Leading change

The Lead Nurse for the Critical Care Outreach Team (CCOT) led the implementation of a ten-minute daily emergency call safety huddle at Surrey and Sussex Healthcare NHS Trust, which has increased efficiency in team working and improved patient safety.

Where to look

The UK Resuscitation Council Advanced Life Support guidelines highlight the importance of effective communication amongst members of a team during an emergency, suggesting it is integrally linked to patient safety and outcomes. Promptly identifying and managing a critically unwell patient, they report, is key to preventing harm to patients and a short daily meeting can help emergency teams work together more effectively.

Traditionally, the response to cardiac arrest has been reactive, with a cardiac arrest team attending the patient after the cardiac arrest has been identified. In some hospitals, the role of the cardiac arrest team has been incorporated into that of the medical emergency team (MET; sometimes known as the Rapid Response team), with the MET responding not only to cardiac arrests, but also to patients with acute physiological deterioration. The MET usually comprises medical and nursing staff from different specialties, such as intensive care and general medicine, and responds to specific calling criteria. MET interventions often involve simple tasks such as starting oxygen therapy and intravenous fluids.

The Lead Nurse for the Critical Care Outreach Team (CCOT) identified that Kent, Surrey and Sussex’s Academic Health Science Network (AHSN) had produced guidance highlighting the effectiveness of a ‘Ten Minute Meeting’ core huddle. This led the Lead Nurse to consider practice locally. Unwarranted variation was identified in several debriefs following an emergency. Staff reported a lack of clarity regarding each other’s roles, skill sets and experience. It was reported that this was inhibiting effective team work during these incidents.

What to change

Surrey and Sussex Healthcare NHS Trust provides emergency and non-emergency services to the residents of east Surrey, north-east West Sussex, and South Croydon. The CCOT offer 24/7 support and advice to staff and patients across the Trust as well as attending medical emergencies and cardiac arrest calls to support the Medical Emergencies Team.

The CCOT nurse conducted a review of current practice which identified unwarranted variation in how the emergency situations were responded to. Before the change, the Medical Emergency Team (MET) on call would attend the emergency, meeting as a group at the bedside of an acutely deteriorating patient. Members of the team were frequently from a range of specialities, dependent on the on-call rota. This meant team members weren’t clear as to each other’s competencies, skill sets or roles, which meant the team had to quickly establish how to both deal with the emergency as well as work effectively as a newly formed team. In practice, this led to unwarranted variation. The nurse lead identified this as an opportunity to streamline and standardise the emergency response through the development of the daily emergency call safety huddle.

How to change

NHS Improvement advocate the use of ‘safety huddles’ to support effective communication at key points in the care of individuals, to improve safety. A safety huddle is a short multidisciplinary briefing, held at a predictable time and place, and focused on the patients most at risk. Effective safety huddles involve agreed actions, are informed by visual feedback of data and provide the opportunity to celebrate success in reducing harm. These:

• enhance teamwork through communication and co-operative problem-solving;
• share understanding of the focus and priorities for the day; and,
• improve situational awareness of safety concerns.

In October 2016, the Lead Nurse for the CCOT led the introduction of a ten-minute daily emergency call safety huddle at 9am between members of the cardiac arrest and medical emergency team. At this meeting, roles are allocated, such as intravenous (IV) access, arterial blood gas (ABG) and blood sampling, airway, documentation, and learning from previous emergencies is discussed. A lead and second lead are allocated for if there is a simultaneous emergency call. Any learning needs for team members are also discussed such as EZIO insertion and running an emergency.

Roles and training needs as well as common themes or learning from previous emergencies are documented through a standardised checklist. This is to create effective team working and improve patient safety. Using a Plan-Do-Study-Act (PDSA) method, the huddles continue to be reviewed and renewed to ensure best practice and standardisation remains central to all practices by the team.

This was led by the Critical Care Outreach Nurse (CCON) as doctors often rotate and changeover. The new approach supported consistency in application and effective oversight, management and escalation where needed.

Adding value

Better outcomes – A Medical Emergency Team (MET) audit took place over a 29-day period in January/February 2018 and covered 111 medical emergency calls. This demonstrated an increase in patients who made an immediate improvement (79% in 2018 compared to 61% in 2017), versus patients who made no improvement immediately post MET call (21% in 2017 and 4% in 2018).

Better experience – In July 2017, 9 months after the daily huddles were introduced, a structured interview process was undertaken to gain qualitative feedback from members of the emergency team. There was an overall decrease in stress reported by the team members. They felt better prepared and knew what was expected of them at an emergency. The 2018 survey was sent to nursing and medical staff who had attended the safety huddles, to which there were 29 responses:

• 100% of respondents found the huddle to be useful as it identified and allocated roles and created familiarity between team members;
• 87% of respondents felt learning needs that were identified at the safety huddle had been addressed.

Better use of resources – The audit identified that 100% of respondents to the survey felt that the huddle improved team working; 91% of respondents felt patient safety was improved through increased efficiency during emergencies, effective team working, better organisation and early involvement with critical care.

Challenges and lessons learnt for implementation

Improved communication, safety, quality, patient and staff experience is what was behind this quality improvement project. The Trust has a positive culture for change and strives to improve patient safety or experience so it was not hard to get colleagues on board to the new concept.

The hardest part of the change process was agreeing a time and place for the daily meeting – the time was agreed based on when the medical team changed shift and is incorporated into their night to day handover.

The daily emergency call safety huddles are now embedded as part of the Trust’s safety culture and introduction is being considered into the ‘hospital at night’ meetings to support ‘out-of-hours’ care. Work on implementing a debrief after all emergencies is taking place so staff can reflect and learn from the high-pressured situations.

Find out more

For more information contact:

• Claire Rowley – Lead Nurse for the Critical Care Outreach Team, Surrey and Sussex NHS Trust, claire.rowley5@nhs.net