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SOAP Obstetric Anesthesia Expert Opinion


Every Woman Who Delivers by Cesarean Deserves a Pre-operative Huddle

SOAP Patient Safety Committee
“How We Do It” Expert Opinion

Editor: Rachel Kacmar, MD

Contributors:
Steve Pratt, MD (Beth Israel Deaconess Medical Center), Jeanette Bauchat, MD (Northwestern University), Grant Lynde, MD (Emory University), Jill Mhyre, MD (University of Michigan), Gill Hilton, MD/Steve Lipman, MD (Stanford University), Paula Craigo, MD (Mayo Rochester), Eva Szabo, MD (University of New Mexico), May Pian-Smith, MD (Massachusetts General Hospital, Grace Shih, MD (University of Kansas), Heather Nixon, MD (University of Illinois Chicago), Jean Miles, MD (Memorial Healthcare System, South Florida)

Background
Communication on labor and delivery is an integral part of successful clinical care and effective communication contributes to a culture of patient safety. The Joint Commission reported that up to 70% of sentinel perinatal events involving mortality or permanent disability involved at least one communication breakdown.1 Poor communication was also listed as a root cause in over 60% of all sentinel events reviewed by the Joint Commission 2011-2013 and over 50% of all Anesthesia sentinel events from 2004-2013.2 Multidisciplinary communication between nurses, obstetricians and anesthesiologists is obviously crucial to successful patient care on labor and delivery, however without a structured framework for such interactions we face a continued patient safety risk.

The challenge of efficient and meaningful communication is tackled in a number of ways on labor and delivery units. Many institutions utilize multidisciplinary board rounds and/ or team sign-outs so all care providers are aware of pertinent patient issues. For cesarean deliveries, a pre-incision time-out, as mandated by the Joint Commission, is standard across all institutions, even in the case of emergency or “STAT” procedures. Also mandated by the Joint Commission is a specific time-out prior to any anesthesia procedure; in many institutions this is extended to a more general “pre-anesthesia time-out” that will occur even prior to induction of general anesthesia. Separate from these two mandated time-outs is a pre-procedure briefing or huddle. This preoperative, patient-specific discussion is at times merged with the pre-anesthesia time-out, but creating a culture in which the care team can meet and discuss the upcoming procedure prior to proceeding to the operating room can be advantageous.

“Huddles” are typically short briefings that afford providers the opportunity to share and review information and coordinate plans for ongoing patient care.3 Multiple studies have demonstrated the positive effect of huddles on patient safety including identifying errors or near misses, providing a venue to raise concerns, and enriching multidisciplinary and interdepartmental relationships though working towards a common goal.4,54,5 In 2004 the Institute for Healthcare Improvement suggested that huddles occur with regularity and frequency.6

Regular huddles can contribute to many facets of high quality patient care. The following are only a few of the potential outcomes:

Accountability
Huddles can provide structure to facilitate increased quantity and quality of information sharing and may increased accountability of all team members to verbalize concerns about patient status or the plan of care.3 Participants may also feel increased responsibility for patient safety when regular huddles are held.44 Accountability can be extended to healthcare efficiency. Regular pre-operative huddles between nursing, surgery and anesthesiology lead to a 1000-fold increase in on-time first case starts in one pediatric hospital.7 Starting scheduled procedures on time leads to less rushing and potentially more providers available (out of the operating room) throughout the day.

Empowerment
Nurses participating in huddles have reported feeling more empowered to speak up or express disagreement, which they feel has increased the level of trust from fellow providers.3 Indeed highly reliable organizations emphasize huddles that exhibit deference to expertise and instead encourage individuals with the most relevant knowledge to participate, independent of seniority or hierarchy.8 By involving providers of all roles and ranks in huddles, mutual respect develops and the team can come to a shared understanding of the situation and confirmed agreement for the next steps.9

Culture of Collaboration
Goldenhar et al. also reported that a huddle system promoted a sense of community and a culture of collaboration. This led to a cohesive view of patient safety, anti-competitiveness and improved collegiality.3 A culture of open communication, shared learning and interdependence, lead not only to a dynamic, functional unit but may spread to create a higher-performing organization.8

Although labor and delivery huddles are multidisciplinary in nature, involving nurses, obstetricians and anesthesiologists, perhaps we should also seek increased participation by the pediatric and/ or neonatal intensive care teams in pre-procedure huddles. In 2013 Dadiz et. al. reported that improved OB to Peds handoff on maternal and fetal status before delivery was one of the most common cited areas for improvement in delivery room communication.10 This could improve the overall team dynamic as well as communication during delivery and any neonatal resuscitation efforts. Participants in huddles have reported an increased sense of community and connection to other teams in the institution which ultimately improved collaboration across units.3

How can we accomplish this?
A number of institutions employ a laminated card or wall chart (See examples) which list suggested subjects for the pre-procedure huddle. Such a tool would not only act as a valuable cognitive aid during huddles; its presence outside patient rooms or in the pre-operative arena may also remind providers to participate in or even initiate these gatherings. Routinely going through a checklist could be thought of as rigid, however, the actual huddle discussion will depend on each patient and clinical situation, thus providing continuity through structure while allowing variety in content.8 In non-obstetric operating rooms, standardized pre-procedure communication between surgeons and anesthesiologists led to improved intraoperative collaboration and higher provider satisfaction.11 Routine use of a checklist may also serve to help providers recall critical communication points during more urgent or even STAT cesarean deliveries or operative procedures when there is limited time to communicate vital patient or situational information.10

Pre-procedure, patient- specific team huddles should likely be standard of care in every labor and delivery unit. While pre-anesthetic and pre-surgical incision time-outs are widely in place, structured bedside or pre-operative holding team member meetings occur in only a few of the surveyed obstetric units (See Table). Even brief huddles have the power to help systematize relevant information sharing, create a common goal of patient safety and empower all team members to contribute and to be accountable for reliable patient care. The potential to improve patient satisfaction12 and employee satisfaction4 through the implementation of huddles across an organization will also be beneficial as we enter a new era in healthcare. With support from senior institutional and clinical leadership, labor and delivery units should strive to lead the movement towards regular pre-procedural huddles and tremendous potential patient safety benefits.

Key Points:

  • Effective multidisciplinary communication is critical to optimize patient safety on labor and delivery.
  • While pre-anesthesia and pre-incision time-outs for cesarean deliveries are consistently in place in academic institutions, separate patient-specific, pre-procedure team huddles are not widely implemented.
  • Huddles have the potential to improve patient care through increased provider accountability for patient safety and healthcare efficiency, greater empowerment for all providers to speak up, and a broad culture of collaboration across disciplines and the organization.
  • Printed cognitive aids and/ or specific huddle checklists may improve compliance with huddles as well as ensure crucial information is not missed in more urgent situations.
  • As the rate of cesarean delivery continues to rise, labor and delivery units will continually need to maintain patient safety standards. Encouraging widespread use of patient-specific, pre-procedure multidisciplinary huddles should be the next step in this ongoing challenge.

Please use the below links to access current practices reported by SOAP Patient Safety Committee members as well as specific established tools for pre-procedure huddles, pre-anesthesia and pre-incision time-outs.

  1. Joint Commission on Accreditation of Healthcare Organizations. Preventing infant death and injury during delivery.
    Jt Comm Perspect 2004;24:14-5

  2. Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Data: Root Causes by Event Type 2004-2013. Office of Quality Monitoring. Available at:
    http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2Q2013.pdf. Accessed June 11, 2014.

  3. Goldenhar LM, Brady PW, Sutcliffe KM, Muething SE. Huddling for high reliability and situation awareness.
    BMJ Qual Saf 2013;22:899-906

  4. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care.
    Qual Saf Health Care 2004;13 Suppl 1:i85-90


  5. Paull DE, Mazzia LM, Wood SD, Theis MS, Robinson LD, Carney B, Neily J, Mills PD, Bagian JP. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program.
    Am J Surg 2010;200:620-3


  6. Institute for Healthcare Improvement. (2004). Meeting tools: Huddles. Retrieved from http://www.ihi.org/knowledge/Pages/Tools/Huddles.aspx

  7. Wright JG, Roche A, Khoury AE. Improving on-time surgical starts in an operating room.
    Can J Surg 2010;53:167-70


  8. Provost SM, Lanham HJ, Leykum LK, McDaniel RR, Jr., Pugh J. Health care huddles: Managing complexity to achieve high reliability.
    Health Care Manage Rev 2014


  9. Lyndon A, Zlatnik MG, Wachter RM. Effective physician-nurse communication: a patient safety essential for labor and delivery.
    Am J Obstet Gynecol 2011;205:91-6


  10. Dadiz R, Weinschreider J, Schriefer J, Arnold C, Greves CD, Crosby EC, Wang H, Pressman EK, Guillet R. Interdisciplinary simulation-based training to improve delivery room communication.
    Simul Healthc 2013;8:279-91


  11. Khoshbin A, Lingard L, Wright JG. Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children.
    Can J Surg 2009;52:309-15

  12. Cooper RL, Lee JY. Using Huddles to Enhance Patient Experience. Healthcare Executive
    2013;Nov/ Dec:48-50