TeamSTEPPS for Code Blue Teams: Piloting SBAR & CUS for Interprofessional Team Education April 8, 2015

Rules of Engagement Audio for the webinar can be accessed in two ways: Through the phone (*Please mute your computer speakers) Through your computer A Q&A session will be held at the end of the presentation Written questions are encouraged throughout the presentation and will be answered during the Q&A session To submit a question, type it into the Chat Area and send it at any time during the presentation The lines may open for call-in questions during the Q&A session

Acknowledgements Project Sponsors Project Team Jim Battles, PhD (AHRQ) Heidi King, MS (DoD) Project Team Health Research & Educational Trust (HRET) Barb Edson (Project Director) Chris Hund (Project Manager) IMPAQ International David Baker (Team Lead)

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Today’s Presenters Ken Miller, RN, MSN, CCRN Edward Lee, MD Simulation Education Program Coordinator Department of Nursing Practice, Research, and Education Edward Lee, MD Assistant Clinical Professor, Hospitalist Section UCLA Department of Internal Medicine Chair, Code Blue QI Committee

Objectives Provide an overview of Code Blue teams and interprofessional team education at UCLA Describe the identification of the need for TeamSTEPPS tools among code blue team members Describe how interprofessional code team training and TeamSTEPPS tools are being implemented Present data measuring the effectiveness of the intervention

Code Blue Team Overview Ronald Reagan UCLA Medical Center Level I Trauma Center 520 Acute inpatient beds 6 different intensive care units (ICU) Teaching hospital with 76 ACGME accredited programs and over 1000 physician trainees Tertiary/quaternary referral center High volume transplant center

Code Blue Team Overview Code Blue Team Composition Medical ICU Resident and Intern Coronary Care Unit Resident and Intern Anesthesia Senior Resident Critical Care Transport RN Pharmacist Respiratory Therapist EMT/Escort Security, Chaplain, Bed Control *Nurses from the affected unit

In-Situ Education 3-Minute Mock Codes Emphasis on the first three minutes of a code Objectives include the development of: Leadership Skills Role Designation SBAR Communication Early and High Quality Compressions

Interprofessional Education (IPE) August 2012 – Begin advanced simulation training for internal medicine junior and senior residents. Sessions scheduled “just in time” prior to residents being on the code pager. January 2013 – Sessions become interprofessional with med/surg nurses, ICU nurses, and critical care transport nurses. July 2014 – Department of Anesthesia commits residents to the IPE sessions.

Interprofessional Education (IPE) 2013-2014 – 13 sessions 2014-2015 – 20 sessions 2015-2016 – Anticipated 25 sessions

Interprofessional Education (IPE) 3 Cases per Session (1/2 day) Intracranial hemorrhage Cardiogenic shock Advanced arrhythmia GI Bleed Status Asthmaticus Sepsis Dual patient triage scenario Debriefing after each case Teamwork and communication Medical decision making

Identifying Areas for Improvement Sources of information Personal experience in codes at UCLA Informal survey of healthcare providers about issues related to teamwork and communication Quality improvement committee reviews Data from event reports Observation of teams during IPE sessions

Identifying Areas for Improvement Four Items Identified Issue Intervention Key information not effectively shared Team members not speaking up when problems are noticed Orders not heard/completed Team not “on the same page”

Identifying Areas for Improvement UCLA became a TeamSTEPPS training center in early 2013, practically coinciding with the start of IP Code Team training TeamSTEPPS provided the mental framework and vocabulary to better understand teamwork, helping us to more effectively train our providers

Identifying Areas for Improvement Four Items Identified Issue Intervention Effective Communication SBAR Advocacy and Assertion CUS, Assertive Statement Verify and Validate Information Exchange Closed-Loop Communication Shared Mental Model Using the Huddle

SBAR Examples of the Problem Code Team did not hear from primary MD that a patient with an intracranial bleed was taking Coumadin. Primary MD did not feel comfortable with information relayed by nurse, leading to a delay in management of septic patient.

SBAR Poor communication noted during nurse-to-primary MD communication and during primary MD-to-Code Blue Team communication Intervention – SBAR Situation―What is going on with the patient? Background―What is the clinical background or context? Assessment―What do I think the problem is? Recommendation―What would I recommend?

Assertive Statement, CUS Examples of the Problem While waiting for norepinephrine drip to be prepared, the anesthesia resident fails to suggest bolusing pressors despite having drugs available. Team leader reads EKG as non-STEMI. Another team member clearly sees that the EKG shows a STEMI, but fails to speak up.

Assertive Statement, CUS Failure to “speak up” when mistakes or delays in care were noticed by a team member CUS Concern Uncomfortable Safety issue Creating a culture of collaboration Team training facilitates the notion that all team members are important and have contributions to make

Closed Loop Communication Examples of the Problem Vitamin K is ordered by MD, but is not clearly communicated to anyone, resulting in the drug not being given to the patient. Arterial blood gas ordered by MD, but nobody took responsibility thus the blood was not sent. This was only realized when results were later requested, only to discover that the ABG was never done.

Closed-Loop Communication Communication, particularly orders, often not clearly directed Closed-Loop Communication

Huddle – Shared Mental Model Examples of the Problem Providers physically segregate based on specialty Providers cognitively segregate based on tasks (Ex – airway team only communicating with each other) Anesthesia resident nearly gives succinylcholine for induction because he was not aware that the team was considering increased intracranial pressure

Huddle – Shared Mental Model Teams tend to self-segregate into groups (silos) resulting in poor communication between providers Huddle Brief, ad-hoc “meeting” to regain situation awareness and bring everyone back to a shared mental model Effective for discussing critical events/actions Breaks down silos by encouraging cross communication

Implementation Team training works, but only if you do it!! Get institutional buy-in Identify champions from each provider group Train the trainers Motivate providers to participate A simulation center is helpful, but not required!

Implementation Get institutional buy-in Patient outcomes Financial considerations (risk management) Reportable data Educational needs of training programs

Implementation Identify champions from each provider group Understanding of politics/motivations Understanding of schedules, practical barriers Understanding of areas for improvement Important for curriculum design to ensure that key competencies are being addressed

Implementation Train the trainers All instructors take a 2-day simulation instructor course Most instructors have participated in a TeamSTEPPS course Structured debriefing is used by all instructors and addresses teamwork/communication first Model behaviors – describe and demonstrate the skills

Implementation Motivate providers to participate Mandatory Offer CME or CE credits Show outside data – Everyone wants to improve Pilot in certain areas then show gains to more resistant areas to get buy-in Peer pressure/Word of mouth

Barriers Encountered Time (participants and instructors) Support from institution Participation from some groups Scaling to the entire health system

Measuring Progress 2012 – Began collecting data on teamwork and communication using 5 questions included on our event reporting system Was a code leader clearly evident throughout the code? Was information consistently shared among team members? Were the workload and tasks appropriately distributed between team members? Did team members communicate effectively with one another? Rate the overall teamwork during the code.

Measuring Progress Limitations Not a validated questionnaire Event reports on codes are completed by nurses Subjective rating scale Bias – nurse who completes the report was also present during the resuscitation Positive response – defined as an answer of 4 or 5 on 1-5 scale or “Yes” to Yes/No questions

Measuring Progress

Measuring Progress What about patient outcomes? Caveat - Many quality improvement projects related to resuscitation were initiated between 2012 to current

Measuring Progress

Summary Interprofessional team training is an important part of Code Blue Team performance TeamSTEPPS concepts are effective at teaching teamwork skills and creating a culture of mutual support Pick specific skills to emphasize that are relevant to your Code Blue Teams – We emphasize SBAR, CUS, Closed-Loop Communication, and Huddles Barriers to progress exist, but can be overcome!

Summary In hospital cardiac arrest outcomes can be improved!!!!

Questions and Answers

Thank You! For more information, please contact our team at: AHRQTeamSTEPPS@aha.org