Improving Daily Patient Goal-Setting and Team Communication: The Liber8 Glass Door Project

Why does this study matter?
For me, this study is interesting for a few reasons. There are more traditional clinical issues associated with reducing adverse events and improving team communication (and this study is in a clinical journal). But this study also reminded me of a project we evaluated a few years ago. A combined entertainment, education, and caregiver note system was installed as part of the TV at the footwall in the patient room. At that time, if the patient was watching TV, you couldn’t pull up the other functions. The result was that nurses created an ad-hoc marker system of notes on the glass door. Sometimes simple works. Some of you know the acronym: keep it simple stupid. In this study, someone planned it, and someone measured it.

How was the study done?
This was a sub-study of a larger national study for the PICU Liber8 project
This is a bundle of 8 evidence-based care components to minimize complications and improve functional recovery in critically ill kids. In this before and after study, the site was a 12-bed Med-Surg PICU in Ontario, Canada. As part of the larger study, the team found that their paper-based checklist wasn’t being used to facilitate goal-setting and team communication. Their intervention was a door decal identifying targeted goals for care and a visual indicator of progress. It was developed with care providers and a family representative in early 2019, was piloted later in the year, and implemented in November 2019, just before COVID. There was an evaluation in the few months before the implementation, two weeks after the implementation, and again 1 year after the launch. The researchers used surveys, observational audits of clinical rounding, interviews, and focus groups.     

So what do we learn from the study?
As a quality improvement study, the team looked at the door as a communication tool, not a documentation standard. They looked at how often it was used (as uptake vs compliance) and whether use was sustained. They measured: performance – how often there was verbal discussion of patient goals; efficiency of rounding - how long rounds took; and acceptability - from both provider and family perspectives. What did they learn?

With a total of 74 patient days reviewed in the first evaluation of uptake, researchers found the glass door was used 91% of the time compared to 23% for the old paper tool. A year later, use actually improved and was up to just over 93%. Part of this was probably due to visibility, but also that the intervention was created with the specific needs of the unit in mind. Audits of 49 and 50 rounding events before and after showed verbal goal discussion increased from 40 to almost 60%. These differences in discussion topics were statistically significant for:  breathing and respiratory issues, cardiovascular targets, family concerns, and hematology/infectious disease conditions. Median rounding times decreased from nearly 12 minutes to 7.5 minutes.

Of 67 provider respondents, 91% said the door was helpful for team discussion, collaboration, and goal awareness. Sixty-one percent said the glass door often or routinely helped them understand the patient's goals. More than 80% preferred the door to the old paper system. Out of 29 families that completed surveys, 83% found it helpful in ensuring thorough discussion and goal planning. Sixty-six percent found the door helpful in understanding care goals. Some found it to be too technical, and the decal location on the door may have been better for staff use.

Can we say the results are definitive?
There are some inherent limitations in a QI study, and in this case, there was not a review of clinical outcomes. The authors did note that there were times when the discussed goals didn’t match what was on the door, but it wasn’t clear whether this was a result of the audit process or something else. Audits only happened during rounds, but goals could be set early in the day and adjusted at any time. Auditors also missed any discussion that happened outside of rounds, but the same process was used before and after, so inconsistencies were probably similar. The decal was English only, so not entirely inclusive, and uptake was measured overall, and not the change for each domain for each patient.

What’s the takeaway?
After this was implemented, our friend COVID-19 meant restricted visitor policies. The door actually became a further facilitator of team communication and family engagement. While the decal replaced paper, the organization introduced an electronic health record in 2022. In this case, “What’s Old is New”. Instead of being better, the EHR actually made things more siloed and eliminated family input, so the providers have continued to use the glass door as a way to collaborate among the PICU team. Maybe technology will change down the road, but at this point, out of sight can mean out of mind, and the $40 decal served as a pretty effective way to advance goal-setting awareness and tracking. Think about all of the existing units not being renovated yet. My takeaway is ‘always be mindful of the simple solution.’

Summary of:
Jones, I. G. R., Friedman, S., Vu, M., Awladthani, S., Watts, C., Simpson, A., Al-Farsi, A. A., Gupta, R., Cupido, C., & Choong, K. (2023). Improving Daily Patient Goal-Setting and Team Communication: The Liber8 Glass Door Project*. Pediatric Critical Care Medicine, Issue 5, Volume 24, Page(s) 382.

 
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