PRACTICE IMPROVEMENT
SITUATION, BACKGROUND, ASSESSMENT, AND
RECOMMENDATIONGUIDED HUDDLES IMPROVE
COMMUNICATION AND TEAMWORK IN THE
EMERGENCY DEPARTMENT
Authors: Heather A. Martin, DNP, RN, PNP-BC, and Susan M. Ciurzynski, PhD, RN, PNP-BC, Rochester, NY
Earn Up to 8.0 CE Hours. See page 545.
Problem: Thousands of people die annually in hospitals
because of poor communication and teamwork between health
care team members. Standardized tools and strategies help
increase the amount and quality of communication. Two
structured communication methods include implementing
huddles and the use of the situation, background, assessment,
and recommendation (SBAR) communication framework.
Methods: To improve communication among nurse practi-
tioners and registered nurses within a pediatric emergency
department, a performance-improvement project with the
structured processes of a joint patient evaluation and huddle
was implemented. Data were gathered from 32 nurses and 2
nurse practitioners using structured observation and pre- and
post-implementation surveys. The following outcomes were
measured: presence or absence of joint patient evaluation and
SBAR-guided huddle, verbalization of treatment plan, commu-
nication, teamwork, and nurse satisfaction.
A
pproximately 180,000 patients die annually in the
United States because of adverse medical events. 1
Most of these events are related to miscommunication
among health care teams. 2 Effective face-to-face communica-
Heather A. Martin, Member, Genesee Valley, is Emergency Medicine Quality
Assurance Coordinator and Pediatric Emergency Medicine Nurse Practi-
tioner, University of Rochester Medical Center, Rochester, NY.
Susan M. Ciurzynski is Associate Professor of Clinical Nursing, University of
Rochester School of Nursing, Rochester, NY.
For correspondence, write: Heather A. Martin, DNP, RN, PNP-BC,
University of Rochester Medical Center, 601 Elmwood Ave, Box 655,
Rochester, NY 14642; E-mail: heather_martin@urmc.rochester.edu.
J Emerg Nurs 2015;41:484-8
Available online 2 July 2015.
0099-1767
Copyright 2015 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2015.05.017
484 JOURNAL OF EMERGENCY NURSING
Results: Eighty-three percent of patient encounters included a
joint evaluation. A huddle structured with SBAR was conducted
86% of the time. Registered nurses and nurse practitioners
verbalized patients treatment plans in 89% of cases and 97%
of cases, respectively. Improved teamwork, communication,
and nursing satisfaction scores were demonstrated among the
nurse practitioners and registered nurses.
Implications for practice: This project showed the feasibility
of a simple and inexpensive joint nurse practitionerregistered
nurse patient evaluation followed by a structured huddle, which
improved communication, teamwork, and nurse satisfaction scores.
This performance-improvement project has the potential to enhance
efciency by reducing redundancy, as well as to improve patient
safety through the use of structured communication techniques.
Keywords: Communication; Teamwork; Emergency department;
Huddle; SBAR
tion between professionals is crucial for successful teamwork
and essential to high-quality patient care. 3
Processes to improve communication among ED staff
should be standardized as much as possible to improve the
efciency of the emergency department by minimizing the
time it takes to carry out a patients treatment plan. Teams
that jointly evaluate a patient, obtain the patients history
together, and perform a physical examination conjointly are
able to reduce redundancy, save time, and increase patient and
staff satisfaction. 4 Furthermore, well-functioning, patient-
focused teams have been associated with increased productivity,
increased quality of care, decreased costs, and improved patient
outcomes. 3 In addition, nursing satisfaction improves when
nurses are allowed to participate in the team as part of
collaboration related to patient care decisions. 5
The Institute of Healthcare Improvement 6 and Team-
STEPPS 7 recommend standardizing communication strategies
(eg, huddles) to increase the amount and quality of communi-
cation, as well as to prevent adverse patient outcomes. Specically,
VOLUME 41 ISSUE 6 November 2015

the use of the situation, background, assessment, and recom-
mendation (SBAR) framework has been implemented across the
US as a best practice in delivering information in a rapid
transmission, 6 which is often necessary in a busy ED setting.
With the goal to improve communication, teamwork,
and nurse (registered nurse [RN]) job satisfaction in our
pediatric emergency department, a performance-improve-
ment (PI) project was instituted in which the nurse
practitioner (NP) provider and RN conducted a joint
history and physical assessment, followed by a huddle
standardized with the SBAR framework. The purpose of
this article is to describe the ndings of this PI project,
including the feasibility of initiating this approach and
association with teamwork, communication, and nurse
satisfaction scores.
Methods
ETHICS
Permission to conduct this project was obtained from the
medical centers nursing and medical leadership teams. In
addition, approval as exempt status was received from the
medical centers institutional review board.
SETTING
The PI project took place in an academic medical centers
pediatric emergency department located in western New
York State during the autumn and winter months of 2013
2014. This pediatric emergency department provides care
to approximately 30,000 children annually and is the Level
I Trauma Center for the area. The sample consisted of RNs who
were employed full time and part time in the pediatric
emergency department, along with 2 board-certied pediatric
NPs. Because the project was a department PI initiative, all RNs
and NPs were included in this intervention.
PROCESS
Staff Education
Before the start of the practice change, a 1-hour
educational in-service was developed and presented to
pediatric ED nursing staff (N = 33). The education
highlighted the importance of effective communication
among team members and the outcomes hypothesized
from implementing structured communication tech-
niques. A verbal, step-by-step scenario of an NP and RN
entering a patient room together to obtain the history and
perform the physical examination, followed by a demon-
November 2015 VOLUME 41 ISSUE 6
Martin and Ciurzynski/PRACTICE IMPROVEMENT
stration of a huddle structured with the SBAR framework,
was provided.
NP-RN Joint Evaluation
After staff education, the NPs and RNs began the process of
conducting joint, simultaneous patient evaluations of
eligible patients. Eligible patients were dened as those
who did not require immediate lifesaving treatment or
resuscitation. The current practice of an NP and RN being
assigned to care for patients based on their workload and
availability did not change. For this PI project, it was
emphasized that once an NP and RN were identied as
assigned to care for the same patient, they coordinated a time
when both were available to go into the examination room
together. Once the NP and RN were in the room, the patient
or family member was asked to relay the reason for coming to
the hospital and precipitating symptoms. After the NP and RN
team heard the patients history, they performed a physical
examination together. By doing this, the NP and RN were able
to assess and discuss their ndings concurrently.
Huddles Structured With SBAR
After the joint evaluation, the NP and RN were asked to
huddle to discuss the patients history and physical ndings
using the SBAR format. This huddle could have been
completed within the examination room with the patient
present or outside the room in a private, quiet area where
the plan could be discussed. The option of stepping out of
the patients room was given to the team members in case
there were sensitive issues that needed to be discussed, such
as concerns of potential child abuse.
At any time, a team member could speak up and
disagree with what was being said or include additional
information considered important to properly care for the
patient. By following the SBAR format, the team members
could communicate in a concise and anticipated method.
The nal element of the huddle included the recommen-
dation of the treatment plan. Together, the NP and RN
determined a plan of care for the patient and negotiated
who was going to be responsible for each part of the plan,
based on their scope of practice.
METHODS OF EVALUATION
Design
The PI project was evaluated by using a structured
observational audit with the Huddle, SBAR, and Communi-
cation Observation Tool (HSCOT) and self-administered pre-
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PRACTICE IMPROVEMENT/Martin and Ciurzynski
and post-test survey using the Collaboration and Satisfaction
About Care DecisionsPEDS ED (CSACD) survey. 8
Measures and Data Analysis
Outcomes measured in this project included NP/RN
teamwork and communication, RN job satisfaction, and
effectiveness of the huddle in creating a clear treatment plan,
as well as feasibility of both the joint evaluation and the
SBAR-guided huddle. Data were analyzed using SPSS
software, version 20 (IBM, Armonk, NY). Data obtained
from the HSCOT instrument (N = 36), including
perception of the joint evaluation and huddle, and the
CSACD survey were analyzed using descriptive statistics.
Huddle, SBAR, and Communication
To assess teamwork, communication, and the feasibility of
the joint evaluation and huddle conducted using the SBAR
framework, the project manager observed the NP and RN
performing these components. The observer determined if a
joint evaluation took place and rated the quality and
effectiveness of the SBAR-guided huddle using a structured
list of criteria. Data were collected using the HSCOT
instrument, which was developed for this project based on
The Joint Commission Hand-Off Communication Audit
Tool. 9 This audit tool was originally created as a method to
measure the effectiveness of using the SBAR framework
during the handoff of a patient from one unit to the next or
between providers. The revised tool was reviewed by an
expert panel including 3 doctoral prepared nurses and an
associate director of nursing for the organization.
Collaboration and Satisfaction About Care Decisions
All NPs and RNs were asked to complete the CSACD
survey 8 to measure the perceived amount of collaboration
(including teamwork and communication) and satisfaction
in the pediatric emergency department. The CSACD survey
contains 9 items and 2 subscales representing collaboration
and satisfaction with care decisions. In this self-administered
questionnaire, the participants rate their level of agreement
on a 7-point Likert scale (1, strongly disagree, to 7, strongly
agree), which was scored by taking a mean of all responses.
Data were collected at baseline (immediately after the
educational in-service, N = 33) and at the end of each
patient encounter following the NP/RN joint evaluation
and huddle that the project manager (pediatric emergency
NP) observed (N = 64). Some RNs and NPs participated in
multiple patient encounters during this project and were
allowed to complete a CSACD survey for each encounter.
486 JOURNAL OF EMERGENCY NURSING
Results
SAMPLE AND DEMOGRAPHIC DATA
Of the 32 subjects who participated in the PI project, 30
(94%) were women. The age distribution of the sample was
25 to 62 years, with a mean of 37 years (SD, 10.5 years).
The majority of the subjects (84%) recognized their race as
being white. All but 1 subject identied their ethnicity as
being non-Hispanic or non-Latino. The average number of
years the subjects had been an RN was 11.5 years, with an
average of 4.8 years working in the pediatric emergency
department. The majority of the RNs (69%) were
employed full time, 25% were employed part time, and
6% were per-diem staff. The educational preparation of the
RNs included an associates degree is 22%, bachelors
degree in 56%, masters degree in nursing in 12%, and
masters degree in another eld in 9%. For the NP subjects
(n = 2), the average length they had been an NP and within
the pediatric emergency department was 6 years.
CSACD SURVEY RELIABILITY
Psychometric testing of the CSACD instrument among the current
sample was found to have a high level of reliability (Cronbach =
0.97; inter-item correlations ranged from 0.81 to 0.93).
NP AND RN JOINT EVALUATIONS
Joint patient evaluations took place in the majority of patient
encounters (83%) with minimal interruptions noted. Of the
36 patient encounters observed, 30 (83%) had a joint patient
evaluation and 31 (86.1%) had a huddle conducted. For the 6
encounters (16.7%) that did not have a joint evaluation, the
following reasons were provided: immediate acuity of the
patient and too busy caring for other patients.
The RNs rated their experience with the joint
evaluation slightly higher than the NPs. Specically, 83%
of the RNs reported they had a great experience with the
joint evaluation. In comparison, the NPs rated the joint
evaluation as being great 78% of the time and poor in
22% of the encounters. When the project manager inquired
about the lower scoring of the patient encounters by the
NPs, the reason given was that they wanted more input
from and interaction by the RN than what were provided.
STRUCTURED HUDDLE BASED ON SBAR FRAMEWORK
On the basis of the observations conducted, 86% of the 36
patient encounters had a structured huddle after the joint
patient evaluation. In 1 encounter this huddle occurred
when there was no joint evaluation. Of the huddles that
VOLUME 41 ISSUE 6 November 2015

were completed, 7 (23%) were interrupted. Interruptions
occurred when the RN conducting the joint evaluation with
the NP was also responsible for managing the unit.
COMMUNICATION AND TEAMWORK
After implementation of the joint evaluation and huddle,
there was an improvement in the mean communication
score between the NP and RN. Specically, the mean
increased from 5.68 (SD, 1.11) at baseline to 6.59 (SD,
1.12) after the intervention. Perceptions of teamwork
improved between the NP and RN after implementation of
this project. Specically, the mean (SD) increased from 5.47
(SD, 1.08) at baseline to 6.46 (1.13) after the intervention.
RN JOB SATISFACTION
There was an improvement in satisfaction of the RN after
the implementation of this project from a baseline mean of
5.17 (SD, 1.09) to a post-intervention mean of 6.45 (SD,
0.72). In addition, most of the RNs rated their perception
of the joint evaluation and huddle as satisfactory (83% and
86%, respectively). One comment shared by an RN was as
follows: I appreciated working directly with the NP and
being able to participate in the decision making.
PATIENT TREATMENT PLAN
In 86% of the patient encounters observed, both the NP and
RN verbalized the next steps in the treatment plan and what
role each team member had in determining what diagnostic
tests needed to be completed, what medications should be
ordered, and what consultations needed to be completed. Of
the 4 cases (11%) in which the NP and RN did not know the
next steps in the treatment plan, a huddle did not take place
where this information would have been discussed.
Discussion
Throughout this PI project, we emphasized the need for the RN
and NP to evaluate the patient together and to summarize this
evaluation by using a structured process (ie, huddle) and
structured tool (ie, SBAR) to improve communication. We
found that there was an improvement in NP and RN
communication with the addition of a joint patient evaluation
followed by a structured huddle. Our ndings are consistent with
previous research that also showed that consistent, structured
techniques improve perception of communication among team
members. 3 Interestingly, in 1 case in which the NP and RN did
not conduct a joint evaluation and huddle at the bedside, the NP
and RN came together outside the room and conducted the
November 2015 VOLUME 41 ISSUE 6
Martin and Ciurzynski/PRACTICE IMPROVEMENT
recommendation portion of the huddle to determine the
treatment plan for the patient. This effort was applauded and
showed that, in certain cases in which a joint patient evaluation
may not be entirely feasible, it should be feasible for the NP and
RN to at least huddle and discuss the assessment and treatment
plan based on the SBAR framework. This nding may be
explained by the fact that the RN and NP recognize that for an
effective treatment plan to take place, they must communicate
face to face and a huddle is a method by which they are able to
achieve this interaction. It can therefore be concluded that the
huddle was imperative to the determination and undertaking of
the patient treatment plan in the current project.
Our nding of increased teamwork scores was not
surprising, based on empirical evidence that emphasizes the
importance of collaboration among members of a team. By
increasing communication, collaboration, and coordination
of patient care, along with the ability to express ideas among
team members, teamwork among medical staff members
can be improved. 10 The RNs and NPs in this project were
given the tools needed to increase communication and the
ability to coordinate patient care, which was associated with
an increase in teamwork.
With the application of the joint patient evaluation,
satisfaction among pediatric emergency nurses improved. This
nding may be attributed to staff feeling that their skills and
knowledge were of greater value as they contributed to the
treatment plan. The inclusion of the RN with the NP during
the joint patient evaluation allowed the RN to add his or her
input to the assessment and the recommended treatment plan.
This explanation is supported by the literature, in which
authors have concluded that increased communication and
teamwork lead to an increase in nursing satisfaction. 6
Before this project, it was common for the RN to assess
the patient on his or her own, followed by the NP repeating
the same examination. At the completion of the NP
examination, a treatment plan would be formed based on
the NP examination alone, without input from the RN
regarding his or her assessment and recommendations for
treatment. As a result, staff members were not working in
teams but rather in parallel silos. Having a joint evaluation
conducted by the NP and RN not only improved
communication and teamwork within the team but also
reduced the redundancy of the patient telling his or her
story multiple times. On the basis of this projects ndings,
it would be important for future studies to explore factors
surrounding RN contributions in patient treatment plans.
It is important to note that there was a high success rate
with this project that might be attributed to the RN and NP
staff being a highly motivated group that was invested in
creating change to improve their work environment. With other
groups of providers who rotate through the pediatric emergency
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PRACTICE IMPROVEMENT/Martin and Ciurzynski
department and do not consider this unit their home, there may
be less inclination to perform a joint evaluation and huddle with
the nursing staff. This interpretation is supported by literature
stating that colleagues from within their respective professional
groups are closely connected and communication is improved
within these groups. 11 The high success rate may also be
attributed to the baseline data being obtained immediately after
the 1-hour educational in-service. The CSACD survey was
distributed immediately after the education because of the
convenience of having all staff members present for a training
session. In the future, the survey should be distributed before
any education to minimize undue inuence.
From the ndings of this PI project and on the basis of
support from the literature, we conclude that it would be
feasible to implement the standard practice of joint patient
evaluations between the RN and NP in the pediatric emergency
department for noncritically ill patients. In the future, this
should be a practicable project to implement within an
emergency department with similar demographic characteristics
and a similar organizational structure. The implementation of
this project is relatively inexpensive and simple. In 2009 medical
errors specically related to poor communication and teamwork
resulted in the spending of over $1 billion, with a median cost of
$939 per error. 12 Thus, improved communication and
teamwork among medical teams can lead to enhanced patient
safety, as well as cost savings to the institution. Future research
and quality-improvement assessment should evaluate the
comparison of cost to potential value of this PI intervention.
For example, it would be wise to analyze if ED length of stay is
reduced by the application of joint patient evaluations and
huddles structured with SBAR.
Conclusions
Communication occurs in complex environments, such as the
emergency department, where information needs to be relayed
in a short period. To accomplish this, it is optimal to use
structured communication techniques, such as huddles and the
SBAR framework, to promote improved communication
between staff members. This PI project showed that a joint
patient evaluation followed by a structured huddle can improve
communication, teamwork, and nursing satisfaction between
NPs and RNs within a pediatric emergency department. Since
the conclusion of this PI project, the NPs and RNs have
continued to jointly evaluate the patients, as well as huddle to
discuss the proposed treatment plan, because of the high success
rate discovered with this initiative. The joint evaluation followed
by a huddle was found to be a feasible and effective measure to
undertake to determine a patients treatment plan that could
potentially increase patient safety in the emergency department.
488 JOURNAL OF EMERGENCY NURSING
Acknowledgment
We thank Mary G. Carey, PhD, RN, CNS, FAHA, M.
Colleen Davis, MD, MPH, FAAP, FACEP, Teresa Glessner,
DNP, RN, ACNP-BC, NEA-BC, CCRN, and Anne Swantz,
MS, RN, CPNP-BC, for their guidance and support
throughout this entire project. We also recognize Marcy
Noble, RN, BSN, CPEN, and the entire nursing staff of the
pediatric emergency department for their participation and
enthusiasm in making this project a success.
REFERENCES
1. Levinson DR. Adverse events in hospitals: Medicares responses to
alleged serious events. Report No. 0EI-01-08-00590. Washington, DC:
US Department of Health and Human Services, Ofce of the Inspector
General. http://psnet.ahrq.gov/resource.aspx?resourceID=23433. Pub-
lished October 2011. Accessed February 9, 2015.
2. The Joint Commission. Sentinel event data. Root causes by event type. 2004-
2Q 2014. http://www.jointcommission.org/assets/1/18/Root_Causes_By_
Event_Type. Accessed February 9, 2015.
3. Leonard M, Frankel A. Role of effective teamwork and communication
in delivering safe, high-quality care. Mt Sinai J Med. 2011;78:820-826.
4. Mazzocato P, Forsberg H, Schwartz U. Team behaviors in emergency
care: a qualitative study using behavior analysis of what makes teams
work. Scand J Trauma Resusc Emerg Med. 2011;19:70-76.
5. Ajeibe D, McNeese-Smith D, Phillips L, Leach L. Effect of nurse-
physician teamwork in the emergency department nurse-physician
perception of job satisfaction. J Nurs Care. 2014;3:1-8.
6. Institute for Healthcare Improvement. Balance supply and demand on a daily,
weekly, and long-term basis: use regular huddles and staff meetings to plan
production and to optimize team communication. http://www.ihi.org/
resources/Pages/Changes/UseRegularHuddlesandStaffMeetingstoPlan
ProductionandtoOptimizeTeamCommunication.aspx. Published April 27,
2011. Accessed October 1, 2012.
7. Agency for Healthcare Research & Quality. TeamSTEPPS: national
implementation. http://teamstepps.ahrq.gov. Accessed October 1, 2012.
8. Baggs J. Development of an instrument to measure collaboration and
satisfaction about care decisions. J Adv Nurs. 1994;20(1):176-182.
9. Joint Commission Center for Transforming Healthcare. Facts about the Hand-off
Communications Project. http://www.centerfortransforminghealthcare.org/
projects/detail.aspx?Project=1. Published October 2013. Accessed March 1, 2014.
10. Lown B, Manning C. The Schwartz Center Rounds: evaluation of an
interdisciplinary approach to enhancing patient-centered communication,
teamwork, and provider support. Acad Med. 2010;85(6):1073-1081.
11. Creswick N, Westbrook J, Braithwaite J. Understanding communication
networks in the emergency department. BMC Health Serv Res. 2009;9:247.
12. David G, Gunnarsson C, Waters H, Horblyuk R, Kaplan H. Economic
measurement of medical errors using a hospital claims database. Value
Health. 2013;16(2):305-310.
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