TeamSTEPPS Improves Emergency Care in North Carolina Critical Access Hospital

Patient Safety
February 2012

Montgomery Memorial Hospital, a critical access hospital in Troy, North Carolina, is using AHRQ's TeamSTEPPS® system to improve emergency care for pediatric and other patients in its small rural facility.

"Like the vast majority of emergency departments (EDs) in the United States, Montgomery Memorial does not have a pediatric emergency medicine-trained physician on staff. This is also true of all the critical access hospitals in North Carolina," says Jessica Katznelson, MD, who was instrumental in developing the training in her role as Associate Professor of Pediatric and Emergency Medicine at the University of North Carolina at Chapel Hill (UNC).

Katznelson and her collaborator, William Mills, MD, created training simulations that incorporated computerized pediatric mannequins to mimic actual human responses to treatments. The training is called Critical Access for Pediatric Emergencies or CAPE.

Hospital staff are finding the training to be consistently valuable. According to Michelle Yarboro, RN, Montgomery Memorial Hospital's project CAPE leader, "We're now applying our TeamSTEPPS concepts to all of our ED patients, not just pediatric cases."

At Montgomery Memorial, Yarboro notes, "We've seen so many improvements since implementing the TeamSTEPPS system we learned through our project CAPE training. Our communications are much clearer throughout the chaotic code environment of the emergency room. Because of the value we gained, we are applying the same concepts to all our emergency patients."

The training program is based on a 2007 study, which found that simulation exercises improve medical team performance on certain essential tasks. Before the training, the study found, the average number of basic tasks the teams performed was about 18. After training, this number increased to 27.

When UNC hospitals offered CAPE training on pediatric emergency care to rural hospitals, Montgomery staff applied for the program. The hospital was accepted as part of a pilot project that includes five critical access hospitals in North Carolina.

UNC's Division of Pediatric Emergency Medicine is staffed by clinicians who are board-certified in pediatric emergency medicine. It also has a state-of-the-art patient simulation center capable of running complex and interactive pediatric scenarios, including trauma evaluations and resuscitations. The program uses TeamSTEPPS, AHRQ's teamwork training system that improves patient safety.

Katznelson, now Assistant Professor of Pediatrics at Johns Hopkins University School of Medicine, explains, "The expertise and resources of the UNC pediatric emergency medicine group and the patient simulation center were used to create a didactic and hands-on educational opportunity for physicians and nurses from critical access hospital EDs."

She continues, "This expertise was then used to support, mentor, and provide ongoing feedback to the critical access hospitals as they implement an in-house, hands-on continuing education program utilizing mock resuscitation scenarios to reinforce the thought process and skills necessary to assess and stabilize a seriously ill or injured pediatric patient. Our primary goal was to create a model for a self-sustaining and affordable program for small critical access hospitals."

One or two ED physicians and two ED nurse representatives from each institution—none of whom had previously been trained in pediatrics—participated in an intensive 2-day workshop at UNC. The workshop included sessions on pediatric assessment and stabilization, small group opportunities to practice procedural skills, TeamSTEPPS training, and mock resuscitation scenarios using the simulation center. The overall focus was on crucial cognitive and procedural skills and teamwork. Once the hospital staff completed their training at UNC, they returned and trained their colleagues at each of their hospitals. Afterwards, Katznelson and Mills visited the hospitals to observe mock emergency drills.

One advantage of the training at Montgomery Memorial Hospital is that there has been an increased level of empowerment among emergency nurses. Yarboro says that rather than having nurses passively awaiting instructions from physicians, each member of the care team now knows what his/her role is and acts accordingly. "Expectations are clearer now. A nurse is designated as a team leader responsible for making assignments. This results in greater efficiency and effectiveness."

Overall, Yarboro believes, "Our high-risk situations are now much safer. The closed-loop communications model promotes teamwork, increased patient safety, and significantly improved communication among team members."

Information on the TeamSTEPPS system is available at

Impact Case Study Identifier: 
AHRQ Product(s): TeamSTEPPS®
Topics(s): Patient Safety
Geographic Location: North Carolina
Implementer: Montgomery Memorial Hospital
Date: 02/01/2012
Page last reviewed October 2014