed by implementation of floor-based watcher huddles starting in July 2015. Watcher huddles were piloted on 1 floor and introduced gradually to the other 5 floors over a 9-month period. During that time, the Situation Awareness Committee monitored the implementation progress and made changes on the basis of usability and utility feedback from frontline stakeholders (eg, timing of daily safety brief and watcher huddles, coordination of watcher huddle attendees, etc).
Daily Safety Brief
We did not have an existing patient flow huddle or “safety officer of the day” to manage safety issues between the numerous and diverse resident teams and hospitalists; these resources were the foundation for Cincinnati Children’s Hospital’s 3-times daily all-inclusive inpatient huddle. However, we appreciated the transformative effect that escalating a concern from bedside to C-suite could have on our safety culture.
Thus, in May 2015, our hospital administration convened the daily safety brief. This meeting between hospital administrators and leaders from each department (eg, laboratory services, radiology, pharmacy, respiratory therapy, nursing clinical directors, environmental services, pediatric chief residents, etc) was intended to improve interdepartmental communication and quickly resolve current or anticipated safety issues. It was held every weekday morning at 9:05 am and lasted 15 minutes. The on-call hospital administrator led the meeting and performed a roll call of the represented departments. Each representative would reply with any relevant safety issues, and specifically, the nursing clinical directors and pediatric chief residents reported watcher patients separately identified by charge nurses and supervising residents.
In the early weeks of the daily safety brief, the identification of watcher patients often differed between the nursing clinical directors and pediatric chief residents. We felt this reflected the absence of shared understanding of what is meant by “watcher.” Neither charge nurses nor supervising residents based this designation on set criteria or routinely discussed these patients together.
To establish set criteria to identify watcher patients, the Situation Awareness Committee developed a list of triggers to alert nurses and residents to a deterioration risk (Table 1). This list included parental concerns, communication concerns, high-risk conditions or medications, increased oxygen requirement, “gut feeling” that a patient was at risk, and need for increased monitoring. It was modified periodically with hospital protocol changes (eg, updated asthma exacerbation treatment algorithm) and further involvement of subspecialty attending physicians.
In July 2015, we piloted twice-daily watcher huddles on an inpatient noncritical care floor. The supervising residents and charge nurse met at a designated time and location to discuss watcher patients based on the list of triggers. The watcher huddles occurred immediately after morning and evening sign-out between the day and night supervising residents. The attending physician was present at morning sign-out and was able to weigh in on the daytime plan for each watcher patient. Similar sign-outs occurred between the day and night charge nurses.
During the watcher huddles, a plan, expected outcome, and time frame for the expected outcome of each watcher patient was discussed. Afterward, each attendee was responsible for informing the respective members of their team (ie, interns or bedside nurses) of the plan, expected outcome, and time frame. The bedside nurse was additionally responsible for contacting the watcher patient’s intern at the end of the designated time frame to discuss whether the plan for that patient had succeeded or failed. If the goal was achieved, the patient was assessed for removal from the watcher patient list; if the goal was not achieved, a new plan was made with another expected outcome and time frame to be followed. The supervising residents and attending physician were involved in these discussions. The same process of discussing a plan, expected outcome, and time frame could occur at any time of day outside of the watcher huddles for newly admitted patients or existing patients whose clinical status worsened. The process is depicted in the swim lane diagram in Fig 1.
Only minor changes were made as a result of the watcher huddle pilot. The evening huddle was delayed to 2 hours after evening sign-out so the nurses could complete urgent tasks at shift change (ie, on this pilot floor, it was hanging total parenteral nutrition), but the overall process remained the same. During the daily safety brief, nurse- and resident-reported watcher patients from this pilot floor began to match. In the occasional cases in which they did not match, the discrepant information was fed back to the charge nurse and supervising residents for reconciliation.
In October 2015, we introduced twice-daily watcher huddles to a second floor. Because this happened to be our pulmonary floor at the beginning of the respiratory illness season, we included lead respiratory therapists in the watcher huddle. Like in our pilot, the nurse and resident lists of watcher patients from this floor presented in the daily safety brief began to match. Additionally, issues with breathing treatments or equipment (eg, disagreements about going “off” bronchiolitis protocol, adjusting high flow nasal cannula settings, needing overnight continuous positive airway pressure device, etc) were addressed promptly by the respiratory therapy director at the daily safety brief. An additional challenge that spread to this floor was the location of the evening huddle because there is a single set of night supervising residents responsible for all 6 floors. The evening charge nurses from both this and the original pilot floor met the supervising residents at a single designated time and location rather than the daytime floor-based locations.
In January 2016, we introduced twice-daily watcher huddles to a third floor. The implementation challenge here was that the team on this floor was also responsible for patients on another floor not yet involved in the watcher huddles phase of the intervention; the watcher huddles were introduced to this other floor in February 2016. As they did for the evening huddle, the charge nurses for both floors met with the supervising residents at a single designated time and location. After the successful collaboration of this group of nurses and residents, twice-daily watcher huddles were introduced to the remaining 2 floors in March 2016.
Measures and Analysis
The outcome measure was the proportion of unplanned ICU (ie, any critical care unit: pediatric, neurologic, intermediate care, or cardiovascular) transfers from inpatient noncritical care floors that were UNSAFE. We used a run chart to identify signals of special cause variation in the outcome measure.
A retrospective analysis of ICU transfers was performed for the 16 months before implementation of the daily safety brief. During implementation of the daily safety brief and watcher huddles, we collected and reviewed data on ICU transfers daily and again monthly. We used procedure notes, progress notes, and medication administration records in the electronic medical record to categorize transfers as safe or UNSAFE on the basis of previously noted criteria (ie, presence of intubation, vasopressors, or >3 fluid boluses within 1 hour before or after transfer).
For this initiative, unexpected deaths on inpatient noncritical care floors were failure to rescue events and therefore also considered UNSAFE.
In the 16 months before the daily safety brief was implemented, 49 of the 322 unplanned ICU transfers were UNSAFE; the median proportion of UNSAFE transfers was 15.5% during this pre-intervention period. In the 12 months after the daily safety brief was implemented, 13 of the 329 unplanned ICU transfers were UNSAFE; the median proportion of UNSAFE transfers was 3% during this post-intervention period. These findings represent an 81% reduction in the proportion of UNSAFE unplanned ICU transfers. Our run chart is shown in Fig 2.
Of the 13 total UNSAFE transfers after implementation of the daily safety brief, 6 occurred before the start of the watcher huddles; of the remaining 7 UNSAFE transfers, all but 1 were on floors not yet involved in the watcher huddles. Between full implementation of the watcher huddles on all inpatient noncritical care floors in March 2016 to May 2016 (1 year after the daily safety brief was implemented), only 1 of 88 unplanned ICU transfers was an UNSAFE. There were no unexpected deaths on inpatient noncritical care floors after the daily safety brief was implemented.
We believe the daily safety brief and watcher huddles significantly reduced UNSAFE transfers by improving interdisciplinary communication and situation awareness. We adapted a dynamic system requiring frequent follow-up and early intervention, making communication among team members in a busy inpatient setting an especially vital element. Whenever a goal was not achieved, a new plan and goal were made and communicated to all team members. This improved communication manifested as the watcher patients from the nurses and residents presented in the daily safety brief began to match. The 81% reduction of UNSAFE transfers surpassed our goal, but perhaps more notably, there was only 1 UNSAFE transfer once the daily safety brief and watcher huddles were fully implemented, and there were no unexpected deaths on the inpatient noncritical care floors.
We credit the success of the intervention’s implementation to several contextual factors described above, in particular the co-location of nurses and residents in floor-based teams and tremendous hospital administration and residency leadership support. Additionally, linking the pieces of the intervention together by presenting the results of the watcher huddles at the daily safety brief maintained charge nurse and supervising resident accountability and ultimately aided sustainability of the watcher huddles. The pediatric chief residents provided monthly feedback on the watcher huddles and the outcome measure to pediatric residents in house staff meetings, which encouraged ownership of the process.
To create a culture of safe, highly reliable care, it is necessary for leaders to teach technical and nontechnical skills along with designed processes.1 Safe, highly reliable care requires clear, effective communication across interdisciplinary teams, so leaders are often challenged to find ways to build strong relationships among them. The need to design a process with this focus is an organizational responsibility. Implementing targeted and systematic communication between disciplines, as we did, can improve outcomes because this communication promotes the accurate sharing of an assessment of a patient’s current condition and allows the team to understand problems and predict their status in the near future.6 Knowing this prediction allows the team to then make a mitigation plan in the event that the patient’s condition begins to deteriorate. In particular, nurse and resident communication strategies improve teamwork, and hospitals that promote a culture of empowerment to all members of the interdisciplinary team are models that reduce failures and ultimately patient harm.7
We did not include actual measurements of provider situation awareness in the study of our intervention, but we used its components of perception, comprehension, and projection by having the members of the watcher huddles work together to reconcile watcher patients and devise a plan, expected outcome, and time frame for the expected outcome. The key to situation awareness is understanding the information at hand and recognizing patterns so that plans can be made for safety events before they unfold.5 Vigilance and monitoring require that these elements are clearly identified, defined, and supported in practice.7 Decreasing patient harm is related to enhanced situation awareness among health care providers, but objectively proving this relationship is challenging because most validated measurement tools are exercised in simulations.8 Conversely, decreased situation awareness is a predictor of adverse events and poor outcomes.9
One of the main limitations of our initiative was the inability to monitor the accuracy of decision-making, including how often and how completely watcher patient plans were communicated from the supervising resident to the attending physician. To address this limitation, all attending physicians (both general pediatrics and subspecialty pediatrics) were educated regarding watcher patients and watcher huddles; thereafter, attending physicians were asked to set expectations to be involved in the process. Our next steps include creating a bundle to educate future stakeholders (eg, nurses, respiratory therapists, residents, attending physicians, etc) and expanding watcher huddles to surgical resident teams.
If situation awareness is better understood, health care professionals can use deliberate actions that would lead to improvement in the overall operational safety and patient outcomes.8 Making each level of the hospital highly reliable improves the organization’s overall effectiveness. Combining high reliability thinking and situation awareness can lead to potentially transformative concepts for health care systems.4 The process developed through our quality improvement effort supports the idea that a systems approach of consistent and reliable communication can improve patient outcomes by reducing failure to rescue events.
By making all care team members aware of an at-risk patient’s clinical status, watcher huddles incorporated into the daily inpatient routine can significantly decrease the number of UNSAFE transfers to a higher level of care. Ultimately, our success arose from the coordinated efforts of all types of providers at all levels of clinical practice; not only have we decreased an outcome that would predict higher mortality but we have also taken steps to transform the culture of safety at our institution.
Thank you to the Situation Awareness Committee for their collaboration and assistance with data review and implementation. This project was a success because of participation from our Pediatric and Internal Medicine/Pediatrics residents at the University of Tennessee in Memphis, as well as the nurses, attending physicians, respiratory therapists, and staff at Le Bonheur Children’s Hospital in Memphis, Tennessee.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- ↵Agency for Healthcare Research and Quality. Failure to Rescue. 2016. Available at: https://psnet.ahrq.gov/primers/primer/38/failure-to-rescue. Accessed August 1, 2017
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- Copyright © 2017 by the American Academy of Pediatrics