RESEARCH ARTICLE

Implementation of a Communication Bundle forHigh-Risk PatientsMichelle W. Parker, MD,a Matthew Carroll, MD,b Benjamin Bolser, MD,a Janelle Ballinger, RN,c John Brewington, MD,d Suzanne Campanella, MPH,e

Andrew Davis-Sandfoss, BS,f Karen Tucker, RN,c Patrick W. Brady, MD, MSca,g

A B S T R A C T BACKGROUND: Interventions that facilitate early identification and management of hospitalizedpediatric patients who are at risk for deterioration are associated with decreased mortality. In ourlarge pediatric hospital with a history of success in decreasing unrecognized deterioration, patientsat higher risk of deterioration are termed “watchers.” Because communication errors oftencontribute to unrecognized deterioration, clear and timely communication of watcher status to allteam members and contingency planning was desired.

OBJECTIVES: Increase the percentage of eligible watchers with a complete communication,teamwork, and planning bundle within 2 hours of identification from 28% to 80%.

METHODS:Watchers admitted to Hospital Medicine on 2 targeted units were eligible. Stakeholderswere educated to facilitate ownership. Daily data analysis enabled real-time failure identification.Automated physician notification provided reminders for timely communication.

RESULTS: The percentage of watchers with a complete situation awareness bundle within 2 hoursincreased from 28% to 81% and was sustained for more than 2 years. There was no change in ratesof rapid response team calls or ICU transfers on our intervention units, but these both increasedthroughout the hospital. Education facilitated modest improvement, with marked improvementsand sustainment through use of technology.

CONCLUSIONS: A novel bundle that included contingency planning and communicationexpectations was created to improve situation awareness for watchers. Multidisciplinary engagementand use of automated technology facilitated by an electronic health record helped implement andsustain bundle adherence.

aDivisions of HospitalMedicine, cPatient

Services Administration,and dPulmonary

Medicine, and gJames M.Anderson Center for

Health SystemsExcellence, Cincinnati

Children’s HospitalMedical Center,

Cincinnati, Ohio; bDivisionof Hospital Medicine,

Cook Children’s MedicalCenter, Fort Worth, Texas;eRollins School of PublicHealth, Emory University,

Atlanta, Georgia; andfCollege of Medicine,

University of Cincinnati,Cincinnati, Ohio

www.hospitalpediatrics.orgDOI:https://doi.org/10.1542/hpeds.2016-0170Copyright © 2017 by the American Academy of Pediatrics

Address correspondence to Michelle W. Parker, MD, Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center,3333 Burnet Ave MLC 3024, Cincinnati, OH 45229-3039. E-mail: michelle.parker@cchmc.org

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Dr Brady is supported by a Patient-Centered Outcomes Research Mentored Clinical Investigator Award from the Agency forHealthcare Research and Quality (award K08HS023827).The content is solely the responsibility of the authors and does not necessarilyrepresent the official views of the funding organizations. The funding organizations had no role in the design, preparation, review, orapproval of this paper; nor the decision to submit the manuscript for publication.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Drs Parker, Bolser, Brewington, and Brady and Ms Ballinger conceptualized and designed the study and drafted the initial manuscript;Dr Carroll, Ms Campanella, and Mr Davis-Sandfoss conducted the initial analyses and reviewed and revised the manuscript; Ms Tuckerconceptualized and designed the study and critically reviewed the manuscript; and all authors approved the final manuscript assubmitted.

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Interventions facilitating early identificationand management of hospitalized childrenat risk for deterioration, such as rapidresponse teams (RRT), are associatedwith decreased mortality andcardiopulmonary arrest rates.1–4

Over the previous 5 years, our institutionhas designed interventions to improvesituation awareness (SA), defined as“the perception of elements in theenvironment within a volume of timeand space, the comprehension of theirmeaning, and the projection of theirstatus in the near future.”5–7 Previousinterventions, including standardizedsafety huddles, proactive risk assessment,and tools to aid in robust contingencyplanning, led to a significant, sustaineddecrease in unrecognized clinicaldeterioration and serious safety events(SSEs) among inpatients.1

Root cause analyses of preventable adverseevents often list communication errors as aleading contributor to mistakes.3 Despiteencouraging advances to improveprocesses designed for better SA, we foundthat we were not reliably communicatingand documenting plans on our highestacuity patients outside of the ICU, whomwe call “watchers.” This term is broadlyused across our institution; however, theprocess for determining watcher statusand the actions following watcherdetermination were variable andunreliable on Hospital Medicine (HM) andnon-HM units. Common communicationchallenges that occurred before our workincluded involvement of only some teammembers in the discussion of watcherdetermination and failure to establish aclear contingency plan and criteria forescalation of care. We believed that becausethe identification of high-risk status wasinsufficient to alter the trajectory ofdeterioration, a robust effector arm tocommunicate about, document, andultimately mitigate patient risk wasnecessary.

Our specific aim with this study was toincrease the percentage of eligible watcherswith a complete communication, teamwork,and planning bundle within 2 hours ofwatcher identification from 28% to 80%.

METHODSHuman Subjects Protection

Our project was undertaken in accordancewith institutional review board policy onsystems improvement work and did notrequire formal review.

Setting

In our large, academic medical center, carefor HM patients occurs primarily in 2 unitsand is provided by teams of residentssupervised predominantly by pediatrichospitalists and rarely by community-basedpediatricians. Our patients included thosewith medical complexity, neurologicimpairment, and diseases like bronchiolitiswith high rates of deterioration and needfor ICU care. Reflective of the acuity of HMpatients, the baseline rate of RRT calls andICU transfers for HM units was ∼150% ofthe baseline rate of RRT calls and ICUtransfers for non-HM units in aggregate.Hospitalists are in house until midnight andon call 24 hours a day. Data for this qualityimprovement (QI) initiative were collectedfrom November 5, 2012, to December 31,2015. Two HM units comprise 11% ofthe institutional beds. RRT calls fordeteriorating patients facilitate discussionbetween the floor and ICU teams todetermine if transfer to a higher level ofcare is indicated.

Planning the Intervention

One HM attending physician and a clinicalmanager charge nurse co-led amultidisciplinary team that includedanother HM attending physician, a researchassistant, a chief pediatric resident, HM unitbedside nurses, and 2 QI coaches. The teammapped the existing process ofcommunication and planning for high-riskpatients, characterized barriers to timelycompletion of the process, identified keydrivers of watcher identification anddocumentation (Fig 1), and developedinterventions to meet its aim.8 Processadherence was tracked on run charts.Eligible patients were younger than 18 yearsold and admitted to the HM service in 1 of2 target nursing units. For our project, weconsidered a patient a watcher if he or shewas identified as such in the electronichealth record (EHR) or received an RRT call

without previous watcher identification.Patients transferring to the ICU within4 hours of admission to the floor wereexcluded because the priority for theserapid transfers was smooth transfer to theICU and not mitigation planning ordocumentation on the floor, which was aprimary target of the bundle we created.

To standardize communication andcontingency planning, we created a bundleof expectations following designation ofwatcher status. The bundle initiallyconsisted of the following 5 components,with all documentation componentscompleted in the EHR: (1) identification ofthe patient as a watcher in the EHR bynursing staff; (2) documentation ofphysician awareness of watcher status; (3)documentation of respiratory therapistawareness of watcher status; (4)completion of a structured SA note by anyphysician on the care team, detailing theclinical concern and contingency planning;and (5) documentation within the SA notethat the family was notified of the patient’sstatus change. A successful bundle requiredcompletion of all components within 2 hoursof the patient being designated a watcher orwithin 4 hours for patients newly admittedto the floor because of the additionalclinical evaluation required in thosecircumstances. Because of their frequentinteraction with patients, bedside nursestypically were the first to notice a concernmeriting potential watcher status. Abroader goal of the bundle, not directlymeasured, was for a bedside evaluation tooccur between the nurse, physician, andfamily to discuss watcher concerns,including appropriateness of watcherdesignation.

Improvement Activities

Education

Several interventions addressed thechallenge of monthly changes in residentstaffing. To improve ownership of thisnew process, our team presented to theentire resident group at a regularlyscheduled meeting and discussed theglobal concepts of SA and the specific goalsof the project. After this orientation, eachHM team received a written and in-personsummary that was included in previously

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established, rotation-specificcommunication. A flyer summarizing keyinformation was placed in residentworkrooms. The project goals andinterventions were also reviewed atdivisional HM meetings, given the attendingphysicians’ involvement in discussions ofwatcher designation and contingencyplanning.

To spread knowledge of the new process tothe nursing staff, we used a variety of

educational methods, including a flyerposted in a high-traffic area summarizingthe nursing responsibilities and just-in-time,face-to-face education during daily nursingshift huddles and monthly staff meetings.

Process Integration

To facilitate successful completion of thephysician SA note, our team capitalized onthe existing EHR to create a structured SAnote template (Fig 2) that would allow the

physician to quickly communicate thepertinent information.

We trialed multiple strategies to integrateour project into the workflow of the nursingstaff. Because the charge nurses alreadyheld the responsibility for communication ofSA concerns within the institutional safetyhuddles,1,9 we tested the modification of anexisting SA concern checklist (SupplementalFig 6). We added a check box fordocumentation of watcher designation inthe EHR, which also served as a visiblereminder of the project. In our EHR,customizable tabs on the nursing displayprovide streamlined shortcuts for chartingresponsibilities. We met with each nurse toensure that the “SA Concerns” tab wasdisplayed in their EHR view.

Identification and Education

We employed mitigation strategies for thefirst 18 months of the project. Residentphysicians who did not successfullycomplete the physician portion of the SAbundle were approached within severaldays of the failure to elicit reasons for thebarrier. Categorization of these reasonsinformed the modification of the educationprocess. Residents who successfullycompleted the physician portion of the SAbundle were recognized in the weeklyresidency newsletter. A similar strategyof individually contacting nurses wasemployed. Biweekly run charts summarizingeach resident team’s successful completionof the physician bundle measures weredisplayed in common residency spaces toprovide feedback on the team’sperformance.

Automation of Communication

To achieve a higher-reliability intervention,we partnered with the Information Services(IS) department to create a novel,automated paging system. IS had previouslycreated a function that uses informationfrom the EHR and monitors changes topatient status, such as new SA concerns,at 5-minute intervals. For our project, ISgenerated a program to retrieve data fromthis existing process and send an alert pageto the resident and respiratory therapistwhen a patient was designated as awatcher. After verifying the reliability of the

FIGURE 1 SA bundle key driver diagram.

FIGURE 2 Structured physician SA concern note template. PEWS, Pediatric Early WarningSystem.

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paging function, we eliminated notificationof the physician and respiratory therapistfrom the tracked bundle measures.

Methods of Evaluation

Preintervention data were collected throughmanual review of the EHR for eligiblepatients from September 17, 2012, toNovember 4, 2012. Postintervention datawere collected from November 5, 2012, toDecember 31, 2015. A research assistantreceived an automated e-mail as a part ofinternal hospital communication wheneveran RRT call was activated on a patient in theHM service. Identification for data collectionof watchers without an RRT call was initiallymanual, but with the implementation ofautomated paging, it was later incorporatedin a system similar to the RRT notifications.Once an eligible patient was identified, theresearch assistant reviewed the EHR forcompletion of the bundle. The final 3 bundlemeasures were as follows: (1) identificationof the patient as a watcher in the EHR bynursing staff, (2) completion of an SA noteby any physician on the care team, detailingthe clinical concern and contingencyplanning, and (3) documentation that the

family was notified of the patient’s statuschange. A successful SA bundle required all3 components. Qualitative data about staffimpressions of the project impact werecollected after the implementation of ourinterventions.

Analysis

The research assistant recorded data andused Microsoft Excel10 (Redmond, WA) tocreate run charts, which were updatedbiweekly to reflect the percentage ofpatients who received a complete SA bundleand each of the bundle components. Foranalysis of rates of RRT and ICU transferfor intervention units and hospitalwidecomparisons, data from the 2 interventionunits were pooled and run charts wereupdated monthly. Established rules forspecial cause variation were used toidentify significant improvement.

RESULTS

We improved the percentage of completedbundles from 28% to 81% (Fig 3). During theinitial interventions, there was significantweekly variability in adherence. Our firstsustained improvement occurred alongside

implementation of the automated residentpaging notification. An increase in themedian to 81% occurred after amodification to the SA note template toallow for documentation of an unsuccessfulattempt to reach the family for notificationof watcher status. Time criterion alone wasa common mode of failure of a bundlemeasure. For example, after completion ofthe physician SA note reached 80%, 33% ofthe failures to complete the note werecompleted within 4 hours, 12% between4 and 6 hours, 14% more than 6 hours afteridentification, and 41% were nevercompleted. One contextual element forwhich we tracked data and designedinterventions to support was the regularturnover of resident physicians. To evaluatethe potential unintended impacts on RRT orICU transfer frequency, we compared thesedata from our intervention units andhospital in aggregate. There was no changein the median percentage of RRT or ICUtransfers for the HM units (Fig 4).Comparatively, the hospitalwide RRT rateincreased from 1.4 to 1.8 per 10 000 patientdays, and the ICU transfer rate increased

FIGURE 3 Run chart of adherence to the complete SA bundle within 2 hours of watcher designation over time. Performance on 2 target HM units iscombined. Solid boxes denote time points of implemented interventions, whereas dashed boxes denote interventions that werediscontinued. RN, registered nurse.

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from 0.8 to 0.9 per 10 000 patient days(Fig 5). A potential unintended consequencewas alert fatigue related to the automatedpaging of residents; however, this was notperceived by them to be a barrier.Improvements for individual componentsof the SA bundle are illustrated inSupplemental Figs 7–9.

Project feedback from the nursing staff waspositive. One charge nurse commented,“The plan…is much more in depth, and withit being documented, there is no worryif a nurse misunderstood or passed oninaccurate information.” A bedside nursesaid, “[Physicians] have a more thoroughplan of care…and more precise criteria ofwhat the next steps will be and when an[RRT] will be called.”

DISCUSSION

Using QI methods, we created andimplemented an SA communication bundlefor high-risk patients admitted to HM. Wereached our goal of 80% bundle completion,as well as 80% completion of individualbundle measures, and have sustained oursuccess for more than 2 years. We believethat early recognition of and clear

communication about patients at high riskof deterioration may prevent SSEs and mayfacilitate team collaboration.

Our project built on previous work thatdeveloped a proactive system to standardizelanguage on watchers. Because we wantedto make the process of watcheridentification as robust as possible, we didnot predetermine criteria for patients toreceive the watcher designation. Nursingstaff most commonly identified patients aspotential watchers outside of rounds, whichis not surprising given their frequency ofinteraction and reassessment intervals. Toprioritize the input of the entire care team,and once a nurse identified a potentialwatcher, we designed watcherdetermination to be a collaborativedecision made after a bedside assessment.11

Although not directly measured, theexpectation from local culture andproject-specific education was for theattending physician to be involved inmitigation planning regardless of thetime of day. This approach was alsofacilitated by the multidisciplinary teammembers who served as liaisons to thefrontline staff.

Leveraging the existing safety culture thathas been associated with a reduction in thenumber and frequency of SSEs,12 we foundthat providers were receptive to thecreation and implementation of our bundle.We tested many methods for education onthe roles and ownership of the process.To provide education and feedback onperformance, we communicated individuallyregarding each failure and recognizedproviders who were successfully completingthe bundle. Despite numerous educationalinterventions, we were unable to reach ourgoal. Because lower-reliability interventions,including education alone, are typicallyunable to produce a level of reliable (80% to90%) success,13–15 this was not surprising.

In striving toward a higher reliabilityintervention, we employed technology toprovide innovative solutions. Becauseauthors of previous studies have shown thatstructured communication is associatedwith improved outcomes,16,17 we createda standardized note template to integrateinto the physician workflow, which alsofacilitated physicians’ ability to quicklycommunicate essential information. Notecompletion was challenging for severalreasons, including the presence of multiplephysicians on multiple HM teams, monthlyturnover of resident teams, competingpatient care demands related to volume oracuity, and time constraints. Support fromIS enabled us to overcome this majorbarrier by the creation of an automatedcommunication system using anelectronically generated page when apatient was noted as a watcher in the EHR.This helped spread awareness of the projectand reminded physicians of the time framefor note completion. We elicited feedbackfrom the resident teams regarding alertfatigue, and we found none.

It is interesting to note that during the timeframe when our units saw a stable rate ofRRT calls and ICU transfers, hospitalwiderates increased for both. Institutional datahave shown a consistent upward trend inRRT calls and ICU transfers over the past6 years. Although we cannot definitively saythat the HM unit trend is solely related toour work, this project was the only targeted,SA-related work done on the HM units

FIGURE 4 Combined rates of RRT calls and ICU transfers per 10 000 patient days over time forthe 2 HM intervention units.

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during this time frame. Because our unitspreviously saw a much higher rate of RRTcalls and ICU transfers, we believe thesedata reflect a consequence of our work. It ispossible that this framework of clear andtimely communication facilitated patientcare, leading to improved clinical outcomes,or that our intervention delineated criteriafor escalation that helped avoid RRT callsand transfers. Qualitative feedback fromnursing staff employed before and after theproject’s implementation indicated thatthere was a perceived improvement inclarity of contingency planning forwatchers. This positive impact on staffexperience likely facilitated team cohesion,which is especially important for children atrisk for deterioration.18

Our study has some limitations. First, ourinstitution has a well-established culturethat prioritizes both QI and patient safety,and as such, it has already implementedmany measures resulting in positiveoutcomes. This environment primes suchwork for success; however, institutions witha higher rate of SSEs may see moresignificant, clinically relevant improvementsin patient outcomes. Second, our project

relied heavily on the EHR to assist in datacollection for identification of eligiblepatients and successful completion ofbundle measures. We believe that anautomated system for inclusion of eligiblepatients is likely more effective than manualreview, and implementation in a systemwithout an EHR may mandate significantadditional effort. Third, we considered anattempted family notification as a success,even if the family was unable to bereached. Through feedback, our teammembers noted that they were trying,at times repeatedly, to contact thefamily. We decided that this exemplifiedthe behavior we wanted to incentivize, andthat doing all that we could to contactfamilies should drive how we think ofsuccess. Finally, we measured onlydocumentation of the communication asreflected by signed notes, which mayunderestimate our actual successbecause busy providers may chooseto prioritize patient care tasks overtimely documentation. This assertion issupported by the higher success ratewhen not accounting for our 2-hourtime criterion.

With any QI initiative, sustainability is animportant consideration. Because we havesuccessfully sustained our interventionthrough seasonal variation affecting patientacuity and through multiple new groups ofresidents, we believe this system is stable,and the expectation of communicationregarding watchers has become part of theculture in our 2 intervention units. Ongoinginterventions regarding education offrontline staff have shifted to establishedforums such as scheduled orientationtimes. Although not systematicallyimplemented and tracked like in ourintervention units, the use of the SA noteand expectations of contingency planninghave spread to other units within ourinstitution through rotation of residentsfamiliar with our process and expectationsgiven at standardized safety huddles.1

CONCLUSIONS

We implemented and sustained a novel SAcommunication and contingency planningbundle for patients at the highest risk ofdeterioration. Strong contributors to oursuccess included a collaborative approachto clinical assessments, a multidisciplinaryrepresentation of stakeholders, andcapitalization on technological capabilitiesto facilitate the automation of keyinterventions. With the learning we haveachieved through first implementing thisbundle in HM units, our next steps includeassessing opportunities to spread our workwithin our institution and beyond.

Acknowledgments

We would like to thank the followingcolleagues for their invaluable support forour project: Caitlin Clohessy, PatriciaFeghali, Melissa Forton, James Frebis, DianeHerzog, Heather Jordan, Alyssa Mohr, HadleySauers-Ford, Ikaika Tadaki, Paul Yelton, andJanet Zahner.

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FIGURE 5 Hospital-wide rates of RRT calls and ICU transfers per 10 000 patient days over time.Data reflect all inpatient units in aggregate.

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DOI: 10.1542/hpeds.2016-0170 originally published online August 29, 2017; 2017;7;523Hospital Pediatrics 

Patrick W. BradyBrewington, Suzanne Campanella, Andrew Davis-Sandfoss, Karen Tucker and Michelle W. Parker, Matthew Carroll, Benjamin Bolser, Janelle Ballinger, John

Implementation of a Communication Bundle for High-Risk Patients

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