S.A.F.E - Improving Child Health Outcomes through Situation Awareness

Author: Darren Cooper 
S.A.F.E Programme Manager
Royal College of Paediatrics and Child Health

Looking at comparable healthcare systems in Europe, the United Kingdom has the worst five-year average mortality and excess deaths in childhood. Yes, there have been improvements in the last twenty years, but not at the same level as in comparable countries. When looked at more closely, it is clearly a complex issue that requires joined-up thinking and real determination to resolve, but some of the key factors for these poor rates include:
- frequent failure to recognise the severity of illness;
- variable skill sets;
- inappropriate response to deterioration;
- poor communication; and
- variable engagement with patients and parents.

Comparison of five-year average mortality in childhood in European countries and excess deaths in UK (relative to comparator countries) according to method of first access to medical care, 2003-7 World Health Organisation Regional Office for Europe. European Detailed Mortality Database. 

Part of the solution is looking at what others do better - what has Austria done to deliver such a significant improvement, what is Sweden doing so well, so consistently, and do these improvements deliver better outcomes? Learning what works well elsewhere and teaching what works well here is central to quality improvement and a key driver behind the Situation Awareness for Everyone (S.A.F.E) Programme.

What is situation awareness in healthcare and how does the S.A.F.E Programme fit in with this?
Key to delivering safe care to patients is having as much information as possible in order to make the right clinical decisions. Situation awareness is having all of this information for any given situation, with the aim of bringing in multiple perspectives such as consultants, registrars, nurses, porters, or patients and their families, who each have a different piece of the puzzle. To be situationally aware is to bring all of these pieces together and fully understand the situation, allowing clinical teams to take the right decisions.

S.A.F.E is all about improving communication - both within clinical teams and between clinical teams and patients and their families. The aim of the programme is two-fold: firstly, to provide an evidence base to support the concept that improved situation awareness leads to improved outcomes for paediatric patients in acute settings; and secondly, to support the spread of improved situation awareness by providing a suite of tools that hospitals can use to improve it locally.

Twelve sites are participating in S.A.F.E - six specialist children’s and six district general hospitals - each with between one and three wards taking part providing a wide variety of unit types and various local and contextual differences.

The programme uses the 
Institute for Healthcare Improvement (IHI) Breakthrough Series Collaborative model, bringing the twelve sites together for learning sessions roughly every other month. Between these learning sessions, the central team will visit sites and provide any further support requested. As the programme progresses, each site will share their learning and experience with the other sites, as well as with people external to the programme who are interested. The programme also has an embedded evaluation team from the Anna Freud Centre who will be undertaking both a quantitative and qualitative evaluation of the programme.

An exciting aspect of the programme is the involvement of both specialist children’s and district general hospitals. Studies to date focused on the former, but there has been little work on translating this to acute settings where there isn’t the level of resource devoted to paediatric care. Not only does S.A.F.E provide an opportunity to better understand this relationship, but it also allows the development of a suite of tools that is flexible enough for use in both settings.

The ‘huddle’ intervention
Central to the S.A.F.E Programme is the introduction of the ‘huddle’. This is based on work on situation awareness and safety at
Cincinnati Children’s Hospital Medical Center, where the huddle is a key intervention. The huddle is a short, free, frank exchange of information between those involved in a patient’s care, to encourage information sharing and prevent unnecessary or unrecognised deterioration and delays in care. More importantly, parents and patients can be part of the huddle, as they will have information that is essential to the decision making process.

Participating sites are refining various aspects of the huddle - including attendance, timing, and scripting - to develop a huddle that suits local requirements. These all contribute to the suite of tools by demonstrating what works and what doesn’t in different types of units, with different local contexts.

What progress so far?
So far there have been two learning sets, with site visits in between and already there has been great progress across the sites. While they may not be able to demonstrate improvements yet, it is clear that not only is there great enthusiasm for the programme, but that the sites bring with them huge numbers of ideas. Some of these are simple, such as the sites that have very visible information about the huddles, including huddle points and ‘eye’ indicators for patients they feel need to be watched closely, while others suggested at a recent learning session are more outlandish as a means of starting important conversations - safety paintball is a personal favourite. This involves nursing and medical teams wearing white, while patients and parents use small powder paintballs to mark staff about the safety of their care, using a colour coded system.

The future?
There is still a long way to go with the programme, and we can’t prejudge the outcomes in terms of if improved situation awareness improves outcomes for paediatric patients in acute settings. Over the next 18 months, the programme will take the learning and experiences of the sites and develop the suite of tools for improving situation awareness.

Progress updates can be found on the 
S.A.F.E webpage and the S.A.F.E blog. For further information, e-mail Darren.Cooper@rcpch.ac.uk

S.A.F.E is part of the Health Foundation’s Closing the Gap in Patient Safety Programme. The Health Foundation is an independent charity working to improve the quality of healthcare in the UK. It is also supported by WellChild, the UK national charity for sick children.

The S.A.F.E partnership is made up of the Royal College of Paediatrics and Child Health, Great Ormond Street Hospital, the Anna Freud Centre, and UCLPartners.

Related Links:
BBC News - Health Secretary Alex Neil Calls for Hospital 'Safety Huddles'
2. BBC News - Huddles 'Help Children's Hospital Care'
3. CareTrack Kids (Australia)
Children's Hospitals' Solutions for Patient Safety - Hospital Resources
5. Cincinnati Children's - Becoming a High Reliability Organization
6. Cincinnati Children's - Operationalizing High Reliability [Video]
Cincinnati Children's Blog - Healthcare Systems Nationwide Focusing on Reduction of Medical Mishaps, Look at Cincinnati Children’s as Example
8. Harvard Business Review - How Every Hospital Should Start the Day
9. Health Foundation - Closing the Gap in Paediatric Safety: Using Clinical Huddle to Improve Situational Awareness with an Emphasis on Communication
10. Health Care Huddles: Managing Complexity to Achieve High Reliability (Provost SM, et al.)
HPI - Daily Check-in for Safety: From Best Practice to Common Practice
12. HPI - Resources
13. HRET - Daily Safety Huddle [Video]
Huddling for High Reliability and Situation Awareness (Goldenhar LM, et al.)
IHI - Conduct Safety Briefings
16. IHI - Huddles
17. IHI - Safety Briefings Tool
18. IHI - WIHI: Situational Awareness and Patient Safety
19. Improving Situation Awareness to Reduce Unrecognized Clinical Deterioration and Serious Safety Events (Brady PW, et al.)
Making it Safer Together (MiST) Paediatric Patient Safety Collaborative
21. A Multicenter Collaborative Approach to Reducing Pediatric Codes Outside the ICU (Hayes  LW, et al.)
National Patient Safety Conference, Dublin 2013 - Dr. Stephen Muething's Presentation [Video]
PfP Resource Centre - Pediatric Safety
24. PIPSQC Presentations - Making Healthcare Safer for Children
25. S.A.F.E Blog - Learning Together - the S.A.F.E Collaborative 
S.A.F.E Programme - Situation Awareness for Everyone
27. Scottish Government - Scottish NHS Safety Drive - Cabinet Secretary Urges Continued Focus on Safety
28. A Step Toward High Reliability: Implementation of a Daily Safety Brief in a Children's Hospital (Saysana M, et al.)
A Qualitative Study Examining the Influences on Situation Awareness and the Identification, Mitigation and Escalation of Unrecognised Patient Risk (Brady PW, et al.)