Interdisciplinary Teamwork:
An Essential Ingredient for Improving Outcomes
The event
During a training exercise, a simulated patient with community-acquired pneumonia was admitted to a medicine ward and began exhibiting mild tachycardia and fever coupled with increasing leukocytosis and oxygen requirements. The nurse assessed the patient but elected not to communicate the changes until the patient's blood pressure dropped to 88/48 mm Hg (baseline 120/84 mm Hg). The nurse then called the intern to report the vital sign changes but did not communicate what she thought was going on with the patient. The intern came to evaluate the patient, ordered a 500 cc IV normal saline bolus and reviewed current antibiotic coverage. He did not communicate a diagnosis. Before leaving, the intern informed the nurse to call again if the BP did not return to normal after the fluid challenge.
The simulated patient in this exercise displayed signs and symptoms of severe sepsis which warranted serial serum lactate levels, pan cultures, and aggressive IV fluid resuscitation along with transfer to a monitored inpatient unit to improve the outcome.
Critical analysis
A key competency of interdisciplinary teamwork is calling for help early if one is unsure about what is causing changes in a patient's condition. In this training exercise, the nurse elected not to consult with the unit resource nurse or notify the medicine team until the patient exhibited hypotension. Nor did the intern call his senior resident to discuss this patient. An early consult with a clinical expert often helps to clarify the diagnosis and treatment options to prevent complications.
SBAR (Situation-Background-Assessment-Recommendation) is an essential method to communicate a patient problem among the healthcare team. In this exercise, the nurse relayed changes in vital signs but did not provide salient background information or an assessment of what was going on with the patient. Without this information, the intern was limited in conjecturing what could be causing the patient's problem while responding.
Talking out loud among team members is a competency that promotes situational awareness which helps to advance thinking about the diagnosis and care required. During this exercise, the nurse and intern rarely conversed with one another, missing the opportunity to include severe sepsis in the differential diagnosis and place appropriate care orders. Talking out loud supports team members' ability to provide safe care.
"Highly effective teams exhibit knowledge, skill and attitude competencies that impact patient outcomes," said Clarence Braddock III, MD, MPH, Medical Director of Graduate Medical Education and Associate Dean for Medical Education at Stanford's School of Medicine. "Quality healthcare today is a team-based effort and the new era in health care demands integrating team training through continuing education. As an academic medical center, with monthly resident rotation, we face unique challenges in building ongoing excellence in team performance."
In 2010, the SHC TRANSFORM Program began providing interdisciplinary simulation training on select inpatient units (i.e., B2, B3, D1CSU, E3) to improve teamwork performance and reduce complication and mortality rates. "While many hospitals exclusively focus team training efforts on high-risk, infrequent clinical scenarios such as resuscitation, we're focused on early detection and treatment of hospital-acquired complications to impact everyday team performance and clinical outcomes," said Nancy Szaflarski, PhD RN, Program Director of Clinical Effectiveness Innovations and the project's innovator. "Thus far, we've achieved significant improvement in safety culture, teamwork climate and clinical outcomes. As importantly, we have been able to sustain the gains with regular training to maintain team performance," said Szaflarski. Braddock and Szaflarski are contemplating how to spread team training throughout other inpatient areas.
"Team training is a hallmark of healthcare organizations committed to improving quality, safe care," Braddock said. "The TRANSFORM Program is a valuable step toward improving performance of our clinical teams at the frontline of care."