194 - Implementation and outcomes of an improvement effort focused on teamwork on an inpatient acute care pediatric neurosurgery service

Poster Number: 194
Publication Number: 194.143

Emily Levoy, Stanford University, Menlo Park, CA, United States; Amelia M. Sperber, Lucile Packard Children's Hospital Stanford, San Jose, CA, United States; May Casazza, Lucile Packard Children's Hospital Stanford, Stanford, CA, United States; Diana Poon, Lucile Packard Children's Hospital Stanford, Fremont, CA, United States; Jennifer Vargas, Lucile Packard Children's Hospital, Stanford, South San Francisco, CA, United States; Sandra Yang, Lucile Packard Children's Hospital Stanford, Daly City, CA, United States; Gerald Grant, Stanford University, Stanford, CA, United States; Sara J. Singer, Stanford University School of Medicine, Stanford, CA, United States; Nivedita Srinivas, Stanford University School of Medicine, Divisions of Pediatric Hospital Medicine and Infectious Diseases, Palo Alto, CA, United States

Background: Effective teamwork is essential for patient safety. Increased patient safety reports related to teamwork between pediatric neurosurgery (PNSGY) physicians, advanced practice providers (APPs) and nurses on acute care at a quaternary children’s hospital prompted an institutional improvement effort focused on teamwork in 2020.

Objective: To describe the implementation and outcomes of a project to improve teamwork between physicians, APPs and nurses on a pediatric neurosurgery acute care service.

Design/Methods: A multidisciplinary team including PNSGY nurses, APPs and physicians met twice monthly. A 16-item survey was developed using modified validated questions measuring teamwork in 7 domains, piloted and disseminated to all PNSGY nurses, APPs and physicians to measure teamwork and identify improvement opportunities. Structured survey debriefing sessions followed to promote multidisciplinary discourse on teamwork issues. Nursing-centered training on PNSGY clinical topics was identified as an area of need and educational interventions were developed and implemented (Figure 1). A follow-up survey was conducted one year later and results were compared using t-tests and chi-squared tests. Nurses also ranked the top 3 most effective interventions.

Results: Response rate at baseline was 84% (58/69) and 71% (50/70) on follow-up. Nurses at baseline had lower ratings of teamwork for 12 survey items versus physicians and APPs (p < 0.05). After interventions, improvements were seen amongst nurses in: “using ‘we’ rather than ‘they’” (21% vs. 51%, p=0.003), “shared understanding of each other’s role on the team” (59% vs. 78%, p = 0.03), “I am confident that this team works effectively” (47% vs. 80%, p = 0.001) and “getting others on the team to listen” (47% vs. 76%, p=0.004), corresponding to improvements in domains of Team Identity, Team Confidence, Shared Knowledge and Personal Sense of Power. The average Teamwork score on a 7-point Likert scale improved from 4.12 to 5.25 (p < 0.0001). Decreases were seen in total (35 to 27) and teamwork-related (23 to 13) PNSGY safety reports after interventions. The 3 most effective teamwork interventions were: interprofessional training (35/41, 83%), “Buzz of the Month” clinical pearls (14/41, 34%), and structured opportunities to discuss teamwork (10/41, 24%).Conclusion(s): Nurses had discrepant views of teamwork from physicians and APPs at baseline. Interprofessional training, administration of a teamwork survey and structured debriefing resulted in improvements in several teamwork domains by nurses and a trend toward fewer reported safety events.
Table 1: Demographics of survey respondents.
Figure 1: Timeline of Pediatric Neurosurgery Teamwork Project InterventionsThe teamwork project was launched in November 2020 and included the following interventions:
New hire interprofessional onboarding training: trainings including in-person simulations with an opportunity to interface with PNSGY faculty and APPs.
Escalation protocol: dissemination of standardized expectations regarding nursing escalation of clinical concerns to PNSGY residents, APPs, fellows, and attendings including contact information and expectations regarding response time.
Survey debrief sessions: held with residents, nurses, faculty and APPs to discuss the PNSGY teamwork survey results, including the discrepant perceptions of teamwork between nurses and PNSGY physicians and APPs, and to identify additional areas for improvement.
Neuroscience fair: day-long event with pediatric neurosurgery education stations for nurses staffed by faculty and APPs.
“Buzz of the Month” educational topic: Monthly clinical PNSGY pearl for nurses distributed by email and discussed at nursing huddles.
Regular Outreach with PNSGY faculty and APPs: regular attendance at nursing huddles and staff meetings by PNSGY faculty and APPs to discuss pediatric neurosurgery topics and updates in management.
Teamwork project meetings: Bimonthly multidisciplinary improvement team meetings to discuss teamwork progress and additional areas for opportunity.