When a patient’s condition deteriorates, time is of the essence, especially if that patient is a child.

For the Acute Care Pediatrics team at Royal University Hospital, using their Team STEPPS training has made escalating concerns and communicating those concerns an easier process for nursing staff. The team participated in Team STEPPS training as part of Safer Every Day (a 90-day initiative devoted to improving safety). STEPPS stands for Strategies and Tools to Enhance Patient and Performance Safety. This U.S.-based program includes a comprehensive set of ready-to-use materials and a training curriculum to successfully integrate teamwork and communication principles into a variety of settings.

When concerns need escalation, Tammy Lucas, manager of Acute Care Pediatrics, and her team use a tool called the Pediatric Early Warning Score (PEWS) concern form if a patient is declining. The Pediatric Early Warning Score is broken into three categories; green means no concern, yellow indicates that there is some concern and red indicates a more serious concern.

“If a child is scoring red that means that we’re going to be taking vitals every hour and physicians will be assessing the child,” says Lucas. “It may also mean more tests and perhaps bringing in a specialist.”

Using the form sets off a chain reaction of responses and accountabilities to which everyone must adhere.

“It’s a legal part of a patient’s chart,” explains Lucas. “Once a nurse fills the form out, a charge nurse has to come and assess the child. Then the resident has to be notified and is required to see the child within 20 minutes.”

If things do not go as planned, there are additional steps for escalation.

“The PEWS form acts as a checklist for the healthcare team and helps provide the evidence for escalating a concern,” explains Lucas. “A nurse uses it to explain that their reasons for escalating aren’t just a subjective assessment of the patient; it’s based on vital signs and the patient’s PEWS score.”

“Our goal is to provide the same level of care for every patient on the unit and the same level of response if they are declining,” says Lucas. “This escalation tool is focused around the patient and being able to escalate a safety concern for any patient on the unit regardless of what service area the patient comes to us from, such as surgical services or orthopedics.” For the Pediatrics team, this form has become standard. “This is just the way we do things on this unit now,” explains Lucas. “PEWS is about raising the concern and working together to get the help needed for the patient.”

The training and education that the team received through Team STEPPS has allowed for better overall operationalization of PEWS through focusing on team communication and how the team works together.

“Working together, supporting each other and communicating with each other on a more cohesive level have been foundational pieces that the Acute Care Pediatrics team has learned through Team STEPPS,” explains Dr. Vicki Cattell, Director of Safety and Wellness. Feeling comfortable enough to ask for help when it’s needed is not always easy.

In fact, the team recently experienced what happens when communication breaks down and people are reluctant to ask for the help they need.

“It was a bad day,” explains Lucas. “We were very busy and at over capacity with many admissions and discharges happening and just a lot of things going on on the ward. People were stressed and struggling to communicate with each other. It’s hard to ask for help when the person you are asking is just as busy as you are, so personalities collided a bit and there were a few tears.”

Lucas didn’t want the team to ignore what was happening or try to shake it off for the next shift. Instead, she put the team’s Team STEPPS training into action. “Once the craziness had died down a bit and we got the patients settled, we pulled the team together right there on the unit and debriefed about what was happening.” By debriefing in the moment, the team was able to talk about their perspectives and vent their frustrations, much of which was caused by feeling a lack of mutual support and feeling unable to ask for help.

“We talked about how to mitigate this for next time,” says Lucas. “We all agreed that, in the future, when someone asks you for help and you can’t provide it at that moment for whatever reason, it’s now your due diligence to tell someone else that your colleague needs help.”

Team STEPPS conducting a meeting.

Team STEPPS conducting a meeting.

As Lucas explains, sometimes asking for help is difficult. “We all want to provide the best possible care for our patients so we all want to be perfect and to believe that we never need help because we are just that good right? But in reality, we all need a hand once in a while, which is why what we learned from our Team STEPPS training is so important,” says Lucas. “The day to day work that happens on a unit can be so unpredictable, so we need to respect, coach and empower each other to ask for help or support when it’s needed because if we don’t, things can just get that much worse.”

“When staff feel equally heard and mutually supported and respected, it’s easier to sustain positive changes,” says Dr. Cattell. “Those results ultimately benefit the patient because the team is able to deliver safer, quality care.”