Using Teamwork to Improve Patient Outcomes

2015 - 1 February – Team Science
Seth Bauer, PharmD, FCCM
Seth Bauer, PharmD, FCCM, discusses the role of teamwork in improving patients outcomes.



A team includes two or more people interacting interdependently toward a common goal. In the intensive care unit (ICU), the common goal is improved patient outcomes, often thought of as survival or discharge from the ICU. Additional goals such as liberation from mechanical ventilation and patient safety (prevention of adverse events) should not be overlooked, though. Teams may be formed across medical specialties or disciplines, and in the ICU often include physicians, nurses, pharmacists, respiratory therapists, dieticians, physical therapists, social workers, and others. Each of these caregivers has a specific role in patient care, and each can contribute positively to patient outcomes. In light of the benefits of multiprofessional critical care teams to patients and their families, team-based care is expressly included in the Society of Critical Care Medicine’s (SCCM) envisioned future statement and guiding principles for the organization and members.(1)

Teamwork can be described in many ways, but researchers have utilized an input, process/mediator and output framework to describe ICU team performance. In this framework, team and task characteristics are components of the inputs, transition and action processes are components of the process/mediator, and patient or team outcomes are components of the outputs.(2) Examples of transition processes include multidisciplinary patient care rounds and use of daily goals checklists. Patient care rounds are an important team activity where the patient’s plan of care is discussed formally and tasks prioritized. Initiation of patient care rounds has been associated with positive patient outcomes. For example, implementation of daily multidisciplinary rounds by the nursing staff, a physician, and a respiratory therapist to review a checklist of ventilator bundle goals for each patient decreased the incidence of ventilator-associated pneumonia (VAP) from 1.5 per month to 0.5 per month in a study of surgical trauma ICU patients.(3) Similar findings of a reduced VAP incidence with the institution of multidisciplinary patient care rounds were also observed in an open trauma ICU.(4) Daily patient care rounds led by an intensivist have been associated with decreases in hospital length of stay (LOS), hospital costs and postoperative complications.(5) Additionally, nurses’ reports of collaboration with physicians on the decision to transfer patients out of the ICU were positively associated with patient mortality.(6)
 
Completion of a daily patient-centered goals form during multiprofessional rounds was associated with an increase in the understanding of daily goals (>85% of nurses and medical residents) and decreased the average patient ICU LOS by about one day.(7) Although the study could not establish a causal relationship between the use of the goals form and a decrease in ICU LOS, the authors attributed the benefit to clarifying tasks, care plans and communication plans among caregivers.
 
In the Keystone ICU project, clinicians in 108 adult ICUs in Michigan adopted evidence-based procedures to decrease catheter-related bloodstream infections, including use of a checklist to ensure protocol adherence. The observed 66% reduction in the incidence of catheter-related bloodstream infection is well-known to ICU clinicians. It is easily overlooked, though, that in addition to the study procedures, the ICUs also implemented the use of daily goals sheets to improve clinician communication, and implemented a unit-based safety program to improve safety culture, which may also have positively impacted the study results.(8)

The benefit of checklists has also been demonstrated in pediatric ICUs. In one study, implementation of a rounding checklist in a pediatric ICU was associated with fewer accidental extubations.(9) Many institutions have adopted checklists for patient care with positive results, but ensuring compliance with checklist completion may be challenging and overuse of checklists should be avoided.(10)

Interestingly, although interventions to improve teamwork and perceptions of caregiver teamwork have been associated with reductions in intermediate endpoints (i.e., patient LOS), an association with patient mortality has not been consistently demonstrated. Additionally, ICUs with higher levels of teamwork do not reliably perform better when compared with ICUs with lower levels of teamwork.(11) These inconsistent findings regarding the influence of teamwork on patient mortality are likely due to confounding or lack of adequate study power and should be addressed in future studies. Improvements in the quality of teamwork have been associated with a broad variety of positive patient outcomes, and efforts to improve teamwork within an ICU should be investigated and implemented as much as possible.
 
While improved team interactions have been associated with positive patient outcomes, poor team interactions have been associated with ICU adverse events. In an observational single-center study, communication events between nurses and physicians comprised only 2% of observed activities in the ICU, but were associated with 37% of errors.(12) A similar finding was observed in a multicenter study where poor teamwork contributed to 32% of patient safety incidents.(13) About half of all ICU adverse events are adverse drug events (ADEs).(14) Patients experiencing two or more ADEs have a threefold increase in the risk of ICU death(15) and half of all ADEs occur at the prescription stage.(16) Medication errors may be prevented by the inclusion of a pharmacist as an ICU team member. In one study from the United States where pharmacists were present at the time of medication prescription (either during patient care rounds or for consultation in the ICU), a 66% reduction in the number of preventable ADEs was observed.(17) Similarly, in a Dutch study, ICU hospital pharmacist review of admission orders was associated with a 75% reduction in preventable ADEs.(18) Furthermore, the presence of clinical pharmacists in ICUs has been associated with a shorter time to liberation from mechanical ventilation,(19) lower mortality rates, and shorter ICU LOS in patients with infections.(20)

In conclusion, the complexity of the care of critically ill patients requires a coordinated team effort. Practitioners in the ICU should seek opportunities to improve teamwork in their own institutions. Team efforts such as multidisciplinary patient care rounds and a checklist with patient care goals may improve patient outcomes and avoid adverse events.

References:

1. Society of Critical Care Medicine. About SCCM: Strategic Plan. Available at: http://www.sccm.org/About-SCCM/Pages/Governance.aspx. Accessed December 12, 2014.
2. Dietz AS, Pronovost PJ, Mendez-Tellez PA, et al. A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies? J Crit Care. 2014;29(6):908-914.
3. Stone ME Jr., Snetman D, O'Neill A, et al. Daily multidisciplinary rounds to implement the ventilator bundle decreases ventilator-associated pneumonia in trauma patients: but does it affect outcome? Surg Infect (Larchmt). 2011;12(5):373-378.
4. Johnson V, Mangram A, Mitchell C, Lorenzo M, Howard D, Dunn E. Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia? Am Surg. 2009;75(12):1171-1174.
5. Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA. Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection. Crit Care Med. 2001;29(4):753-758.
6. Baggs JG, Schmitt MH, Mushlin AI, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med. 1999;27(9):1991-1998.
7. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-75.
8. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.
9. Sharma S, Peters MJ. 'Safety by DEFAULT': introduction and impact of a paediatric ward round checklist. Crit Care. 2013;17(5):R232.
10. Hales BM, Pronovost PJ. The checklist--a tool for error management and performance improvement. J Crit Care. 2006;21(3):231-235.
11. Reader TW, Flin R, Mearns K, Cuthbertson BH. Developing a team performance framework for the intensive care unit. Crit Care Med. 2009;37(5):1787-1793.
12. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23(2):294-300.
13. Pronovost PJ, Thompson DA, Holzmueller CG, et al. Toward learning from patient safety reporting systems. J Crit Care. 2006;21(4):305-315.
14. Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8):1694-1700.
15. Garrouste-Orgeas M, Timsit JF, Vesin A, et al. Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II. Am J Respir Crit Care Med. 2010;181(2):134-142.
16. Valentin A, Capuzzo M, Guidet B, et al. Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care Med. 2006;32(10):1591-1598.
17. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282(3):267-270.
18. Klopotowska JE, Kuiper R, van Kan HJ, et al. On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study. Crit Care. 2010;14(5):R174.
19. Marshall J, Finn CA, Theodore AC. Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay. Crit Care Med. 2008;36(2):427-433.
20. MacLaren R, Bond CA, Martin SJ, Fike D. Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections. Crit Care Med. 2008;36(12):3184-3189.