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

Training on handover of patient care within UK medical schools

BACKGROUND

Much evidence exists to demonstrate that poor handover can directly impact patient safety. There have been calls for formal education on handover, but evidence to guide intervention design and implementation is limited. It is unclear how undergraduate medical schools are tackling this issue and what barrier or facilitators exist to handover education. We set out to determine curriculum objectives, teaching and assessment methods, as well as institutional attitudes towards handover within UK medical schools.

METHODS

A descriptive, non-experimental, cross-sectional study design was used. A locally developed online questionnaire survey was sent to all UK Medical Schools, after piloting. Descriptive statistics were calculated for closed-ended responses, and free text responses were analysed using a grounded theory approach, with constant comparison taking place through several stages of analysis.

RESULTS

Fifty percent of UK medical schools took part in the study. Nine schools (56%) reported having curriculum outcomes for handover. Significant variations in the teaching and assessments employed were found. Qualitative analysis yielded four key themes: the importance of handover as an education issue, when to educate on handover, the need for further provision of teaching and the need for validated assessment tools to support handover education.

CONCLUSIONS

Whilst undergraduate medical schools recognised handover as an important education issue, they do not feel they should have the ultimate responsibility for training in this area and as such are responding in varying ways. Undergraduate medical educators should seek to reach consensus as to the extent of provision they will offer. Weaknesses in the literature regarding how to design such education have exacerbated the problem, but the contemporaneous and growing published evidence base should be employed by educators to address this issue.

Development of a structured year-end sign-out program in an outpatient continuity practice

BACKGROUND

In an effort to prevent medical errors, it has been recommended that all healthcare organizations implement a standardized approach to communicating patient information during transitions of care between providers. Most research on these transitions has been conducted in the inpatient setting, with relatively few studies conducted in the outpatient setting.

OBJECTIVES

To develop a structured transfer of care program in an academic outpatient continuity practice and evaluate whether this program improved patient safety as measured by the documented completion of patient care tasks at 3 months post-transition.

DESIGN

Graduating residents and the corresponding incoming interns inheriting their continuity patient panels were randomized to the pilot structured transfer group or the standard transfer group. The structured transfer group residents were asked to complete written and verbal sign-outs with their interns; the standard transfer group residents continued the current standard of care.

PARTICIPANTS

Thirty-two resident-intern pairs in an academic internal medicine residency program in New York City.

MAIN MEASURES

Three months after the transition, study investigators evaluated whether patient care tasks assigned by the graduating residents had been successfully completed by the interns in both groups. In addition, follow-up appointments, continuity of care and house officer satisfaction with the sign-out process were evaluated.

KEY RESULTS

Among patients seen during the first 3 months, the clinical care tasks were more likely to be completed by interns in the structured group (73 %, n = 49) versus the standard group (46 %, n = 28) (adjusted OR 3.21; 95 % CI 1.55-6.62; p = 0.002). This was further enhanced if the intern who saw the patient was also the assigned primary care provider (adjusted OR 4.26; 95 % CI 1.7-10.63; p = 0.002).

CONCLUSIONS

A structured outpatient sign-out improved the odds of follow-up of important clinical care tasks after the year-end resident clinic transition. Further efforts should be made to improve residents' competency with regard to sign-outs in the ambulatory setting.

Effect of surgery resident change of shift on trauma resuscitations and outcomes

INTRODUCTION

The ability of surgery residents to provide continuity of care has come under scrutiny with work hour restrictions. The impact of the surgery resident sign-out period (6-8am and 6-8pm) on trauma outcomes remains unknown. We hypothesize that during shift change, resuscitation times are prolonged with worse outcomes.

METHODS

Records of patients treated at a university-based urban trauma center during 2008 and 2009 were reviewed. Patients were separated into a shift change group (6-8am and 6-8pm) and a control group of all other time periods and compared using ANOVA, chi square, and unpaired t-tests.

RESULTS

We reviewed the charts of 4361 consecutive trauma patients. There was no difference in gender, acuity, resuscitation times, Glasgow Coma Scale, revised trauma score, injury severity score (ISS), or probability of survival score between patients arriving during shift change compared to other times (p>0.2). There was no difference in total emergency department time for patients arriving during shift change (p = 0.07), even when stratified by ISS (ISS<15, p = 0.09; ISS>15, p = 0.2). Length of stay was increased for patients arriving during shift change compared to other times (5 vs 4 days, p<0.05). This was more pronounced for those with ISS>15 (16 vs 11 days, p = 0.03); however, there was no impact on intensive care unit length of stay, ventilator days, and mortality (p>0.3) regardless of ISS.

CONCLUSIONS

Trauma outcomes are generally unaffected by patient arrival during shift change when resident sign-outs occur. Although adaptations are being made to accommodate trauma patient arrival during these times, we need to continue paying close attention, especially to seriously injured patients, to ensure that there are no delays in care that may potentially affect patient outcomes.

Last chance to observe: assessing residency preparedness following the 4th-year subinternship

BACKGROUND

The subinternship is an integral part of the 4th year of medical school. There is little description of innovations aimed at assessing the preparedness and confidence of graduating students as they move on the next step in their training.

DESCRIPTION

An innovation including an Objective Structured Clinical Examination (OSCE) at the conclusion of the subinternship was designed. We focused on key themes of transitions of care, communication within the health care system, and communication with patients and providers.

EVALUATION

A pre- and postsurvey addressed student self-perceived skill, confidence, and overall perception of importance. Improvement (p<.05) was seen across all themes from pre- to postsurvey, with more favorable scores on the postsurvey.

CONCLUSIONS

A subinternship innovation including an OSCE was feasible and had a positive effect on student assessment, perception and confidence. As the landscape of medical education evolves, assessing students' preparedness for residency will become increasingly imperative.

Human factors in clinical handover: development and testing of a 'handover performance tool' for doctors' shift handovers

OBJECTIVE

To develop and test a handover performance tool (HPT) able to help clinicians to systematically assess the quality and safety of shift handovers.

DESIGN

The study used a mixed methods approach. In the development phase of the tool, a review of the literature and a Delphi process were conducted to sample five generic non-technical skills: communication, teamwork, leadership, situation awareness and task management. Validity and reliability of the HPT were evaluated through direct observation and during simulated handover video sessions.

SETTING

This study was conducted in the Paediatrics, Obstetrics and Gynaecology wards of a UK district hospital.

PARTICIPANTS

Thirty human factor experts participated in the development phase; 62 doctors from various disciplines were asked to validate the tool.

MAIN OUTCOME MEASURES

Item development, HPT validity and reliability.

RESULTS

The tool developed consisted of 25 items. Communication, teamwork and situation awareness explained, respectively, 55.5, 47.2 and 39.6% of the variance in doctors rating of quality. Internal consistency and inter-rater reliability of the HPT were good (Cronbach's alpha = 0.77 and intra-class correlation = 0.817).

CONCLUSIONS

Communication determined the majority of handover quality. Teamwork and situation awareness also provided an independent contribution to the overall quality rating. The HPT has demonstrated good validity and reliability providing evidence that it can be easily used by raters with different backgrounds and in several clinical settings. The HPT could be utilized to assess doctors' handover quality systematically, as well as teaching tool in medical schools or in continuing professional development programmes for self-reflective practice.

Do mood and the receipt of work-based support influence nurse perceived quality of care delivery? A behavioural diary study

AIMS AND OBJECTIVES

To examine the effect of nurse mood in the worst event of shift (negative affect, positive affect), receipt of work-based support from managers and colleagues, colleague and patient involvement on perceived quality of care delivery.

BACKGROUND

While the effect of the work environment on nurse mood is well documented, little is known about the effects of the worst event of shift on the quality of care delivered by nurses.

DESIGN

This behavioural diary study employed a within-subject and between-subject designs incorporating both cross-sectional and longitudinal elements.

METHODS

One hundred and seventy-one nurses in four large district general hospitals in England completed end-of-shift computerised behavioural diaries over three shifts to explore the effects of the worst clinical incident of shift. Diaries measured negative affect, positive affect, colleague involvement, receipt of work-based support and perceived quality of care delivery. Analysis used multilevel modelling (MLWIN 2.19; Centre for Multi-level Modelling, University of Bristol, Bristol, UK).

RESULTS

High levels of negative affect and low levels of positive affect reported in the worst clinical incident of shift were associated with reduced perceived quality of care delivery. Receipt of managerial support and its interaction with negative affect had no relationship with perceived quality of care delivery. Perceived quality of care delivery deteriorated the most when the nurse reported a combination of high negative affect and no receipt of colleague support in the worst clinical incident of shift. Perceived quality of care delivery was also particularly influenced when the nurse reported low positive affect and colleague actions contributed to the problem.

CONCLUSIONS

Receipt of colleague support is particularly salient in protecting perceived quality of care delivery, especially if the nurse also reports high levels of negative affect in the worst event of shift.

RELEVANCE TO CLINICAL PRACTICE

The effect of work-based support on care delivery is complex and requires further investigation.

Ensuring patient safety in care transitions: an empirical evaluation of a Handoff Intervention Tool

Successful handoffs ensure smooth, efficient and safe patient care transitions. Tools and systems designed for standardization of clinician handoffs often focuses on ensuring the communication activity during transitions, with limited support for preparatory activities such as information seeking and organization. We designed and evaluated a Handoff Intervention Tool (HAND-IT) based on a checklist-inspired, body system format allowing structured information organization, and a problem-case narrative format allowing temporal description of patient care events. Based on a pre-post prospective study using a multi-method analysis we evaluated the effectiveness of HAND-IT as a documentation tool. We found that the use of HAND-IT led to fewer transition breakdowns, greater tool resilience, and likely led to better learning outcomes for less-experienced clinicians when compared to the current tool. We discuss the implications of our results for improving patient safety with a continuity of care-based approach.

Taking a detour: positive and negative effects of supervisors' interruptions during admission case review discussions

PURPOSE

During admission case review, teams work to develop a shared understanding of the problems they need to address during the patient's hospitalization. However, research on the effects of the case review on patient care is limited. Informed by rhetorical genre theory, the authors explored the impact of team's communication practices on the comprehensiveness of the case review.

METHOD

Using a multiple-case-study approach, the authors in 2010 observed in person, audio-recorded, and transcribed data from overnight and morning case review discussions for 19 patient cases in the internal medicine department of an academic medical center. They also extracted data from the corresponding admission notes. They used a constant-comparison approach to identify emerging themes within and across cases.

RESULTS

The authors identified detours, which typically arose from supervisors' interruptions, in all 19 cases. They identified five detour types: pausing the presentation, referring to a section later in the presentation, presenting sections out of sequence, skipping a section, and truncating the presentation. Although supervisors' interruptions during case review discussions allowed for teaching and patient care, they also created detours from the usual case presentation, which then could lead to the omission of relevant case details.

CONCLUSIONS

Supervisors' interruptions during case review discussions can lead to detours, which simultaneously afford valuable opportunities for teaching and threaten comprehensive information sharing. Future research should explore detours in other teaching settings to better understand their positive, negative, and unintended consequences for patient care.

Improving interunit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach

Patient care transitions across specialties involve more complexity than those within the same specialty, yet the unique social and technical features remain underexplored. Further, little consensus exists among researchers and practitioners about strategies to improve interspecialty communication. This concept article addresses these gaps by focusing on the hand-off process between emergency and hospital medicine physicians. Sensitivity to cultural and operational differences and a common set of expectations pertaining to hand-off content will more effectively prepare the next provider to act safely and efficiently when caring for the patient. Through a consensus decision-making process of experienced and published authorities in health care transitions, including physicians in both specialties as well as in communication studies, the authors propose content and style principles clinicians may use to improve transition communication. With representation from both community and academic settings, similarities and differences between emergency medicine and internal medicine are highlighted to heighten appreciation of the values, attitudes, and goals of each specialty, particularly pertaining to communication. The authors also examine different communication media, social and cultural behaviors, and tools that practitioners use to share patient care information. Quality measures are proposed within the structure, process, and outcome framework for institutions seeking to evaluate and monitor improvement strategies in hand-off performance. Validation studies to determine if these suggested improvements in transition communication will result in improved patient outcomes will be necessary. By exploring the dynamics of transition communication between specialties and suggesting best practices, the authors hope to strengthen hand-off skills and contribute to improved continuity of care.

An intervention to improve ambulatory care handoffs at the end of residency

INTRODUCTION

The medical literature shows evidence of numerous initiatives to improve inpatient physician handoffs. In contrast, handoffs of ambulatory patients to incoming interns or junior residents at the end of residency are an area of potential concern that has been overlooked.

OBJECTIVES

To examine handoffs of high-risk ambulatory patients by outgoing residents to junior colleagues and to compare current practice to a standard handoff process. We hypothesized the intervention would lead to increases in the number and quality of ambulatory care handoffs.

METHODS

Fourteen graduating internal medicine and combined internal medicine-pediatrics residents who practiced at an academic continuity clinic were randomized to an intervention or a control group. E-mail instructions were sent asking the intervention group to write a handoff note using the clinic's electronic medical record system. The e-mail included a detailed outline of information to incorporate and highlight features of the electronic medical record that would facilitate the process. The handoff notes of the intervention and control group were independently evaluated and scored for quality using a predetermined point system.

RESULTS

Six of the 7 residents (86%) in the intervention group completed 19 handoff notes; none of the residents in the control group completed handoff notes. Most of the handoffs provided a brief paragraph or 2 of background information on the patient and then focused on issues needing short-term follow-up during the coming months.

CONCLUSIONS

The standardized handoff process implemented via simple e-mail instructions increased the number of outpatient handoffs at the completion of residency. Further study with a larger number of residents, identification and removal of barriers to the handoff process, and correlation of handoffs to clinical outcomes are key next steps.

Factors that impact on the safety of patient handovers: an interview study

AIMS

Improvement of clinical handover is fundamental to meet the challenges of patient safety. The primary aim of this interview study is to explore healthcare professionals' attitudes and experiences with critical episodes in patient handover in order to elucidate factors that impact on handover from ambulance to hospitals and within and between hospitals. The secondary aim is to identify possible solutions to optimise handovers, defined as "situations where the professional responsibility for some or all aspects of a patient's diagnosis, treatment or care is transferred to another person on a temporary or permanent basis".

METHODS

We conducted 47 semi-structured single-person interviews in a large university hospital in the Capital Region in Denmark in 2008 and 2009 to obtain a comprehensive picture of clinicians' perceptions of self-experienced critical episodes in handovers. We included different types of handover processes that take place within several specialties. A total of 23 nurses, three nurse assistants, 13 physicians, five paramedics, two orderlies, and one radiographer from different departments and units were interviewed.

RESULTS

We found eight central factors to have an impact on patient safety in handover situations: communication, information, organisation, infrastructure, professionalism, responsibility, team awareness, and culture.

CONCLUSIONS

The eight factors identified indicate that handovers are complex situations. The organisation did not see patient handover as a critical safety point of hospitalisation, revealing that the safety culture in regard to handover was immature. Work was done in silos and many of the handover barriers were seen to be related to the fact that only few had a full picture of a patient's complete pathway.

Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training

The medical education community's conversations about residents' duty hours have long focused solely on the number of those hours. In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) enacted its most recent iteration of standards regarding duty hours. Those standards, as well as a 2008 Institute of Medicine report, look beyond the quantity of duty hours to address their quality as well. Indeed, the majority of the 2011 ACGME standards specify requirements for the qualitative components of residents' working and learning environments, including supervision of residents; professionalism, personal responsibility, and patient safety; transitions of care; and clinical responsibilities (including workload). The authors believe that focusing on these qualitative (rather than quantitative) components of the resident's working and learning environment provides the greatest promise for balancing patient care with resident education, thus optimizing the safety and effectiveness of both. For each of the four qualitative components that the authors discuss (enhancing supervision, nurturing professionalism and personal responsibility, ensuring safe transitions of care, and optimizing workloads and cognitive loads), they offer agendas for faculty development, educational program planning, and research. Thus, the authors call on the medical education community to expand its discussion beyond counting duty hours to focus on these critical issues that ensure quality resident education and patient care and to implement necessary strategies to address them.

Evaluation of medical consultation letters at King Fahd Hospital, Al Hufuf, Saudi Arabia

BACKGROUND

In surgical wards, it is of paramount importance to communicate with other health care providers, mostly physicians, referring patients to them for their consultation on any health conditions that affect pre-operative, operative and post-operative patient care. The purposes of this investigation were to assess the appropriateness of physician responses in medical consultation reports and compare physician responses when using these reports from different levels of health care providers.

METHODS

This study was conducted in Al-Hufuf, Saudi Arabia. The researchers evaluated all the surgical consultation letters in the files during the period between March 2010 and March 2011. From the explored 234 files, only 200 consultation letters were chosen as there was a referral data plus consultation data in the same file. We evaluated the quality of consultation report included the ethical concerns towards colleagues and patient, consideration of patient safety in all opinions, comprehensive pertinent scientific information, addressing the patient's medical condition with putting possible differential diagnosis, conclusion and precise management plans suggested.

RESULTS

The results showed that the specialists' consultation letters had the highest percentage of fulfillment of all the six items in the consultation report. There is no uniform existing consultation report form.

CONCLUSION

Specialist form showed the highest number of mentioning the diagnosis. Consultant form showed the highest number of mentioning the concise aim of referral. The highest percentage of all categories mentioned all items in consultation report with a good level were the specialists.

Validation of a handoff assessment tool: the Handoff CEX

AIMS AND OBJECTIVES

Test the feasibility and validity of a handoff evaluation tool for nurses.

BACKGROUND

No validated tools exist to assess the quality of handoff communication during change of shift.

DESIGN

Prospective cohort study.

METHODS

A standardised tool, the Handoff CEX, was developed based on the mini-CEX. The tool consisted of seven domains scored on a 1-9 scale. Nurse educators observed shift-to-shift handoff reports among nurses and evaluated both the provider and recipient of the report. Nurses participating in the report simultaneously evaluated each other as part of their handoff.

RESULTS

Ninety-eight evaluations were obtained from 25 reports. Scores ranged from 3-9 in all domains except communication and setting (4-9). Experienced (>five years) nurses received significantly higher mean scores than inexperienced (≤ five years) nurses in all domains except setting and professionalism. Mean overall score for experienced nurses was 7·9 vs 6·9 for inexperienced nurses. External observers gave significantly lower scores than peer evaluators in all domains except setting. Mean overall score by external observers was 7·1 vs. 8·1 by peer evaluators. Participants were very satisfied with the evaluation (mean score 8·1).

CONCLUSIONS

A brief, structured handoff evaluation tool was designed that was well-received by participants, was felt to be easy to use without training, provided data about a wide range of communication competencies and discriminated well between experienced and inexperienced clinicians. Relevance to clinical practice.  This tool may be useful for educators, supervisors and practicing nurses to provide training, ongoing assessment and feedback to improve the quality of handoff.

Effects of education on interns' verbal and electronic handoff documentation skills

BACKGROUND

Improving handoff communications is a National Patient Safety Goal. Interns and residents are rarely taught how to safely handoff their patients. Our objective was to determine whether teaching safe handoff principles would improve handoff quality.

METHODS

Our study was conducted on the inpatient services at 2 teaching hospitals. In this single-institution, randomized controlled trial, internal medicine interns (N  =  44) and residents (N  =  24) participated in a 45-minute educational session on safe handoff communication skills. Residents received additional education on effective feedback practices and were asked to provide each intern with structured feedback. Quality of interns' electronic and verbal handoffs was measured by using a Handoff Evaluation Tool created by the authors. The frequency of handoff communication failures was also assessed through semistructured phone interviews of postcall interns.

RESULTS

Interns who received handoff education demonstrated superior verbal handoff skills than control interns (P < .001), while no difference was seen in electronic handoff skills. Communication failures related to code status (P < .001) and overnight tasks (P < .050) were less frequent in the intervention group.

CONCLUSIONS

Interns' electronic handoff documentation skills did not improve with the intervention. This may reflect greater difficulty in changing physicians' electronic documentation habits.

Bridging the gap between problem recognition and treatment: the use of proactive work behaviors by experienced critical care nurses

Delayed access to physicians has been identified as a factor in preventable adverse patient events during hospitalization. Nurses as front-line providers are well positioned to provide a timely response to the needs of patients. Yet legal regulations and hospital policies limit the actions nurses can initiate without physician authorization. The purpose of this qualitative study was to describe what experienced critical care nurses do when they recognize a problem that warrants treatment but lack physician authorization to intervene. The 13 nurses who participated in this study bridged the gap between problem recognition and treatment by communicating proactively, being persistent, running interference for other nurses, and, in some situations, acting without physician authorization. Revising legal regulations and hospital policies to incorporate greater acknowledgment of the overlapping functions between medicine and nursing and recognition of the knowledge and expertise of experienced nurses may be important in reducing unnecessary treatment delays during hospitalization.

Can we make postoperative patient handovers safer? A systematic review of the literature

Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.

The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care

In 2010, the Accreditation Council for Graduate Medical Education released its resident duty hours restrictions, requiring that faculty monitor their residents' patient handoffs to ensure that residents are competent in handoff communications. Although studies have reported the need to improve the effectiveness of the handoff and a variety of curricula have been suggested and implemented, a common method for teaching and evaluating handoff skills has not been developed. Also in 2010, engineers, informaticians, and physicians interested in patient handoffs attended a symposium in Savannah, Georgia, hosted by the Association for Computing Machinery, entitled Handovers and Handoffs: Collaborating in Turns. As a result of this symposium, a workgroup formed to develop practical and readily implementable educational materials for medical educators involved in teaching patient handoffs to residents. In this article, the result of that yearlong collaboration, the authors aim to provide clarity on the definition of the patient handoff, to review the barriers to performing effective handoffs in academic health centers, to identify available solutions to improve handoffs, and to provide a structured approach to educating residents on handoffs via a curricular blueprint. The authors' blueprint was developed to guide educators in customizing handoff education programs to fit their specific, local needs. Hopefully, it also will provide a starting point for future research into improving the patient handoff. Increasingly complex patient care environments require both innovations in handoff education and improvements in patient care systems to improve continuity of care.

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements

With changes in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements related to transitions in care effective July 1, 2011, sponsoring institutions and training programs must develop a common structure for transitions in care as well as comprehensive curricula to teach and evaluate patient handoffs. In response to these changes, within the Duke University Health System, the resident-led Graduate Medical Education Patient Safety and Quality Council performed a focused review of the handoffs literature and developed a plan for comprehensive handoff education and evaluation for residents and fellows at Duke. The authors present the results of their focused review, concentrating on the three areas of new ACGME expectations--structure, education, and evaluation--and describe how their findings informed the broader initiative to comprehensively address transitions in care managed by residents and fellows. The process of developing both institution-level and program-level initiatives is reviewed, including the development of an interdisciplinary minimal data set for handoff core content, training and education programs, and an evaluation strategy. The authors believe the final plan fully addresses both Duke's internal goals and the revised ACGME Common Program Requirements and may serve as a model for other institutions to comprehensively address transitions in care and to incorporate resident and fellow leadership into a broad, health-system-level quality improvement initiative.

Does clinical incident seriousness and receipt of work-based support influence mood experienced by nurses at work? A behavioural diary study

BACKGROUND

While the relationship between general perceptions of the work environment and negative mood is well detailed, little is known about the effect of specific clinical incident characteristics on the mood experienced at work by nurses. This study examines the effect of incident seriousness and receipt of work-based support in the worst event of a shift from managers and colleagues on the Negative and Positive Affect experienced by nurses at work.

METHODS

We approached the total cohort of medical and surgical nurses in 4 large district general hospitals in England, 17% volunteered. Some 171 nurses filled end of shift and standard entry (every 90 min) computerised behavioural diaries over three consecutive shifts. The diaries measured Incident Seriousness, Receipt of Managerial and Co-worker Support, Negative Affect and Positive Affect. Results were analysed using multilevel modelling (MLwiN 2.19).

FINDINGS

Following the worst clinical incident of a shift, nurses reported higher Negative Affect (β=1.28, [95%CI: 0.12, 2.45], z=2.17, p<.05) and lower Positive Affect (β=-2.39, [95%CI: -3.96, -0.82], z=2.99, p<.005) which persisted for the remainder of the shift. Most critically, Negative Affect was more elevated after serious incidents (β=0.07, [95%CI: 0.04, 0.10], z=3.5, p<.005). Nurses who reported Receipt of Managerial Support following an incident reported significantly lower levels of Positive Affect compared to those reporting no such contact (β=-5.30, [95%CI: -9.51, -1.09], z=2.47, p<.05). The interaction between Incident and the Receipt of Work-Based Support on NA was not significant (β=2.34 [95%CI: -0.82, 3.95], z=1.45, p>.05). Receipt of Colleague Support had no relationship with Negative Affect or Positive Affect. Free text reports mainly revealed the negative impact of managerial support, although there were instances of contact with managers which were sought following exposure to difficult clinical situations.

DISCUSSION

Serious clinical incidents have enduring effects on Negative Affect and Positive Affect for the remainder of the shift. Nurse Positive Affect was significantly worse following the worst clinical incident of shift when managerial support was received. Further research is required to determine the positive and negative effects of managerial support on the mood experienced by nurses at work.

Narrative, written sign-outs and interns' and senior medical students' confidence: a randomized, controlled crossover trial

BACKGROUND

Failures of communication during the transfer of patient care errors.

METHODS

We created a new format for written sign-out material, based on aviation industry practice and cognitive psychology theory, designed to improve interns' and senior medical students' communication during transfers of patient care responsibility. We carried out a randomized, blinded, crossover trial, comparing a new, narrative, written sign-out report to a usual written sign-out. Thirty-two interns and fourth-year medical students rated their confidence across various clinical tasks and answered clinical questions regarding hypothetical patients presented to them in written, new, narrative sign-out compared with the customary format.

RESULTS

There was no statistical difference in confidence when interns and senior medical students received usual versus narrative sign-outs.

CONCLUSIONS

Although a limited measure suggested some improvement in competence, the narrative format did not improve participants' self-rated confidence during patient-care transfer.

[Medical handovers in ICU: a snapshot of practice in the South West of France]

INTRODUCTION

Medical handover is critical for quality of care in ICU. Time assigned to medical handovers can vary across different units, with significant impact on the organization of medical work. We aimed to study the time spent for medical handover in ICU and its variation across academic, general and private hospitals in the area of the South West of France, the Midi-Pyrénées region.

METHODS

Between August and October 2010, we questioned by phone, 86 physicians issued from 19 different ICUs. This prospective observational study mainly focused on four items: unit's characteristics, health diaries organization, medical handovers procedures, and self-assessment of satisfaction for medical handover (numeric scale from 0 to 10).

RESULTS

Eleven general hospital centers, three private hospitals, five university hospitals were concerned by the survey. The mean time spent for medical handover was 59±35 min on monday morning, significantly longer than other days, evening, and to weekend handovers (P<0.001 for all comparisons). When reporting it to the number of ICU bed, the time spent for handover per patient was significantly shorter in private hospital compared to general and academic hospital (P<0.05 for all comparison).

CONCLUSION

Time spent for medical handover is important, with an approximate total time of 1h 30 min on monday, and 1h the other days. Physician in private hospitals spend less time for medical handovers. This fact should be considered for medical timework organization, especially in academic hospital and in hospital with large ICU.

Handover patterns: an observational study of critical care physicians

BACKGROUND

Handover (or 'handoff') is the exchange of information between health professionals that accompanies the transfer of patient care. This process can result in adverse events. Handover 'best practices', with emphasis on standardization, have been widely promoted. However, these recommendations are based mostly on expert opinion and research on medical trainees. By examining handover communication of experienced physicians, we aim to inform future research, education and quality improvement. Thus, our objective is to describe handover communication patterns used by attending critical care physicians in an academic centre and to compare them with currently popular, standardized schemes for handover communication.

METHODS

Prospective, observational study using video recording in an academic intensive care unit in Ontario, Canada. Forty individual patient handovers were randomly selected out of 10 end-of-week handover sessions of attending physicians. Two coders independently reviewed handover transcripts documenting elements of three communication schemes: SBAR (Situation, Background, Assessment, Recommendations); SOAP (Subjective, Objective, Assessment, Plan); and a standard medical admission note. Frequency and extent of questions asked by incoming physicians were measured as well. Analysis consisted of descriptive statistics.

RESULTS

Mean (± standard deviation) duration of patient-specific handovers was 2 min 58 sec (± 57 sec). The majority of handovers' content consisted of recent and current patient status. The remainder included physicians' interpretations and advice. Questions posed by the incoming physicians accounted for 5.8% (± 3.9%) of the handovers' content. Elements of all three standardized communication schemes appeared repeatedly throughout the handover dialogs with no consistent pattern. For example, blocks of SOAP's Assessment appeared 5.2 (± 3.0) times in patient handovers; they followed Objective blocks in only 45.9% of the opportunities and preceded Plan in just 21.8%. Certain communication elements were occasionally absent. For example, SBAR's Recommendation and admission note information about the patient's Past Medical History were absent from 22 (55.0%) and 20 (50.0%), respectively, of patient handovers.

CONCLUSIONS

Clinical handover practice of faculty-level critical care physicians did not conform to any of the three predefined structuring schemes. Further research is needed to examine whether alternative approaches to handover communication can be identified and to identify features of high-quality handover communication.

E-learning and deliberate practice for oral case presentation skills: a randomized trial

BACKGROUND

Oral case presentations are critical for patient care and student assessment. The best method to prepare early medical students for oral presentations is unknown.

AIM

We aimed to develop and evaluate a curriculum of on-line learning and deliberate practice to improve pre-clinical students' case presentation skills.

METHODS

We developed a web-based, interactive curriculum emphasizing conciseness and clinical reasoning. Using a waitlist control design, we randomly assigned groups of second-year students to receive the curriculum in December 2010 or in April 2011. We evaluated their presentations at three time points. We also examined the performance of an untrained class of students as a historical comparison.

RESULTS

We evaluated 132 second-year medical students at three time points. After the curriculum, mean scores of the intervention students improved from 60.2% to 70.1%, while scores of the waitlist control students improved less, from 61.8% to 64.5% (p < 0.01 for between-group difference in improvement). Once all students had received the curriculum, mean scores for the intervention and waitlist control students rose to 77.8% and 78.4%, respectively, compared to 68.1% for the untrained comparison students (p < 0.0001 compared to all curriculum students).

CONCLUSION

An on-line curriculum followed by deliberate practice improved students' oral presentation skills.

Evaluation of patient handoff methods on an inpatient teaching service

BACKGROUND

The patient handoff process can be a highly variable and unstructured period at risk for communication errors. The morning sign-in process used by resident physicians at teaching hospitals typically involves less rigorous handoff protocols than the resident evening sign-out process. Little research has been conducted on best practices for handoffs during morning sign-in exchanges between resident physicians. Research must evaluate optimal protocols for the resident morning sign-in process.

METHODS

Three morning handoff protocols consisting of written, electronic, and face-to-face methods were implemented over 3 study phases during an academic year. Study participants included all interns covering the internal medicine inpatient teaching service at a tertiary hospital. Study measures entailed intern survey-based interviews analyzed for failures in handoff protocols with or without missed pertinent information. Descriptive and comparative analyses examined study phase differences.

RESULTS

A scheduled face-to-face handoff process had the fewest protocol deviations and demonstrated best communication of essential patient care information between cross-covering teams compared to written and electronic sign-in protocols.

CONCLUSION

Intern patient handoffs were more reliable when the sign-in protocol included scheduled face-to-face meetings. This method provided the best communication of patient care information and allowed for open exchanges of information.

Socio-Technical Systems Analysis in Health Care: A Research Agenda

Given the complexity of health care and the 'people' nature of healthcare work and delivery, STSA (Sociotechnical Systems Analysis) research is needed to address the numerous quality of care problems observed across the world. This paper describes open STSA research areas, including workload management, physical, cognitive and macroergonomic issues of medical devices and health information technologies, STSA in transitions of care, STSA of patient-centered care, risk management and patient safety management, resilience, and feedback loops between event detection, reporting and analysis and system redesign.

Restructuring an inpatient resident service to improve outcomes for residents, students, and patients

PURPOSE

This study assesses the effects of a resident teaching service restructuring on resident, student, and patient outcomes.

METHOD

Interventions included eliminating a "day float" admitting team, converting one-resident:one-intern teams to one-resident:two-intern teams, reducing patient caps from 11 to 7 patients per intern, and increasing pairing between resident teams and attendings. Resident end-of-rotation evaluations and time spent in categorized activities; student end-of-clerkship evaluations, patient logs, and subject exam scores; and hospital-collected patient outcome data were compared before (2007-2008) versus after (2008-2009) the changes.

RESULTS

Interns covered fewer patients per day post intervention (9.9 apiece to 6.3 apiece), whereas the total number of patients covered increased (2,501 to 2,916). Enjoyment of the rotation was higher post intervention for interns and senior residents. Residents' time in direct patient care activities and with interns increased post intervention, but residents spent less time with medical students. Students' ratings of several aspects of the clerkship were significantly higher in the postintervention year. Students evaluated more previously unevaluated patients post intervention (32.6% to 45.8%, P < .001), but subject exam scores were unchanged. The median length of stay decreased post intervention (5.0 to 4.0 days, P = .02), and fewer patients required ICU care (11.2% to 7.9%, P < .001). These differences persisted after adjusting for multiple covariates.

CONCLUSIONS

An intervention that reduced handoffs and intern patient census and that increased hospitalist pairing was associated with improved resident and student experiences, a favorable impact on patient outcomes, and probable cost savings.

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.

Handing over patient care: is it just the old broken telephone game?

BACKGROUND

Handing over patient care remains a poorly understood process and remains a leading cause of medical error. We sought to examine how hand off delivery methods affect hand off quality and whether improvement would occur over time without formal training.

DESIGN

Three simulated-patient hand offs were developed; each with a distinct delivery method: in-person (IP), video-based (VB), and screen-based (SB). Participants were evaluated up to 4 times, each 6 months apart. During evaluations, residents received the 3 hand offs, answered a sleep and preference questionnaire, and proceeded to hand off the same 3 patients. Sessions were video-reviewed and hand offs scored for quality measures: word accuracy, errors of omission or commission, and appropriateness of clinical judgment. Quality measures among delivery methods and changes over time were compared.

RESULTS

Sixty-eight General Surgery residents (postgraduate year [PGY] 1-2) participated in at least 2 testing sessions, with 13 participating in 4. The IP method was superior to VB and SB for most hand off quality measures (each p < 0.001). With repeated testing, hand off quality measures improved (p < 0.001). However, patient hand offs continued to remain non-optimal, with appropriate judgment present in only 47%-77% of the hand offs. Sleep hours (mean 5 ± 2) were not found to be associated with hand off quality measures (p > 0.05). Most trainees preferred the IP method (73% vs 5% VB, 15% SB, 7% other; p < 0.001).

CONCLUSIONS

There is a need to provide formal training in hand off quality early in residency training. General surgery trainees clearly prefer and performed better, though not perfect, hand offs with the in-person method.

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.

Patient safety stories: a project utilizing narratives in resident training

Incident reports have traditionally been the vehicle for identifying, assessing, and responding to quality gaps in hospitals. Yet because of a variety of barriers, residents often fail to participate in this formal process. The authors created a project to engage residents in incident reporting through the use of an online, anonymous narrative format, faculty-facilitated discussion groups, and involvement of patient safety officers in the educational process. During three months, 36 residents submitted a total of 79 stories about patient care that did not "go as intended." The authors reviewed and scored each story for contributing factors and outcomes. The residents met monthly in small groups with trained faculty facilitators to analyze the stories, which were also shared with the patient safety officers. The stories, narratives of both personal involvement and observed events, ranged from near-misses to sentinel events. Key contributing factors included lapses of professionalism, decision errors, communication/information mishaps, transition mix-ups, and workload difficulties. The narrative format proved a feasible tool for collecting significant, previously unrecognized patient safety issues. Internal medicine residents were willing to discuss gaps in care when given the tools and opportunity for anonymous storytelling and blame-free dialogue.

Falling through the cracks: information breakdowns in critical care handoff communication

Handoffs have been recognized as a major healthcare challenge primarily due to the breakdowns in communication that occur during transitions in care. Consequently, they are characterized as being "remarkably haphazard". To investigate the information breakdowns in group handoff communication, we conducted a study at a large academic hospital in Texas. We used multifaceted qualitative methods such as observations, shadowing of care providers and their work activities, audio-recording of handoffs, and care provider interviews to examine the handoff communication workflow, with particular emphasis on investigating the sources of information breakdowns. Using a mixed inductive-deductive analysis approach, we identified two critical sources for information breakdowns - lack of standardization in handoff communication events and unsuccessful completion of pre-turnover coordination activities. We propose strategic solutions that can effectively help mitigate the handoff communication breakdowns.

Nursing priorities, actions, and regrets for ethical situations in clinical practice

PURPOSE

Nurses in all clinical settings encounter ethical issues that frequently lead to moral distress. This critical incident study explored nurses' descriptions of ethically difficult situations to identify priorities, action responses, and regrets.

METHODS

Employing the critical incident technique, researchers developed a questionnaire that collected information on ethically difficult situations, nurse actions, and situational outcomes. Data on nursing priorities and actions were analyzed and categorized using a constant comparison technique.

FINDINGS

Addressing patient autonomy and quality of life were ethical priorities in the majority of cases. In many cases, nurses analyzed ethics from a diffuse perspective and only considered one dimension of the ethics conflict. However, some nurses were specific in their ethical analysis and proactive in their action choices. Nurses also identified 12 ethics-specific nurse activities, five ways of being, three ways of knowing, and two ways of deliberating. In 21 cases, nurses chose not to pursue their concerns beyond providing standard care. Several nurses expressed significant regret in their narration; most regretted unnecessary pain and suffering, and some claimed they did not do enough for the patient.

CONCLUSIONS

Not enough specific, evidence-based ethics actions have been developed. Stronger and more proactive nursing voices with early ethics interventions would make valuable contributions to quality of care for patients, especially at the end of life.

CLINICAL RELEVANCE

Ever-expanding treatment options raise ethical issues and challenge nurses to be effective patient advocates. Evidence-based nursing interventions that promptly identify and address moral conflict will benefit patients, their families, and the entire healthcare team by mitigating potential moral distress and disengagement.

Patient acuity rating: quantifying clinical judgment regarding inpatient stability

BACKGROUND

New resident work-hour restrictions are expected to result in further increases in the number of handoffs between inpatient care providers, a known risk factor for poor outcomes. Strategies for improving the accuracy and efficiency of provider sign-outs are needed.

OBJECTIVE

To develop and test a judgment-based scale for conveying the risk of clinical deterioration.

DESIGN

Prospective observational study.

SETTING

University teaching hospital.

SUBJECTS

Internal medicine clinicians and patients.

MEASUREMENTS

The Patient Acuity Rating (PAR), a 7-point Likert score representing the likelihood of a patient experiencing a cardiac arrest or intensive care unit (ICU) transfer within the next 24 hours, was obtained from physicians and midlevel practitioners at the time of sign-out. Cross-covering physicians were blinded to the results, which were subsequently correlated with outcomes.

RESULTS

Forty eligible clinicians consented to participate, providing 6034 individual scores on 3419 patient-days. Seventy-four patient-days resulted in cardiac arrest or ICU transfer within 24 hours. The average PAR was 3 ± 1 and yielded an area under the receiver operator characteristics curve (AUROC) of 0.82. Provider-specific AUROC values ranged from 0.69 for residents to 0.85 for attendings (P = 0.01). Interns and midlevels did not differ significantly from the other groups. A PAR of 4 or higher corresponded to a sensitivity of 82% and a specificity of 68% for predicting cardiac arrest or ICU transfer in the next 24 hours.

CONCLUSIONS

Clinical judgment regarding patient stability can be reliably quantified in a simple score with the potential for efficiently conveying complex assessments of at-risk patients during handoffs between healthcare members.

Neonatal Informatics: Information Technology to Support Handoffs in Neonatal Care

Communication failures during physician handoffs represent a significant source of preventable adverse events. Computerized sign-out tools linked to hospital electronic medical record systems and customized for neonatal care can facilitate standardization of the handoff process and access to clinical information, thereby improving communication and reducing adverse events. It is important to note, however, that adoption of technological tools alone is not sufficient to remedy flawed communication processes. OBJECTIVES: After completing this article, readers should be able to: Identify key elements of a computerized sign-out tool.Describe how an electronic tool might be customized for neonatal care.Appreciate that technological tools are only one component of the handoff process they are designed to facilitate.