Situational Awareness Huddles in a Pediatric Cardiac Intensive Care Unit During the COVID-19 Pandemic

Particular challenges in our pediatric CICU included the severity of underlying illnesses in patients with congenital or acquired heart disease, requirements to conserve PPE, a limited number of isolation rooms, and delayed test results early in the pandemic. These challenges were coupled with significant distress among staff as PPE, patient care, and staff protection guidelines changed almost daily. Another consideration was the need to include the operating room staff and cardiothoracic surgery staff in our conversations, because they would be responsible for cannulating any patient who needed extracorporeal membrane oxygenation (ECMO).

We developed a huddle process in our CICU during the COVID-19 pandemic to create situational awareness among staff regarding both infected patients and PUIs. The purpose of this process was to prepare staff for major patient events such as intubation or ECMO cannulation. During the huddles, team members also discussed infected patients and PUIs who had a high risk of acute decompensation.

The primary driving force for initiating the huddles was distress among staff caused by their concerns about potential exposure when caring for patients who may be infected with COVID-19. It quickly became evident that shared cognition was extremely effective in mitigating some of this anxiety and allowing staff to feel better prepared for potential and actual events.

As the first step in preparation for potential events, we disseminated process maps developed by pediatric ICU nursing staff at our institution (Figures 1 and 2). Drawing on their experience with simulation, they developed a process map for both airway management and cardiopulmonary resuscitation for PUIs. These documents served as guidelines for CICU staff to prepare for potential events. The process maps clearly defined personnel needed in the room, including physicians, nurses, and respiratory therapists, and the location of each provider; additional providers stationed outside the room provided equipment or medications as necessary and did not enter the room unless required. The maps were posted on the door of each room housing PUIs or COVID-19–positive patients. Bedside providers could then reference these maps and know who their team members would be if an emergency occurred.

The second step in preparation was a staff huddle that occurred at the beginning of each shift in the CICU. The attending physician responsible for the care of the patient under discussion led the huddle. Providers performed a huddle only for patients who met certain criteria: a high risk for acute decompensation during the upcoming shift or a planned intervention (eg, intubation) during that shift. Attendees at the huddle were the attending physician and fellow physician; an advanced practice provider (as appropriate); the bedside nurse, resource nurse, and charge nurse; and the bedside respiratory therapist and resource respiratory therapist. If the team was considering ECMO or mechanical circulatory support for the patient, the ECMO primer and the operating room team lead were invited to participate in the huddle (Figure 3). Logistics did not allow all operating room staff or cardiothoracic surgery staff to be present consistently. The process maps posted on room doors were updated during these huddles to reflect the appropriate staff names.

Discussion during the huddle focused on causes of decompensation and early recognition of symptoms. The attending physician assigned a role to each team member and identified who would be inside the room and who would remain outside the room in the event of decompensation or a necessary intervention. These assignments served to both minimize the staff’s risk of exposure and reduce the amount of PPE they used. Team members were given the opportunity to voice concerns or ask questions about their role or the overall process. The team also discussed ECMO and the patient’s candidacy for extracorporeal cardiopulmonary resuscitation. When not present during the huddle, the cardiothoracic surgery team was made aware of these patients each shift.

Huddles were held during every shift until the patient was determined to be at lower risk for acute decompensation. For example, huddles were held for a patient with cardiomyopathy and decompensated heart failure until a left ventricular assist device was placed; for a patient with trisomy 21 who had tested positive for SARS-CoV-2 and had an unrepaired complete atrioventricular septal defect and acute heart failure requiring intubation; and for a patient with complex congenital heart disease who had been admitted with acute decompensated heart failure and ventricular arrhythmias, and required ECMO cannulation. In addition to the preshift huddle, a second huddle was held before any significant intervention or procedure such as intubation. During these secondary huddles, the team confirmed each member’s role and plans for mitigating decompensation, and had another opportunity to ask questions or voice concerns.

After the huddles had been integrated into the daily operations of the CICU, we developed and administered a survey to staff (attending physicians, advanced practice providers, nurses, and respiratory therapists). This survey comprised 11 items that focused on both the huddle process and content, with each item rated on a 7-point Likert scale. We sent the survey via email using SurveyMonkey. Survey participants provided consent for their participation, although the survey was exempt from institutional review board approval because of the anonymous nature of surveys and the absence of patient-related information from the survey and its results.

In total, 36 providers responded to the survey: 4 attending physicians (11%), 3 charge nurses (8%), 10 resource nurses (28%), 13 bedside nurses (36%), 5 respiratory therapists (14%), and 1 advance practice provider (3%). Survey respondents indicated that it was clear who was leading the huddle (97%), felt supported by their team (100%), and were confident in their team’s ability in the event of a decompensating patient (97%). Participants knew how to obtain PPE in an emergent situation (100%), understood the plan for resuscitation (100%), and understood their role in the resuscitation (100%). All respondents indicated that they found the huddles helpful and would like to see them used in the future in similar patient situations. Survey results are summarized in Figure 4.

Survey respondents were given the opportunity to provide free-text comments at the conclusion of the survey. Important comments identified various issues such as maintaining decorum during an emergency, even when a huddle had been held; the challenge of gathering all key participants at a huddle in a timely manner; and ensuring that staff donned proper PPE before entering the room of a patient requiring enhanced respiratory precautions.

The COVID-19 pandemic has created a new reality in ICUs. The care provided to complex patients in an ICU has always required a multidisciplinary approach; the presence of enhanced respiratory isolation requirements, PUIs, and limited PPE, among other factors, has added a layer of complexity to this care. Because patients could not be strictly isolated in a separate unit, situational awareness was crucial among staff, as they could move quickly between caring for a noninfected patient and caring for an infected patient. For acutely decompensating patients, the need for staff to focus on their own safety by wearing appropriate PPE was paramount. By preparing for such scenarios in advance, staff more readily assumed their roles upon arrival at an event.

Among the challenges we faced while implementing these huddles was bringing providers from all necessary disciplines to the huddle in a timely fashion. In a busy ICU, where providers typically focus on acute events and evolving medical situations, it can be difficult for staff to take a moment to focus on a scenario that may or may not occur. This difficulty in focusing on potential events, coupled with the need to involve the ECMO team and operating room nursing staff, increased the difficulty of consistently accomplishing these huddles. By limiting the huddles to patients who we believed were at imminent risk of decompensation or were undergoing a procedure during that shift, the CICU team maintained staff commitment, engagement, and willingness to participate.

The driving force of the initial success of the huddles seemed to be staff anxiety surrounding the rapidly evolving medical situation as the pandemic unfolded. Providers in an ICU are by nature prepared for a certain degree of uncertainty and ambiguity in their day-to-day care of patients, but the familiar and predictable work structure in and the environment of the ICU usually mitigate this unpredictability. When that structure or environment becomes compromised, however—as both have during the COVID-19 pandemic—provider discomfort and anxiety increased rapidly. The huddles seemed to restore the structure that some providers thought was lacking for staff treating these high-risk patients.

Although not all staff working a given shift participated in each huddle, the situational awareness from the huddle “socialized” the presence of high-risk patients requiring isolation in the CICU. Staff throughout the unit were knowledgeable about these patients and scenarios. This socialization helped prevent an excessive response by staff to any emergency and limited responders to those who had participated in the huddle and had been assigned a role. This limitation helped preserve PPE as well.

As huddles become more common in ICUs, it becomes increasingly important that the content of the huddle provides staff with the necessary tools to optimize patient care and potentially improve outcomes.^12,13  Although the initial goal of our huddle process was to decrease anxiety among staff, the process has set the stage for an altered approach to patient care in the CICU. The ability to be proactive during these situations changes providers’ mindset: they arrive at an emergency already understanding the patient’s situation, plans for mitigating the event and for resuscitation, and their role in the process.^10,11 

Another positive aspect of this process has been generalization of the huddle process to other patients and situations in the CICU. Now, huddles are commonly held before a routine intubation or procedure in the CICU. When a process becomes second nature to staff during routine day-to-day operations, they can more easily incorporate it into less routine situations. Huddles also improve communication among team members as important aspects of the huddle process, such as role assignment and emergency preparedness, become the rule rather than the exception. This preparedness includes the use of the process maps for all patients who are at risk of decompensation, not only those who require isolation.

The literature supports the huddle process because it improves staff satisfaction with patient care, the safety of patient interventions, and is thought to improve patient outcomes.¹⁴  We witnessed such improvements in real time: staff felt better prepared to care for more complex patients with acute medical issues and a high risk for decompensation. The knowledge and confidence provided by the huddles empowered bedside staff to provide more efficient care to their patients.¹⁵ 

Limitations of this study include all those inherent in a single-center report, such as extrapolating the data to other centers with different staffing models or center-based biases that influence huddle practices. Another limitation was the limited number of survey responses from staff who participated in huddles. Although we distributed the survey after the patient situations cited by example above, the survey items focused more on the huddle process in general rather than on particular procedures or resuscitations that followed a huddle. However, participants included some thoughts regarding their experiences after huddles in the free-text portion of the survey.

We have described the implementation of bedside huddles to increase situational awareness among staff and reduce their anxiety in a busy tertiary pediatric CICU during the rapidly evolving COVID-19 pandemic. This process would be especially helpful for institutions where patients with COVID-19 are cared for within regular ICUs and cannot be grouped in separate areas. Situational awareness huddles have become a regular practice in our CICU for patients who require enhanced respiratory precautions and who are at risk of imminent deterioration. The results of our survey suggest that situational awareness huddles should have a regular role in the ICU and should be held for any patient who is at risk for decompensation. Next steps include convening a task force that will continue to generalize this process for all patients in the CICU, and developing simulation scenarios that will improve staff readiness for acute decompensation among this unique patient population.