Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

Using a Direct Observation Tool (TOC-CEX) to Standardize Transitions of Care by Residents at a Community Hospital

Background: High-quality transitions of care are crucial for patient safety in hospitals, yet few undergraduate curricula include transition-of-care training. In 2012, the Wayne State University Office of Graduate Medical Education (WSUGME) required its residency programs to use the SAIF-IR mnemonic (summary, active issues, if-then contingency planning, follow-up activities, interactive questioning, readback) to ensure accurate and uniform handoffs. Subsequent program evaluations indicated that resident awareness and adoption of the mnemonic at our primary clinical site, Ascension Providence Rochester Hospital (APRH), could be improved. According to our institution's 2016 Clinical Learning Environment Review (CLER), 88% of residents reported following a standardized transition of care handoff, and 53% reported that faculty rarely supervised their handoffs. A 2016 WSUGME internal survey also revealed low rates of awareness (7% to 10%) of the mandated mnemonic. WSUGME then created a direct observation tool, the Transitions of Care-Clinical Evaluation Exercise (TOC-CEX), for faculty to monitor resident skill in using the mnemonic and thus standardize transitions of care as a practice habit at APRH. Methods: Since 2014, WSUGME had relied on 2 methods for training residents in the required handoff mnemonic: (1) introduction to the SAIF-IR mnemonic during the WSUGME orientation for all interns and (2) simulations during an objective simulated handoff evaluation activity for all postgraduate year (PGY) 1s and PGY 2s. In 2017, WSUGME innovated a direct observation tool, the TOC-CEX, for adoption by faculty at APRH to assess resident knowledge of and monitor their skill in using the SAIF-IR mnemonic in 3 primary care programs. The total number of possible participants was 138, and the actual number of individuals in the sample was 95. A majority (86%) of the observations during the study period were of PGY 1 residents, and thus the analysis reflects the ratings of 99% of all interns but only 69% of all possible residents. Results: WSUGME found that faculty use of a direct observation instrument in the clinical learning environment during 2017-2019 increased awareness and adoption of the SAIF-IR mnemonic among residents. Using a z-test of equal proportions on resident responses on an internal WSUGME survey, we found a significant rise in the percentage reporting yes to the question "Does your program have a mechanism for monitoring handoffs?" (χ2 [3]=23.6, P<0.0001) and in the percentage identifying SAIF-IR in response to the question "Does your program endorse a specific mnemonic for organizing the contents of a verbal handoff?" (χ2 [3]=45.0, P<0.0001). The increase from 2016 to 2017 is the result of the implementation of the TOC-CEX in the interim (question 1: χ2 [1]=12.4, P<0.0005; question 2: χ2 [1]=10.1, P<0.0025). Conclusion: Our research found that use of the TOC-CEX to monitor resident handoffs resulted in improved awareness and adoption of the SAIF-IR mnemonic in the clinical learning environment. Program leadership reported that the practice was both feasible and well accepted by residents, faculty, and the APRH chief medical officer as the TOC-CEX became a customary component of APRH organizational culture and was perceived as central to quality patient care.

Identifying facilitators and barriers to develop implementation strategy for an ED to Ward handover tool using behaviour change theory (EDWHAT)

Background

Effective clinical handover is fundamental to clinical practice and recognised as a global quality and safety priority. Problems with clinical handover from the emergency department (ED) to inpatient ward across four hospitals in the Illawarra Shoalhaven Local Health District (ISLHD) were identified in a number of reportable clinical incidents. To address this, an ED to inpatient ward electronic clinical handover tool was developed and implemented. However, site uptake of the tool varied from 45 to 90%.

Aim

To determine the facilitators and barriers of the ED to Ward Handover Tool (EDWHAT) implementation and design strategy to improve local compliance and inform wider implementation.

Methods

An exploratory convergent mixed-method approach was used. Data were collected via a 13-item electronic survey informed by the Theoretical Domains Framework (TDF) distributed to eligible nurses across the health district. Descriptive statistics for quantitative data and thematic analysis for qualitative data were conducted. The data were then integrated and mapped to the TDF and the Behaviour Change Wheel to identify specific behaviour change techniques to support implementation.

Results

There were 300 respondents. The majority of nurses knew where to locate the tool (91.26%), but 45.79% felt that it was not adequate to ensure safe handover. The most frequently reported factors that hindered nurses from using the tool were inability to access a phone near a computer (44.32%) (environmental domain), being told to transfer the patient before being able to complete the form (39.93%) (reinforcement) and the other nurse receiving (or giving) the handover not using the form (38.83%) (social influence). An implementation checklist to identify barriers and solutions to future uptake was developed.

Conclusion

To improve uptake, the functionality, content, and flow of the handover tool must be revised, alongside environmental restructuring. Nurses would benefit from an awareness of each speciality’s needs to develop a shared mental model and monitoring, and enforcement of tool use should become part of a routine audit.

Quality analysis of operative reports and referral data for appendiceal neoplasms with peritoneal dissemination

BACKGROUND

Peritoneal metastasis from appendiceal neoplasms is a rare disease usually found unexpectedly and is associated with deficits in quality reporting of findings.

METHODS

Retrospective review of our appendiceal peritoneal metastases carcinomatosis database evaluating quality of index operative and pathology reports. Operative report quality was graded by 2 standards; general quality, based on Royal College of Surgeons quality metrics and peritoneal metastases assessment. Pathology report quality was assessed by the accuracy of diagnosis.

RESULTS

Three hundred and seventy-five index operative reports and 490 outside pathology reports were reviewed. General quality of the index operative reports was excellent, with nearly 80% of reports encompassing all the Royal College of Surgeons quality metrics. Peritoneal metastases assessment was poor. Forty-four percent of the reports performed no peritoneal evaluation, while 48.3% only involved partial peritoneal evaluation. Only 7.7% of the reports performed a complete evaluation. Of the pathology reports, 48.4% had discrepancies with final pathologic findings. Low-grade disease and high-grade disease were misdiagnosed 36.06% and 62.7% of the time, respectively. Discordant treatment occurred in 15.3% and 30.0% of cases for misdiagnosed low-grade and high-grade disease, respectively. Incomplete cytoreduction was attempted in nearly a third of referral cases, which was associated with a significantly increased risk for ultimate incomplete cytoreduction with an odds ratio of 4.72.

CONCLUSION

This review finds that referral operative reports' descriptions of the technical aspects of a procedure is usually complete. However, oncologic parameters and descriptions of peritoneal metastases are frequently incomplete. Further, pathology reports from outside institutions can lead to inappropriate clinical management decisions. We propose a simplified algorithm to assist nonperitoneal surface malignancy surgeons.

Cross-Cover Curriculum for Senior Medical Students

INTRODUCTION

Cross-cover, the process by which a nonprimary team physician cares for patients, usually during afternoons, evenings, and weekends, is common in academic medical centers. With the advent of residency duty-hour restrictions, cross-cover care has increased, making education in effective cross-coverage an urgent need.

METHODS

We implemented a cross-cover didactic activity composed of 18 interactive cases with 29 senior medical students enrolled in an internal medicine residency preparation course. The curriculum was facilitated by one faculty member and one senior medical resident and utilized think-pair-share learning techniques to discuss an approach to a range of common (both urgent and routine) cross-cover scenarios. We analyzed confidence and feelings of preparedness pre- and postintervention. We also examined differences in medical knowledge based on two multiple-choice written cross-cover cases that addressed both medical management and triage.

RESULTS

This curriculum significantly improved feelings of confidence (from 1.8 to 3.2, p < .0001), reduced anxiety (from 4.5 to 4.1, p < .03), and improved performance in clinical case scenarios (from 82% to 89%, p < .02).

DISCUSSION

This curriculum covered not only the important medical aspects of cross-cover care (e.g., diagnostics and management) but also equally important roles of cross-cover, such as how to effectively triage cross-cover scenarios. The curriculum was well received by students.

Rapid sequence induction traceability in an ICU dedicated patient data management system: a multicentric retrospective study

PURPOSE

Patient data management systems (PDMS) are widely used in intensive care units (ICUs) to improve care traceability. Verbal orders are still used for prescriptions requiring immediate execution but should be subsequently recorded in the system. We assessed the rapid sequence induction (RSI) traceability for endotracheal intubation in an ICU dedicated PDMS.

MATERIALS AND METHODS

A retrospective study was conducted on anonymous databases in 21 ICUs. Endotracheal tube insertions performed during one year were compared to the number of RSI registered in the PDMS.

RESULTS

We listed 5516 endotracheal tube insertions. A suxamethonium injection was registered in 829 cases and a rocuronium administration in 909 cases. The RSI traceability rate in the overall cohort was 31.5% and was greater in the units where nurses were allowed to record a drug administration before the computerized physician order entry.

CONCLUSIONS

PDMS are supposed to improve prescription completeness and traceability, but our study suggests an opposite result. A co-responsibility policy between physicians and nurses should be promoted to improve care traceability. PDMS ergonomic improvements and enhanced integration in clinical workflow might also result in better compliance with documentation requirements. In each centre, indicators of PDMS correct use should be defined and periodically monitored.

Exploring current physicians' failure to communicate clinical feedback back to transferring physicians after transitions of patient care responsibility: A mixed methods study

INTRODUCTION

After patient care transitions occur, communication from the current physician back to the transferring physician may be an important source of clinical feedback for learning from outcomes of previous reasoning processes. Factors associated with this communication are not well understood. This study clarifies how often, and for what reasons, current physicians do or do not communicate back to transferring physicians about transitioned patients.

METHODS

In 2018, 38 physicians at two academic teaching hospitals were interviewed about communication decisions regarding 618 transitioned patients. Researchers recorded quantitative and qualitative data in field notes, then coded communication rationales using directed content analysis. Descriptive statistics and mixed effects logistic regression analyses identified communication patterns and examined associations with communication for three conditions: When current physicians 1) changed transferring physicians' clinical decisions, 2) perceived transferring physicians' clinical uncertainty, and 3) perceived transferring physicians' request for communication.

RESULTS

Communication occurred regarding 17% of transitioned patients. Transferring physicians initiated communication in 55% of these cases. Communication did not occur when current physicians 1) changed transferring physicians' clinical decisions (119 patients), 2) perceived transferring physicians' uncertainty (97 patients), and 3) perceived transferring physicians' request for communication (12 patients). Rationales for no communication included case contextual, structural, interpersonal, and cultural factors. Perceived uncertainty and request for communication were positively associated with communication (p < 0.001) while a changed clinical decision was not.

DISCUSSION

Current physicians communicate infrequently with transferring physicians after assuming patient care responsibilities. Structural and interpersonal barriers to communication may be amenable to change. Clarity about transferring physicians' uncertainty and desire for communication back may improve clinical feedback communication.

Weekend handover: Improving patient safety during weekend services

Clinical Handover has been identified as one of the most high-risk processes within medicine. Inadequate handover is a significant cause of avoidable adverse events across many hospitals. A likert-survey of the weekend handover system at a district general hospital demonstrated significant dissatisfaction amongst junior doctors. Intending to improve patient safety and reduce stress for on-call junior doctors, a weekend handover proforma was compiled according to the Royal College of Physicians and Surgeons guidelines. The proforma was trialed on six medical wards for six months with a before and after questionnaire being sent to doctors on the wards involved to determine the proforma's merits on a scale of 1 (least effective) to 10 (most effective). Reports subsequent to implementation demonstrated a 67% increase ease of identifying outstanding weekend jobs. 57% of doctors reported better understanding of their patient's diagnosis and management plan and 53% stated it was easier to identify the patients that required regular medical review over the weekend. Results also highlighted a 55% reported an increase in safety of weekend handovers (p<0.01). A closed loop audit of handover practice through the use of a standardised proforma showed improved quality, detail and consistency of handovers. The reduction in stress for junior doctors managing unknown patients with a clear concise plan, directed by a senior from the parent team during the week, has improved patient safety and doctor satisfaction.

Utilizing Electronic Medical Records to Standardize Handoffs in Academic Ophthalmology

Purpose Formalized handoff procedures have been shown to increase patient safety and quality of care across multiple medical and surgical specialties,1–4 but literature regarding handoffs in ophthalmology remains sparse. We instituted a standardized handoff utilizing an electronic medical record (EMR) system to improve care for patients shared by multiple resident physicians across weekday, weeknight, and weekend duty shifts. We measured efficiency, efficacy, and resident satisfaction before and after the standardized handoff was implemented.

Methods Resident physicians surveyed were primarily responsible for patient care on consult and call services at two quaternary academic medical centers in a major metropolitan area. Patient care was performed in outpatient, emergency, and inpatient settings. Annual anonymous questionnaires consisting of 6 questions were used to collect pre- and postintervention impressions of the standardized EMR handoff process from ophthalmology resident physicians (9 per year; 3 preintervention years and 1 postintervention year). An additional anonymous postintervention questionnaire consisting of 12 questions was used to further characterize resident response to the newly implemented handoff procedure.

Results Prior to implementation of a standardized EMR-based handoff procedure, residents unanimously reported incomplete, infrequently updated handoff reports that did not include important clinical and/or psychosocial information. Following implementation, residents reported a statistically significant increase in completeness and timeliness of handoff reports. Additionally, resident perception of EMR handoff utility, efficiency, and usability were comprehensively favorable. Residents reported handoffs only added a mean of 6.5 minutes to a typical duty shift.

Conclusion Implementation of our protocol dramatically improved resident perceptions of the handoff process at our institution. Improvements included increased quality, ease-of-use, and efficiency. Our standardized EMR-based handoff procedure may be of use to other ambulatory-based services.

An initiative to improve advanced notification of inter-hospital transfers

Poor communication during inter-hospital transfer (IHT, the transfer of patients between acute care hospitals) is common. Clinicians often report feeling unprepared to care for IHT patients due to inadequate advance notification. The aim of this project was to improve advance notification of general medicine service patient transfers to a tertiary care referral hospital. We used quality improvement principles to design and implement two interventions: (1) Use of a checklist; (2) Redesign role/responsibilities within the Access Center and Bed Control Department. Data on frequency of advance notification was collected over 9 months and plotted on a statistical process control chart with evaluation for special cause variation. We also evaluated barriers/facilitators to implementation and surveyed clinicians on information received with the advance notification. 103 patients underwent IHT during the study. Frequency of advance notification increased from a baseline of 63.6%-85.4% post-intervention. Several contributors to successful implementation were identified, including ensuring key stakeholder input and leveraging existing systems structure, among others. Survey results highlighted potential targets for future IHT improvements such as improved clinical information available to admitting clinicians in advance of patient transfer. In conclusion, we successfully improved advance notification of IHT, an essential step to improve communication. Next steps include sustainment and automation of these efforts and ongoing targeted process improvement efforts with an ultimate goal of improving patient outcomes during IHT.

Handover Practices in Trauma and Acute Care Surgery: A Multicenter Survey Study

BACKGROUND

The handover period has been identified as a particularly vulnerable period for communication breakdown leading to patient safety events. Clear and concise handover is especially critical in high-acuity care settings such as trauma, emergency general surgery, and surgical critical care. There is no consensus for the most effective and efficient means of evaluating or performing handover in this population. We aimed to characterize the current handover practices and perceptions in trauma and acute care surgery.

METHODS

A survey was sent to 2265 members of the Eastern Association for the Surgery of Trauma via email regarding handoff practices at their institution. Respondents were queried regarding their practice setting, average census, level of trauma center, and patients (trauma, emergency general surgery, and/or intensive care). Data regarding handover practices were gathered including frequency of handover, attendees, duration, timing, and formality. Finally, perceptions of handover including provider satisfaction, desire for improvement, and effectiveness were collected.

RESULTS

Three hundred eighty surveys (17.1%) were completed. The majority (73.4%) of respondents practiced at level 1 trauma centers (58.9%) and were trauma/emergency general surgeons (86.5%). Thirty-five percent of respondents reported a formalized handover and 52% used a standardized tool for handover. Only 18% of respondents had ever received formal training, but most (51.6%) thought this training would be helpful. Eighty-one percent of all providers felt handover was essential for patient care, and 77% felt it prevented harm. Seventy-two percent thought their handover practice needed improvement, and this was more common as the average patient census increased. The most common suggestions for improvement were shorter and more concise handover (41.6%), different handover medium (24.5%), and adding verbal communication (13.9%).

CONCLUSION

Trauma and emergency general surgeons perceive handover as essential for patient care and the majority desire improvement of their current handover practices. Methods identified to improve the handover process include standardization, simplification, and verbal interaction, which allows for shared understanding. Formal education and best practice guidelines should be developed.

Noise and turn-taking impact postanesthesia care unit handoff efficiency

Background

Optimal handoffs are pivotal for patient safety, yet some of the underlying communication mechanisms which support effective handoffs remain to be understood. As handoffs are conversations between providers, understanding communication mechanisms is necessary to improve handoff protocol development. The objective of this study was to characterize communication variables influencing the efficiency of handoffs in the postanesthesia care unit.

Methods

We conducted a single-center, observational study of handoffs over a three-week period in June/July of 2017. We recorded 96 handoffs between the cardiac operating room and postanesthesia care unit. We defined and measured efficiency by dividing the count of unique, nonrepetitive pieces of information by duration of the handoff conversation. Furthermore, we calculated and measured two communication variables: turn-taking and noise. We utilized West and Zimmerman’s Syntactic Scale to analyze turn taking by segregating noise into three subcategories: environmental noise caused by equipment, environmental noise caused by staff, and third-party interruptions. Finally, we recorded and measured the frequency and duration of noise and turn-taking during the handoff events.

Results

Due to technical issues, we transcribed and analyzed a total of 85 observations. Providers passed an average of 31.68 unique pieces of information during each handoff with the average length being 1 min and 46 s. Overlaps was the most common type of turn-taking behavior. Activity noise was the most common type of noise. Activity noise took place an average of 3.64 times per handoff and lasted an average of 9.83 s. Turn-taking accounted for 15.6% of variance in handoff efficiency. Together, noise and turn-taking accounted for 25.2% of the variance in handoff efficiency.

Conclusion

Because turn-taking and noise account for over a quarter the variance in handoff efficiency, recommendations include providing quiet locations for handoffs to take place. Additionally, we recommend that receivers provide input in any handoff interventional studies as their involvement would decrease the need to interrupt or clarify information from the sender.

Structured Handover in General Surgery: An Audit of Current Practice

INTRODUCTION

Verbal handover alone compromises patient safety, and supporting written documents significantly increases retention of information, with printed handover sheets being the best at avoiding data loss. The Royal College of Surgeons (RCS) has produced guidelines on safe handover practice, in which a minimum dataset is recommended for inclusion when handing over patients to incoming surgical teams, and studies have indicated better adherence to these guidelines when preprinted handover proformas are used.

METHODS

All surgical handover sessions were attended for a one-week period, and copies of handover sheets were taken. These were analyzed against RCS guidelines on the essential dataset for safe handover practice. A standardized handover sheet, developed in accordance with these guidelines and designed to encourage impartation of this minimum dataset, was then circulated among members of the surgical department and made readily available on wards. After a 6-week period, a postintervention audit was conducted using the same methods.

RESULTS

Striking differences were seen in the quality of information handed over preintervention and postintervention. The documentation of patient location increased significantly (56%-87%, P < 0.0001; 95% CI, 0.460-0.151), as did the documentation of important outstanding clinical tasks (45%-89%, P = 0.004; 95% CI, 0.439-0.089). Documentation of blood results increased (P < 0.0001; 95% CI, 0.523-0.226), and the proportion of patients for whom the occurrence of a senior review was documented increased from 28% (18) to 85% (45) (P < 0.0001; 95% CI, 0.717-0.419) CONCLUSIONS: The use of a structured, computer-generated handover proforma significantly improved compliance with RCS guidelines within the surgical department of our hospital, and we recommend its continued use among on-call surgical teams.

Subtle skills: Using objective structured clinical examinations to assess gastroenterology fellow performance in system based practice milestones

BACKGROUND

System based practice (SBP) milestones require trainees to effectively navigate the larger health care system for optimal patient care. In gastroenterology training programs, the assessment of SBP is difficult due to high volume, high acuity inpatient care, as well as inconsistent direct supervision. Nevertheless, structured assessment is required for training programs. We hypothesized that objective structured clinical examination (OSCE) would be an effective tool for assessment of SBP.

AIM

To develop a novel method for SBP milestone assessment of gastroenterology fellows using the OSCE.

METHODS

For this observational study, we created 4 OSCE stations: Counseling an impaired colleague, handoff after overnight call, a feeding tube placement discussion, and giving feedback to a medical student on a progress note. Twenty-six first year fellows from 7 programs participated. All fellows encountered identical case presentations. Checklists were completed by trained standardized patients who interacted with each fellow participant. A report with individual and composite scores was generated and forwarded to program directors to utilize in formative assessment. Fellows also received immediate feedback from a faculty observer and completed a post-session program evaluation survey.

RESULTS

Survey response rate was 100%. The average composite score across SBP milestones for all cases were 6.22 (SBP1), 4.34 (SBP2), 3.35 (SBP3), and 6.42 (SBP4) out of 9. The lowest composite score was in SBP 3, which asks fellows to advocate for cost effective care. This highest score was in patient care 2, which asks fellows to develop comprehensive management plans. Discrepancies were identified between the fellows’ perceived performance in their self-assessments and Standardized Patient checklist evaluations for each case. Eighty-seven percent of fellows agreed that OSCEs are an important component of their clinical training, and 83% stated that the cases were similar to actual clinical encounters. All participating fellows stated that the immediate feedback was “very useful.” One hundred percent of the fellows stated they would incorporate OSCE learning into their clinical practice.

CONCLUSION

OSCEs may be used for standardized evaluation of SBP milestones. Trainees scored lower on SBP milestones than other more concrete milestones. Training programs should consider OSCEs for assessment of SBP.

Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study

OBJECTIVE

To characterize interactivity during resident and nurse handoffs by investigating listening and question-asking behaviors during conversations.

MATERIALS AND METHODS

Resident (n = 149) and nurse (n = 126) handoffs in an inpatient medicine unit were audio-recorded. Handoffs were coded based on listening behaviors (active and passive), question types (patient status, coordination of care, clinical reasoning, and framing and alignment), and question responses. Comparisons between residents and nurses for listening and question-asking behaviors were performed using the Wilcoxon rank-sum tests. A Poisson regression model was used to investigate differences in the question-asking behaviors between residents and nurses, and the association between listening and question-asking behaviors.

RESULTS

There were no significant differences between residents and nurses in their active (18% resident vs 39% nurse handoffs) or passive (88% resident vs 81% nurse handoffs) listening behaviors. Question-asking was common in resident and nurse handoffs (87% vs 98%) and focused primarily on patient status, co-ordination, and framing and alignment. Nurses asked significantly more questions than residents (Mresident = 2.06 and Mnurse = 5.52) by a factor of 1.76 (P < 0.001). Unit increase in listening behaviors was associated with an increase in the number of questions during resident and nurse handoffs by 7% and 12%, respectively.

DISCUSSION AND CONCLUSION

As suggested by the Joint Commission, question-asking behaviors were common across resident and nurse handoffs, playing a critical role in supporting resilience in communication and collaborative cross-checks during conversations. The role of listening in initiating question-asking behaviors is discussed.

Failure to Rescue Event Mitigation System Assessment: A Mixed-methods Approach to Analysis of Complex Adaptive Systems

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

Is there a need for formal undergraduate patient handover training and could an educational workshop effectively provide this? A proof-of-concept study in a Scottish Medical School

BACKGROUND

Poor communication between healthcare professionals is recognised as accounting for a significant proportion of adverse patient outcomes. In the UK, the General Medical Council emphasises effective handover (handoff) as an essential outcome for medical graduates. Despite this, a significant proportion of medical schools do not teach the skill.

OBJECTIVES

This study had two aims: (1) demonstrate a need for formal handover training through assessing the pre-existing knowledge, skills and attitudes of medical students and (2) study the effectiveness of a pilot educational handover workshop on improving confidence and competence in structured handover skills.

DESIGN

Students underwent an Objective Structured Clinical Examination style handover competency assessment before and after attending a handover workshop underpinned by educational theory. Participants also completed questionnaires before and after the workshop. The tool used to measure competency was developed through a modified Delphi process.

SETTING

Medical education departments within National Health Service (NHS) Lanarkshire hospitals.

PARTICIPANTS

Forty-two undergraduate medical students rotating through their medical and surgical placements within NHS Lanarkshire enrolled in the study. Forty-one students completed all aspects.

MAIN OUTCOME MEASURES

Paired questionnaires, preworkshop and postworkshop, ascertained prior teaching and confidence in handover skills. The questionnaires also elicited the student's views on the importance of handover and the potential effects on patient safety. The assessment tool measured competency over 12 domains.

RESULTS

Eighty-three per cent of participants reported no previous handover teaching. There was a significant improvement, p<0.0001, in confidence in delivering handovers after attending the workshop. Student performance in the handover competency assessment showed a significant improvement (p<0.05) in 10 out of the 12 measured handover competency domains.

CONCLUSIONS

A simple, robust and reproducible intervention, underpinned by medical education theory, can significantly improve competence and confidence in medical handover. Further research is required to assess long-term outcomes as student's transition from undergraduate to postgraduate training.

UC Care Check-A Postoperative Neurosurgery Operating Room Checklist: An Interrupted Time Series Study

BACKGROUND

The effectiveness of neurosurgical operating room (OR) checklists to improve communication, safety attitudes, and clinical outcomes is uncertain.

PURPOSE

To develop, implement, and evaluate a post-operative neurosurgery operating room checklist.

METHODS

Four large academic medical centers participated in this study. We developed an evidence-based checklist to be performed at the end of every adult-planned or emergent surgery in which all team members pause to discuss key elements of the case. We used a prospective interrupted time series study design to assess trends in clinical and cost outcomes. Safety attitudes and communication among OR providers were also assessed.

RESULTS

There were 11,447 neurosurgical patients in the preintervention and 10,973 in the postintervention periods. After implementation, survey respondents perceived that postoperative checklists were regularly performed, important issues were communicated at the end of each case, and patient safety was consistently reinforced. Observed to expected (O/E) overall mortality rates remained less than one, and 30-day readmission rate, length of stay index, direct cost index, and perioperative venous thromboembolism and hematoma rates remained unchanged as a result of checklist implementation.

CONCLUSION

A neurosurgical checklist can improve OR team communication; however, improvements in safety attitudes, clinical outcomes, and health system costs were not observed.

Transitions of Care: The Presence of Written Interfacility Transfer Guidelines and Agreements for Pediatric Patients

OBJECTIVE

Every year, emergency medical services agencies transport approximately 150,000 pediatric patients between hospitals. During these transitions of care, patient safety may be affected and contribute to adverse events when important clinical information is missing, incomplete, or inaccurate. Written interfacility transfer policies are one way to standardize procedures and facilitate communication between the hospitals leading to improved patient safety and satisfaction for children and families.

METHODS

We assessed the presence and components of written interfacility transfer guidelines and agreements for pediatric patients via a survey sent to US hospital emergency department (ED) nurse managers during 2010 and 2013.

RESULTS

Although there was an increase in the presence of written interfacility transfer guidelines and agreements, a third of hospitals did not have either by 2013, and only 50% had guidelines with all recommended pediatric components. Hospitals with medium and low ED pediatric patient volumes were less likely to have written guidelines or agreements compared with hospitals with high volume. Hospitals with advanced pediatric resources, such as a pediatric emergency care coordinator or EDs designated approved for pediatrics, were more likely to have guidelines or agreements than less resourced hospitals.

CONCLUSIONS

Although there was improvement over time, opportunities exist for increasing the presence of written interfacility transfer guidelines as well as agreements for pediatric patients. Further studies are needed to demonstrate whether improved delivery of patient care is associated with the presence of written interfacility transfer guidelines and agreements and to identify other elements in the process to ensure optimal pediatric patient care.

Impact of staff turnover during cardiac surgical procedures

OBJECTIVE

The impact of staff turnover during cardiac procedures is unknown. Accurate inventory of sharps (needles/blades) requires attention by surgical teams, and sharp count errors result in delays, can lead to retained foreign objects, and may signify communication breakdown. We hypothesized that increased team turnover raises the likelihood of sharp count errors and may negatively affect patient outcomes.

METHODS

All cardiac operations performed at our institution from May 2011 to March 2016 were reviewed for sharp count errors from a prospectively maintained database. Univariate and multivariable analyses were performed.

RESULTS

Among 7264 consecutive cardiac operations, sharp count errors occurred in 723 cases (10%). There were no retained sharps detected by x-ray in our series. Sharp count errors were lower on first start cases (7.7% vs 10.7%, P < .001). Cases with sharp count errors were longer than those without (7 vs 5.7 hours, P < .001). In multivariable analysis, factors associated with an increase in sharp count errors were non-first start cases (odds ratio [OR], 1.3; P = .006), weekend cases (OR, 1.6; P < .004), more than 2 scrub personnel (3 scrubs: OR, 1.3; P = .032; 4 scrubs: OR, 2; P < .001; 5 scrubs: OR, 2.4; P = .004), and more than 1 circulating nurse (2 nurses: OR, 1.9; P < .001; 3 nurses: OR, 2; P < .001; 4 nurses: OR, 2.4; P < .001; 5 nurses: OR, 3.1; P < .001). Sharp count errors were associated with higher rates of in-hospital mortality (OR, 1.9; P = .038).

CONCLUSIONS

Sharp count errors are more prevalent with increased team turnover and during non-first start cases or weekends. Sharp count errors may be a surrogate marker for other errors and thus increased mortality. Reducing intraoperative team turnover or optimizing hand-offs may reduce sharp count errors.

Inter-hospital transfer and patient outcomes: a retrospective cohort study

BACKGROUND

Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied.

OBJECTIVE

To evaluate the association between IHT and healthcare utilisation and clinical outcomes.

DESIGN

Retrospective cohort.

SETTING

CMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data.

PARTICIPANTS

Beneficiaries≥age 65 enrolled in Medicare A and B, with an acute care hospitalisation claim in 2013 and 1 of 15 top disease categories.

MAIN OUTCOME MEASURES

Cost of hospitalisation, length of stay (LOS) (of entire hospitalisation), discharge home, 3 -day and 30- day mortality, in transferred vs non-transferred patients.

RESULTS

The final cohort consisted of 53 420 transferred patients and 53 420 propensity-score matched non-transferred patients. Across all 15 disease categories, IHT was associated with significantly higher costs, longer LOS and lower odds of discharge home. Additionally, IHT was associated with lower propensity-matched odds of 3-day and/or 30- day mortality for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher propensity-matched odds of mortality for other disease categories (oesophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructivepulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease).

CONCLUSIONS

In this nationally representative study of Medicare beneficiaries, IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients' disease category. These findings demonstrate heterogeneity among transferred patients depending on the diagnosis, presenting a nuanced assessment of this complex care transition.

Oncologists' Views Regarding the Role of Electronic Health Records in Care Coordination

BACKGROUND

Electronic health records (EHRs) play a significant role in complex health care processes, especially in information transfer with patients and care coordination among providers. EHRs may also generate unintended consequences, introducing new patient safety risks. To date, little investigation has been performed in oncology settings, despite the need for quality provider-patient communication and information transfer during oncology visits. In this qualitative study, we focused on oncology providers' perceptions of EHRs for supporting communication with patients and coordination of care with other providers.

METHODS

We conducted semistructured interviews with oncologists from an urban academic medical center to learn their perceptions of the use of EHRs before, during, and after clinic visits with patients. Our interview guide was developed on the basis of the work system model. We coded transcripts using inductive content analysis.

RESULTS

Data analysis yielded four main themes regarding oncologists' practices in using the EHR and perceptions about EHRs: (1) EHR use for care coordination (eg, timeliness of receiving information, SmartSet documentation); (2) EHR use in the clinic visit (eg, educating patients, using as a reinforcement tool); (3) safety hazards in care coordination associated with EHRs (eg, incomplete documentation, error propagating, no filtering mechanism to capture errors); and (4) suggestions for improvements (eg, improved SmartSet functionalities, simplification of user interface).

CONCLUSION

Current EHRs do not adequately support teamwork of oncology providers, which could lead to potential hazards in the care of patients with cancer. Redesigning EHR features that are tailored to support oncology care and addressing the concerns regarding information overload, improved organization of flagging abnormal results, and documentation-related workload are needed to minimize potential safety hazards.

Cross-Cover Documentation: Multicenter Development of Assessment Tool for Quality Improvement

Construct: We aimed to develop an assessment tool to measure the quality of electronic health record inpatient documentation of cross-cover events. Background: Cross-cover events occur in hospitalized patients when the primary team is absent. Documentation is critical for safe transitions of care. The quality of documentation for cross-cover events remains unknown, and no standardized tool exists for assessment. Approach: We created an assessment tool for cross-cover note quality with content validation based on input from 15 experts. We measured interrater reliability of the tool and scored cross-cover note quality for hospitalized patients with overnight rapid response team activation on internal medicine services at 2 academic hospitals for 1 year. Patients with a code blue or a clinically insignificant event were excluded. The presence of a note, writer identity (resident or faculty), time from rapid response to documentation, note content (subjective and objective information, diagnosis, and plan), and patient outcomes were compared. Results: The instrument included 8 items to determine quality of cross-cover documentation: reason for physician notification, note written within 6 hours, subjective and objective patient information, diagnosis, treatment, level of care, and whether the attending physician was notified. The mean Cohen's kappa coefficient demonstrated good interrater agreement at 0.76. The instrument was scored in 222 patients with cross-cover notes. Notes documented by faculty scored higher in quality than residents (89% vs. 74% of 8 items present, p < .001). Cross-cover notes often lacked subjective information, diagnosis, and notification of attending, which was present in 60%, 62%, and 7% of notes, respectively. Conclusions: This study presents reliability evidence for an 8-item assessment tool to measure quality of documentation of cross-cover events and indicates improvement is needed for cross-cover education and safe transitions of care in acutely decompensating medical patients.

Hand-off bundle implementation associated with decreased medical errors and preventable adverse events on an academic family medicine in-patient unit: A pre-post study

To determine the impact of the implementation of a hand-off bundle on medical errors at an inpatient unit of an academic community teaching hospital. Our secondary objective was to determine the research utility of the use of an all-electronic data collection system for medical errors.A retrospective review was conducted of 1290 admissions 6 months before and after implementation of an improved computerized hand-off tool and training bundle. The study took place at an academic community teaching hospital on a Family Medicine inpatient service caring for patients of all ages. The comparison focused on preventable and non-preventable adverse events.A significant decrease in medical errors was noted. Medical error rate dropped from 6.0 (95% CI, 4.2-8.3) to 2.2 (95% CI, 1.2-3.7) per 100 admissions (P < .001). Preventable medical errors dropped from 0.65 (95% CI, 0.18-1.67) to 0.15 (95% CI, 0.03-0.82) per 100 admissions (P = .194). Non-intercepted potential adverse events dropped from 1.30 (95% CI, 0.56-2.57) to 0.44 (95% CI, 0.09-1.30) per 100 admissions (P = .131). Intercepted potential adverse events dropped from 0.98 (95% CI 0.36-2.13) to 0.74 (95% CI 0.24-1.7) per 100 admissions (P = .766) and errors with little potential for harm dropped from 2.77 (95% CI 1.61-4.43) to 0.74 (95% CI 0.24-1.7) per 100 admissions (P = .009).Implementation of a standardized hand-off bundle was associated with a reduction in medical errors despite a low overall event rate. Further studies are warranted to determine the generalizability of this finding, to examine the overall epidemiology of medical errors and the reporting of such events within general medical teaching units.

Handovers Among Staff Intensivists: A Study of Information Loss and Clinical Accuracy to Anticipate Events

OBJECTIVES

Handovers are associated with medical errors, and our primary objective is to identify missed diagnosis and goals immediately after a shift handover. Our secondary objective is to assess clinicians' diagnostic accuracy in anticipating clinical events during the night shift.

DESIGN

Single-center prospective observational cohort study.

SETTING

Thirty-bed tertiary ICU in Sao Paulo, Brazil.

PATIENTS

Three-hundred fifty-two patient encounters over 44 day-to-night handovers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We used a multimethods approach to measure transmission of information among staff physicians on diagnoses and goals for the night shift. We surveyed clinicians immediately after a handover and identified clinical events through chart abstractions and interviews with clinicians the next morning. Nighttime clinicians correctly identified 454 of 857 diagnoses (53%; 95% CI 50-56) and 123 of 304 goals (40%; 95% CI, 35-46). Daytime clinicians were more sensitive (65% vs 46%; p < 0.01) but less specific (82% vs 91%; p < 0.01) than nighttime clinicians in anticipating clinical events at night, resulting in similar accuracy (area under the receiver operating characteristic curve, 0.74 [95% CI, 0.68-0.79] vs 0.68 [95% CI 0.63-0.74]; p = 0.09). The positive predictive value of both daytime and nighttime clinicians was low (13% vs 17%; p = 0.2). Gaps in diagnosis and anticipation of events were more pronounced in neurologic diagnoses.

CONCLUSIONS

Among staff intensivists, diagnoses and goals of treatment are either not conveyed or retained 50-60% of the cases immediately after a handover. Clinicians have limited ability to anticipate events, and the expectation that anticipatory guidance can inform handovers needs to be balanced against information overload. Handovers among staff intensivists showed more gaps in the identification of diagnostic uncertainty and for neurologic diagnoses, which could benefit from communication strategies such as cognitive checklists, prioritizing discussion of neurologic patients, and brief combined clinical examination at handover.

Telemedicine for Interfacility Nurse Handoffs

OBJECTIVE

To compare nurse preparedness and quality of patient handoff during interfacility transfers from a pretransfer emergency department to a PICU when conducted over telemedicine versus telephone.

DESIGN

Cross-sectional nurse survey linked with patient electronic medical record data using multivariable, multilevel analysis.

SETTING

Tertiary PICU within an academic children's hospital.

PARTICIPANTS

PICU nurses who received a patient handoff between October 2017 and July 2018.

INTERVENTIONS

None.

MAIN RESULTS AND MEASUREMENTS

Among 239 eligible transfers, 106 surveys were completed by 55 nurses (44% survey response rate). Telemedicine was used for 30 handoffs (28%), and telephone was used for 76 handoffs (72%). Patients were comparable with respect to age, sex, race, primary spoken language, and insurance, but handoffs conducted over telemedicine involved patients with higher illness severity as measured by the Pediatric Risk of Mortality III score (4.4 vs 1.9; p = 0.05). After adjusting for Pediatric Risk of Mortality III score, survey recall time, and residual clustering by nurse, receiving nurses reported higher preparedness (measured on a five-point adjectival scale) following telemedicine handoffs compared with telephone handoffs (3.4 vs 3.1; p = 0.02). There were no statistically significant differences in both bivariable and multivariable analyses of handoff quality as measured by the Handoff Clinical Evaluation Exercise. Handoffs using telemedicine were associated with increased number of Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver components (3.3 vs 2.8; p = 0.04), but this difference was not significant in the adjusted analysis (3.1 vs 2.9; p = 0.55).

CONCLUSIONS

Telemedicine is feasible for nurse-to-nurse handoffs of critically ill patients between pretransfer and receiving facilities and may be associated with increased perceived and objective nurse preparedness upon patient arrival. Additional research is needed to demonstrate that telemedicine during nurse handoffs improves communication, decreases preventable adverse events, and impacts family and provider satisfaction.

Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit

Objective

The risk of medical errors increases upon transfer out of the intensive care unit (ICU). Discrepancies in the documented care plan between notes at the time of transfer may contribute to communication errors. We sought to determine the frequency of clinically meaningful discrepancies in the documented care plan for patients transferred from the pediatric ICU to the medical wards and identified risk factors.

Materials and Methods

Two physician reviewers independently compared the transfer note and handoff document of 50 randomly selected transfers. Clinically meaningful discrepancies in the care plan between these two documents were identified using a coding procedure adapted from healthcare failure mode and effects analysis. We assessed the influence of risk factors via multivariable regression.

Results

We identified 34 clinically meaningful discrepancies in 50 patient transfers. Fourteen transfers (28%) had ≥1 discrepancy, and ≥2 were present in 7 transfers (14%). The most common discrepancy categories were differences in situational awareness notifications and documented current therapy. Transfers with handoff document length in the top quartile had 10.6 (95% CI: 1.2-90.2) times more predicted discrepancies than transfers with handoff length in the bottom quartile. Patients receiving more medications in the 24 hours prior to transfer had higher discrepancy counts, with each additional medication increasing the predicted number of discrepancies by 17% (95% CI: 6%-29%).

Conclusion

Clinically meaningful discrepancies in the documented care plan pose legitimate safety concerns and are common at the time of transfer out of the ICU among complex patients.

Information flow during pediatric trauma care transitions: things falling through the cracks

Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Every year, nearly 10 million children are evaluated in emergency departments (EDs) for traumatic injuries, resulting in 250,000 hospital admissions and 10,000 deaths. Pediatric trauma care in hospitals is distributed across time and space, and particularly complex with involvement of large and fluid care teams. Several clinical teams (including emergency medicine, surgery, anesthesiology, and pediatric critical care) converge to help support trauma care in the ED; this co-location in the ED can help to support communication, coordination and cooperation of team members. The most severe trauma cases often need surgery in the operating room (OR) and are admitted to the pediatric intensive care unit (PICU). These care transitions in pediatric trauma can result in loss of information or transfer of incorrect information, which can negatively affect the care a child will receive. In this study, we interviewed 18 clinicians about communication and coordination during pediatric trauma care transitions between the ED, OR and PICU. After the interview was completed, we surveyed them about patient safety during these transitions. Results of our study show that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, important patient care information is often lost when transitioning patients between units. To safely manage the transition of this fragile and complex population, we need to find ways to better manage the information flow during these transitions by, for instance, providing technological support to ensure shared mental models.

Does medical training in Thailand prepare doctors for work in community hospitals? An analysis of critical incidents

BACKGROUND

Compulsory 3-year public service was implemented in 1967 as a measure to tackle the maldistribution of doctors in Thailand. Currently, therefore, most medical graduates work in rural community hospitals for their first jobs. This research explored doctors' perceptions of preparedness for practice using a critical incident technique.

METHODS

A self-administered critical incident questionnaire was developed. Convenient samples were used, i.e. Family Medicine residents at Ramathibodi Hospital who had worked in a community hospital after graduation before returning to residency training. Participants were asked to write about two incidents that had occurred while working in a community hospital, one in which they felt the knowledge and skills obtained in medical school had prepared them for managing the situation effectively and the other in which they felt ill-prepared. Data were thematically analysed.

RESULTS

Fifty-six critical incidents were reported from 28 participants. There were representatives from both normal and rural tracks of undergraduate training and community hospitals of all sizes and all regions. Doctors felt well-prepared to provide care for patients in emergency situations and as in-patients, but under-prepared for obstetric and paediatric emergencies, out-patient care, and palliative care. Moreover, they felt poorly prepared to deal with difficult patients, hospital administration and quality assurance.

CONCLUSIONS

Long-term solutions are needed to solve the rural doctor shortage. Medical graduates from both normal and rural tracks felt poorly prepared for working effectively in community hospitals. Medical training should prepare doctors for rural work, and they should be supported while in post.

Using Incident Reports to Assess Communication Failures and Patient Outcomes

INTRODUCTION

Communication failures pose a significant threat to the quality of care and safety of hospitalized patients. Yet little is known about the nature of communication failures. The aims of this study were to identify and describe types of communication failures in which nurses and physicians were involved and determine how different types of communication failures might affect patient outcomes.

METHODS

Incident reports filed during fiscal year 2015-2016 at a Midwestern academic health care system (N = 16,165) were electronically filtered and manually reviewed to identify reports that described communication failures involving nurses and physicians (n = 161). Failures were categorized by type using two classification systems: contextual and conceptual. Thematic analysis was used to identify patient outcomes: actual or potential harm, patient dissatisfaction, delay in care, or no harm. Frequency of failure types and outcomes were assessed using descriptive statistics. Associations between failure type and patient outcomes were evaluated using Fisher's exact test.

RESULTS

Of the 211 identified contextual communication failures, errors of omission were the most common (27.0%). More than half of conceptual failures were transfer of information failures (58.4%), while 41.6% demonstrated a lack of shared understanding. Of the 179 identified outcomes, 38.0% were delays in care, 20.1% were physical harm, and 8.9% were dissatisfaction. There was no statistically significant association between failure type category and patient outcomes.

CONCLUSION

It was found that incident reports could identify specific types of communication failures and patient outcomes. This work provides a basis for future intervention development to prevent communication-related adverse events by tailoring interventions to specific types of failures.

The variables perceived to be important during patient handover by South African prehospital care providers

Introduction

High-acuity patients are typically transported directly to the emergency centre via ambulance by trained prehospital care providers. As such, the emergency centre becomes the first of many physical transition points for patients, where a change of care provider (or handover) takes place. The aim of this study was to describe the variables perceived to be important during patient handover by a cohort of South African prehospital care providers.

Methods

A purpose-designed questionnaire was used to gather data related to prehospital emergency care provider opinions on the importance of certain patient variables.

Results

We collected 175 completed questionnaires from 75 (43%) BAA, 49 (28%) ANA, 15 (9%) ECT, 16 (9%) ANT and 20 (11%) ECP respondents. Within the ten handover variables perceived to be most important for inclusion in emergency centre handover, five were related to vital signs. Blood pressure was ranked most important, followed by type of major injuries, anatomical location of major injuries, pulse rate, respiration rate and patient history. These were followed by Glasgow Coma Score, injuries sustained, patient priority, oxygen saturations and patient allergies.

Conclusion

This study has provided some interesting results related to which handover elements prehospital care providers consider as most important to include in handover. More research is required to correlate these findings with the opinions of emergency centre staff.

•

There is a paucity of literature related to handover within the African context.

•

Adverse events as a result of poor handover have a significant cost implication that healthcare systems can ill-afford.

•

Identification of the importance of handover variables in emergency centre handover have the potential to improve handover.

A Multidisciplinary Model for Reviewing Severe Maternal Morbidity Cases and Teaching Residents Patient Safety Principles

The Joint Commission recommends that severe maternal morbidity (SMM) cases involving peripartum ICU admissions and blood transfusion > 4 units undergo systematic reviews to determine opportunities for improvement in care. This article describes a retrospective study of an SMM multidisciplinary committee review using a published template.

METHODS

Residents attend a patient safety and quality improvement (PSQI) course at orientation, learn in serial PSQI educational sessions, and receive individual training on the SMM review. The multidisciplinary SMM review process determines contributory factors, identifies best practices, recognizes care improvement opportunities, and facilitates adoption of appropriate interventions. How the process educated residents on the Clinical Learning Environment Review (CLER) focus areas was explored.

RESULTS

From January 2015 to June 2017, 45 SMM cases were reviewed. Reviewers were primarily residents/fellows (64.4% of cases), nurses (11.1%), and maternal-fetal medicine faculty (24.4%). Transfusion > 4 units occurred in 44.4% of cases, and ICU admission in 68.9%. Causes of SMM included obstetric bleeding (57.8%), hypertensive crisis (42.2%), and cardiac disease (24.4%). Preterm delivery occurred in 60.0% of cases; 71.1% were postpartum, and 80.0% had cesarean deliveries. Contributory provider factors included diagnostic delays (55.6%) and treatment delays or errors (44.4%). Contributory patient factors included psychiatric/behavioral health (20.0%) and health care barriers (22.2%). Morbidity could have been prevented by provider factors in 53.3% of cases and by patient factors in 37.8%. Interventions initiated included recruiting a safety nurse, TeamSTEPPS® training, and adoption of hypertension and postpartum hemorrhage safety bundles.

CONCLUSION

SMM reviews can be successfully implemented and provide training on safety and quality.

Pediatric early warning score and deteriorating ward patients on high-flow therapy

BACKGROUND

Delivery of non-invasive ventilation commonly occurs in the pediatric intensive care unit (PICU). With the advent of high-flow nasal cannula (HFNC), patients with respiratory distress may be rescued on the ward without a PICU admission. We evaluated our ward HFNC algorithm to determine its safety profile and independent predictors for non-responders, defined as requiring subsequent PICU admission.

METHODS

A retrospective chart review of patients <17 years of age admitted with respiratory distress between 2016 and 2017 was carried out. Pediatric Early Warning System (PEWS) respiratory score was used to assess the clinical response of patients requiring HFNC. Variables associated with non-responders were evaluated, and their PICU admission was studied for escalation of care and criticality.

RESULTS

Patients with comorbidities (P = 0.02) were more likely to require HFNC. Of the 18 patients initiated on HFNC, 44% (n = 8) remained on the ward. Non-responders (n = 10; 56%) had higher (2.7 vs 1.8; P = 0.03) and worsening (-0.1 vs 0.3; P = 0.05) PEWS respiratory scores 90 min after HFNC initiation. Eighty percent (n = 8) of non-responders required escalation to continuous positive airway pressure or bilevel positive airway pressure in the PICU. For both HFNC responders and non-responders, there were no requirements for intubation, evidence of air leak or difference in days of respiratory support.

CONCLUSIONS

High and worsening PEWS scores 90 min after HFNC initiation may indicate non-response when coupled with a standardized ward HFNC algorithm for respiratory distress. Further improvements may be seen with an earlier initiation of HFNC in the emergency department and more aggressive flow escalation on the ward.

Artificial intelligence systems for complex decision-making in acute care medicine: a review

The integration of artificial intelligence (AI) into acute care brings a new source of intellectual thought to the bedside. This offers great potential for synergy between AI systems and the human intellect already delivering care. This much needed help should be embraced, if proven effective. However, there is a risk that the present role of physicians and nurses as the primary arbiters of acute care in hospitals may be overtaken by computers. While many argue that this transition is inevitable, the process of developing a formal plan to prevent the need to pass control of patient care to computers should not be further delayed.

The first step in the interdiction process is to recognize; the limitations of existing hospital protocols, why we need AI in acute care, and finally how the focus of medical decision making will change with the integration of AI based analysis. The second step is to develop a strategy for changing the focus of medical education to empower physicians to maintain oversight of AI. Physicians, nurses, and experts in the field of safe hospital communication must control the transition to AI integrated care because there is significant risk during the transition period and much of this risk is subtle, unique to the hospital environment, and outside the expertise of AI designers.

AI is needed in acute care because AI detects complex relational time-series patterns within datasets and this level of analysis transcends conventional threshold based analysis applied in hospital protocols in use today. For this reason medical education will have to change to provide healthcare workers with the ability to understand and over-read relational time pattern centered communications from AI. Medical education will need to place less emphasis on threshold decision making and a greater focus on detection, analysis, and the pathophysiologic basis of relational time patterns. This should be an early part of a medical student’s education because this is what their hospital companion (the AI) will be doing.

Effective communication between human and artificial intelligence requires a common pattern centered knowledge base. Experts in safety focused human to human communication in hospitals should lead during this transition process.

Characterising ICU-ward handoffs at three academic medical centres: process and perceptions

BACKGROUND

There is limited literature about physician handoffs between the intensive care unit (ICU) and the ward, and best practices have not been described. These patients are uniquely vulnerable given their medical complexity, diagnostic uncertainty and reduced monitoring intensity. We aimed to characterise the structure, perceptions and processes of ICU-ward handoffs across three teaching hospitals using multimodal methods: by identifying the handoff components involved in communication failures and describing common processes of patient transfer.

METHODS

We conducted a study at three academic medical centres using two methods to characterise the structure, perceptions and processes of ICU-ward transfers: (1) an anonymous resident survey characterising handoff communication during ICU-ward transfer, and (2) comparison of process maps to identify similarities and differences between ICU-ward transfer processes across the three hospitals.

RESULTS

Of the 295 internal medicine residents approached, 175 (59%) completed the survey. 87% of the respondents recalled at least one adverse event related to communication failure during ICU-ward transfer. 95% agreed that a well-structured handoff template would improve ICU-ward transfer. Rehabilitation needs, intravenous access/hardware and risk assessments for readmission to the ICU were the most frequently omitted or incorrectly communicated components of handoff notes. More than 60% of the respondents reported that notes omitted or miscommunicated pending results, active subspecialty consultants, nutrition and intravenous fluids, antibiotics, and healthcare decision-maker information at least twice per month. Despite variable process across the three sites, all process maps demonstrated flaws and potential for harm in critical steps of the ICU-ward transition.

CONCLUSION

In this multisite study, despite significant process variation across sites, almost all resident physicians recalled an adverse event related to the ICU-ward handoff. Future work is needed to determine best practices for ICU-ward handoffs at academic medical centres.

An Electronic Handover System to Improve Information Transfer for Surgical Patients

Proper clinical transfers of patient care (known as handovers) are important to patient safety. The aim of this study was to investigate the efficacy and satisfaction of an electronic system for clinical transfers of patients with complex surgical procedures. The design was a single-center observational study auditing the handover process. The electronic handover system combined with an electronic health record system was developed to help verbal handover. The system has a checklist to guide the structured handover process and provided information from the health record system. With the system, the elapsed time for surgical handover decreased from 10.5 to 5.4 minutes. The questionnaire analysis showed that clinician satisfaction with surgical handover increased from 69.4% to 79.3%, and the perception of communication completeness increased from 67.2% to 81.6%. The electronic handover system improved communication for the transfer of care for surgical patients.

Using a society database to evaluate a patient safety collaborative: the Cardiovascular Surgical Translational Study

AIM

To assess the utility of using external databases for quality improvement (QI) evaluations in the context of an innovative QI collaborative aimed to reduce three infections and improve patient safety across the cardiac surgery service line.

METHODS

We compared changes in each outcome between 15 intervention hospitals (infection reduction protocols plus safety culture intervention) and 52 propensity score-matched hospitals (feedback only).

RESULTS

Improvement trends in several outcomes among the intervention hospitals were not statistically different from those in comparison hospitals.

CONCLUSION

Using external databases such as those of professional societies may permit comparative effectiveness assessment by providing concurrent comparison groups, additional outcome measures and longer follow-up. This can better inform evaluation of continuous QI in healthcare organizations.

Efficiency of electronic signout for ED-to-inpatient admission at a non-teaching hospital

Admission handoff is a high-risk component of patient care. Previous studies have shown that a standardized physician electronic signout ("eSignout") may improve ED-to-inpatient handoff safety and efficiency in teaching hospitals. This model has not yet been studied in non-teaching hospitals. The objectives of the study were to determine the efficiency of an eSignout platform at a community affiliate hospital by comparing ED length of stay (LOS) for a 5-month period before and after implementation and to compare the quality assurance (QA) events among admitted patients for the same time period. A retrospective, interventional study was conducted with the main outcome measures including ED LOS with calculation of 95% CI, mean comparison (t test), and number of QA events before and after implementation of the eSignout model. Prior to eSignout implementation, 1045 patients were admitted [mean ED LOS 330.0 min (95% CI 318.6-341.4)]. Following implementation, 1106 patients were admitted [mean ED LOS 338.9 min (95% CI 327.4-350.4, p = 0.2853)]. Nine pre-implementation QA events and six post-implementation events were identified. Use of a physician eSignout in a non-teaching hospital had no statistically significant effect on ED LOS for the admitted patients. The effect of an electronic interdepartmental handoff tool for patient safety and clinical operations in the non-teaching setting is unclear.

Convergent parallel mixed-methods study to understand information exchange in paediatric critical care and inform the development of safety-enhancing interventions: a protocol study

INTRODUCTION

The effective exchange of clinical information is essential to high-quality patient care, especially in the critical care unit (CCU) where communication failures can have profoundly negative impacts on critically ill patients with limited physiological capacity to tolerate errors. A comprehensive systematic characterisation of information exchange within a CCU is needed to inform the development and implementation of effective, contextually appropriate interventions. The objective of this study is to characterise when, where and how healthcare providers exchange clinical information in the Department of Critical Care Medicine at The Hospital for Sick Children and explore the factors that currently facilitate or counter established best rounding practices therein.

METHODS AND ANALYSIS

A convergent parallel mixed-methods study design will be used to collect, analyse and interpret quantitative and qualitative data. Naturalistic observations of rounds and relevant peripheral information exchange activities will be conducted to collect time-stamped event data on workflow and communication patterns (time-motion data) and field notes. To complement observational data, the subjective perspectives of healthcare providers and patient families will be gathered through surveys and interviews. Departmental metrics will be collected to further contextualise the environment. Time-motion data will be analysed quantitatively; patterns in field note, survey and interview results will be examined based on themes identified deductively from literature and/or inductively based on the data collected (thematic analysis). The proactive triangulation of these systemic, procedural and contextual data will inform the design and implementation of efficacious interventions in future work.

ETHICS AND DISSEMINATION

Institutional research ethics approval has been acquired (REB #1000059173). Results will be published in peer-reviewed journals and presented at relevant conferences. Findings will be presented to stakeholders including interdisciplinary staff, departmental management and leadership and families to highlight the strengths and weaknesses of the exchange of clinical information in its current state and develop user-centred recommendations for improvement.

Clinical handover practices among healthcare practitioners in acute care services: A qualitative study

AIMS AND OBJECTIVES

To examine clinical handover practices in acute care services in Ireland. Objectives were to examine clinical handover practices between and within teams and between shifts, to identify resources and supports to enhance handover effectiveness and to identify barriers and facilitators of effective handover.

BACKGROUND

Clinical handover is a high-risk activity, and ineffective handover practice constitutes a risk to patient safety. Evidence suggests that handover effectiveness is achieved through staff training and standardised handover protocols.

DESIGN

The study design was qualitative-descriptive using inductive analysis.

METHODS

The study involved a series of focus group discussions and interviews among a sample of healthcare practitioners recruited from 12 urban and regional acute hospitals in Ireland. A total of 116 healthcare professionals took part in 28 interviews and 13 focus group discussions. We analysed the data using the directed content analysis method.

RESULTS

Data collection generated rich qualitative data, yielding five categories from which two broad themes emerged: "policy and practice" and "handover effectiveness." The themes and their associated categories indicate that there is limited organisational-level policy and limited explicit training in clinical handover, that medical and nursing handovers are separate activities with somewhat different purposes and different modes of execution, and that several factors in the acute care setting, including location, timing and documentation, act as either barriers or enablers to handover effectiveness.

CONCLUSION

The evidence in the current study suggests that clinical handover merits increased level of prominence in hospital policies or operating procedures. Medical and nursing handover practices represent distinct activities in their content and execution that may be related to cultural and organisational factors.

RELEVANCE TO CLINICAL PRACTICE

Achieving multidisciplinary team handover requires a change in embedded traditional practices. Several aspects of the clinical handover activities of nursing and medical staff appear to diverge from best-practice evidence.

Comparative assessment of content overlap between written documentation and verbal communication: an observational study of resident sign-outs

Objective

Effective sign-outs involve verbal communication supported by written or electronic documentation. We investigated the clinical content overlap between sign-out documentation and face-to-face verbal sign-out communication.

Methods

We audio-recorded resident verbal sign-out communication and collected electronically completed ("written") sign-out documentation on 44 sign-outs in a General Medicine service. A content analysis framework with nine sign-out elements was used to qualitatively code both written and verbal sign-out content. A content overlap framework based on the comparative analysis between written and verbal sign-out content characterized how much written content was verbally communicated. Using this framework, we computed the full, partial, and no overlap between written and verbal content.

Results

We found high a high degree of full overlap on patient identifying information [name (present in 100% of sign-outs), age (96%), and gender (87%)], past medical history [hematology (100%), renal (100%), cardiology (79%), and GI (67%)], and tasks to-do (97%); lesser degree of overlap for active problems (46%), anticipatory guidance (46%), medications/treatments (15%), pending labs/studies/procedures (7%); and no overlap for code status (<1%), allergies (0%) and medical record number (0%).

Discussion and Conclusion

Three core functions of sign-outs are transfer of information, responsibility, and accountability. The overlap-highlighting what written content was communicated-characterizes how these functions manifest during sign-outs. Transfer of information varied with patient identifying information being explicitly communicated and remaining content being inconsistently communicated. Transfer of responsibility was explicit, with all pending and future tasks being communicated. Transfer of accountability was limited, with limited discussion of written contingency plans.

Use of methylene blue in hepatic arterial infusion pump resulting in serotonin syndrome. A case report

We report a case of a 35 year old woman with colon cancer metastatic to liver and lung who presented for exploratory laparotomy and/placement of hepatic arterial infusion pump for chemotherapy. Surgical course was notable for aberrant hepatic artery anatomy requiring extended dissection time, vascular surgery consultation, and use of substantial methylene blue to aid in visualization. Of note, patient's history was also significant for anxiety and depression, for which she was being treated with the selective serotonin reuptake inhibitor (SSRI) duloxetine (Cymbalta). The patient subsequently developed serotonin syndrome in the postoperative period but fully recovered. Our case highlights the need for close attention to methylene dosing recommendations and improved communication between perioperative care providers (surgery, anesthesia, nursing, and pharmacy) to prevent such occurrences.

Handoff Tool Enabling Standardized Transitions Between the Emergency Department and the Hospitalist Inpatient Service at a Major Cancer Center

Communication failures during patient handoff can lead to serious errors. A quality improvement team created a standardized handoff tool/process (DE-PASS: Decisive problem requiring admission, Evaluation time, Patient summary, Acute issues/action list, Situation unfinished/awareness, Signed out to) for admitting patients from the emergency department (ED) to the hospitalist inpatient service of a tertiary cancer center. DE-PASS mirrors the institution's ED workflow, stratifies patients as stable/urgent/emergent, and establishes requirements for verbal and email communications between providers. Comparison of preintervention and postintervention results from the 1-month pilot revealed that within a 24-hour period, DE-PASS reduced the number of intensive care unit transfers by 58% ( P = .393), the number of rapid-response team calls by 39% ( P = .637), and time to inpatient order by 31% ( P = .004). ED physicians' and hospitalists' satisfaction with DE-PASS increased. Reduction in intensive care unit transfers was sustained after the pilot ( P = .029). DE-PASS feasibility was evidenced by 100% uptake. By stratifying patients by risk level, DE-PASS reduced admission-to-evaluation times for unstable patients, potentially improving patient safety.

A Standardized Handoff Simulation Promotes Recovery From Auditory Distractions in Resident Physicians

INTRODUCTION

Despite the increasing use of training simulations to teach and assess resident handoffs, simulations that approximate realistic hospital conditions with distractions are lacking. This study explores the effects of a novel simulation-based training intervention on resident handoff performance in the face of prevalent hospital interruptions.

METHODS

After a preliminary educational module, entering postgraduate year 1 residents (interns) completed one of the following three handoff simulations: (1) no interruption, (2) hospital noise, or (3) noise and pager interruptions. Trained receivers rated interns using an evidence-based Handoff Behaviors Checklist and a previously validated Handoff Mini-Clinical Examination Exercise instrument.

RESULTS

Of 127 eligible interns, 125 (98.4%) completed an online preparatory module and a handoff simulation. Interns receiving auditory interruptions were less likely to be heard adequately (48.8% noise and 71.8% noise + pager vs. 100.0% uninterrupted, P < 0.001) and scored lower on establishing appropriate handoff settings (5.7 ± 2.3 noise and 6.2 ± 1.8 noise + pager vs. 8.0 ± 0.8 uninterrupted, P < 0.001). Interns receiving noise only shared a written sign-out document more effectively (71.1% vs. 30.2% uninterrupted and 43.6% noise + pager, P < 0.001). There were no differences in averaged performance metrics on the Handoff Behaviors Checklist.

DISCUSSION

While common hospital interruptions created nonideal circumstances for the handoff, interns receiving interruptions were rated similarly and recovered effectively. However, interns exposed to noise only used the written sign-out form more actively. Our findings suggest that this intervention was successful in promoting handoff proficiency despite exposure to common but significant hospital interruptions.

[Structured patient handovers in perioperative medicine : Rationale and implementation in clinical practice]

Clear and consistent communication is pivotal for well-functioning teamwork, in operating theatres as well as intensive care units. However, patient handovers significantly vary between specialties and locations. If communication is not well structured, it might increase the risk for mishaps and malpractice. Therefore, implementing structured handover protocols is pivotal. The perioperative setting is a high-risk environment that is prone to communication failures due to operational design (frequent change of shift due to working time restrictions) and a high work load and multitasking (operating room management, short surgery times, concurrent emergencies). Hence teamwork in the operating room and intensive care unit requires clear and consistent communication. In the perioperative setting, the patient is transferred several times: from the ward to operating room, to recovery, intermediate care/intensive care unit and back to normal ward. This necessitates multiple handovers. Since 2005, the World Health Organization (WHO) requests a structured handover concept that processes all relevant information in a predefined order. The SBAR concept (situation, background, assessment, recommendation) is an intuitive communication concept that can improve quality of patient handovers. This underlines the clinical relevance of a structured handover concept that leads to improved outcomes for every patient.In this review, basic measures for a clear and consistent communication are presented. These are pivotal for an effective teamwork and for ensuing patient safety. Furthermore, we will focus on possibilities to implement structured approaches but also on potential barriers of implementation. Communication failure among different health care providers can be identified more easily and hopefully can be eliminated.

Implementing standardized, inter-unit communication in an international setting: handoff of patients from emergency medicine to internal medicine

Standardized handoffs may reduce communication errors, but research on handoff in community and international settings is lacking. Our study at a community hospital in the United Arab Emirates characterizes existing handoff practices for admitted patients from emergency medicine (EM) to internal medicine (IM), develops a standardized handoff tool, and assesses its impact on communication and physician perceptions. EM physicians completed a survey regarding handoff practices and expectations. Trained observers utilized a checklist based on the Systems Engineering Initiative for Patient Safety model to observe 40 handoffs. EM and IM physicians collaboratively developed a written tool encouraging bedside handoff of admitted patients. After the intervention, surveys of EM physicians and 40 observations were subsequently repeated. 77.5% of initial observed handoffs occurred face-to-face, with 42.5% at bedside, and in four different languages. Most survey respondents considered face-to-face handoff ideal. Respondents noted 9-13 patients suffering harm due to handoff in the prior month. After handoff tool implementation, 97.5% of observed handoffs occurred face-to-face (versus 77.5%, p = 0.014), with 82.5% at bedside (versus 42.5%, p < 0.001), and all in English. Handoff was streamlined from 7 possible pathways to 3. Most post-intervention survey respondents reported improved workflow (77.8%) and safety (83.3%); none reported patient harm. Respondents and observers noted reduced inefficiency (p < 0.05). Our standardized tool increased face-to-face and bedside handoff, positively impacted workflow, and increased perceptions of safety by EM physicians in an international, non-academic setting. Our three-step approach can be applied towards developing standardized, context-specific inter-specialty handoff in a variety of settings.