NURSE-PATIENT COMMUNICATION, INTERDISCIPLINARY COMMUNICATION, AND PATIENT SAFETY

In Our Unit

80 CriticalCareNurse Vol 36, No. 6, DECEMBER 2016 www.ccnonline.org

C
ommunication among team members on a critical care unit is

integrally linked to patient safety.1 When the critical care unit at

Chambersburg Hospital (Chambersburg, Pennsylvania) moved

into the new wing in December 2012, it became apparent that the new

layout was less conducive to facilitating staff interactions than the old

layout had been. The team needed to adapt to preserve patient safety.

The prior unit was designed with a hub-and-spokes layout. Nurses

congregated in the central nursing station to view the cardiac monitors,

document, and obtain medications, enabling constant interactions. The

new critical care unit was constructed in a horseshoe arrangement, with

small working pods between each pair of patients’ rooms—complete with

computers for documentation and medication drawers. Nurses were

encouraged to stay in their “pods” to remain closer to their patients.

Although this new design improved the environment for patients,

critical care staff began struggling with open communication. Thus,

staff made efforts to overcome the hurdles created by their new envi-

ronment. Communication boards were developed within the break

room, e-mails were sent, and staff meetings were held, despite the fact

that bedside staff members’ schedules were not well-suited to structured

meetings.2 Meeting attendance was low, not all e-mails were read, and

boards were infrequently updated. Communication barriers prevailed.

Staff voiced concerns regarding their lack of knowledge about the

environment. Each nurse knew a great deal about his or her 2 assigned

patients in the 18-bed unit, but the nurses were no longer passively

acquiring information about the census of the unit, patients with safety

concerns such as fall risks, patients requiring mechanical ventilation,

or the number of nursing attendants available on the floor. Everyone

was working in relative isolation,

which was not conducive to func-

tioning as a team.

Implementing a Solution
After multiple strategies to improve

communication had failed, unit lead-

ers decided to implement an informal

morning huddle to review staffing.

The unit’s nurse manager had used

this type of effective communication

while leading another unit, and she

was excited to begin using it in the

critical care unit. The new huddle

format began in October 2013, but

was noted to be infrequent and

dependent on which staff member

was in the resource role. Despite the

infrequency, multiple staff members

realized the effectiveness of the brief

staffing huddle, especially in the

way it enabled staff to work together

more cohesively in the decentralized

unit. The positive feedback drove the

team to make the infrequent huddle

a more permanent event. By June 2014,

the preshift huddle was performed

at every shift change, becoming stan-

dard work for every resource nurse

or clinical manager.

This routine gathering of off-going

and oncoming shifts presented an

opportunity to share more than just

staffing information. Material that had

previously been distributed solely in

e-mail format—such as patient safety

Colleen Kylor, RN, BSN, CCRN
Teresa Napier, RN, PCCN
Amber Rephann, RN, BSN
Sara Jane Spence, RN, BSN, BSE, CCRN

Implementation of the Safety Huddle

Authors
Colleen Kylor, Teresa Napier, Amber Rephann, and Sara Jane Spence are nurses,
Chambersburg Hospital, Chambersburg, Pennsylvania.

Corresponding author: Amber Rephann, RN, Chambersburg Hospital, 112 N. Seventh St, Chambersburg,
PA 17201 (e-mail: [email protected]).

To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses,
101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949)
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©2016 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2016768

www.ccnonline.org CriticalCareNurse Vol 36, No. 6, DECEMBER 2016 81

or unit initiative information—

started to be reviewed, facilitating

discussion and increasing retention

for the auditory learners. E-mails

were printed and kept in a “huddle

folder” at the nursing station. Each

printout was dated with a start day

for the specific topic and the date

to retire it. Initially, the folder dura-

tion was 2 weeks for each item, so

that even those staff members work-

ing occasionally would be exposed

to the information. However, it was

noted that the quantity of printouts

became excessive and was perceived

as cumbersome to most staff mem-

bers present, so the “folder time” was

decreased to 1 week. In January 2015,

the decision was made to place all

retiring information into a binder,

thus allowing occasional staff, as

well as those on leave or vacation,

to have access to the information.

The huddle binder also serves as

an archival resource.

Once the safety huddle was in

full swing, it became common

procedure for staff to present to

the nursing station before their

shift. Leaders (formal and informal)

would announce the start of huddle,

signaling everyone to gather and

give their attention to the speaker.

The team was encouraged to become

engaged. A standardized start time

of 5 minutes before the start of the

shift was initiated and upheld. When

a clinical manager was not present

on the unit, the huddle was being

completed by resource staff. It was

incredible to see how the huddle

developed into a standard part of

the work day.

Evolution of the Process
Allowing for continuous feed-

back is necessary to maintain a

sense of buy-in. Although things ran

smoothly, there was some feedback

that information presented focused

on mistakes or near misses that

occurred on the critical care unit

or on other units. Although this

information is crucial for preventing

future events and encouraging staff

involvement in developing solutions,

some staff felt they were bombarded

with “all the things they do wrong.”

Because the intention of the safety

huddle was to share information and

create a positive, collaborative envi-

ronment, leaders were concerned with

the new perception. Success stories

and education were incorporated

into the daily huddles and thank

you cards from patients and families

were shared to provide a balance.

With the addition of so many

types of information, huddle dura-

tion started to run longer, resulting

in an increase in overtime for many

nurses. In response to this dilemma,

the length of the huddle was limited

to 5 minutes. Any item not addressed

within the time frame was skipped,

although exceptions were made for

constructive discussions.

As the huddle developed into a

well-functioning communication

tool, attendance at staff meetings

dropped—all of the information

provided at these monthly meet-

ings repeated what had been

shared at huddles. Thus, in April

2015, the nurse manager aban-

doned the traditional model and

implemented the monthly “virtual

staff meeting.” The contents of

the huddle binder were scanned

and uploaded to the department

intranet on a monthly basis. These

data were condensed into a sum-

mary and distributed via e-mail

as a virtual staff meeting.

Expansion of a Culture
As time passed, the change-

of-shift huddle model spread through-

out the facility. When other manag-

ers, including top nursing leaders,

learned of the critical care unit’s

successes, adoption of this format

was encouraged on all other units.

Through invitation, other disci-

plines began to get involved in the

nursing huddles as well. Providers,

quality management staff, and other

guest speakers now attend on a reg-

ular basis—both to present informa-

tion and to participate in discussion.

Throughout the hospital, the safety

huddle has become the reference

standard for disseminating informa-

tion and is being adapted into other

areas of practice, including postfall

assessments, initial skin assessments,

and pressure ulcer identification.

Many important factors must

be considered to create and sustain

a new practice, and team buy-in is

arguably one of the most important.

Although team buy-in can be elusive,

and achieved in varying degrees,

success lies in management. When

managers encourage feedback from

front-line staff, and adapt to that

feedback, staff are empowered and

are more likely to participate in new

initiatives. The entire process is and

continues to be a journey.

Conclusion
The Joint Commission has iden-

tified communication failure as the

cause of more than 80% of serious

medical errors.3 Communication

in the busy acute care setting can

sometimes be challenging, and its

value overlooked. The huddle

increases effective communication

among members of the heath care

team,4 reducing errors due to

82 CriticalCareNurse Vol 36, No. 6, DECEMBER 2016 www.ccnonline.org

miscommunication and supporting a

culture of patient safety. The critical

care unit at Chambersburg Hospital

is proud to share our huddle journey.

Together, we have created and con-

tinue to develop this strategy for

effective communication, focused on

team work, safety, and quality. ���

Financial Disclosures
None reported.

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References
1. Brady PW, Muething S, Kotagal U, et al.

Improving situation awareness to reduce
unrecognized clinical deterioration and
serious safety events. Pediatrics. 2013;
131(1):e298-e308.

2. Traynor K. Pharmacists say safety huddles
aid problem solving. Am J Health Syst Pharm.
2015;72(10):766,768.

3. The Joint Commission. About the Center
for Transforming Healthcare. http://www
.jointcommission.org/about_us/about
_cth.aspx. Published February 20, 2013.
Accessed December 22, 2013.

4. Glymph D, Olenick M, Barbera S, Brown E,
Prestianni L, Miller C. Healthcare Utilizing
Deliberate Discussion Linking Events
(HUDDLE): a systematic review. AANA J.
2015;83(3):183-188.

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