Implementation of a surgical handover tool in a busy tertiary referral centre: a complete audit cycle

Evaluation of a Novel Emergency General Surgery Handover: A Prospective Feasibility Study

INTRODUCTION

High-quality health information handovers are critical to optimal patient care and trainee education. The purposes of this study were to assess the feasibility of implementing an emergency general surgery (EGS) morning handover and to explore its impact upon markers of clinical care.

METHODS

This prospective feasibility study was conducted at a single academic tertiary-care medical center following implementation of a novel EGS morning handover process. We assessed organizational perspective through a two-part anonymous survey delivered to the EGS service staff (n = 29) and collected feasibility metrics daily at the morning handover meetings. Exploratory clinical metrics of quality improvement were compared between parallel 5-month periods preimplementation and postimplementation of the handover. Data were compared by descriptive statistics.

RESULTS

One hundred and seventeen patients from March 1, 2022, to July 31, 2022, and 185 patients from March 1, 2023, to July 31, 2023, were identified prehandover and posthandover implementation, respectively, with an increase in time to operating room posting by 49% (95% confidence interval [CI]: 1.03-2.14) and no statistically significant change in length of stay. The average duration of the formalized EGS morning handover was 14 min (95% CI: 12:18-15:42) having an average of 12 questions asked (95% CI: 9.98-14.02) and an average attendance of 70% from essential personnel. Eighty-four percent of postimplementation survey responses indicated positive regard toward the new EGS handover.

CONCLUSIONS

The implementation of an EGS morning handover is feasible, necessitating further studies to define the impact of the EGS morning handover upon clinical outcomes.

Daily handover in surgery: systematic review and a novel taxonomy of interventions and outcomes

BACKGROUND

Poor-quality handovers lead to adverse outcomes for patients; however, there is a lack of evidence to support safe surgical handovers. This systematic review aims to summarize the interventions available to improve end-of-shift surgical handover. A novel taxonomy of interventions and outcomes and a modified quality assessment tool are also described.

METHODS

Ovid MEDLINE®, PubMed, Embase, and Cochrane databases were searched for articles up to April 2023. Comparative studies describing interventions for daily in-hospital surgical handovers between doctors were included. Studies were grouped according to their interventions and outcomes.

RESULTS

In total, 6139 citations were retrieved, and 41 studies met the inclusion criteria. The total patient sample sizes in the control and intervention groups were 11 946 and 11 563 patients, respectively. Most studies were pre-/post-intervention cohort studies (92.7%), and most (73.2%) represented level V evidence. The mean quality assessment score was 53.4% (17.1). A taxonomy of handover interventions and outcomes was developed, with interventions including handover tools, process standardization measures, staff education, and the use of mnemonics. More than 25% of studies used a document as the only intervention. Overall, 55 discrete outcomes were assessed in four categories including process (n = 27), staff (n = 14), patient (n = 12) and system-level (n = 2) outcomes. Significant improvements were seen in 51.8%, 78.5%, 58.3% (n = 9761 versus 9312 patients) and 100% of these outcomes, respectively.

CONCLUSIONS

Most publications demonstrate that good-quality surgical handover improves outcomes and many interventions appear to be effective; however, studies are methodologically heterogeneous. These novel taxonomies and quality assessment tool will help standardize future studies.

Handoff standardization in the neonatal intensive care unit with an EMR-based handoff tool

OBJECTIVE

This quality improvement project aimed to improve the accuracy and efficiency of handoff communication among NICU medical providers with an Electronic Medical Record (EMR)-based handoff tool (HT).

STUDY DESIGN

Three Plan-Do-Study-Act (PDSA) cycles were utilized following the implementation of a NICU-specific EMR-based HT and a standardized handoff process. Primary measures included accuracy of demographic components: patient name, bed, age, gestational age, postmenstrual age; and medical components: active diagnoses, weight, vascular access, respiratory support, diet, total fluid goal, medications. Secondary measures included environmental components (start time, duration, location, and distractions) as indicators of efficiency.

RESULTS

Accuracy of handoff components improved from 68% to 99% (p < 0.001). Efficiency of the handoff improved with time needed to complete patient handoff decreasing from 78 to 47 s per patient (p < 0.001).

CONCLUSIONS

Standardizing the NICU handoff process using an EMR-based HT allowed for increased accuracy of handoff components and improved efficiency, which may promote enhanced patient safety.

Quality assessment of weekend discharge: a systematic review and meta-analysis

PURPOSE

Hospital bed utility and length of stay affect the healthcare budget and quality of patient care. Prior studies already show admission and operation on weekends have higher mortality rates compared with weekdays, which has been identified as the 'weekend effect.' However, discharges on weekends are also linked with quality of care, and have been evaluated in the recent decade with different dimensions. This meta-analysis aims to discuss weekend discharges associated with 30-day readmission, 30-day mortality, 30-day emergency department visits and 14-day follow-up visits compared with weekday discharges.

DATA SOURCES

PubMed, EMBASE, Cochrane Library and ClinicalTrials.gov were searched from January 2000 to November 2019.

STUDY SELECTION

Preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Only studies published in English were reviewed. The random-effects model was applied to assess the effects of heterogeneity among the selected studies.

DATA EXTRACTION

Year of publication, country, sample size, number of weekday/weekend discharges, 30-day readmission, 30-day mortality, 30-day ED visits and 14-day appointment follow-up rate.

RESULTS OF DATA SYNTHESIS

There are 20 studies from seven countries, including 13 articles from America, in the present meta-analysis. There was no significant difference in odds ratio (OR) in 30-day readmission, 30-day mortality, 30-day ED visit, and 14-day follow-up between weekday and weekend. However, the OR for 30-day readmission was significantly higher among patients in the USA, including studies with high heterogeneity.

CONCLUSION

In the USA, the 30-day readmission rate was higher in patients who had been discharged on the weekend compared with the weekday. However, interpretation should be cautious because of data limitation and high heterogeneity. Further intervention should be conducted to eliminate any healthcare inequality within the healthcare system and to improve the quality of patient care.

The handover room: a qualitative enquiry into the experience of morning clinical handover for acute medical teams

BACKGROUND

Effective clinical handover has always been integral to delivering safe, high-quality care in medical wards.

AIM

As handover activity increases in importance we wanted to explore the experience of physicians and trainee doctors. There is little research on internal medicine handover with even less based on direct observational research.

METHODS

Data collection over 4 months by two general medicine physicians included participant observation of 37 meetings and 52 audio-recorded individual interviews. Inductive thematic analysis of the transcribed interviews proceeded iteratively in parallel with data collection.

RESULTS

There was an excellent response rate from 27 of 28 invited trainees and 25 of 26 invited physicians. Overall the experience was positive. Acute medicine handover is a complex human endeavour, occurring daily with an unpredictable workload and areas of tension. Themes were grouped as structural (leadership role, start time, sequence, checklist, handbacks and efficiency) and relational (sensitivity, collegiality, acknowledgement, performance anxiety, tension, responsibility and leadership style). The physician leader needs to be skilled to follow the agreed and evolving process as well as being prepared, authoritative, flexible, equitable, aware and sensitive to the needs of senior colleagues and trainees. There was a tension between efficiency and teaching opportunities.

CONCLUSION

This paper adds to a contextually sensitive understanding of the social dynamics of handover in acute medicine. Addressing the structural aspects is important to provide the necessary consistency and efficiency in what is an extremely complex and time-sensitive environment. As we continue to work on the evolution of the handover process in acute internal medicine, we must also attend to the relational aspects which are dynamic and central to its sustainability.

Weekend surgical handover enhances early management of acute clinical changes using a red flag system

INTRODUCTION

Recent implementation of the European Working Time Directive in Ireland has resulted in a change from thetraditional model of patient care to a system characterised by shift work among clinicians. Effective handover ofpatient information is essential for transfer of responsibility between clinicians and maintaining continuity of care. The weekend has been identified as a particularly vulnerable transition of patient care.

AIMS AND METHODS

Our study aims to determine if implementing a formal face-to-face handover accompanied by an electronictemplate in our surgical department can improve the number of adverse events reported back to the primary teamafter a weekend on call. Data was collected over 12 weekends between February and May 2016. A list of adverseevents was established, and during an initial observation period of 6 weeks, we documented the number of adverseevents that were informally handed over. A 6-week intervention was then performed, involving a formal face-to-facehandover on Monday morning supported by an electronic patient census using a red-flag system to highlightpatients who experienced an adverse event over the weekend.

RESULTS

Our results showed the mean number of adverse events recorded pre-intervention was 3.17 ± 0.6 over the 6-week period. Following the introduction of weekend face-to-face handover, there was 147% increase in the number of adverse events recorded with a mean of 7.83 ± 1.2.

CONCLUSION

The introduction of a formal face-to-face weekend handover with a red-flag system resulted in increased reporting of patient adverse events, allowing earlier recognition and management.

Shift-to-Shift Handoff Effects on Patient Safety and Outcomes

Multiple health care organizations have identified handoffs as a source of clinical errors; however, few studies have linked handoff interventions to improved patient outcomes. This systematic review of English-language research articles, published January 2008 to May 2015 and focusing on shift-to-shift handoff interventions and patient outcomes, yielded 10 774 unique articles. Twenty-one articles met inclusion criteria, measuring each of the following: patient falls (n = 7), reportable events (n = 6), length of stay (n = 4), mortality (n = 4), code calls (n = 4), medication errors (n = 4), medical errors (n = 3), procedural complications (n = 2), pressure ulcers (n = 2), weekend discharges (n = 2), and nosocomial infections (n = 2). One study each also measured time to first intervention, restraint use, overnight transfusions, and out-of-hours deteriorations. Studies that reported funding had higher quality scores. It is difficult to identify trends in the handoff research because of simultaneous implementation of multiple interventions and heterogeneity of the interventions, outcomes measured, and settings. The authors call for increased handoff research funding, especially for studies that include patient outcome measures.