The Pre-Induction Huddle

Author: Bronwyn Cooper, M.D.

ASA Monitor 03 2017, Vol.81, 12-13.

Bronwyn Cooper, M.D., is Director of Quality and Patient Safety, University Campus, University of Massachusetts Medical Center, Worcester, Massachusetts.

Bronwyn Cooper, M.D., is Director of Quality and Patient Safety, University Campus, University of Massachusetts Medical Center, Worcester, Massachusetts.

Anesthesiology has led the patient safety movement in medicine. One relatively new area of the past several years is the idea of briefing prior to a surgical procedure. In 2009 the World Health Organization published a three-pronged checklist that would ensure patient safety and better communication. The first should be performed pre-induction and is also called the briefing or “huddle.” The second is the “time out,” which is done pre-incision. The third is the “debrief” performed before the patient leaves the O.R.; it is intended primarily for continued quality improvement and identification of root causes. The time out has become necessary and is reviewed in each hospital by the Joint Commission. The huddle, as well, is fast becoming standard-of-care in many hospitals across the country.

The Joint Commission reported up to 70 percent sentinel perinatal events involving patient mortality or permanent disability caused by at least one communication breakdown. In 2011-13, the Joint Commission found in more than 60 percent of cases that poor communication was the root cause of an adverse event. Overall from 2004-13, at least 50 percent of cases were due to poor communication. Perhaps the first and primary goal of the huddle on labor and delivery is multidisciplinary communication in a structured framework, sharing and reviewing information and coordinating plans for patient care.

Multiple studies have shown that the huddle has some of the following positive effects: identification of errors and near-misses, the chance to raise any concerns that are patient-specific, ability to enrich the multidisciplinary relationship striving toward a common goal, information sharing and, most important, patient safety. There is an increased accountability of all team members: obstetrician, OB resident (in a teaching hospital), circulating nurse (who usually leads the huddle in many hospitals), the anesthesiologist, the nurse anesthetist, the anesthesia resident, and the scrub nurse or technician. Some hospitals have even demonstrated improvement in on-time first case starts, which has been shown to lead to less rushing and increased availability of providers. Seniority and hierarchy matters none in this team approach. Anyone may have some relevant knowledge that others may not have, which will lead to better care of the pregnant patient.

Besides the relevance of the WHO checklist with the three components, many hospitals have adopted formal training of TeamSTEPPS, which is an evidence-based set of teamwork tools aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals – hence, also the multidisciplinary approach. There are three potential team competency outcomes within this training: 1) performance, 2) attitudes and 3) knowledge. Within this triad, there is leadership, situation monitoring, mutual support and communication. Under “knowledge” is a shared mental model. Under “attitudes” is mutual trust and team orientation. And under “performance” is adaptability, accuracy, productivity, efficiency and, most important of all, safety. One additional vital concept in TeamSTEPPS is SBAR, which stands for situation, background, assessment and recommendation. This is a technique for communicating critical information. In the huddle, all of these aspects are highly important pieces of information.

What exactly is included in the huddle on labor and delivery? Different institutions have designed their own elements that are specifically tailored to their requirement. And this is exactly how the WHO envisioned it to be. Table 1 answers the question and gives an example from a condensed version of what many centers around the U.S. are currently using.

There may be other concerns such as I.V. access, amount of fluids administered, I.V. infusions such as pitocin or magnesium sulfate, epidural status (working versus requiring multiple boluses), baseline vital signs, other lab tests sent, and time of last antibiotic. Both the Society for Obstetric Anesthesia and Perinatology and the Anesthesia Patient Safety Foundation have written similar articles on this topic and are referenced below.

In conclusion, more studies need to be performed on labor and delivery to demonstrate the potential benefits of the huddle, such as improved communication, increased provider satisfaction, decreased errors and sentinel events/near-misses, and on-time starts. Some studies have even suggested an improvement in patient satisfaction and feeling of decreased anxiety, while others have shown a decrease in provider burnout. Even prior to the Surgical Safety Checklist, the Joint Commission in 2007 released a National Patient Safety Goal to improve communication among caregivers. Currently, many institutions do not perform a huddle at all or at least not during emergency/STAT/code white Cesarean sections when errors and lack of communication can be at their highest because of chaos and pressure in the delivery room. At this point, a modified huddle in the delivery room, including the NICU staff, would be extremely helpful, possibly led by the obstetrician (in a loud voice). In a true emergency, it is usually the time C/S is called for delivery of the baby, which everyone on the team is trying to make asshort as possible. The huddle, on the other hand, could take only a minute or less in an abbreviated form, possibly done while checking the FHR, and save the mother and baby harm and decrease the amount of chaos, especially in high-risk settings. This is the direction in which we are all moving forward together.

Bibliography:

Dadiz R, Weinschreider J, Schriefer J, et al. Interdisciplinary simulation-based training to improve delivery room communication. Simul Healthc. 2013;8(5):279–291.

Preventing infant death and injury during delivery. Jt Comm Perspect. 2004;24(9):14–15.

SOAP Patient Safety Committee, Kacmar R (ed). Every woman who delivers by cesarean deserves a pre-operative huddle: “how we do it” expert opinion. Society for Obstetric Anesthesia and Perinatology (SOAP) website. https://soap.org/expert-opinions-every-woman.php. Last accessed January 13, 2017.

Kacmar RM, Mhyre JM. Obstetric anesthesia patient safety: practices to ensure adequate venous access and safe drug administration during transfer to the operating room for emergency cesarean delivery. APSF Newsletter. 2015;30(2):23–24,42.

Lyndon A, Zlatnik MG, Wachter RM . Effective physician-nurse communication: a patient safety essential for labor and delivery. Am J Obstet Gynecol. 2011;205(2):91–96.

Saver C . Multiple OR multidisciplinary team huddles promote ownership of process improvements. OR Manager. 2014;30(4):24–25.

Wright JG, Rock A, Khoury AE . Improving on-time surgical starts in an operating room. Can J Surg. 2010;53(3):167–170

TeamSTEPPS®: 2013 Conference Materials. Agency for Healthcare Research and Quality website. http://www.ahrq.gov/teamstepps/national-meeting/2013-conference-materials. Published November 2014. Reviewed March 2015. Last accessed January 13, 2017.

World Alliance for Patient Safety. WHO surgical safety checklist and implementation manual. Geneva, Switzerland: World Health Organization; 2008. http://www.who.int/patientsafety/safesurgery/ss_checklist/en. Last accessed January 13, 2017.

Brock D, Abu-Rish E, Chiu CR, et al. Interprofessional education in team communication: working together to improve patient safety. Postgrad Med J. 2013;89(1057):642–651.

Kawano T, Tani M, Taniwaki M, Ogata K, Yokoyama M . A preliminary study of patients’ perceptions on the implementation of the WHO surgical safety checklist in women who had Cesarean sections. J Anesth. 2015;29(3):459–462.

Sweeney J, Maietta R, Olson K . An analysis comparing “Sim Huddles” to traditional simulation for obstetric emergency preparedness. Nurs Womens Health. 2015;19(1):16–25

Hullfish KL, Miller T, Pastore LM, et al. A checklist for timeout on labor and delivery: a pilot study to improve communication and safety. J Reprod Med. 2014;59(11-12):579–584.

Govindappagari S, Guardado A, Goffman D, et al. Is communication improved with the implementation of an obstetrical version of the World Health Organization Safe Surgery Checklist [published online ahead of print September 8, 2016]? J Patient Saf.