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Resuscitation events in hospital are invariably high-stake challenging situations that require effective communication, leadership and coordination. A qualitative study by Nallamothu and colleagues, exploring the experiences responders to in-hospital cardiac arrest teams, found that teams, not individuals, are ultimately responsible for providing resuscitation at hospitals.1 Resuscitation is a team endeavour that requires several healthcare professionals of varying experience and backgrounds to coordinate their activities and ensure optimum performance as a team.2 Immediate and effective resuscitation is vital for improving the mortality and morbidity rates of patients for whom resuscitation calls are made.3 As such, the effectiveness of resuscitation teams is an important determinant of patient safety and survival outcomes.1 At North Shore Hospital, which is one of two main hospitals at Waitematā District Health Board (DHB) in Auckland, New Zealand, we established the 777 Planner as an intervention to improve the experiences of team members in resuscitation calls.

Performance in a resuscitation situation is dependent on quality leadership, good communication and team structuring.3 In a study examining 16 teams participating in a simulation of witnessed cardiac arrest, absence of leadership characteristics and the failure to explicitly allocate tasks were linked with poor team performance.2 Clearer leadership from the team leader is associated with superior task performance and more efficient cooperation within the resuscitation team.3 Inadequate communication during a resuscitation call is also one of the most commonly identified underlying causes of clinical errors and adverse patient outcomes.4 The literature suggests that communication between members of the resuscitation team, before and after an event, is generally poor.5 Communication used during an acute emergency situation can often be non-specific, such as failing to use team members’ names or not directly allocating tasks to a person.4  Erroneous communication can contribute to a delay in initiating life saving measures, such as commencement of cardiopulmonary resuscitation (CPR) or the administration of adrenaline. These can have a significant impact on a patient’s outcome.3 Communication can also be a barrier in the ongoing training and skill development of resuscitation team members, as members lose opportunities to successfully volunteer for roles and gain valuable feedback from colleagues.6 Lastly, the lack of clarity between resuscitation team members’ awareness of their fellow team members’ roles, skill-sets and specialities is also identified as an inhibitor of effective teamwork during resuscitations. A feature of effective resuscitation includes specifically assigned roles, so that individual responders commit to responsibilities immediately upon arrival at a resuscitation event.1 Thus leadership, communication and role allocation are modifiable determinants of resuscitation calls.

Every hospital has its own protocol concerning the organisation of resuscitation calls and who is designated to respond to them. At North Shore hospital, emergencies and resuscitation calls are termed ‘777 calls’. The resuscitation team consists of an anaesthetic technician, intensive care unit registrar, on-call medical registrar, on-call house surgeon/junior doctor, cardiology nurse, orderlies/porters and a critical care outreach team (CCOT) nurse for each shift. As part of a clinical governance project conducted at Waitematā DHB, we examined the process of 777 calls. Analysis of the six-month period between June and November 2019 indicated that 76.8% of all 777 calls at North Shore Hospital were made out of hours (between 4pm to 8am, including weekends). The same six month period had 30 in-hospital cardiac arrests, and 80% of these also occurred after hours.

We also found that there were several potential areas for improvement of resuscitation calls. Members of the resuscitation team vary between shifts, and the start of a new shift did not entail any introduction to the other team members. Often, members of the team met for the first time at the bedside of a deteriorating patient. In such a time-dependent situation, knowledge of the roles, the levels of experience and even the names of fellow members were not readily established. Without sufficient knowledge of fellow members, team members were required to work effectively and make important decisions collaboratively to improve a patient’s condition. This is a commonly described feature of hospital resuscitation calls in the literature.6  

Traditionally, the response to medical emergencies such as cardiac arrests has been a reactive one.7 According to Hunziker and colleagues, the process by which the resuscitation team forms and functions materially influences the quality of the resuscitative effort, independent of the individual team members’ skills in resuscitation.9 Advice from the UK Resuscitation Council states that team members must meet for introductions and designate roles and responsibilities before attending actual events.8 However, studies show that resuscitations rarely have any formal briefing.8 Thus, while not unusual, what was commonly occurring at North Shore Hospital was not preferred practice.

We investigated two similar UK-based interventions designed to address similar issues. The studies were carried out in Surrey and Sussex (Redhill) and Brighton and Sussex University Hospital NHS Trust.  The Surrey and Sussex Healthcare NHS Trust initiated a ‘Ten Minute Meeting’ core huddle at 9am between members of the cardiac arrest and medical resuscitation team. This meeting involved the allocation of roles, such as who will conduct chest compressions or arterial blood gas sampling. It also identified the potential leaders for resuscitation calls.7 Research conducted by Claire Rowley from the Surrey and Sussex Healthcare NHS Trust found that these meetings were associated with improved leadership, reduced commotion and overall improved patient safety during resuscitation events.7 Brighton and Sussex University Hospital NHS Trust also found that team members reported feeling less stressed as a result of having better knowledge about their fellow team members.9

As part of our research, we established that the practice for resuscitation events at Waitematā DHB was comparable to that of the NHS Trust. We initiated the 777 Planner, an intervention that was designed to address the issues with resuscitation calls previously discussed when team members meet for the first time in an acute setting. We then surveyed staff to assess its local effectiveness.

The aim of this intervention was to ensure that members of the resuscitation team are competent and confident in the roles that they are performing during a resuscitation call, and to improve leadership and teamwork within the resuscitation team.

Methods

Implementation of 777 Planner

The implementation of our intervention followed Kotter’s Eight Step Model of Change.10 The format of the intervention was based on the work of the previously described two UK-based interventions. The aim of the change was to introduce and embed two 3–5 minute 777 Planner meetings each day at 4pm and 10pm to allow for shift change over. The first of these meetings took place in the acute diagnostic unit at North Shore Hospital in Auckland, New Zealand on 3 March 2020. We designed a 777 Planner template to guide the meeting (Figure 1). The template was designed to allow members of the team to meet, introduce themselves and allocate roles in preparation for resuscitative events prior to later calls. As medical staff rotate between departments and hospitals throughout the year, the 777 Planner and completion of the template was led by the clinical nurse manager, which allowed for continuity of leadership and had the added benefit of alleviating the norms of hospital hierarchy.7

Figure 1: 777 Planner template to be completed during the 777 Planner meeting.

Surveys

Prior to the introduction of the 777 Planner, we conducted a pre-implementation survey among relevant departments to identify perceptions of 777 calls. Data was collected between 30 January and 17 February 2020. Two months after the start of the intervention, we conducted a post-implementation survey among the same groups. The same questions were used for both the pre- and post-intervention surveys, with the addition of two questions concerning the format of the 777 Planner template in the post-implementation survey (Figure 2). The post-intervention survey was conducted between 4 May and 20 May 2020. The surveys were designed to assess the aims of this project. Both surveys were anonymous to allow for truthful feedback. The local research and knowledge centre aided in the design, and there were no ethical requirements for these surveys. The responses to the questions were collected on a Likert scale. The survey was sent to all members of the adult resuscitation teams. Notably, the orderly team declined to participate in this intervention and were therefore not included in the survey.

Figure 2: Questions used in the pre-implementation and post-implementation surveys.

Results

The total number of respondents to the pre-implementation survey was 61 and the post-implementation survey was 62.

Table 1: Number of staff who responded to the pre-implementation and post-implementation surveys based on job title.

Figure 3: Pre-implementation survey results.

Figure 4: Post-implementation survey results.

In the post-implementation survey, staff reported higher rates of agreeableness in every question in comparison to the pre-implementation survey. Specifically, the number of responses of ‘completely agree’ improved significantly, illustrating that team members had greater clarity regarding their roles and the roles of others.

Fifty percent of pre-implementation survey respondents were not clear what other team members roles were in emergency calls, with 53% not aware who was leading the emergency call. Following the introduction of our intervention, this improved to 74% reporting clarity on roles and 79% stating they knew who was leading. The proportion of respondents who were not introduced to the rest of the team before or during emergency calls reduced from 87% to 23%. Only 16% of respondents completely agreed with the statement that the team worked effectively pre- intervention. This rose to 32% following the introduction of the 777 Planner. The post-implementation survey also included questions related to how staff perceived the usefulness of our intervention. Sixty-eight percent of respondents felt that the 777 Planner had improved their experience of 777 calls, and 78% of our respondents found it a useful part of the handover.  

Discussion

This intervention showed that the simple addition of the 777 Planner meeting with a set format had the effect of improving interprofessional practice, team experience, confidence in roles and clarity of responsibilities in resuscitation events at North Shore Hospital. This adds to the weight of the existing literature concerning this topic.

The strengths of this intervention include its simplicity and that it is a low-cost measure to implement and maintain. The 777 Planner is easily reproducible in other healthcare settings with similar resuscitation call requirements. A feature also noted was the learning opportunity that this intervention presents for the consolidation and development of collaborative skills. The prior planning of the resuscitation call lends the opportunity for junior members to step up to leadership responsibilities under supervision, which by necessity may have previously been assumed by senior colleagues. The 777 Planner provides the opportunity to foster and enable learning because the situation is more anticipated and less stressful. Members have had the chance to meet prior to 777 calls and discuss their learning needs. As such, junior staff may more readily volunteer themselves for greater responsibility. Thus, the simplicity, low cost reproducible nature of the 777 Planner, as well as the opportunities for skills development that it provides, are the key strengths of this intervention.

The engagement of the resuscitation team was necessary for success in this project. One of the early issues with implementation was attendance, especially at the 4pm 777 Planner. Discussion with stakeholders enabled us to learn that the main reason was the availability of intensive care unit (ICU) staff. Junior house surgeons and registrars also often reported being tied up with ward work from the day shift, and many forgot to attend. We responded by sending reminders through the hospital pager system and by email. Through these means and with time the workplace culture gradually shifted; the value of the meetings became understood and staff started to diligently attend.

The limitations of this intervention include that there was no 8am 777 Planner. We did investigate the idea of a morning 777 Planner that coincided with the morning medical handover. However, the feedback among stakeholders was that there was a perception of contested time in the mornings, at the start of the busy day shift. Ultimately, our rationale for avoiding a morning 777 Planner also took into account that the majority of 777 calls tended to be out of hours. The 4pm and 10pm 777 Planners were designed to coincide with shift handovers for ease of attendance among members. Another area that could have been measured concurrently with the staff surveys were patient outcomes in resuscitation calls during this period. This should ideally be measured once the 777 Planner is a more established part of the local culture, and may indeed be done in the coming months.

Other limitations of our project include the small sample size of the surveys in comparison to the overall staff size. This could be a source of bias in the results measured; however, it is unclear whether and how this may have skewed the results. Finally, whether our two surveys had the exact same respondents is unknown. This is owing to the anonymised nature of the surveys, and that post-implementation survey respondents were not asked whether they had previously completed the pre-implementation survey.  We therefore have no indication regarding the potential paired nature of our data. This also entailed that statistical analysis was not possible with our dataset; given the unknown number of participants who responded to both surveys, predications based on tests of independent proportions are inappropriate.

An unanticipated event during our intervention was the COVID-19 pandemic. We began our intervention on March 3 2020, and New Zealand went into Level 4 lockdown on 25 March 2020. As a result of increased risk to staff and the greater personal protective equipment required, the hospital resuscitation guidelines were revised. The lockdown was a time of uncertainty when resuscitation became a very topical issue. We found that the 777 Planner became a means of discussing these changes and conveying staff feedback about changing protocols and new guidelines. As a result, the 777 Planner became highly acknowledged by the incident controllers and senior executives as a crucial part of daily operations. Therefore, the possibility also exists that the COVID-19 period made potential respondents more interested in participating in the surveys, at least more than in usual circumstances.

On completion of the post-implementation survey and analysis, this project was formally handed over to the Resuscitation Committee of Waitematā District Health Board. There are several prospective areas for future development. For example, a formalised debriefing session following resuscitation calls has been proposed. This is where a review of role allocation could take place and provide further educational opportunities for feedback.  Additionally, the 777 Planner could be a means of conveying relevant announcements of the upcoming shift. Formally investigating the impact of the 777 Planner on the outcomes of resuscitation events has also been considered for future research. The simplicity and generalisability of the intervention makes it possible to adopt and adapt by other district health boards, and indeed other hospitals internationally.

Overall the 777 Planner was an intervention designed to improve the experience of  resuscitation calls locally. Our data indicated that respondents felt the 777 Planner improved their overall experience of resuscitation calls, particularly concerning clarity of leadership, communication and confidence.

Conclusion

The addition of the 777 Planner to North Shore Hospital improved team members experiences of 777/resuscitation calls. Following the implementation of our intervention, adult resuscitation team members were clearer about their roles and who was leading the emergency response. They also perceived that the team became more effective as a result of this work.

Summary

Abstract

BACKGROUND: This is a baseline quality improvement project conducted at North Shore Hospital in Auckland, New Zealand. We designed a 777 Planner meeting and template for members of the resuscitation team who were designated to respond to 777/resuscitation calls in the hospital after hours. AIM: To ensure that staff at North Shore Hospital are competent and confident in the roles that they are performing during a 777 call, and to improve leadership and teamwork within the resuscitation team. METHODS: We introduced two 777 Planner meetings each day at 4pm and 10pm at North Shore Hospital, with a 777 Planner template to guide the meeting. The 777 Planner enabled members of the team to meet, introduce themselves and allocate roles in preparation for resuscitative events prior to later calls. We conducted pre- and post-implementation surveys to evaluate the experience of 777 calls prior to and after implementation of the 777 Planner. RESULTS: 68% of respondents felt that the 777 Planner improved their experience of 777 calls, and 78% found it a useful part of the handover. 50% of pre-implementation survey respondents were not clear what other team members roles were in emergency calls, and 53% were not aware who was leading the emergency call. Following the implementation of the intervention, this improved to 74% reporting clarity on roles and 79% stating they knew who was leading the 777 call. CONCLUSION: The 777 Planner ultimately improved members of the resuscitation teams experience of 777 calls at North Shore Hospital, particularly concerning leadership, communication and clarity of roles.

Aim

Method

Results

Conclusion

Author Information

Daniel Gibbons: House Surgeon, Waitematā District Health Board, Auckland, New Zealand. Dushiyanthi Rasanathan: House Surgeon, Waitematā District Health Board, Auckland, New Zealand. Naomi Heap: Clinical education and Training Unit Manager, Waitematā District Health Board, Auckland, New Zealand. Dr Jonathan Wallace: Anaesthetic Medical Officer, Associate Director at Institute for Innovation and Improvement (i3) at Waitematā District Health Board, Auckland, New Zealand.

Acknowledgements

Correspondence

Dr Dushiyanthi Rasanathan, Private Bag 93503 Takapuna Auckland City 0740, New Zealand

Correspondence Email

dushi@windowslive.com

Competing Interests

Nil.

1. Nallamothu BK, Guetterman TC, Harrod M, et al. How do resuscitation teams at top-performing hospitals for in-hospital cardiac arrest succeed? A qualitative study. Circulation 2018;138:154-63.

2. Marsch SC, Müller C, Marquardt K, Conrad G, Tschan F, Hunziker PR. Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation 2004;60:51-6.

3. Hunziker S, Tschan F, Semmer NK, Howell MD, Marsch S. Human factors in resuscitation: Lessons learned from simulator studies. J Emerg Trauma Shock 2010;3:389.

4. Yamada NK, Halamek LP. On the need for precise, concise communication during resuscitation: a proposed solution. J Pediatr 2015;166:184-7.

5. Pittman J, Turner B, Gabbott DA. Communication between members of the cardiac arrest team—a postal survey. Resuscitation 2001;49:175-7.

6. Rowley C. Improving patient safety with a daily emergency call safety Huddle. Surrey,  Surrey and Sussex NHS Healthcare Trust (UK), 2019. (Accessed 6 March 2020, at https://www.healthcareconferencesuk.co.uk/assets/presentations-post-conference/july-2019/claire-rowley.pptx.pdf)

7. Rowley C. The Atlas of Shared Learning Case Study. Improving patient safety by introducing a daily Emergency Call Safety Huddle. Surrey and Sussex NHS Healthcare Trust (UK), 2019. (Accessed 11 March 2020 at https://www.england.nhs.uk/atlas_case_study/improving-patient-safety-by-introducing-a-daily-emergency-call-safety-huddle)

8. Gwinnutt C, Davies R, SoarI J. In-hospital resuscitation. London Resuscitation Council (UK), 2015. (Accessed 20 May 2020, at https://www.resus.org.uk/resuscitation-guidelines/in-hospital-resuscitation/)

9. 10 minute medical emergency team meetings [Internet]. Brighton [UK]: NHS Improvement; 2017 [cited 2020 May 1]. Available from: https://improvement.nhs.uk/resources/ten-minute-meetings-for-emergency-teams/

10. Varkey P, Antonio K. Change management for effective quality improvement : a primer. Am J Med Qual 2010;25:268-273.

Contact diana@nzma.org.nz
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Resuscitation events in hospital are invariably high-stake challenging situations that require effective communication, leadership and coordination. A qualitative study by Nallamothu and colleagues, exploring the experiences responders to in-hospital cardiac arrest teams, found that teams, not individuals, are ultimately responsible for providing resuscitation at hospitals.1 Resuscitation is a team endeavour that requires several healthcare professionals of varying experience and backgrounds to coordinate their activities and ensure optimum performance as a team.2 Immediate and effective resuscitation is vital for improving the mortality and morbidity rates of patients for whom resuscitation calls are made.3 As such, the effectiveness of resuscitation teams is an important determinant of patient safety and survival outcomes.1 At North Shore Hospital, which is one of two main hospitals at Waitematā District Health Board (DHB) in Auckland, New Zealand, we established the 777 Planner as an intervention to improve the experiences of team members in resuscitation calls.

Performance in a resuscitation situation is dependent on quality leadership, good communication and team structuring.3 In a study examining 16 teams participating in a simulation of witnessed cardiac arrest, absence of leadership characteristics and the failure to explicitly allocate tasks were linked with poor team performance.2 Clearer leadership from the team leader is associated with superior task performance and more efficient cooperation within the resuscitation team.3 Inadequate communication during a resuscitation call is also one of the most commonly identified underlying causes of clinical errors and adverse patient outcomes.4 The literature suggests that communication between members of the resuscitation team, before and after an event, is generally poor.5 Communication used during an acute emergency situation can often be non-specific, such as failing to use team members’ names or not directly allocating tasks to a person.4  Erroneous communication can contribute to a delay in initiating life saving measures, such as commencement of cardiopulmonary resuscitation (CPR) or the administration of adrenaline. These can have a significant impact on a patient’s outcome.3 Communication can also be a barrier in the ongoing training and skill development of resuscitation team members, as members lose opportunities to successfully volunteer for roles and gain valuable feedback from colleagues.6 Lastly, the lack of clarity between resuscitation team members’ awareness of their fellow team members’ roles, skill-sets and specialities is also identified as an inhibitor of effective teamwork during resuscitations. A feature of effective resuscitation includes specifically assigned roles, so that individual responders commit to responsibilities immediately upon arrival at a resuscitation event.1 Thus leadership, communication and role allocation are modifiable determinants of resuscitation calls.

Every hospital has its own protocol concerning the organisation of resuscitation calls and who is designated to respond to them. At North Shore hospital, emergencies and resuscitation calls are termed ‘777 calls’. The resuscitation team consists of an anaesthetic technician, intensive care unit registrar, on-call medical registrar, on-call house surgeon/junior doctor, cardiology nurse, orderlies/porters and a critical care outreach team (CCOT) nurse for each shift. As part of a clinical governance project conducted at Waitematā DHB, we examined the process of 777 calls. Analysis of the six-month period between June and November 2019 indicated that 76.8% of all 777 calls at North Shore Hospital were made out of hours (between 4pm to 8am, including weekends). The same six month period had 30 in-hospital cardiac arrests, and 80% of these also occurred after hours.

We also found that there were several potential areas for improvement of resuscitation calls. Members of the resuscitation team vary between shifts, and the start of a new shift did not entail any introduction to the other team members. Often, members of the team met for the first time at the bedside of a deteriorating patient. In such a time-dependent situation, knowledge of the roles, the levels of experience and even the names of fellow members were not readily established. Without sufficient knowledge of fellow members, team members were required to work effectively and make important decisions collaboratively to improve a patient’s condition. This is a commonly described feature of hospital resuscitation calls in the literature.6  

Traditionally, the response to medical emergencies such as cardiac arrests has been a reactive one.7 According to Hunziker and colleagues, the process by which the resuscitation team forms and functions materially influences the quality of the resuscitative effort, independent of the individual team members’ skills in resuscitation.9 Advice from the UK Resuscitation Council states that team members must meet for introductions and designate roles and responsibilities before attending actual events.8 However, studies show that resuscitations rarely have any formal briefing.8 Thus, while not unusual, what was commonly occurring at North Shore Hospital was not preferred practice.

We investigated two similar UK-based interventions designed to address similar issues. The studies were carried out in Surrey and Sussex (Redhill) and Brighton and Sussex University Hospital NHS Trust.  The Surrey and Sussex Healthcare NHS Trust initiated a ‘Ten Minute Meeting’ core huddle at 9am between members of the cardiac arrest and medical resuscitation team. This meeting involved the allocation of roles, such as who will conduct chest compressions or arterial blood gas sampling. It also identified the potential leaders for resuscitation calls.7 Research conducted by Claire Rowley from the Surrey and Sussex Healthcare NHS Trust found that these meetings were associated with improved leadership, reduced commotion and overall improved patient safety during resuscitation events.7 Brighton and Sussex University Hospital NHS Trust also found that team members reported feeling less stressed as a result of having better knowledge about their fellow team members.9

As part of our research, we established that the practice for resuscitation events at Waitematā DHB was comparable to that of the NHS Trust. We initiated the 777 Planner, an intervention that was designed to address the issues with resuscitation calls previously discussed when team members meet for the first time in an acute setting. We then surveyed staff to assess its local effectiveness.

The aim of this intervention was to ensure that members of the resuscitation team are competent and confident in the roles that they are performing during a resuscitation call, and to improve leadership and teamwork within the resuscitation team.

Methods

Implementation of 777 Planner

The implementation of our intervention followed Kotter’s Eight Step Model of Change.10 The format of the intervention was based on the work of the previously described two UK-based interventions. The aim of the change was to introduce and embed two 3–5 minute 777 Planner meetings each day at 4pm and 10pm to allow for shift change over. The first of these meetings took place in the acute diagnostic unit at North Shore Hospital in Auckland, New Zealand on 3 March 2020. We designed a 777 Planner template to guide the meeting (Figure 1). The template was designed to allow members of the team to meet, introduce themselves and allocate roles in preparation for resuscitative events prior to later calls. As medical staff rotate between departments and hospitals throughout the year, the 777 Planner and completion of the template was led by the clinical nurse manager, which allowed for continuity of leadership and had the added benefit of alleviating the norms of hospital hierarchy.7

Figure 1: 777 Planner template to be completed during the 777 Planner meeting.

Surveys

Prior to the introduction of the 777 Planner, we conducted a pre-implementation survey among relevant departments to identify perceptions of 777 calls. Data was collected between 30 January and 17 February 2020. Two months after the start of the intervention, we conducted a post-implementation survey among the same groups. The same questions were used for both the pre- and post-intervention surveys, with the addition of two questions concerning the format of the 777 Planner template in the post-implementation survey (Figure 2). The post-intervention survey was conducted between 4 May and 20 May 2020. The surveys were designed to assess the aims of this project. Both surveys were anonymous to allow for truthful feedback. The local research and knowledge centre aided in the design, and there were no ethical requirements for these surveys. The responses to the questions were collected on a Likert scale. The survey was sent to all members of the adult resuscitation teams. Notably, the orderly team declined to participate in this intervention and were therefore not included in the survey.

Figure 2: Questions used in the pre-implementation and post-implementation surveys.

Results

The total number of respondents to the pre-implementation survey was 61 and the post-implementation survey was 62.

Table 1: Number of staff who responded to the pre-implementation and post-implementation surveys based on job title.

Figure 3: Pre-implementation survey results.

Figure 4: Post-implementation survey results.

In the post-implementation survey, staff reported higher rates of agreeableness in every question in comparison to the pre-implementation survey. Specifically, the number of responses of ‘completely agree’ improved significantly, illustrating that team members had greater clarity regarding their roles and the roles of others.

Fifty percent of pre-implementation survey respondents were not clear what other team members roles were in emergency calls, with 53% not aware who was leading the emergency call. Following the introduction of our intervention, this improved to 74% reporting clarity on roles and 79% stating they knew who was leading. The proportion of respondents who were not introduced to the rest of the team before or during emergency calls reduced from 87% to 23%. Only 16% of respondents completely agreed with the statement that the team worked effectively pre- intervention. This rose to 32% following the introduction of the 777 Planner. The post-implementation survey also included questions related to how staff perceived the usefulness of our intervention. Sixty-eight percent of respondents felt that the 777 Planner had improved their experience of 777 calls, and 78% of our respondents found it a useful part of the handover.  

Discussion

This intervention showed that the simple addition of the 777 Planner meeting with a set format had the effect of improving interprofessional practice, team experience, confidence in roles and clarity of responsibilities in resuscitation events at North Shore Hospital. This adds to the weight of the existing literature concerning this topic.

The strengths of this intervention include its simplicity and that it is a low-cost measure to implement and maintain. The 777 Planner is easily reproducible in other healthcare settings with similar resuscitation call requirements. A feature also noted was the learning opportunity that this intervention presents for the consolidation and development of collaborative skills. The prior planning of the resuscitation call lends the opportunity for junior members to step up to leadership responsibilities under supervision, which by necessity may have previously been assumed by senior colleagues. The 777 Planner provides the opportunity to foster and enable learning because the situation is more anticipated and less stressful. Members have had the chance to meet prior to 777 calls and discuss their learning needs. As such, junior staff may more readily volunteer themselves for greater responsibility. Thus, the simplicity, low cost reproducible nature of the 777 Planner, as well as the opportunities for skills development that it provides, are the key strengths of this intervention.

The engagement of the resuscitation team was necessary for success in this project. One of the early issues with implementation was attendance, especially at the 4pm 777 Planner. Discussion with stakeholders enabled us to learn that the main reason was the availability of intensive care unit (ICU) staff. Junior house surgeons and registrars also often reported being tied up with ward work from the day shift, and many forgot to attend. We responded by sending reminders through the hospital pager system and by email. Through these means and with time the workplace culture gradually shifted; the value of the meetings became understood and staff started to diligently attend.

The limitations of this intervention include that there was no 8am 777 Planner. We did investigate the idea of a morning 777 Planner that coincided with the morning medical handover. However, the feedback among stakeholders was that there was a perception of contested time in the mornings, at the start of the busy day shift. Ultimately, our rationale for avoiding a morning 777 Planner also took into account that the majority of 777 calls tended to be out of hours. The 4pm and 10pm 777 Planners were designed to coincide with shift handovers for ease of attendance among members. Another area that could have been measured concurrently with the staff surveys were patient outcomes in resuscitation calls during this period. This should ideally be measured once the 777 Planner is a more established part of the local culture, and may indeed be done in the coming months.

Other limitations of our project include the small sample size of the surveys in comparison to the overall staff size. This could be a source of bias in the results measured; however, it is unclear whether and how this may have skewed the results. Finally, whether our two surveys had the exact same respondents is unknown. This is owing to the anonymised nature of the surveys, and that post-implementation survey respondents were not asked whether they had previously completed the pre-implementation survey.  We therefore have no indication regarding the potential paired nature of our data. This also entailed that statistical analysis was not possible with our dataset; given the unknown number of participants who responded to both surveys, predications based on tests of independent proportions are inappropriate.

An unanticipated event during our intervention was the COVID-19 pandemic. We began our intervention on March 3 2020, and New Zealand went into Level 4 lockdown on 25 March 2020. As a result of increased risk to staff and the greater personal protective equipment required, the hospital resuscitation guidelines were revised. The lockdown was a time of uncertainty when resuscitation became a very topical issue. We found that the 777 Planner became a means of discussing these changes and conveying staff feedback about changing protocols and new guidelines. As a result, the 777 Planner became highly acknowledged by the incident controllers and senior executives as a crucial part of daily operations. Therefore, the possibility also exists that the COVID-19 period made potential respondents more interested in participating in the surveys, at least more than in usual circumstances.

On completion of the post-implementation survey and analysis, this project was formally handed over to the Resuscitation Committee of Waitematā District Health Board. There are several prospective areas for future development. For example, a formalised debriefing session following resuscitation calls has been proposed. This is where a review of role allocation could take place and provide further educational opportunities for feedback.  Additionally, the 777 Planner could be a means of conveying relevant announcements of the upcoming shift. Formally investigating the impact of the 777 Planner on the outcomes of resuscitation events has also been considered for future research. The simplicity and generalisability of the intervention makes it possible to adopt and adapt by other district health boards, and indeed other hospitals internationally.

Overall the 777 Planner was an intervention designed to improve the experience of  resuscitation calls locally. Our data indicated that respondents felt the 777 Planner improved their overall experience of resuscitation calls, particularly concerning clarity of leadership, communication and confidence.

Conclusion

The addition of the 777 Planner to North Shore Hospital improved team members experiences of 777/resuscitation calls. Following the implementation of our intervention, adult resuscitation team members were clearer about their roles and who was leading the emergency response. They also perceived that the team became more effective as a result of this work.

Summary

Abstract

BACKGROUND: This is a baseline quality improvement project conducted at North Shore Hospital in Auckland, New Zealand. We designed a 777 Planner meeting and template for members of the resuscitation team who were designated to respond to 777/resuscitation calls in the hospital after hours. AIM: To ensure that staff at North Shore Hospital are competent and confident in the roles that they are performing during a 777 call, and to improve leadership and teamwork within the resuscitation team. METHODS: We introduced two 777 Planner meetings each day at 4pm and 10pm at North Shore Hospital, with a 777 Planner template to guide the meeting. The 777 Planner enabled members of the team to meet, introduce themselves and allocate roles in preparation for resuscitative events prior to later calls. We conducted pre- and post-implementation surveys to evaluate the experience of 777 calls prior to and after implementation of the 777 Planner. RESULTS: 68% of respondents felt that the 777 Planner improved their experience of 777 calls, and 78% found it a useful part of the handover. 50% of pre-implementation survey respondents were not clear what other team members roles were in emergency calls, and 53% were not aware who was leading the emergency call. Following the implementation of the intervention, this improved to 74% reporting clarity on roles and 79% stating they knew who was leading the 777 call. CONCLUSION: The 777 Planner ultimately improved members of the resuscitation teams experience of 777 calls at North Shore Hospital, particularly concerning leadership, communication and clarity of roles.

Aim

Method

Results

Conclusion

Author Information

Daniel Gibbons: House Surgeon, Waitematā District Health Board, Auckland, New Zealand. Dushiyanthi Rasanathan: House Surgeon, Waitematā District Health Board, Auckland, New Zealand. Naomi Heap: Clinical education and Training Unit Manager, Waitematā District Health Board, Auckland, New Zealand. Dr Jonathan Wallace: Anaesthetic Medical Officer, Associate Director at Institute for Innovation and Improvement (i3) at Waitematā District Health Board, Auckland, New Zealand.

Acknowledgements

Correspondence

Dr Dushiyanthi Rasanathan, Private Bag 93503 Takapuna Auckland City 0740, New Zealand

Correspondence Email

dushi@windowslive.com

Competing Interests

Nil.

1. Nallamothu BK, Guetterman TC, Harrod M, et al. How do resuscitation teams at top-performing hospitals for in-hospital cardiac arrest succeed? A qualitative study. Circulation 2018;138:154-63.

2. Marsch SC, Müller C, Marquardt K, Conrad G, Tschan F, Hunziker PR. Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation 2004;60:51-6.

3. Hunziker S, Tschan F, Semmer NK, Howell MD, Marsch S. Human factors in resuscitation: Lessons learned from simulator studies. J Emerg Trauma Shock 2010;3:389.

4. Yamada NK, Halamek LP. On the need for precise, concise communication during resuscitation: a proposed solution. J Pediatr 2015;166:184-7.

5. Pittman J, Turner B, Gabbott DA. Communication between members of the cardiac arrest team—a postal survey. Resuscitation 2001;49:175-7.

6. Rowley C. Improving patient safety with a daily emergency call safety Huddle. Surrey,  Surrey and Sussex NHS Healthcare Trust (UK), 2019. (Accessed 6 March 2020, at https://www.healthcareconferencesuk.co.uk/assets/presentations-post-conference/july-2019/claire-rowley.pptx.pdf)

7. Rowley C. The Atlas of Shared Learning Case Study. Improving patient safety by introducing a daily Emergency Call Safety Huddle. Surrey and Sussex NHS Healthcare Trust (UK), 2019. (Accessed 11 March 2020 at https://www.england.nhs.uk/atlas_case_study/improving-patient-safety-by-introducing-a-daily-emergency-call-safety-huddle)

8. Gwinnutt C, Davies R, SoarI J. In-hospital resuscitation. London Resuscitation Council (UK), 2015. (Accessed 20 May 2020, at https://www.resus.org.uk/resuscitation-guidelines/in-hospital-resuscitation/)

9. 10 minute medical emergency team meetings [Internet]. Brighton [UK]: NHS Improvement; 2017 [cited 2020 May 1]. Available from: https://improvement.nhs.uk/resources/ten-minute-meetings-for-emergency-teams/

10. Varkey P, Antonio K. Change management for effective quality improvement : a primer. Am J Med Qual 2010;25:268-273.

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Resuscitation events in hospital are invariably high-stake challenging situations that require effective communication, leadership and coordination. A qualitative study by Nallamothu and colleagues, exploring the experiences responders to in-hospital cardiac arrest teams, found that teams, not individuals, are ultimately responsible for providing resuscitation at hospitals.1 Resuscitation is a team endeavour that requires several healthcare professionals of varying experience and backgrounds to coordinate their activities and ensure optimum performance as a team.2 Immediate and effective resuscitation is vital for improving the mortality and morbidity rates of patients for whom resuscitation calls are made.3 As such, the effectiveness of resuscitation teams is an important determinant of patient safety and survival outcomes.1 At North Shore Hospital, which is one of two main hospitals at Waitematā District Health Board (DHB) in Auckland, New Zealand, we established the 777 Planner as an intervention to improve the experiences of team members in resuscitation calls.

Performance in a resuscitation situation is dependent on quality leadership, good communication and team structuring.3 In a study examining 16 teams participating in a simulation of witnessed cardiac arrest, absence of leadership characteristics and the failure to explicitly allocate tasks were linked with poor team performance.2 Clearer leadership from the team leader is associated with superior task performance and more efficient cooperation within the resuscitation team.3 Inadequate communication during a resuscitation call is also one of the most commonly identified underlying causes of clinical errors and adverse patient outcomes.4 The literature suggests that communication between members of the resuscitation team, before and after an event, is generally poor.5 Communication used during an acute emergency situation can often be non-specific, such as failing to use team members’ names or not directly allocating tasks to a person.4  Erroneous communication can contribute to a delay in initiating life saving measures, such as commencement of cardiopulmonary resuscitation (CPR) or the administration of adrenaline. These can have a significant impact on a patient’s outcome.3 Communication can also be a barrier in the ongoing training and skill development of resuscitation team members, as members lose opportunities to successfully volunteer for roles and gain valuable feedback from colleagues.6 Lastly, the lack of clarity between resuscitation team members’ awareness of their fellow team members’ roles, skill-sets and specialities is also identified as an inhibitor of effective teamwork during resuscitations. A feature of effective resuscitation includes specifically assigned roles, so that individual responders commit to responsibilities immediately upon arrival at a resuscitation event.1 Thus leadership, communication and role allocation are modifiable determinants of resuscitation calls.

Every hospital has its own protocol concerning the organisation of resuscitation calls and who is designated to respond to them. At North Shore hospital, emergencies and resuscitation calls are termed ‘777 calls’. The resuscitation team consists of an anaesthetic technician, intensive care unit registrar, on-call medical registrar, on-call house surgeon/junior doctor, cardiology nurse, orderlies/porters and a critical care outreach team (CCOT) nurse for each shift. As part of a clinical governance project conducted at Waitematā DHB, we examined the process of 777 calls. Analysis of the six-month period between June and November 2019 indicated that 76.8% of all 777 calls at North Shore Hospital were made out of hours (between 4pm to 8am, including weekends). The same six month period had 30 in-hospital cardiac arrests, and 80% of these also occurred after hours.

We also found that there were several potential areas for improvement of resuscitation calls. Members of the resuscitation team vary between shifts, and the start of a new shift did not entail any introduction to the other team members. Often, members of the team met for the first time at the bedside of a deteriorating patient. In such a time-dependent situation, knowledge of the roles, the levels of experience and even the names of fellow members were not readily established. Without sufficient knowledge of fellow members, team members were required to work effectively and make important decisions collaboratively to improve a patient’s condition. This is a commonly described feature of hospital resuscitation calls in the literature.6  

Traditionally, the response to medical emergencies such as cardiac arrests has been a reactive one.7 According to Hunziker and colleagues, the process by which the resuscitation team forms and functions materially influences the quality of the resuscitative effort, independent of the individual team members’ skills in resuscitation.9 Advice from the UK Resuscitation Council states that team members must meet for introductions and designate roles and responsibilities before attending actual events.8 However, studies show that resuscitations rarely have any formal briefing.8 Thus, while not unusual, what was commonly occurring at North Shore Hospital was not preferred practice.

We investigated two similar UK-based interventions designed to address similar issues. The studies were carried out in Surrey and Sussex (Redhill) and Brighton and Sussex University Hospital NHS Trust.  The Surrey and Sussex Healthcare NHS Trust initiated a ‘Ten Minute Meeting’ core huddle at 9am between members of the cardiac arrest and medical resuscitation team. This meeting involved the allocation of roles, such as who will conduct chest compressions or arterial blood gas sampling. It also identified the potential leaders for resuscitation calls.7 Research conducted by Claire Rowley from the Surrey and Sussex Healthcare NHS Trust found that these meetings were associated with improved leadership, reduced commotion and overall improved patient safety during resuscitation events.7 Brighton and Sussex University Hospital NHS Trust also found that team members reported feeling less stressed as a result of having better knowledge about their fellow team members.9

As part of our research, we established that the practice for resuscitation events at Waitematā DHB was comparable to that of the NHS Trust. We initiated the 777 Planner, an intervention that was designed to address the issues with resuscitation calls previously discussed when team members meet for the first time in an acute setting. We then surveyed staff to assess its local effectiveness.

The aim of this intervention was to ensure that members of the resuscitation team are competent and confident in the roles that they are performing during a resuscitation call, and to improve leadership and teamwork within the resuscitation team.

Methods

Implementation of 777 Planner

The implementation of our intervention followed Kotter’s Eight Step Model of Change.10 The format of the intervention was based on the work of the previously described two UK-based interventions. The aim of the change was to introduce and embed two 3–5 minute 777 Planner meetings each day at 4pm and 10pm to allow for shift change over. The first of these meetings took place in the acute diagnostic unit at North Shore Hospital in Auckland, New Zealand on 3 March 2020. We designed a 777 Planner template to guide the meeting (Figure 1). The template was designed to allow members of the team to meet, introduce themselves and allocate roles in preparation for resuscitative events prior to later calls. As medical staff rotate between departments and hospitals throughout the year, the 777 Planner and completion of the template was led by the clinical nurse manager, which allowed for continuity of leadership and had the added benefit of alleviating the norms of hospital hierarchy.7

Figure 1: 777 Planner template to be completed during the 777 Planner meeting.

Surveys

Prior to the introduction of the 777 Planner, we conducted a pre-implementation survey among relevant departments to identify perceptions of 777 calls. Data was collected between 30 January and 17 February 2020. Two months after the start of the intervention, we conducted a post-implementation survey among the same groups. The same questions were used for both the pre- and post-intervention surveys, with the addition of two questions concerning the format of the 777 Planner template in the post-implementation survey (Figure 2). The post-intervention survey was conducted between 4 May and 20 May 2020. The surveys were designed to assess the aims of this project. Both surveys were anonymous to allow for truthful feedback. The local research and knowledge centre aided in the design, and there were no ethical requirements for these surveys. The responses to the questions were collected on a Likert scale. The survey was sent to all members of the adult resuscitation teams. Notably, the orderly team declined to participate in this intervention and were therefore not included in the survey.

Figure 2: Questions used in the pre-implementation and post-implementation surveys.

Results

The total number of respondents to the pre-implementation survey was 61 and the post-implementation survey was 62.

Table 1: Number of staff who responded to the pre-implementation and post-implementation surveys based on job title.

Figure 3: Pre-implementation survey results.

Figure 4: Post-implementation survey results.

In the post-implementation survey, staff reported higher rates of agreeableness in every question in comparison to the pre-implementation survey. Specifically, the number of responses of ‘completely agree’ improved significantly, illustrating that team members had greater clarity regarding their roles and the roles of others.

Fifty percent of pre-implementation survey respondents were not clear what other team members roles were in emergency calls, with 53% not aware who was leading the emergency call. Following the introduction of our intervention, this improved to 74% reporting clarity on roles and 79% stating they knew who was leading. The proportion of respondents who were not introduced to the rest of the team before or during emergency calls reduced from 87% to 23%. Only 16% of respondents completely agreed with the statement that the team worked effectively pre- intervention. This rose to 32% following the introduction of the 777 Planner. The post-implementation survey also included questions related to how staff perceived the usefulness of our intervention. Sixty-eight percent of respondents felt that the 777 Planner had improved their experience of 777 calls, and 78% of our respondents found it a useful part of the handover.  

Discussion

This intervention showed that the simple addition of the 777 Planner meeting with a set format had the effect of improving interprofessional practice, team experience, confidence in roles and clarity of responsibilities in resuscitation events at North Shore Hospital. This adds to the weight of the existing literature concerning this topic.

The strengths of this intervention include its simplicity and that it is a low-cost measure to implement and maintain. The 777 Planner is easily reproducible in other healthcare settings with similar resuscitation call requirements. A feature also noted was the learning opportunity that this intervention presents for the consolidation and development of collaborative skills. The prior planning of the resuscitation call lends the opportunity for junior members to step up to leadership responsibilities under supervision, which by necessity may have previously been assumed by senior colleagues. The 777 Planner provides the opportunity to foster and enable learning because the situation is more anticipated and less stressful. Members have had the chance to meet prior to 777 calls and discuss their learning needs. As such, junior staff may more readily volunteer themselves for greater responsibility. Thus, the simplicity, low cost reproducible nature of the 777 Planner, as well as the opportunities for skills development that it provides, are the key strengths of this intervention.

The engagement of the resuscitation team was necessary for success in this project. One of the early issues with implementation was attendance, especially at the 4pm 777 Planner. Discussion with stakeholders enabled us to learn that the main reason was the availability of intensive care unit (ICU) staff. Junior house surgeons and registrars also often reported being tied up with ward work from the day shift, and many forgot to attend. We responded by sending reminders through the hospital pager system and by email. Through these means and with time the workplace culture gradually shifted; the value of the meetings became understood and staff started to diligently attend.

The limitations of this intervention include that there was no 8am 777 Planner. We did investigate the idea of a morning 777 Planner that coincided with the morning medical handover. However, the feedback among stakeholders was that there was a perception of contested time in the mornings, at the start of the busy day shift. Ultimately, our rationale for avoiding a morning 777 Planner also took into account that the majority of 777 calls tended to be out of hours. The 4pm and 10pm 777 Planners were designed to coincide with shift handovers for ease of attendance among members. Another area that could have been measured concurrently with the staff surveys were patient outcomes in resuscitation calls during this period. This should ideally be measured once the 777 Planner is a more established part of the local culture, and may indeed be done in the coming months.

Other limitations of our project include the small sample size of the surveys in comparison to the overall staff size. This could be a source of bias in the results measured; however, it is unclear whether and how this may have skewed the results. Finally, whether our two surveys had the exact same respondents is unknown. This is owing to the anonymised nature of the surveys, and that post-implementation survey respondents were not asked whether they had previously completed the pre-implementation survey.  We therefore have no indication regarding the potential paired nature of our data. This also entailed that statistical analysis was not possible with our dataset; given the unknown number of participants who responded to both surveys, predications based on tests of independent proportions are inappropriate.

An unanticipated event during our intervention was the COVID-19 pandemic. We began our intervention on March 3 2020, and New Zealand went into Level 4 lockdown on 25 March 2020. As a result of increased risk to staff and the greater personal protective equipment required, the hospital resuscitation guidelines were revised. The lockdown was a time of uncertainty when resuscitation became a very topical issue. We found that the 777 Planner became a means of discussing these changes and conveying staff feedback about changing protocols and new guidelines. As a result, the 777 Planner became highly acknowledged by the incident controllers and senior executives as a crucial part of daily operations. Therefore, the possibility also exists that the COVID-19 period made potential respondents more interested in participating in the surveys, at least more than in usual circumstances.

On completion of the post-implementation survey and analysis, this project was formally handed over to the Resuscitation Committee of Waitematā District Health Board. There are several prospective areas for future development. For example, a formalised debriefing session following resuscitation calls has been proposed. This is where a review of role allocation could take place and provide further educational opportunities for feedback.  Additionally, the 777 Planner could be a means of conveying relevant announcements of the upcoming shift. Formally investigating the impact of the 777 Planner on the outcomes of resuscitation events has also been considered for future research. The simplicity and generalisability of the intervention makes it possible to adopt and adapt by other district health boards, and indeed other hospitals internationally.

Overall the 777 Planner was an intervention designed to improve the experience of  resuscitation calls locally. Our data indicated that respondents felt the 777 Planner improved their overall experience of resuscitation calls, particularly concerning clarity of leadership, communication and confidence.

Conclusion

The addition of the 777 Planner to North Shore Hospital improved team members experiences of 777/resuscitation calls. Following the implementation of our intervention, adult resuscitation team members were clearer about their roles and who was leading the emergency response. They also perceived that the team became more effective as a result of this work.

Summary

Abstract

BACKGROUND: This is a baseline quality improvement project conducted at North Shore Hospital in Auckland, New Zealand. We designed a 777 Planner meeting and template for members of the resuscitation team who were designated to respond to 777/resuscitation calls in the hospital after hours. AIM: To ensure that staff at North Shore Hospital are competent and confident in the roles that they are performing during a 777 call, and to improve leadership and teamwork within the resuscitation team. METHODS: We introduced two 777 Planner meetings each day at 4pm and 10pm at North Shore Hospital, with a 777 Planner template to guide the meeting. The 777 Planner enabled members of the team to meet, introduce themselves and allocate roles in preparation for resuscitative events prior to later calls. We conducted pre- and post-implementation surveys to evaluate the experience of 777 calls prior to and after implementation of the 777 Planner. RESULTS: 68% of respondents felt that the 777 Planner improved their experience of 777 calls, and 78% found it a useful part of the handover. 50% of pre-implementation survey respondents were not clear what other team members roles were in emergency calls, and 53% were not aware who was leading the emergency call. Following the implementation of the intervention, this improved to 74% reporting clarity on roles and 79% stating they knew who was leading the 777 call. CONCLUSION: The 777 Planner ultimately improved members of the resuscitation teams experience of 777 calls at North Shore Hospital, particularly concerning leadership, communication and clarity of roles.

Aim

Method

Results

Conclusion

Author Information

Daniel Gibbons: House Surgeon, Waitematā District Health Board, Auckland, New Zealand. Dushiyanthi Rasanathan: House Surgeon, Waitematā District Health Board, Auckland, New Zealand. Naomi Heap: Clinical education and Training Unit Manager, Waitematā District Health Board, Auckland, New Zealand. Dr Jonathan Wallace: Anaesthetic Medical Officer, Associate Director at Institute for Innovation and Improvement (i3) at Waitematā District Health Board, Auckland, New Zealand.

Acknowledgements

Correspondence

Dr Dushiyanthi Rasanathan, Private Bag 93503 Takapuna Auckland City 0740, New Zealand

Correspondence Email

dushi@windowslive.com

Competing Interests

Nil.

1. Nallamothu BK, Guetterman TC, Harrod M, et al. How do resuscitation teams at top-performing hospitals for in-hospital cardiac arrest succeed? A qualitative study. Circulation 2018;138:154-63.

2. Marsch SC, Müller C, Marquardt K, Conrad G, Tschan F, Hunziker PR. Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation 2004;60:51-6.

3. Hunziker S, Tschan F, Semmer NK, Howell MD, Marsch S. Human factors in resuscitation: Lessons learned from simulator studies. J Emerg Trauma Shock 2010;3:389.

4. Yamada NK, Halamek LP. On the need for precise, concise communication during resuscitation: a proposed solution. J Pediatr 2015;166:184-7.

5. Pittman J, Turner B, Gabbott DA. Communication between members of the cardiac arrest team—a postal survey. Resuscitation 2001;49:175-7.

6. Rowley C. Improving patient safety with a daily emergency call safety Huddle. Surrey,  Surrey and Sussex NHS Healthcare Trust (UK), 2019. (Accessed 6 March 2020, at https://www.healthcareconferencesuk.co.uk/assets/presentations-post-conference/july-2019/claire-rowley.pptx.pdf)

7. Rowley C. The Atlas of Shared Learning Case Study. Improving patient safety by introducing a daily Emergency Call Safety Huddle. Surrey and Sussex NHS Healthcare Trust (UK), 2019. (Accessed 11 March 2020 at https://www.england.nhs.uk/atlas_case_study/improving-patient-safety-by-introducing-a-daily-emergency-call-safety-huddle)

8. Gwinnutt C, Davies R, SoarI J. In-hospital resuscitation. London Resuscitation Council (UK), 2015. (Accessed 20 May 2020, at https://www.resus.org.uk/resuscitation-guidelines/in-hospital-resuscitation/)

9. 10 minute medical emergency team meetings [Internet]. Brighton [UK]: NHS Improvement; 2017 [cited 2020 May 1]. Available from: https://improvement.nhs.uk/resources/ten-minute-meetings-for-emergency-teams/

10. Varkey P, Antonio K. Change management for effective quality improvement : a primer. Am J Med Qual 2010;25:268-273.

Contact diana@nzma.org.nz
for the PDF of this article

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