Implementation of a new organisational structure in the trigger teams in an emergency department in Denmark to improve quality and patient safety

Background
Previously, physicians from different medical and surgical specialities were dedicated to the role of team leader when receiving critically ill patients. Serious adverse events regarding the trigger teams were reported to the Danish Patient Safety Authority and analyses pointed at lack of communication, safety and leadership as the primary causes. In addition, emergency nurses experienced a low degree of psychological safety, which could challenge patient safety. Aim With this change, it is now a Specialist in Emergency Medicine who must handle the task as team leader in the ED. The aim is to enchance and standardize the quality of the reception, care and treatment provided to adult acutely critical patients and improve psychological safety, thereby improving overall patient safety.

Methods
Normalization Process Theory (NPT) was selected as overall analysis tool and planning/implementation tool. Data was collected both qualitatively via semistructured research interviews and quantitatively via a questionnaire. All ED physicians went through education and simulation, in the role as team leader and trained their Non-technialcal skills (NTS). All the instructors in the simulation were educated in facilitation at CAMES (Copenhagen Academy for Medical Education and Simulation) The qualitative results were analyzed with theories about psychological safety during new work process in emergency departments by Dieckmann et al.

Results
Results showed a higher degree of patient safety because of improved psychological safety in the trigger team, better communication and more uniform execution of the patient evaluation.

- The nurses felt recognised for their competencies. - Within the team, the organisation was clear, and all team members were heard and involved based on their competencies.
- Critical care is no longer felt as delayed due to a lack of leadership and plan for the patient
- All patients are now evaluated through the ABCDE concept
- During the process of change, ongoing feedback and adjustments have further optimised the use of NTS
- Fewer adverse events have been reported after the implementation

Conclusion
- The staff involved in trigger team activation should be educated in NTS and receive continuing simulation training by instructors educated In simulation.
- A clear team leader role enhances the ED nurse’s psychological safety and has improved patient safety.