I. Observation Form: Structured Team Communication Techniques

INTERACTIVE GUIDE

I. Observation Form: Structured Team Communication Techniques

Structured Team Communication Techniques

Technique / Function
Brief / Plan team activities
Debrief / Analyze an interim event
Huddle / Solve a problem
Cross monitoring / Feedback / Improve performance
Assertive statement / Identify potential errors
Check-back / Ensure accurate information transfer
Handoff / Transfer care and responsibility

Team Communication Technique #1 – Brief

A brief is a common short-term planning technique used to provide a team with an understanding of the plans for the day or the shift, roles and responsibilities of team members, available resources, workload, and any special circumstances. Briefs are “pre-game” team meetings.

Brief Checklist
During the brief, the team should address the following questions:
___Who is on the team?
___All members understand and agree upon goals?
___Roles and responsibilities are understood?
___What is our plan of care?
___Staff and provider's availability throughout the shift?
___Workload among team members?
___Availability of resources?

As you watch the video clip, think about:

1. How does this technique contribute to the team’s better understanding of plans and resources?

2. What are some of the advantages of the use of this technique prior to daily inpatient rounds?

This video clip demonstrates the efficiency and effectiveness of briefs in day-to-day patient care. Briefs are helpful to organize work and make explicit the contributions and needs of each team member.

Team Communication Technique #2 – Debrief

A debrief is a recap of a situation or the day’s events for the purposes of process improvement. In a debrief, team members review the content of the earlier brief in an attempt to trouble shoot and correct problems or learn from errors.

Debrief Checklist
The team should address the following questions during a debrief:
___Communication clear?
___Roles and responsibilities understood?
___Situation awareness maintained?
___Workload distribution equitable?
___Task assistance requested or offered?
___Were errors made or avoided? Availability of resources?
___What went well, what should change, what should improve?

As you observe the video illustrating this technique, please reflect on the following questions:

1. How could you apply this tool to your day-to-day practice?

2. What potential is there for debriefs to identify systems-level problems that could further enhance patient care?

This video clip illustrates the usefulness of structured team communication techniques in improving team function.

Team Communication Technique #3 – Huddle

The huddle is a technique to reinforce plans already in place for patient care or to assess the need to change plans. It serves to develop a shared understanding among team members about what is happening now and what to do next. Huddles typically occur in the pre-operative process to verify key information.

Huddle Checklist
The team should address the following questions during a huddle:
___Were teams members able to express concerns?
___How could outcomes have been anticipated?
___Contingency plans identified??
___Resources assigned?
___Was there a consensus?

As you watch this video clip, think about the following questions:

1. When was the last time that you participated in a huddle and what was the outcome of that huddle?

2. In what other situations would a huddle be useful?

This video clip illustrates how using a structured technique for discussing critical issues and emerging events are so important to maintain situation awareness and develop contingency plans.
Team Communication Technique #4 – Cross monitoring /Feedback

Feedback is used frequently as part of cross monitoring. Cross monitoring is monitoring the actions of your team members to provide a safety net so that the team can address and correct errors in real time.

Cross monitoring/ Feedback Checklist
Feedback should be:
___Timely – given soon after the observed behavior occurred
___Respectful – focus on behaviors, not personal attributes
___Specific – be specific about what behaviors need correcting
___Directed towards improvement – plan for future improvement
___Considerate – deliver information with fairness and respect

In the video clip, please observe the scenario and reflect about the following questions:

1. How well did the junior resident demonstrate the effective use of cross monitoring?

2. Did you perceive receptivity of other team members to his comment?

This video clip illustrates how early detection with cross monitoring and direct, timely feedback contributes to effective team function and enhanced understanding of team members.

Team Communication Technique #5 – Assertive Statement

An assertive statement is made in the context of advocating for a patient. When team members’ viewpoints do not coincide with the decision maker, an assertive statement is made to prevent a medical error and promote patient safety. An assertive statement is done in a firm and respectful manner.

Assertive Statement Checklist
An assertive statement consists of five steps:
___Open the discussion in a timely manner
___State the concern, saying, “I am concerned…”
___Offer a solution
___Obtain agreement

As you observe the scenario in this video clip, reflect about the following questions:

1. How did the medical student phrase her assertive statement to make it effective?

2. How does institutional culture contribute to the effective use of this technique?

Advocating for patients and making assertive statements across hierarchical boundaries are all elements of an institutional culture of patient safety.

II. LEARNING STYLE EXERCISE

NOTE: please refer to the “Index of Learning Styles” inventory you completed online in advance of session. (http://www.engr.ncsu.edu/learningstyles/ilsweb.html).

What is your learning style?

Active ------Reflective

Sensing ------Intuitive

Visual ------Verbal

Sequential ------Global

What is your partner’s learning style?

Active ------Reflective

Sensing ------Intuitive

Visual ------Verbal

Sequential ------Global

Interview your partner, then share with the group:

What are at least two ways to enhance the way you receive information?

III. THE I-PASS HANDOFF

I / P / A / S / S
Illness Severity / Patient Summary / Action List / Situation Awareness & Contingency Planning / Synthesis by Receiver
M6E Barton, James
4/19/1998
MRN: 12345678
Visit: 45612
Adm Date: 3/13/11
Attending: Brown, Julie
Code Status:
Allergies: NKDA
Wt: 40 kg
Access:
Resident: Cameron, Jack
Medications
Ampicillin Sulbactam IV
Morphine PCA IV / 13 year old male w h/.o Sickle cell disease previously complicated by recurrent pain crises, stroke, and acute chest.
Admitted 2 days ago with leg pain.
1 day PTA w/ worsening L calf pain not relieved by po analgesics. Day of admission refusal to walk. In ED afebrile, no signs acute chest, baseline neuro exam.
Now today with concern for onset of new fever, hypoxia and RLL infiltrate.
· Probable acute chest syndrome
· New fever, hypoxia, and RLL infiltrate today, tachypnea to 30s, hematology and ICU aware of change in status; Plan to continue amp/sulbactam, wean 2L O2 as tolerated, incentive spirometry, follow cultures
· Pain Crisis - Leg pain well controlled on a morphine PCA; continue at current settings and monitor pain scores
· Anemia/hypertransfusion non-compliance - transfused yesterday, HCT 8→10 today; plan to follow daily hct and emphasize hypertransfusion compliance with grandmother prior to d/c
· History of stroke – residual right-sided weakness at baseline this admission; plan to continue to monitor
· Poor po intake - worsened since admission, felt secondary to pain and respiratory status; continue 1.5x MIVF with D5 ½ NS / q Respiratory check now to get baseline and at least Q4 during the night
q Monitor pain scores
q Monitor ins and outs
q Follow up electrolytes and pending cultures / q If he develops more tachypnea or hypoxemia repeat CXR, consider ICU evaluation for CPAP
q If cultures are positive, adjust antibiotics accordingly
q If significant clinical change Dr. Smith is the attending hematologist tonight please update him / SYNTHESIS BY RECEIVER

Handoff Video: What techniques did they use that were particularly effective? What pitfalls did you notice?

IV. PATIENT SUMMARY

Exercise 1

You are the night shift intern who admitted AJ and wrote the H&P below. It is 8am and your shift is about to end. After reviewing the information below, compose an example of what a patient summary for AJ might look like on the written handoff document.

· HPI:

AJ is a 4 year old male who presented to the ED with a 2 day history of worsening intermittent, productive cough and high fevers (Tmax 103°). Earlier today he developed acute worsening of his respiratory effort, and per his mother his breathing was fast and labored. Deep, subcostal retractions were also noted. Multiple family members were also sick at home. His mother notes a decrease in his PO intake of fluids, though no diarrhea or vomiting. No complaints of ear, abdominal, or joint pain, as well as no rash.

· PMH:

Ex-26 week preemie due to preeclampsia in mom, intubated for two weeks following birth, no history of BPD

3 prior admissions to general pediatric service for pneumonia

· PSH: N/A

· FH: Father – Asthma; Mother – Gestational diabetes, preeclampsia

· SH: Lives with parents and 2 year old sister, attends preschool, no tobacco use in the home

· Immunizations: Up to date for age per ACIP guidelines

· ROS: Denies headache, lethargy, chest pain, hemoptysis, rash, dysuria, diarrhea, and vomiting

· Allergies: NKDA

· Medications: Ibuprofen PRN for fever

· Physical Exam:

o Vitals – T 102.5°, RR 40, HR 120, Pulse Ox 89-91% on room air

o Gen – Ill appearing, labored breathing, crying and clinging to mother

o HEENT – Normocephalic, tympanic membranes slightly erythematous though with good landmarks, dry oral mucosa, mild pharyngeal erythema though no exudate or tonsillar enlargement

o Neck – Supple, full range of motion, no adenopathy

o Cardiac – Tachycardic, no murmurs, and cap refill of 2-3 seconds

o Lungs – Labored breathing and retractions, crackles and decreased aeration at the left lung base, no wheezing

o Abd – Soft, non-tender, normal bowel sounds

o Musculoskeletal – No joint swelling

o Neuro – Grossly intact exam

o Skin – No rash, abrasions, or petechial noted

· Labs:

o CBC: WBC 19K with 8% bandemia, Hgb/Hct 12.3/36, Plts 520K

o Electrolyte Panel: Na 130, K 4.5, Cl 107, HCO3 21, BUN 20, Cr 0.6

o ESR: 72, CRP: 21

o Capillary blood gas: 7.46/24/base excess of 6

· Imaging:

o Chest X-Ray: Left lower lobe infiltrate

ED course:

AJ was placed on 2L of supplemental oxygen therapy and an IV fluid bolus of 20 ml/kg of normal saline was administered. His first dose of ampicillin was administered in the ED and he was subsequently admitted to the floor with pneumonia, respiratory distress and hypoxia.

On admission to the floor:

AJ arrived to the floor with tachypnea and continued tachycardia. Maintenance IV fluids with D5NS were continued. His oxygen was increased to 2.5 L for the respiratory distress. The parents and nurses expressed concern about his status and that he may require closer monitoring in an ICU setting if he did not improve. On admission, the working diagnoses for his hyponatremia included volume depletion as well as SIADH.

Summary statement:
Events leading up to admission:
Hospital Course:
Ongoing Assessment by problem/diagnosis: / Plan by problem/diagnosis:
Patient Summary Video Example
Did they capture all of the essential elements?
Did their verbal handoff differ from your written patient summary?

Patient Summary Exercise 2

HOSPITAL COURSE FOLLOWING ADMISSION:

The day following admission AJ’s respiratory status improved slightly and his oxygen requirement decreased. His work of breathing improved and he was no longer tachypneic. With hydration his Na improved to 136 by the afternoon and the D5NS was stopped, and his fluids were switched to D5 ½ NS.

Early the in the morning on the following day he developed an increase in his oxygen requirement and worsening respiratory distress. A stat chest X-Ray was ordered and revealed worsening of the left sided infiltrate and a moderate sized effusion. AJ had an urgent ultrasound of the chest obtained that should a moderate to large sized free-flowing effusion. Plans for placement for a chest tube for drainage of the effusion were initiated. His Na that morning was also found to be 139, and he was continued on maintenance IVF with D5 ½ NS given his NPO status prior to the procedure. A chest tube was subsequently placed by interventional radiology without complication later that morning and exudative fluid obtained. The surgery service was consulted to assist with management of the chest tube. Following placement of the chest tube AJ’s respiratory status improved and his oxygen was weaned to 1L. In addition, his tachypnea and tachycardia improved throughout the day. His chest tube was kept to low wall suction and he continued to have drainage of fluid from the tube throughout the day.

You are the day intern leaving and need to handoff back to the night intern. Please compose a patient summary on the patient now 48 hours into admission.

Summary statement:
Events leading up to admission:
Hospital Course:
Ongoing Assessment by problem/diagnosis: / Plan by problem/diagnosis:

V. Contingency Planning

Exercise

Refer to the patient summary you wrote about AJ, the 4 year-old ex-premie who was admitted with pneumonia and hyponatremia.

What contingency plans would you recommend for this patient at the time of the handoff after admission (before complication of the effusion)?

NOTES: