The Implication of Teamwork and Communication on ICU Patient Discharge

Process

Frances Lin (PhD Candidate)Professor Wendy ChaboyerProfessor Marianne Wallis

School of Nursing & Midwifery Research Centre for Clinical and Community Practice Innovation

Griffith University, Gold Coast, Australia

Better teamwork was found to be associated with less mistakes, decreased LOS, reduced cost, and increased patient safety (Jain et al., 2006; Nemeth, et al., 2006; Pronovost et al., 2003;Salas & Cannon-Bowers, 2000; Sims, Salas & Burke, 2004).

Sub-optimal communication among team members was found to be associated with increased adverse events (Pronovost et al., 2002).

Poor communication between doctors and nurses was associated with preventable adverse events (Donchin et al., 1995).

Poor clinical handover was associated with increased mistakes (Jagsi et al, 2005), preventable adverse events (Petersen, 1994) and critical incidents (Sabir et al., 2006).

The Impact of Teamwork and Communication on Patient Safety

A literature review of organisational, individual and teamwork factors contributing to THE ICU discharge process (Lin, Chaboyer, & Wallis, 2009)

Organisational Factors

Guidelines, policiesResource availability Flow and performance

Teamwork FactorsCommunicationCoordination

StructureLeadership

ICUDischarge

Patient FactorsClinical conditionsCommunication

Personality and social factors

IndividualeFactors Knowledge/experience,

Decision making Skill mix

Use/not use protocols

Aim of The Study To describe ICU patient discharge process in an Australian

metropolitan hospital in order to make recommendations for clinical practice improvement.

This research was the first phase of a larger action research project - Enhancing Intensive Care Unit discharges through multidisciplinary approaches. Phase 2 and 3 of the larger study focused on implementing and evaluating an improved ICU patient discharge process.

Research Questions

1. What is the ICU patient discharge process?

2. What are the factors contributing to the ICU patient discharge process?

3. How are discharge decisions made in the ICU patient discharge process and who are the main decision-makers?

4. What roles, responsibilities does each member play in the discharge process and how do the team members interact?

5. What are the vulnerabilities in this process that may present risks to patient safety?

Methodology Qualitative research. Theoretical underpinnings: Distributed Cognition (Hutchins, 1999) and

Activity Theory (Engestrom, 1987).

Methods: Cognitive ethnography: using ethnographic data collection

techniques (Williams, 2006).

Setting: A large Australian metropolitan tertiary public teaching hospital with a level 3 ICU was selected.

Participant recruitment: ICU and ward. Ethics approval was obtained and all participants gave written

consent.

Activity Theory

Rules Division of LabourCommunity

Tools

Subject Objective Outcome

(Engestrom, 1987)

Distributed Cognition

The ICU discharge process is a cognitive process which involves multidisciplinary teams.

The elements of Distributed Cognition: Cognitive process is distributed among members of the group. Team members interact with each other in a meaningful context. Team members interact with artefacts (tools, discharge decision-

making principles). (Hutchins, 1999)

Data Collection

Field work: Participants recruitment. Observations. One on one semi-structured interviews. Contact summaries. Field notes.

Examining/collecting existing documents. Demographic data sheet. Hospital database.

Data Analysis

Preliminary data analysis during data collection: Managing data. Contact summaries and case summaries.

Transcribing data: checking transcripts against audio tape files. Coding, recoding, and recoding. Synthesising codes. Looking for patterns and themes. Data triangulation.

Figure - Activity Theory in ICU patient discharge process adopted from Engestrom (1987)

Rules

Subject

Tools

Objective

Community

Division of Labour

Discharge summariesComputer programs for bed management

Conflicting objectives across departments

RoutinesGuidelines and policiesCapacity alert

Bed cleanersDischarge script

Outcome

Distrusting relationships, teamwork, communication

ICU and ward doctors, nurses, ward clerks, etc

Findings – Description of The ICU Discharge Process

Themes & Subthemes (on teamwork and communication)

Communicating ineffectively among teams and departments Barriers of ICU to ward nursing handover. Communicating ineffectively between departments. Communicating insufficiently between medical and nursing teams

within departments. Working collaboratively to optimise the discharge process

Working beyond team and departmental boundaries for optimised discharge.

Pushing the discharge process forward. Nurses safe-guarding the discharge process to improve

communication among teams. Supporting inexperienced team members.

DiscussionSub-optimal communication may contribute to adverse events, and

discharge delays ICU to ward nursing handovers – followed a strong routine but need

standardised protocol and structure as suggested by the Australian Commission on Safety and Quality in Health Care (2010) and Australian Resource Centre for Healthcare Innovations (2009).

Tools’ design and use issues - such as computer programs were not used effectively to communicate vital information timely. The use of some tools was found to optimise coordinated patient care (Maloney, Wolfe, Gesteland, Hales, & Nkoy, 2007; Nicholls & Young, 2007).

The poor communication may have contributed to discharge delays .

The lack of interdisciplinary communication between doctors and nurses in ICU and on the wards may have patient safety implications (Alvarez & Coiera, 2006; Donchin et al. 1995; Nadzam, 2009; The Joint Commission, 2007).

Discussion

Collaborative teamwork optimised the discharge process Collaborative teamwork shortened ICU discharge delays, which

improved the efficient use of hospital resources and may optimise patient outcome (Valentin et al., 2006).

Supporting other team members (ICU nurses supporting junior doctors, ICU liaison nurse supporting ward nurses) are essential for better teamwork (Flin et al., 2008), which may contribute to better patient outcomes (Ball, Kirkby, & Williams, 2003; Chaboyer et al., 2005; Priestley et al., 2004).

Research limitations

Single setting. Researcher as instrument. Participants change of behaviour due to the observer’s presence.

Conclusion and Recommendations

Improve clinical communication Standardise clinical handover structure and protocol. Leadership involvement in improving interdisciplinary communication. Reinforce tools’ use in clinical communication using organisational

change principles. Redesign tools related to handover.

Encourage collaborative teamwork Adopt collaborative teamwork initiatives across the hospital.

Contributions of The Research Findings Interventions informed by the research findings were

implemented. Examples of the interventions: ICU to ward nursing handover process was redesigned, emphasis

was given to the face to face handover. Tools modified and implemented to facilitate communications. ICU provide predicted discharge date to the wards in order to help

the wards to plan patient care.

Outcome: shortened discharge delays (4.6 hours prior, and 1.0 post intervention), but no change to mortality.

(Chaboyer, et al., 2010, Submitted for publication)

Acknowledgement

The participants The hospital Queensland Health Clinical Practice Improvement Centre (CPIC)

funding The research group for the larger project Supervisors

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