Verbal Communication During Airway Management and Emergent Endotracheal Intubation: Observations of Team Behavior Among Multi-institutional Pediatric Intensive Care Unit In Situ Simulations.

OBJECTIVE: To assess health-care teams' verbal communication, an observable teamwork behavior, during simulations involving pediatric emergency airway management and intubation. METHODS: We conducted video-recorded, risk-informed in situ simulations at 5 hospitals with pediatric intensive care units in the Chicago, Illinois, area. Clinicians participated in their clinical roles (eg, attending physician, bedside nurse) and had access to hospital operational systems (eg, electronic health record, medical imaging, laboratory services). Video-recordings were transcribed; 3 pediatric critical care physicians analyzed the transcripts to assess preintubation communication: (a) the declaration of an airway emergency, (b) intubation medication request(s), and (c) preintubation medication administration. RESULTS: Ten pediatric intensive care unit simulations were analyzed. Statements to notify the care team of an airway emergency varied widely. In 3 simulations, a dosage for every medication was verbalized in the physician's initial medication request; however, in 4 simulations, a nurse was the first to verbalize the medication dosage(s) before administration. In 6 of the simulations where preintubation medications were administered, multiple requests for medications were verbalized. A clinician verbally confirmed that each medication was administered in only 2 of the simulations. CONCLUSIONS: No uniform statement was identified to declare an airway emergency among the care teams. Preintubation medication dosages were not consistently included in intubation medication orders, and frequently, there were multiple requests to obtain medications. Using standardized language to declare an airway emergency and verbally communicating medication requests and dosages and confirming administration may improve the quality of care in this critical event.

Redesigning Transplant Organ Labeling to Prevent Patient Harm and Organ Loss.

BACKGROUND: In 2012, the Health Resources and Services Administration and the United Network for Organ Sharing launched the "Electronic Tracking and Transportation" (ETT) project, in response to "labeling and packaging issues" being a frequently reported safety incident. This article describes an improvement project conducted as part of this United Network for Organ Sharing project. METHODS: An interdisciplinary team conducted a Process Failure Modes and Effects Analysis, laboratory simulations of organ labeling during procurement, and a heuristic evaluation of a label software application to inform the design of TransNet, a system that uses barcode technology at the point of organ recovery. A total of 42 clinicians and staff from 10 organ procurement organizations and 2 transplant centers in the United States participated. Processes Addressed: Key features of the redesigned labeling system include independent, double entry of label information into the software application, a machine-readable barcode on each organ's label, and a handheld printer for at "point of use" label printing. OUTCOMES: The new labeling system, TransNet, has become mandatory since June 2017. A survey conducted on early adopters (N = 11), after 1 year of use, indicates the process is safer and more efficient. IMPLICATIONS FOR PRACTICE: The findings from this study suggest that the application of quality planning methods, common in other industries, when redesigning a health-care process, are valuable and revelatory and should be adopted more extensively. Future evaluation of TransNet effectiveness to reduce safety incidents is critical.

Patients' views of teamwork in the emergency department offer insights about team performance.

BACKGROUND: Research into efforts to engage patients in the assessment of health-care teams is limited. OBJECTIVE: To explore, through qualitative methods, patient awareness of teamwork-related behaviours observed during an emergency department (ED) visit. DESIGN: Researchers used semi-structured question guides for audio-recorded interviews and analysed their verbatim transcripts. SETTING AND PARTICIPANTS: Researchers conducted individual phone interviews with 6 teamwork subject matter experts (SMEs) and held 5 face-to-face group interviews with patients and caregivers (n = 25) about 2 weeks after discharge from the emergency department (ED). RESULTS: SMEs suggested that a range of factors influence patient perspectives of teams. Many patients perceived the health-care team within the context of their expectations of an ED visit and their treatment plan. Four themes emerged: (i) patient-centred views highlight gaps in coordination and communication; (ii) team processes do concern patients; (iii) patients are critical observers of ways that team members present their team roles; (iv) patients' observations of team members relate to patients' views of team effectiveness. Analysis also indicated that patients viewed health-care team members' interactions with each other as proxy for how team members actually felt about patients. DISCUSSION: Results from both sets of interviews (SME and patient) indicated that patient observations of teamwork could add to assessment of team processes/frameworks. Patients' understanding about teamwork organization seemed helpful and witnessed interteam communication appeared to influence patient confidence in the team. CONCLUSION: Patients perspectives are an important part of assessment in health care and suggest potential areas for improvement through team training.

Failure mode and effects analysis: a comparison of two common risk prioritisation methods.

BACKGROUND: Failure mode and effects analysis (FMEA) is a method of risk assessment increasingly used in healthcare over the past decade. The traditional method, however, can require substantial time and training resources. The goal of this study is to compare a simplified scoring method with the traditional scoring method to determine the degree of congruence in identifying high-risk failures. METHODS: An FMEA of the operating room (OR) to intensive care unit (ICU) handoff was conducted. Failures were scored and ranked using both the traditional risk priority number (RPN) and criticality-based method, and a simplified method, which designates failures as 'high', 'medium' or 'low' risk. The degree of congruence was determined by first identifying those failures determined to be critical by the traditional method (RPN≥300), and then calculating the per cent congruence with those failures designated critical by the simplified methods (high risk). RESULTS: In total, 79 process failures among 37 individual steps in the OR to ICU handoff process were identified. The traditional method yielded Criticality Indices (CIs) ranging from 18 to 72 and RPNs ranging from 80 to 504. The simplified method ranked 11 failures as 'low risk', 30 as medium risk and 22 as high risk. The traditional method yielded 24 failures with an RPN ≥300, of which 22 were identified as high risk by the simplified method (92% agreement). The top 20% of CI (≥60) included 12 failures, of which six were designated as high risk by the simplified method (50% agreement). CONCLUSIONS: These results suggest that the simplified method of scoring and ranking failures identified by an FMEA can be a useful tool for healthcare organisations with limited access to FMEA expertise. However, the simplified method does not result in the same degree of discrimination in the ranking of failures offered by the traditional method.

Academic-Community Hospital Comparison of Vulnerabilities in Door-to-Needle Process for Acute Ischemic Stroke.

BACKGROUND: Although best practices have been developed for achieving door-to-needle (DTN) times ≤60 minutes for stroke thrombolysis, critical DTN process failures persist. We sought to compare these failures in the Emergency Department at an academic medical center and a community hospital. METHODS AND RESULTS: Failure modes effects and criticality analysis was used to identify system and process failures. Multidisciplinary teams involved in DTN care participated in moderated sessions at each site. As a result, DTN process maps were created and potential failures and their causes, frequency, severity, and existing safeguards were identified. For each failure, a risk priority number and criticality score were calculated; failures were then ranked, with the highest scores representing the most critical failures and targets for intervention. We detected a total of 70 failures in 50 process steps and 76 failures in 42 process steps at the community hospital and academic medical center, respectively. At the community hospital, critical failures included (1) delay in registration because of Emergency Department overcrowding, (2) incorrect triage diagnosis among walk-in patients, and (3) delay in obtaining consent for thrombolytic treatment. At the academic medical center, critical failures included (1) incorrect triage diagnosis among walk-in patients, (2) delay in stroke team activation, and (3) delay in obtaining computed tomographic imaging. CONCLUSIONS: Although the identification of common critical failures suggests opportunities for a generalizable process redesign, differences in the criticality and nature of failures must be addressed at the individual hospital level, to develop robust and sustainable solutions to reduce DTN time.

A rater training protocol to assess team performance.

INTRODUCTION: Simulation-based methodologies are increasingly used to assess teamwork and communication skills and provide team training. Formative feedback regarding team performance is an essential component. While effective use of simulation for assessment or training requires accurate rating of team performance, examples of rater-training programs in health care are scarce. We describe our rater training program and report interrater reliability during phases of training and independent rating. METHODS: We selected an assessment tool shown to yield valid and reliable results and developed a rater training protocol with an accompanying rater training handbook. The rater training program was modeled after previously described high-stakes assessments in the setting of 3 facilitated training sessions. Adjacent agreement was used to measure interrater reliability between raters. RESULTS: Nine raters with a background in health care and/or patient safety evaluated team performance of 42 in-situ simulations using post-hoc video review. Adjacent agreement increased from the second training session (83.6%) to the third training session (85.6%) when evaluating the same video segments. Adjacent agreement for the rating of overall team performance was 78.3%, which was added for the third training session. Adjacent agreement was 97% 4 weeks posttraining and 90.6% at the end of independent rating of all simulation videos. DISCUSSION: Rater training is an important element in team performance assessment, and providing examples of rater training programs is essential. Articulating key rating anchors promotes adequate interrater reliability. In addition, using adjacent agreement as a measure allows differentiation between high- and low-performing teams on video review.

Failure mode effects and criticality analysis: innovative risk assessment to identify critical areas for improvement in emergency department sepsis resuscitation.

BACKGROUND: Sepsis is an increasing problem in the practice of emergency medicine as the prevalence is increasing and optimal care to reduce mortality requires significant resources and time. Evidence-based septic shock resuscitation strategies exist, and rely on appropriate recognition and diagnosis, but variation in adherence to the recommendations and therefore outcomes remains. Our objective was to perform a multi-institutional prospective risk-assessment, using failure mode effects and criticality analysis (FMECA), to identify high-risk failures in ED sepsis resuscitation. METHODS: We conducted a FMECA, which prospectively identifies critical areas for improvement in systems and processes of care, across three diverse hospitals. A multidisciplinary group of participants described the process of emergency department (ED) sepsis resuscitation to then create a comprehensive map and table listing all process steps and identified process failures. High-risk failures in sepsis resuscitation from each of the institutions were compiled to identify common high-risk failures. RESULTS: Common high-risk failures included limited availability of equipment to place the central venous catheter and conduct invasive monitoring, and cognitive overload leading to errors in decision-making. Additionally, we identified great variability in care processes across institutions. DISCUSSION: Several common high-risk failures in sepsis care exist: a disparity in resources available across hospitals, a lack of adherence to the invasive components of care, and cognitive barriers that affect expert clinicians' decision-making capabilities. Future work may concentrate on dissemination of non-invasive alternatives and overcoming cognitive barriers in diagnosis and knowledge translation.

Use of risk assessment analysis by failure mode, effects, and criticality to reduce door-to-balloon time.

STUDY OBJECTIVE: The Centers for Medicare & Medicaid Services currently endorses a door-to-balloon time of 90 minutes or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction. Recent evidence shows that a door-to-balloon time of 60 minutes significantly decreases inhospital mortality. We seek to use a proactive risk assessment method of failure mode, effects, and criticality analysis (FMECA) to evaluate door-to-balloon time process, to investigate how each component failure may affect the performance of a system, and to evaluate the frequency and the potential severity of harm of each failure. METHODS: We conducted a 2-part study: FMECA of the door-to-balloon time system and process of care, and evaluation of a single institution's door-to-balloon time operational data using a retrospective observational cohort design. A multidisciplinary group of FMECA participants described the door-to-balloon time process to then create a comprehensive map and table listing all process steps and identified process failures, including their frequency, consequence, and causes. Door-to-balloon time operational data were assessed by "on" versus "off" hours. RESULTS: Fifty-one failure points were identified across 4 door-to-balloon time phases. Of the 12 high-risk failures, 58% occurred between ECG and catheterization laboratory activation. Total door-to-balloon time during on hours had a median time of 55 minutes (95% confidence interval 46 to 60 minutes) compared with 77 minutes (95% confidence interval 68 to 83 minutes) during off hours. CONCLUSION: The FMECA revealed clear areas of potential delay and vulnerability that can be addressed to decrease door-to-balloon time from 90 to 60 minutes. FMECAs can provide a robust assessment of potential risks and can serve as the platform for significant process improvement and system redesign for door-to-balloon time.