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SYSTEMATIC REVIEW PROTOCOLS

Use of huddles among frontline staff in clinical settings: a scoping review protocol

Pimentel, Camilla B.1,2,3; Hartmann, Christine W.1,4; Okyere, Daniel5; Carnes, Sarah L.5; Loup, Julia R.6; Vallejo-Luces, Tatiana M.7; Sloup, Sharon N.7; Snow, A. Lynn6,7

Author Information
doi: 10.11124/JBISRIR-D-19-00026
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Abstract

Introduction

Team-based models are gaining prominence as the preferred method for delivering coordinated, cost-effective, high-quality health care. In contrast to provider-centric models that have historically dominated health care, team-based approaches operationalize medicine as a cooperative science in which all members of the care team work together for the good of the patient.1 Although many models of team-based care exist, all are characterized by the strategic redistribution of work so that all members of the care team (e.g. physicians, nurses, medical assistants, administrative staff, laboratory workers) are engaged in, are integral to, and share responsibilities for providing patient care. In the United States, healthcare industry leaders like the Mayo Clinic,2 Geisinger Health System,3 Intermountain Healthcare4 and Kaiser Permanente5 have adopted team-based care to simultaneously achieve three primary goals of improved population health, better patient experience and lower per capita costs.

Implementation of team-based care requires increased communication among organizational leaders, healthcare providers and others working at the frontline of health care, as well as patients and their advocates. Increased communication among members of the care team may lead to better understanding of the daily work of frontline staff, which the Institute for Healthcare Improvement (IHI) describes as key to any effort to sustain quality improvement.6 In addition, there is a growing focus on the quality of relationships developed at the point of care between frontline staff and patients.7 Consequently, frontline staff need to acquire skills to learn what works when interacting with patients to best respond to patient needs, and to share knowledge with their team members. The huddling practice is one method for achieving improved communication and relationships that has received much attention by team-based care researchers.

Huddles

Huddles are a powerful method for building and supporting relationships among frontline staff members. These focused stand-up meetings are posited to enhance coordination of care among staff members by enabling collaborative and efficient information exchange and fostering a view of the current clinical state.8 Huddles are also thought to facilitate the ability of staff members to recognize and mitigate issues that adversely impact the consistent delivery of high-quality care. Huddles are thus integral to broad quality improvement initiatives and efforts to improve patient safety, including the TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) teamwork system developed by the US Department of Defense and the Agency for Healthcare Research and Quality (AHRQ).9,10

Huddles are designed to be brief (e.g. 10–15 minutes in duration) to optimize participant engagement, and to focus only on essential patient and procedural information.8,11 Based on AHRQ recommendations, they should also be held on a regular basis.9 In practice, however, they can take on many forms. Some huddles are held as-needed at the patient's bedside and involve only the patient's immediate clinical team.12 Others are scheduled for the start of each workday and involve all clinical and non-clinical staff.13 The structure of the huddle also varies, depending on what, if any, scripts or communication tools or facilitation strategies are employed. A variety of resources are available for use in huddles. Two of the most popular communication tools are CUS (“I am concerned! I am uncomfortable! This is a safety issue!”)14 and SBAR (Situation-Background-Assessment-Recommendation).15 Other resources, such as the Huddle Observation Tool,16 help researchers and healthcare teams evaluate the quality and effectiveness of huddles.

Emerging evidence demonstrates that huddles minimize hierarchical barriers to care delivery, enhance frontline staff satisfaction and improve clinical outcomes.17 Theoretical arguments also lend support to the potential for huddles to improve healthcare delivery. Huddles can promote, for example, relational coordination18 and situation awareness on the unit floor.8 According to the theory of relational coordination, communication that is frequent, timely and accurate can minimize delays, facilitate rapid response, and reduce potential for error. This communication depends on the extent to which team members have shared goals, shared knowledge and mutual respect. High levels of relational coordination allow team members to manage their tasks with fewer errors and less wasted effort, which leads to higher quality outcomes.19 According to the theory of situation awareness, decision making is a function of perception of data elements in the environment, comprehension of their contextual meaning and projections of their future status.20,21 In dynamic, high-risk environments like health care, poor situation awareness is associated with error and accidents.22 Improved situation awareness facilitates better identification and management of patient risks.

In a preliminary search for relevant reviews available through MEDLINE, the Cochrane Database of Systematic Reviews and JBI Database of Systematic Reviews and Implementation Reports, we found two recent systematic reviews focusing on the use of huddles for patient safety in the perioperative17 and acute care settings.23 Owing to the diverse settings in which huddles are used, there remains a need for a broader understanding of huddle processes and their outcomes. To our knowledge, no reviews have described huddles that are used among frontline staff in all clinical settings.

This proposed scoping review will therefore identify gaps in the literature regarding the types of evidence informing this practice and facilitate a greater understanding of the resources available for clinical practitioners seeking to implement huddles – especially huddles that emphasize frontline staff involvement – as part of their quality improvement initiatives. This work will also identify opportunities for more detailed evidence syntheses and empirical research examining characteristics and effectiveness of huddles in specific clinical contexts.

Review objective/questions

The objective of this scoping review is to provide an overview of the current evidence on huddles in healthcare settings that involve frontline staff. Specifically, the review questions are:

  • i) How does existing evidence characterize huddles performed in the clinical context?
  • ii) What processes and outcomes are used to measure huddle effectiveness?

Inclusion criteria

Participants

This scoping review will consider articles that include frontline staff, namely, any staff member who has contact with patients or residents in a clinical setting. This includes all healthcare providers and non-clinical/administrative staff.24

Concept

This review will consider articles that describe, investigate or explore the use of frontline staff huddles to improve processes and outcomes (e.g. staff engagement and satisfaction, perceptions of safety culture, adverse drug events, patient length of stay) related to quality of care in a clinical setting. It will focus, specifically, on articles that describe huddles as a targeted intervention, as opposed to a platform through which other interventions are disseminated.

Context

The context of this review is any clinical or medical setting that provides healthcare patient services, including inpatient or outpatient settings, acute care, primary care, skilled nursing facilities and long-term care.

Types of studies

This scoping review will consider the following for inclusion: qualitative studies, experimental and quasi-experimental studies (e.g. randomized or non-randomized controlled trials, before and after studies, interrupted time-series studies), analytic observational studies (e.g. prospective or retrospective cohort studies, case-control studies), and descriptive cross-sectional studies. Systematic reviews and meta-analyses that meet the inclusion criteria will also be considered, along with dissertations, gray literature and conference proceedings. Study protocols, simulations and summaries lacking original data will be excluded.

Methods

This scoping review protocol has been prospectively registered with the Open Science Framework on January 18, 2019 (https://osf.io/bdj2x/).25 We will follow the JBI methodology for a scoping review.26

Search strategy

An initial limited search of PubMed and CINAHL Plus with Full Text will be performed, followed by analysis of the title, abstract text and Medical Subject Headings (MeSH) used to describe the article. Second, all relevant index terms and keywords will be used in searches of the following databases: PubMed, EBSCOhost (including CINAHL Plus with Full Text, Dentistry & Oral Sciences Source, ERIC, Health Business Elite, Health Policy Reference Center, PsycArticles, PsycBooks, Psychology and Behavioral Sciences Collection, PsycINFO, Rehabilitation & Sports Medicine Source, Social Work Reference Center and SocINDEX with Full Text), and ProQuest (including the Family Health Database, Health & Medical Collection, Health Management Database, Nursing & Allied Health Database, Psychology Database and PTSDpubs). Third, we will search the reference lists of all articles that meet our inclusion criteria and the IHI's white paper that guides healthcare practitioners in the use of daily huddles as part of a quality management system.6 Studies published in English will be considered for inclusion in this review. Studies published from inception to the present will be considered for inclusion. Appendix I lists our search strategy for PubMed, CINAHL Plus with Full Text, EBSCOhost and ProQuest.

Study selection

All articles identified during the searches will be uploaded into EndNote X8.2 (Clarivate Analytics, PA, USA), and duplicates removed. We will conduct an initial screening for inclusion based on the titles and abstracts. The first screening of the abstracts will be independently conducted by two reviewers based on the inclusion criteria to identify articles to include for further review. Disagreements on article inclusion will be resolved by discussion or with two additional reviewers.

Following this, we will retrieve and review the full text of those articles that meet initial screening. Two independent reviewers will assess each article against the inclusion criteria, with disagreements resolved through discussion or with a third reviewer. Full-text articles that do not meet the inclusion criteria will be excluded from the scoping review, and reasons for exclusion will be provided in the final report. Results of our search will be presented in a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.27

Data extraction

Two independent reviewers will extract relevant data from each eligible paper to address the objectives of this scoping review. A third reviewer will perform quality checks on a randomly selected 10% sample of eligible papers, and discrepancies will be discussed and resolved among reviewers. An Excel spreadsheet will be used to collect information, including specific details about the population, concept, context, study methods and key findings relevant to the review objectives. As in the study selection process, disagreements between the two reviewers will be resolved through discussion or with a third reviewer. The draft data extraction tool (Appendix II) will be revised as necessary during the data extraction process. Modifications to our data extraction tool will be detailed in the final report.

Data presentation

The extracted data will be represented in tabular form and as a narrative summary that aligns with the objective of the review. The table will report the following: distribution of studies by year, city/country of origin, and clinical setting; study design and purpose/aims; structure (i.e., theoretical framework), if presented; the definition, purpose and process (e.g., frequency, duration) of huddles; types of staff participating in huddles, if presented; outcomes associated with huddles (alone or as part of multifaceted interventions) and how these outcomes are measured; and measurement or communication tools, if presented. This table may be further refined after data extraction and accompanied by graphic representations such as bar charts and diagrams.

Funding

This work is partially supported by the Department of Veterans Affairs, Office of Geriatrics and Extended Care, through the Veteran Affairs Community Living Centers’ Ongoing National Center for Enhancing Resources and Training (CONCERT).

Appendix I: Search strategies

PubMed

Search (((((((((((huddle[Title/Abstract] OR huddles[Title/Abstract])) OR (tailgate[Title/Abstract] OR tailgates[Title/Abstract])) OR (line-up[Title/Abstract] OR line-ups[Title/Abstract])) OR (pre-shift[Title/Abstract] OR pre-shifts[Title/Abstract])) OR (stand-up[Title/Abstract] OR stand-ups[Title/Abstract])) OR (scrum[Title/Abstract] OR scrums[Title/Abstract])) OR (time-out[Title/Abstract] OR time-outs[Title/Abstract])) OR (briefing[Title/Abstract] OR briefings[Title/Abstract]))) AND ((“Medical Staff, Hospital”[Mesh]) OR staff[Title/Abstract]))) AND ((((((((((((((((((((((((((((((benefit[Title/Abstract] OR benefits[Title/Abstract])) OR (value[Title/Abstract] OR values[Title/Abstract])) OR (impact[Title/Abstract] OR impacts[Title/Abstract])) OR (effect[Title/Abstract] OR effects[Title/Abstract])) OR (change[Title/Abstract] OR changes[Title/Abstract])) OR (integrate[Title/Abstract] OR integration[Title/Abstract])) OR (improve[Title/Abstract] OR improvements[Title/Abstract] OR improves[Title/Abstract])) OR (increase[Title/Abstract] OR increases[Title/Abstract])) OR (decrease[Title/Abstract] OR decreases[Title/Abstract])) OR (enable[Title/Abstract] OR enables[Title/Abstract])) OR (strengthen[Title/Abstract] OR strengthens[Title/Abstract])) OR (accomplish[Title/Abstract] OR accomplishes[Title/Abstract])) OR (consequence[Title/Abstract] OR consequences[Title/Abstract])) OR (influence[Title/Abstract] OR influences[Title/Abstract])) OR (affect[Title/Abstract] OR affects[Title/Abstract])) OR (alter[Title/Abstract] OR alters[Title/Abstract])) OR importance[Title/Abstract]) OR (payoff[Title/Abstract] OR payoffs[Title/Abstract])) OR (result[Title/Abstract] OR results[Title/Abstract])) OR (reduce[Title/Abstract] OR reduces[Title/Abstract] OR reduction[Title/Abstract])) OR (outcome[Title/Abstract] OR outcomes[Title/Abstract])) OR quality[Title/Abstract]) OR (solve[Title/Abstract] OR solves[Title/Abstract])) OR (sustain[Title/Abstract] OR sustains[Title/Abstract])) OR (contributes[Title/Abstract] OR contribute[Title/Abstract] OR contributions[Title/Abstract])) OR (allow[Title/Abstract] OR allows[Title/Abstract])) OR (promote[Title/Abstract] OR promotes[Title/Abstract])) OR (gain[Title/Abstract] OR gains[Title/Abstract])) OR (enhance[Title/Abstract] OR enhances[Title/Abstract])) limited to English

CINAHL Plus with Full Text

(huddle OR huddles) OR (tailgate OR tailgates) OR (line-up OR line-ups) OR (pre-shift OR pre-shifts) OR (stand-up OR stand-ups) OR (scrum OR scrums) OR (time-out OR time-outs) OR (briefing OR briefings)

AND

benefit OR value OR impact OR effect OR change OR integrat OR improve OR increase OR decrease OR enable OR strengthen OR accomplish OR consequence OR influence OR affect OR alter OR importance OR payoff OR result OR reduc OR outcome OR quality OR solv OR sustain OR contribut OR allow OR promot OR gain OR enhance

AND

(medical OR surgical OR surgery OR presurgery OR clinical OR hospital OR long term care OR longterm care OR nursing home OR assisted living OR healthcare OR (health care)) AND (staff OR team)

EBSCOhost

(Includes: Dentistry & Oral Sciences Source, ERIC, Health Business Elite, Health Policy Reference Center, PsycARTICLES, PsycBOOKS, Psychology and Behavioral Sciences Collection, PsycINFO, Rehabilitation & Sports Medicine Source, Social Work Reference Center, SocINDEX with Full Text)

(huddle OR huddles) OR (tailgate OR tailgates) OR (line-up OR line-ups) OR (pre-shift OR pre-shifts) OR (stand-up OR stand-ups) OR (scrum OR scrums) OR (time-out OR time-outs) OR (briefing OR briefings)

AND

benefit OR value OR impact OR effect OR change OR integrat OR improve OR increase OR decrease OR enable OR strengthen OR accomplish OR consequence OR influence OR affect OR alter OR importance OR payoff OR result OR reduc OR outcome OR quality OR solv OR sustain OR contribut OR allow OR promot OR gain OR enhance

AND

(medical OR surgical OR surgery OR presurgery OR clinical OR hospital OR long term care OR longterm care OR nursing home OR assisted living OR healthcare OR (health care)) AND (staff OR team)

Limited to Academic Journals, Reports, Government Documents, and English

ProQuest

(Includes: Family Health Database, Health & Medical Collection, Health Management Database, Nursing & Allied Health Database, PILOTS: Published International Literature on Traumatic Stress, Psychology Database)

ab((huddle OR huddles) OR (tailgate OR tailgates) OR (line-up OR line-ups) OR (pre-shift OR pre-shifts) OR (stand-up OR stand-ups) OR (scrum OR scrums) OR (time-out OR time-outs) OR (briefing OR briefings)) AND ab(benefit OR value OR impact OR effect OR change OR integrat OR improve OR increase OR decrease OR enable OR strengthen OR accomplish OR consequence OR influence OR affect OR alter OR importance OR payoff OR result OR reduc OR outcome OR quality OR solv OR sustain OR contribut OR allow OR promot OR gain OR enhance) AND ab((medical OR surgical OR surgery OR presurgery OR clinical OR hospital OR long term care OR longterm care OR nursing home OR assisted living OR healthcare OR (health care)) AND (staff OR team)), peer-reviewed

Appendix II: Data extraction tool

References

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Keywords:

Communication; delivery of health care; patient care team; patient safety; quality improvement

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