Introduction
Within the space of a few months, COVID-19 has had an unprecedented effect on our
healthcare systems internationally. Elective endoscopy within the UK had all but stopped
as a result of challenges faced early on in the pandemic [1]. We now face the challenge of recovering endoscopy services, and it is almost certain
that working practices will change for the foreseeable future.
Guidance from the British Society of Gastroenterology (BSG) describes strategies for
recovery, including the development of “COVID-minimized” endoscopy units [2]
[3]. This is further supported by guidance from the Joint Advisory Group on Gastrointestinal
Endoscopy (JAG) and the European Society of Gastrointestinal Endoscopy (ESGE) [4]
[5]. As a result, key changes to practice are being undertaken, including patient screening,
room management, and use of personal protective equipment (PPE). However, COVID-19
also presents challenges to our workforce, who will have to adapt to novel environments
and practices. Endoscopy teams will also be re-forming after periods of redeployment,
potentially anxious about the conceivable ongoing personal risk to themselves and
their families.
Effective teamworking is crucial to team performance and, ultimately, to patient outcomes
[6]. Adaptations to practice are evolving rapidly as new guidance is released or updated.
Teams need to be supported in developing flexibility and the additional situational
demand that results. This article outlines practical steps to enhance teamworking
in endoscopy during COVID-19 through the use of a novel toolkit.
Methods
Developing the Endoscopy Team Toolkit
Healthcare systems can be defined by a human factors model of inputs, processes, and
outcomes [7]. Understanding how this model is influenced by the pandemic allows us to design
and implement appropriate interventions to improve patient and organizational outcomes.
Endoscopic nontechnical skills (ENTS) include the communication, teamwork, leadership,
situational awareness, and judgment fundamental to performing endoscopic procedures
[8] and should be considered during the design process. A human factors model for endoscopy
during COVID-19 was therefore developed ([Fig. 1]), which informed a set of key goals for endoscopy teams, as presented below.
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Planning and anticipating problems
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Optimizing communication
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Fostering a sense of team cohesion
-
Flattening hierarchy
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Sharing task burden
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Providing support and wellbeing where needed.
Fig. 1 Input, process, and output model of factors influencing endoscopy team performance
following COVID-19.
The goals listed informed the design and development of a toolkit to support endoscopy
teams, complementing the current BSG, JAG, and ESGE guidance for endoscopy services
[2]
[3]
[4]
[5]. The toolkit consists of four user-friendly cognitive aids that operationalize teamworking
processes, supporting a system of team briefing and debriefing. Input from experts
in human factors (including the Clinical Human Factors Group [9]), nontechnical skills, and patient safety was incorporated, supported by nursing
and clinical oversight. This intervention was designed and implemented promptly in
response to clinical need, and refinements were made following a 6-week period of
testing and user feedback at a tertiary endoscopy unit. A handbook of the toolkit
aids, including descriptors, can be found in the online supplementary material. We
describe the toolkit in more detail in the sections that follow.
Results
Pre-endoscopy huddle and briefing
The terms “huddle” and “briefing” are often used synonymously to describe a meeting
of team members before a task is performed; such meetings have been demonstrated to
improve safety-related outcomes and team performance measures [10]
[11]. Although these processes may already be embedded within endoscopy units, they should
be adapted to the current situation in order to optimize teamworking and preserve
patient safety.
Briefings familiarize team members with each other, allow task planning, and enhance
communication. They can improve the quality of information sharing, promote accountability,
empower team members, and provide a sense of team cohesion [12]. From a human factors perspective, briefings can be invaluable in flattening hierarchy
– reducing the authority gradient between “senior” and “junior” staff by encouraging
contributions from all multidisciplinary team members, thus improving safety. Aligning
team goals, checking shared understanding, and providing the opportunity to share
concerns are important in optimizing teamworking. For the purpose of the toolkit,
we use the term “huddle” to describe a whole team huddle at the start of the day and
“briefing” for the smaller team briefing prior to case and/or list.
Whole team huddle
The whole team huddle describes a daily briefing with all endoscopy staff, including
endoscopists, nurses, healthcare assistants, decontamination staff, and porters ([Fig. 2a]; further detail in the supplementary material). This is an opportunity to touch
base with all staff members and to foster a positive teamworking culture.
Fig. 2 Endoscopy team toolkit: whole team huddle aid [A]; list team briefing [B]; list team
debrief aid [C].
List team briefing
For the core team running an endoscopy list (endoscopist, assistants, room runner),
a more dedicated briefing is required, known as the “list team briefing” ([Fig. 2b]; further detail in the supplementary material). This builds on the principles of
the whole team huddle with more specific, case-centered communication. The briefing
should precede and complement the endoscopy safety checklist and is not a replacement
for it. This is an opportunity to enhance the team-building process, encourage open
contribution, flatten hierarchy, and develop a shared understanding [12].
Team debrief
Debriefing allows the team to collate, process, and act on information derived from
a patient encounter to influence future behaviors and team performance. This process
also strengthens team bonds by promoting interaction between members [13]. Ideally, all team members should be encouraged to contribute to the debrief in
open discussion. The debrief aid provides a framework for these discussions ([Fig. 2c]). Debriefs should be led by a team member following a basic model of “description,
analysis, and application” [14]. Team members describe what happened, consider the reasoning behind this, and offer
solutions if needed. “Active” listening should be encouraged, enabling all team members
to contribute and improving the effectiveness of idea generation. The COVID-19 pandemic
has almost certainly amplified previous stressors and created new concerns in our
workforce, and the debrief is a good opportunity to signpost wellbeing resources.
Elements of the list team debrief are described in detail in the supplementary material.
Optimizing ENTS in PPE
A significant change to practice is the use of PPE during endoscopic procedures. At
the time of writing, the choice of PPE (standard or enhanced) is governed by procedural
type and patient risk stratification, including COVID-19 screening [2]. PPE may affect elements of procedural delivery, most notably ENTS. Both verbal
and nonverbal communication may be impaired through use of respirator masks and head
coverings [15]. These challenges should be anticipated prior to each case and highlighted in the
team briefing as described previously. Team members should consider the following
points to optimize communication ([Fig. 3]; further detail in the supplementary material):
Fig. 3 Endoscopy team toolkit aid for optimizing endoscopic nontechnical skills (ENTS) in
personal protective equipment (PPE).
PPE may also impair effective patient communication, which may be exacerbated by language
difficulties, auditory or visually impairment. Short, directed cues should be agreed
with the patient in advance to convey issues such as pain or to pause or stop a procedure.
Equally, instructions and procedural progress should be succinctly verbalized or gestured
by team members to the patient. Situational awareness, and the ability to perceive,
comprehend, and anticipate events, may also be compromised when PPE is in use. Team
members should remember to remain vigilant at all times and be encouraged to speak
up if they recognize a loss of situational awareness in other team members.
Discussion
The initial implementation of briefings and debriefings may be perceived as “added
work” owing to the change to workflow needed to accommodate them [11]. Leadership from medical, nursing, and management teams is required to embed these
changes from the outset. Benefits will be seen if staff are engaged in the process
early on, recognizing that their involvement is valued with ongoing modifications
tailored to their working needs. The toolkit may be used initially in a “checklist-style”
fashion, but as endoscopy teams become more familiar with the process, it can become
more of an aide memoire. Some elements may appear repetitive; however, these processes
can be adapted to suit local needs, and need not be exhaustively adhered to. Cognitive
aids can be tailored further, followed by periods of testing and implementation.
To maintain consistency, a standardized time and location for the whole team huddle
should be defined. It is important to set a time limit in order to focus discussion
and minimize perceived disruptions to workflow. To promote engagement, the huddle
lead can be rotated among medical and nursing staff. Huddles should adhere to social
distancing principles and be supported by video conferencing if it is difficult to
accommodate all staff members in a single space. Huddle discussions should be visually
represented within a confidential area in the department, for example a whiteboard
in staff areas, to provide a brief description of outcomes and engage staff members
who cannot attend. Case briefs and debriefs should be short and succinct to facilitate
workflow, whereas more time should be allocated for list debriefs to focus on team
and procedural outcomes.
Conclusions
Endoscopy teams will continue to adapt to changes in practice precipitated by the
COVID-19 pandemic. A toolkit of cognitive aids, based on human factors principles,
may be useful in supporting this adjustment and will be helpful in the long term.
