"There is a chain of Chinese whispers ...": empirical data support the call to formally teach handover to prequalification doctors

Are weekend handovers of adequate quality for the on-call general medical team?

Weekend handover is vital for patient safety--poor handover is a cause of avoidable adverse events. This study evaluated whether the quality of information handed over for patients requiring weekend review was adequate. Two external doctors imagined themselves as the doctor on-call and judged whether the handed-over information was adequate for each case. Of the 1,130 handovers evaluated, 867 were handed over using a computerised proforma and discussed at the handover meeting, 148 using the computerised proforma but not discussed, 30 handovers were handwritten. Of handovers of patient details and background information, 87.3% were judged of adequate quality by the first auditor and 86.0% by the second. Similarly 70.6% and 75.8% of handovers of action plans were of adequate quality. Use of computerised proforma and discussion at a handover meeting gave the highest percentage of handovers of adequate quality, however, there was room for improvement. Training in handover may improve communication.

SHARING-improving and documentation of handover: mind the gap

The dangers of incomplete or inadequate handover as trainee doctors change shifts are all too apparent. This paper describes SHARING as a systematic method of transferring information and responsibility.

Educational interventions to improve handover in health care: a systematic review

CONTEXT

Effective handover within the health care setting is vital to patient safety. Despite published literature discussing strategies to improve handover, the extent to which educational interventions have been used and how such interventions relate to the published theoretical models of handover remain unclear. These issues were investigated through a systematic review of the literature.

METHODS

Any studies involving educational interventions to improve handover amongst undergraduate or postgraduate doctors or nurses were considered. A standardised search of online databases was carried out independently by both authors and consensus reached on the inclusion of studies. Data extraction and quality assessment were also completed independently, after which a content analysis of interventions was conducted and key themes extracted.

RESULTS

Ten studies met the inclusion criteria. Nine studies reported outcomes demonstrating improved attitudes or knowledge and skills, and one demonstrated transfer of skills to the workplace. Amongst the included studies, the strength of conclusions was variable. Poor reporting of interventions impeded replication. Analysis of available content revealed themes in three major areas: teamwork and leadership; professional responsibility with regard to error prevention, and information management systems. Methods used included exercises based on simulation and role-play, and group discussions or lectures focused on errors and patient safety.

CONCLUSIONS

There is a paucity of research describing educational interventions to improve handover and assessing their effectiveness. The quality of published studies is generally poor. Some evidence exists to demonstrate that skills can be transferred to the workplace, but none was found to demonstrate that interventions improve patient safety.

Doctors' Handovers in an Acute Medical Assessment Unit: A Hierarchical Task Analysis

Doctors' shift handovers have not been well documented, so handovers in an acute medical assessment unit (AMAU) were examined by conducting a hierarchical task analysis (HTA). To construct the HTA, activities doctors engaged in pre-handover, during handover, and post-handover were observed. Interviews and a focus group were also conducted to create the HTA. Findings showed that there are critical tasks that should be completed at each phase of the handover process. But these were sometimes omitted, especially in the pre-handover stage, resulting in extended or delayed handover meetings. Doctors believed that various safety nets were in place to catch any omitted information. Post-handover activities involved prioritizing tasks. However, doctors who had received handover believed that their period of responsibility and accountability for transferred patients was likely to be too short, and therefore expressed that prioritizing tasks for every patient was inefficient. Future research should examine handovers in the context of organizational resilience, and include other clinical staff that influence the information provided at handover.

Patient handoffs: standardized and reliable measurement tools remain elusive

BACKGROUND

Numerous quality improvement projects on patient handoffs have been conducted, yet standardized, reliable measurement tools remain elusive.

HANDOFF QUALITY MEASURES CLASSIFIED BY PRIMARY HANDOFF PURPOSE

The literature review, which yielded approximately 400 relevant articles, led to the identification of seven primary functions for patient handoffs, each of which implies different interventions to improve them: (1) Framing 1, information processing is the most prevalent in the patient handoff literature; (2) Framing 2, stereotypical narratives, emphasizes highlighting deviations from typical narratives, such as a patient who is allergic to the preferred antibiotic for treating his or her diagnosed condition; (3) Framing 3, resilience, takes advantage of the transparency of the thought processes revealed through the conversation to identify erroneous assumptions and actions; (4) Framing 4, accountability, emphasizes the transfer of responsibility and authority; (5) Framing 5, social interaction, considers the perspective of the participants in the exchange; (6) Framing 6, distributed cognition, addresses how a transfer to a new care provider affects a network of specialized practitioners performing dedicated roles who may or may not be transitioning at the same time; (7) Framing 7, cultural norms, relates to how group values (instantiated as social norms for acceptable behavior) in an organization or suborganization are negotiated and maintained over time.

DISCUSSION

The diversity of handoff measurement approaches suggests a lack of consensus about the primary purpose of a handoff, as well as about what interventions are most promising for improving handoff processes. Recognizing that there are simultaneously multiple purposes for handoffs is a critical precursor to quality improvement.

Care coordination in intensive care units: communicating across information spaces

OBJECTIVE

This study explores the interactions among phases of team coordination, patient-related information, decision-making levels, and role holders in intensive care units (ICUs).

BACKGROUND

The effects of communication improvement initiatives on adverse patient events or improved outcomes have been difficult to establish. Conceptual inconsistencies and methodological shortcomings suggest insufficient understanding about clinical communication and care coordination.

METHOD

Data were collected by shadowing a charge nurse, fellow, resident, and nurse in each of eight ICUs and recording each of their conversations during 12 hrs (32 role holders during 350 hrs).

RESULTS

Hierarchical log linear analyses show statistically significant three-way interactions between the patient information, phases of team coordination, and decision levels, chi2(df = 75) = 212, p < .0001; between roles, phases of team coordination, and decision levels, chi2(df = 60) = 109, p < .0001; and between roles, patient information, and decision levels, chi2(df = 60) = 155, p < .0001. Differences among levels of the variables were evaluated with the use of standardized parameter estimates and 95% confidence intervals.

CONCLUSION

ICU communication and care coordination involve complex decision structures and role interactions across two information spaces. Different role holders mediate vertical and lateral process flows with goals and directions representing an important conceptual transition. However, lateral isolation within decision levels (charge nurses) and information overload (residents) are potential communication and care coordination vulnerabilities. Results are consistent with and extend the findings of previous studies.

APPLICATION

The profile of ICU communication and care coordination provides a systemic framework that may inform future interventions and research.