Burns surgery handover study: trainees' assessment of current practice in the British Isles

Patient handoffs in surgery: Successes, failures and room for improvement

Patient handoffs are transitions where communication failures may lead to errors in patient care. Face-to-face handoffs are preferred, however may not always be feasible. Different models and strategies have been described, yet there are few experimental studies. Expanding the problem, the on-call surgeon may be responsible for many patients, few or none that they admitted. Effective handoffs improve the quality of care and result in fewer errors. Herein we review different models of patient handoffs, comment on common pitfalls, and suggest areas for new research.

Clinical handover: An audit from Australia

BACKGROUND

The Australian National Safety and Quality Health Service (NHQHS) Standards (the "Standards") provide external criteria for hospitals to assess their practices. Since the introduction of the Standards, no Australian hospital has published a report on how its handover practices compare to these Standards.

AIMS

To evaluate house medical officer (HMO) shift-to-shift handover practices against the Standards at a large regional hospital.

METHOD

All HMOs employed by Barwon Health were invited to participate in our qualitative and quantitative study by completing an online questionnaire and taking part in a focus group.

RESULTS

Of the 100 HMOs, 61 completed the questionnaire and 11 HMOs participated in focus groups. Questionnaire results revealed that HMOs were concerned about the quality of shift-to-shift handovers. Fifty-three per cent reported that current shift-to-shift handover practices could be putting patients at risk of adverse events. Ninety-eight per cent indicated that the handover processes could be improved. One hundred per cent of the HMOs stated that the quality of handover varies according to the doctors involved. In the focus groups, issues were raised about current handover structure, documentation, attendance, content, and training.

CONCLUSION

HMOs in the current study identified multiple deficiencies in handover practice with regard to structure, documentation, attendance, content, and training. The primary methods to improve handover include making it more structured and standardised, and to provide HMOs with handover training.

Development of an orthopedic surgery trauma patient handover checklist

BACKGROUND

In surgery, preoperative handover of surgical trauma patients is a process that must be made as safe as possible. We sought to determine vital clinical information to be transferred between patient care teams and to develop a standardized handover checklist.

METHODS

We conducted standardized small-group interviews about trauma patient handover. Based on this information, we created a questionnaire to gather perspectives from all Canadian Orthopaedic Association (COA) members about which topics they felt would be most important on a handover checklist. We analyzed the responses to develop a standardized handover checklist.

RESULTS

Of the 1106 COA members, 247 responded to the questionnaire. The top 7 topics felt to be most important for achieving patient safety in the handover were comorbidities, diagnosis, readiness for the operating room, stability, associated injuries, history/mechanism of injury and outstanding issues. The expert recommendations were to have handover completed the same way every day, all appropriate radiographs available, adequate time, all appropriate laboratory work and more time to spend with patients with more severe illness.

CONCLUSION

Our main recommendations for safe handover are to use standardized checklists specific to the patient and site needs. We provide an example of a standardized checklist that should be used for preoperative handovers. To our knowledge, this is the first checklist for handover developed by a group of experts in orthopedic surgery, which is both manageable in length and simple to use.

Handover practice amongst core surgical trainees at the Oxford School of Surgery

PURPOSE

To date no studies have specifically evaluated the use of handovers amongst core surgical trainees (CSTs) in the United Kingdom. We examined handover practice at the Oxford School of Surgery to assess and improve CSTs'perception of handover use as well as its quality, and ultimately patient care.

METHODS

Based on guidelines published by the British Medical Association and Royal College of Surgeons, a 5-point Likert style questionnaire that collected data on handover practice, its educational value, and the CSTs'satisfaction with handover was given to 50 CSTs in 2010.

RESULTS

Forty CSTs (80.0%) responded to the questionnaire. The most striking findings revolved around the perceived educational value, formal training, and auditing practice of handovers throughout various units, which were all remarkably lower than expected. As a result, handover practice amongst CSTs was targeted and revised at the University Hospital's Department of Plastic Surgery, with the implementation of targeted changes to improve handover practice.

CONCLUSION

The execution of daily handovers was an underused educational tool amongst surveyed CSTs and may be an important modality to target, particularly in the competency-based, time-limited training CSTs receive. We recommend modifications to current practice based on our results and the literature and encourage the assessment of handover practice at other institutions.

Handover in Trauma and Orthopaedic Surgery - A Human Factors Assessment

Handovers permeate healthcare delivery systems. They are critical for patient safety and continuity of care, but also for logistics and clinical efficiency. Poor handovers can cause reduced efficiency, delayed discharge or time to operation, and contributes to patient harm. The Objective was to conduct a human factors assessment (HFA) using a systems approach to study the handover process at an Orthopaedic unit, determine barriers to information transfer, and suggest improvements. A direct observation model was used to help provide insights on the evening handover process. A Systems Engineering Initiative for Patient Safety (SEIPS) model was used to provide a framework. A total of ten handover sessions were observed and the junior doctors were interviewed using a semi-structured approach. Participants had two chief centres of complaint: workspace and environmental issues (such as a small, hot, uncomfortable room), and the lack of the junior house officer at handover leading to 'signal loss' with respect to sick patients who may not be handed over fully. The process also lacked standardisation and structure compounding the potential loss of information.

CONCLUSION

Good handover remains a cornerstone of safe and effective clinical practice and continuity of care. This study has shown how an HFA can be useful in determining problems with the handover process locally. It suggests an approach for improvement and recommends better training at all levels in this aspect of patient care.

Hospital handoffs as multifunctional situated routines: implications for researchers and administrators

Patient handoffs involve the exchange of information between health professionals accompanying a transfer of responsibility for, or control of, a patient. Concerns over the safety risks of poor handoffs have resulted in regulatory pressure to standardize practice and considerable growth in research. But handoffs involve more than information transfer, and their consequences for health care organizations extend beyond the safety of patients. Using an organization theory lens, we review the literature on handoffs and propose a framework that characterizes handoffs as multifunctional, situated organizational routines. We also identify implications for researchers and hospital policymakers. Standardization and improvement efforts run the risk of causing unintended problems if they overlook the complexity of handoff and the larger organizational functions it serves. Deepening our understanding of the multifunctional, situated nature of handoff can lead to improvement efforts that not only safeguard individual patients, but also enhance the capabilities of the larger health care organization.

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.