Patient Safety and Collaboration of the Intensive Care Unit Team

Patient safety in the ICU and collaboration among ICU care providers are interconnected.Safe delivery of patient care has been in the spotlight since the release of the Institute of Medicine’s report,1To Err Is Human, which attributed 44000 to 88000 preventable deaths in hospitals to medical errors in 1997. More recently, HealthGrades2 reported that from 2004 through 2006, an estimated 238337 deaths were due to potentially avoidable patient safety incidents. Serious medical errors with the potential for causing harm or that actually cause harm are common in critical care areas. One estimate is that 148000 life-threatening serious errors (both intercepted and nonintercepted) occur in critical care areas of teaching hospitals annually.3 Incidents due to error occur commonly during the ordering or administration of medications used for treatment, when communicating clinical information, and as a result of failure to follow protocols such as washing hands before inserting a central catheter.3 Causes of error include workload, fatigue, circadian dysrhythmia, overconfidence, and failure to work together as a team.4 The relationship between nurse and physician team members is a prominent feature in detecting and reporting errors.5Within the past 10 to 15 years, the delivery of care in intensive care units (ICUs) has demanded more of a team effort. The team includes physicians, nurses, respiratory therapists, physical therapists, nutritionists, social workers, and other skilled professionals.6 Although team-oriented organizational structures and work patterns are evolving, the difficulty lies in transforming interpersonal and interprofessional relationships. Health care providers have been slow to adapt to the concepts of team and interdisciplinary collaboration.7 What follows is an overview of behaviors necessary for interdisciplinary collaboration in the ICU, barriers to effective communication, and the impact of communication failures. A proposal for team training and an approach for implementation are presented.Promoting patient safety through ICU interdisciplinary collaboration requires knowledge of the constituency of the ICU team, attributes of interdisciplinary collaboration, barriers to this collaboration, and behaviors and interventions that can facilitate collaboration.The ICU team is a self-organizing, complex entity that expands and contracts depending on the needs of the moment.8 The core team may consist of the bedside nurse, respiratory therapist, and physician and may expand to include other disciplines such as social workers, dietitians, and physical therapists. The degree of collaboration and conflicts within the team fluctuate.8One view of ICU team collaboration depicts it as being rooted in ownership and the trade of commodities, the commodities being specialized knowledge, technical skills, equipment, clinical territory, and the patient.9 From this perspective, the key problems facing interdisciplinary teams are respecting the interface between individual and collective knowledge, and the balance between individual and collective responsibility. Recognition of others’ possession of knowledge and skills is part of the smooth collaborative functioning of a team.9Effective communication among caregivers is essential for a functioning team. The Joint Commission10 reports that ineffective communication is the most commonly cited cause for sentinel events. Indeed, their 2008 National Patient Safety Goals include improving the effectiveness of communication among care-givers. A component of this goal is the implementation of a standardized approach to “hand off ” communications.11 Although physicians’ reports of collaboration have not correlated with patients’ outcomes, nurses’ reports of the lack of collaboration are predictive of poor outcomes for patients. Nursing reports of lack of collaboration are associated with a higher rate of patients’ dying and being readmitted to the intensive care unit during the same hospital admission.12 Interestingly, physicians are more satisfied than nurses with collaboration between physicians and nurses. Although nurses think that decision making in the ICU should include input from other disciplines, physicians think that input from ICU nurses is well received and report high levels of teamwork with nurses.13,14Team collaboration is an inter-professional process for communication and decision making. The shared knowledge and skills of care providers influence the care given, and each provider contributes to the final integrated management plan.15Collaborative communication is the ability of 2 or more team members to send and receive information or commands clearly and accurately and to provide useful feedback.16 Team members share responsibility for decision making, problem solving, conflict management, and coordination.17 Barriers to effective communication and shared understanding include differences in status, training, language, and professional norms. Team members may lack conviction that their input is needed or desired.18 Behaviors that increase risk of injury to operating room patients includeIn the ICU, these behaviors can be translated into a poor end-of-shift report, tension between physicians and nurses, and failure to anticipate potential problems such as the development of stridor after endotracheal extubation.Professional status in health care influences beliefs about how easy or appropriate it is to speak up to offer ideas, ask questions, or raise concerns. Power is defined as the capability of one member to direct the behavior of another, and it can inhibit upward flow of information.18 Power differences in teams intensify the interpersonal risk faced by members who wish to contribute. Psychological safety is a belief that it is safe for one to take a personal risk, such as speaking up, without fear of ridicule, humiliation, or punishment.19 It has been reported that physicians felt significantly more psychological safety than did nurses, who in turn reported more psychological safety than did respiratory therapists.20 Health care teams where the physician leaders are perceived as welcoming others’ input demonstrate higher psychological safety.20Enhancing the team collaboration of ICU team members is one means of improving patient safety. Interdependence and communications across professional group boundaries facilitates catching errors.5 Sound decision making requires team members to gather and integrate information, make logical and sound judgments, identify alternatives, consider the consequences of each alternative, and select the best one.15 Formal team training is one way of improving team collaboration. Team training improves the quality of teamwork behaviors and decreases the number of observed clinical errors.21A team is more than a group of people assembled together at the same point in time; effective teams have certain characteristics that distinguish them from other groups. Team training such as crew resource management training imparts these characteristics.The term high-reliability teams has been used to describe teams that consistently and effectively work interdependently toward a shared goal in a complex environment.22 Such teams are able to make good decisions in complex and changing environments and under high levels of stress consistently and effectively over time.17 These teams are skilled in closed-loop communication, that is, the exchange of clear information, acknowledgment of receipt of that information, and confirmation of its correct understanding. Team members are aware that any one of them may possess the required expertise for any given situation and they defer to this expertise; they value all opinions.22High-reliability teams is a concept that has evolved from high-reliability theory.22 High-reliability theory focuses on organizations with complex environments, such as air traffic control systems and nuclear power-generation plants, where ample opportunities are available for errors to lead to catastrophic consequences. What separates these organizations from other complex industries is that their errors are prevented or managed such that the consequences are minimized. High-reliability theory proposes that such organizations promote a culture that prioritizes safety and vigilance and responsiveness to potential accidents.23Crew resource management (CRM) training has been used for more than 20 years in the aviation industry to teach techniques in team building, error recognition, and communication that prevent or minimize the effects of human error. These techniques were developed on the basis of the cognitive and social skills noted in successful airline captains and their crews.17 Crews consisting of the copilot, engineer, and cabin personnel are able to interpret cues, make contingency plans, use available resources to build shared problem models, and expand the team to include those outside the aircraft such as the plane maintenance personnel.17 The critical care equivalent of the airline crew includes the attending physician, bedside nurse, respiratory therapist, pharmacist, patient and patient’s family, and others such as the physical or occupational therapist and dietitian. Since the institution of CRM training, the aviation industry has noted a marked decrease in the frequency of fatal crashes. CRM has been promoted by the Institute of Medicine as a means of reducing the risk of harming patients.24CRM promotes a culture of safety through changing attitudes and behaviors. Gaining knowledge about human factors and the nature of errors is a key feature of CRM training. Participants learn about individual processes such as the effects of fatigue and how to lessen the contribution of fatigue to errors. They also learn how to recognize subtle warning signs such as confusion among team members about care plans or conflicting input such as an order to administer 40 mg of furosemide intravenously to a patient with a serum potassium level of 2.9 mmol/L that could lead to an adverse event.17 They receive training in team processes such as interpersonal skills (learning each team member’s name and making eye contact when speaking to a member), conflict resolution, and critiquing team performance in a nonthreatening manner that addresses positive as well as negative aspects of team members’ performance.17 System processes such as checklists for procedures and standardizing handoffs for conveying information are also taught as interventions that prevent, capture, and mitigate errors before those errors develop into accidents or adverse outcomes.17Behaviors that are taught as countermeasures to error include briefings, monitoring, cross-checking decision making, and review and modification of plans.4 Participants in CRM training learn to actively participate in the decision-making process, communicate and acknowledge decisions clearly, routinely question actions and decisions, and plainly state operational decisions to other team members. They also learn to establish and convey the essentials for safety to team members, share the overall plan with the entire team, provide an atmosphere that invites open communication, and speak up regarding their own ideas, opinions, and recommendations.17Once it has been decided to effect a change, it is necessary to communicate the desired outcomes to all persons involved, from the bedside nurse to the organization’s leaders. It is also essential to assemble the implementation group, secure organizational resources, and identify the change champions.Today’s organizational leaders and health care providers seek to improve patient safety. Formal teamwork training such as CRM training is one means of attaining this goal. The pertinent desired outcomes are decreased clinical error rates, improved attitudes toward teamwork among physicians and staff, and reports of interdisciplinary collaboration from nurses and physicians. Baseline measurements of these entities provide a motivating rationale for change that can be discussed with a small group of like-minded leaders. Effective change leaders help teams to learn by communicating a motivating rationale for change.18 In orchestrating the proposed change, the leader shares the organization’s purpose and engages others in a way that embodies those values.25 Assembling this group creates interconnections, and attention to the quality of these relationships increases group members’ receptivity to possibilities.26This implementation group should include the safety officer, the quality improvement coordinator, management representation from the ICUs and respiratory therapy department, and the medical directors of these units. Together, these individuals and the change leader will create the vision and develop the statement that connects the current conditions and responses. A charter is then crafted that includes measures to ensure that the participating units are progressing in the desired direction.Change teams exist within organizational contexts. The organizational context can provide the resources to support practice, experimentation, and reflection on what works.18 For formal team training to occur, money must be budgeted to hire a firm to provide CRM training. Experts in CRM are brought in to train the change group, nurses, respiratory therapists, and physicians in the ICUs in new skills that pertain to their work activities. Change leaders create the organizational conditions for people to set a clear intent, agree on how they will work together, and then practice to become better observers, learners, and colleagues as they co-create the environment.26 Internal and external environmental appraisals must be applied by the teams and the leaders to current task strategies and to anticipated future situations.17 Periodic CRM retraining will be necessary for new responses and approaches to patient safety issues.25Champions in each area must be identified by the change group to work with CRM consultants in adapting CRM tools to their specific unit according to their need. Problem solving occurs at the local level, and those that own the problem must be the ones to discover and implement the solution.27 Champions are individuals who informally emerge in an organization. They contribute to the innovation by actively and enthusiastically promoting its progress through the critical stages.28 Champion behavior is related to team performance and positively influences team members’ beliefs in the effectiveness of their efforts.28Organizational leaders and members of the change group should periodically be present in the ICUs during times when the new CRM tools are used. A determinant of the success of teamwork implementation is the sustained commitment and active involvement of executive leaders.21 Rewards and public recognition should be given to areas that successfully implement teamwork skills. Leaders should institute a reward system for teamwork successes, serve as role models for teamwork themselves, and encourage staff to engage in teamwork behaviors.21One example of CRM implementation can be found in a midwestern academic medical center. Administrators hired a firm that provided CRM training. Three pilots provided an 8-hour course to personnel from the operating room, ICUs, and the emergency department, including physicians, nurses, and respiratory therapists as well as the hospital’s patient safety officer, quality improvement coordinator, and chief medical officer. In addition to the course, the pilots provided consultation on development of CRM tools.Two pilots worked with a medical-neurosurgical ICU’s clinical nurse specialist to develop a structured communication format that ensured consistent identification of patients in unstable condition to be seen at the beginning of clinical rounds. They used the format of a prebrief, a structure used in aviation to provide an overview of the upcoming mission and to identify priorities. In an aviation prebrief, critical points and anticipated outcomes are discussed and specific duties are assigned.17 This work group developed a unit-specific prebrief for conveying a global view of the ICU’s operations for the day.Taking advantage of a process that was already in place, the unit clerk announces the start of the prebrief at 9:00 am (when the physician team usually met to review radiographs). The group assembles around the central station where the unit clerk is stationed. The group includes the unit clerk, the unit attendant, the janitorial staff, dietitian, pharmacist, respiratory therapist, nursing students, medical students, nurses, the clinical nurse specialist, and the physicians. The prebrief lasts 5 minutes or less and is led by the attending physician, fellow, or clinical nurse specialist if the attending physician or fellow are unable to begin at 9:00. The information to be reviewed is on a laminated 4 × 6-in (10 × 15-cm) card that is posted next to the unit clerk (Table 1).Each team member is then provided the opportunity for input, beginning with the unit clerk and ending with the attending physician. The prebrief ends with a statement by the prebrief leader about the expectation that people speak up if they see an unsafe situation. The support of the unit’s management is readily evident through the frequent presence of the nurse manager and the unit’s medical director and their stated expectations of daily attendance by all staff members unless they are directly involved in patient care at that moment.The most immediate outcome of team training is improved team behaviors. Effective team behaviors result in greater patient safety through reduction of medical errors and better management of incidents.21Once CRM training is complete, the immediate anticipated outcomes are survey results that indicate improved attitudes of participants toward patient safety and team-work and implementation of CRM tools such as checklists and briefings in the ICUs. In the preceding example, the author, the institution’s quality improvement coordinator, and patient safety officer evaluated the prebrief. The author conducted a survey 1 month after implementation and had a 63% return rate, with the following results: 89% of respondents thought that the briefing was useful and 84% thought that it helped to create a stronger team.In addition, data were collected for 16 days to identify who spoke up, the type of input given, and whether patients were prioritized on the basis of input. On 11 of the 16 days, at least 1 team member spoke up: the unit attendant on 4 occasions, the unit clerk on 6 occasions, nurses 3 times, the respiratory therapist once, the clinical nurse specialist once, the manager once, and physicians once. Both operational and patient care issues were identified during the observation period (Table 2). All patients with care issues identified in the pre-brief were prioritized to be seen first during clinical rounds. The team members of the unit have received positive feedback for their adoption of this tool through visits from the chief medical officer, state regulators, and administrative leaders.Over a longer the change leader can to see improved attitudes among staff toward team-work and improved quality of team-work behaviors. will be as of future such as procedures to be used for or future patients to other units if one unit is behaviors will be such as team members for help when they are and actively other members who of team leaders will be with the stated of Team leaders will differences and behaviors that include and of For example, the physician will input from each individual as part of the clinical rounds. Team leaders will recognize others’ possession of knowledge and such as the respiratory therapist to support to for a more members that they work in a team by interpersonal and the more and they are to participating in quality improvement The effects can include among staff members, of nurses, and among patients and their communication to poor management of and errors at the team Team training improves the quality of teamwork behaviors and significantly clinical across professional group boundaries facilitates of errors.5 collaboration decreases the risk of adverse outcomes for safety in the ICU and collaboration among ICU care providers are collaboration to errors and risk of outcomes for ICU patients. Formal team training crew resource management is one way to improve collaboration and patient safety.