TeamSTEPPS A new tool to improve patient care in Franklin County Lindsay Sherrard, MD CFMH Medical Staff Meeting May 27, 2009

What is TeamSTEPPS? teamwork system evidenced-based developed by the DoD and AHRQ Used in numerous hospitals and clinics across the country It’s all about improving patient safety and quality of care

Why improve patient safety? annual cost of medical errors 44-98K lives $38 billion Most errors are preventable Root cause of errors usually communication, a learnable skill

Why did CFMH choose TeamSTEPPS? Teamwork skills must be practiced “Our malpractice suits, high severity case claims, and the associated reserves required were reduced by 50% over a 3-year period after training teamwork in our Labor and Delivery Units.” -Benjamin P. Sachs, MD, BS Chief of Ob/Gyn, Beth Israel Deaconess Medical Center

Case Study 38y G1 at 41 weeks, BP 144/85, preeclampsia labs negative and NST/AFI ok Given misoprostol at 10pm and sent home with BP 124/90 Returned in active labor at 12m, BP 174/104 SROM at 1:30, ctx q1-2 min, epidural at 3:30 FWB nonreassuring at 4:30 Started pushing at 5:20, late decels at 5:30, FHR continued to slow Forceps delivery attempted at 6:20 Emergency c-section at 6:45, stillborn (FHR was in 130s prior to c-section) Uterus had ruptured; placenta was in the abdomen

Case Study Postpartum hemorrhage from uterine atony; got hysterectomy 3 hours after delivery Severe DIC, ARDS, sepsis, wound infection 3 week hospitalization, still not completely recovered 3 years later

Case Study: What went wrong? 4 errors in judgment: Should not have been sent home with high BP Later, with high BP and non-reassuring FHTs a clear plan was not developed, discussed with patient, or documented C-section should have been done at 5:30 at the lastest for non-reassuring FHTs Forceps should have been attempted in OR (if at all)

Case Study: What went wrong? 6 system failures: Poor communication b/t doctors, nurses, patient Lack of mutual performance cross-monitoring Inadequate conflict resolution Poor situational awareness Physician workload too high Attending on call for 21 very busy hours

This is the sort of situation we hope to prevent with TeamSTEPPS!

What does TeamSTEPPS teach? Four areas in which a team must be competent leadership situation monitoring mutual support communication

Leadership each team needs at least one leader direct others, delegate tasks, manage resources provide encouragement and performance expectations facilitate problem solving and conflict resolution

Situation Monitoring being aware of the needs of others in one’s team and other teams watching each others’ backs

Mutual Support helping others do tasks to evenly distribute work giving and receiving constructive feedback

Communication using structured techniques to communicate critical information acknowledgement of understanding the information

So, what is different at CFMH?

Leadership at CFMH You may notice people leading team events: Brief (planning) Huddle (problem solving) 8am and 8pm daily with representatives from all departments Debrief (process improvement)

Situation Monitoring at CFMH We should all be considering “STEP”: Status of the patient Team members’ (fatigue, workload, skill, etc) Environment (equipment, bed availability) Progress towards the goal (plan still appropriate?)

Situation Monitoring at CFMH I’M SAFE Checklist Illness Medication Stress Alcohol/Drugs Fatigue Eating/Elimination We should be looking out for one another!

Mutual Support at CFMH Task assistance: it is expected that assistance will be actively sought and offered Feedback: provided for the purpose of improving team performance, this should be timely, respectful, specific, directed towards improvement, and considerate Advocacy for the patient: using the “two challenge rule” which is everyone’s responsibility

Mutual Support at CFMH DESC Script Describe the situation Express concerns Suggest alternatives Consensus should be sought to meet team goals with commitment to a common mission

Communication at CFMH Specific communication strategies have been taught to staff These are designed to be clear and concise

Communication at CFMH Nurses will call using the SBAR technique: Situation “I’m calling about Ms. Hodges in room 102 because she is having shortness of breath” Background “She is the 62-year-old female POD#1 from abdominal surgery with no history of cardiac or lung disease Assessment “Breath sounds are decreased on the right and I’m concerned about pneumothorax.” Recommendation “I feel strongly the patient needs to be assessed now; are you available to come in?”

Communication at CFMH In critical situations the “Call-Out” strategy may be used. Example: Leader: “Airway status?” EMT: “Airway clear.” Leader: “Breath sounds?” EMT: “Breath sounds decreased on right” Leader: “Blood pressure?” Nurse: “BP is 96/62”

Communication at CFMH Check-back for closed-loop communication: Doctor: “Give 25mg Benadryl IV push” Nurse: “25mg Benadryl IV push” Doctor: “That’s correct”

Communication at CFMH I PASS the BATON (handoff technique) Introduction (your role) Patient (identifiers) Assessment (diagnoses) Situation (current status) Safety concerns (allergies, critical labs) Background (past history, medications) Actions (what was done today, needs to be done?) Timing (prioritize actions) Ownership (who is responsible for what?) Next (the plan?)

Barriers to Teamwork Team member changes Lack of time Poor communication Hierarchy and lack of role clarity Defensiveness Conventional thinking Complacency Conflict Lack of coordination and follow up Distractions, fatigue, workload Misinterpretation of cues

Tools and Strategies for Teamwork Brief, huddle and debrief STEP Two challenge rule DESC script SBAR Call-out Check-back Handoff

Good Teamwork Outcomes Shared goals Adaptability Mutual trust Team performance Patient safety and outcomes!

References TeamSTEPPS Curriculum. Agency for Healthcare Research and Quality, Kohn LT, et al, ed. To Err is Human: Building a Safer Health System. Institute of Medicine. Washington: National Academy Press, Sachs BP. A 38-year-old woman with fetal loss and hysterectomy. JAMA: 2005 Aug 17;294(7):