Using “Best-Fit” Interventions to Improve the Nursing Intershift Handoff Process at a Medical Center in Lebanon

Interventions to Engage Patients and Families in Patient Safety: A Systematic Review

The involvement of patients and families is essential for improving patient safety. However, the role of patients and caregivers in patient safety has recently been receiving attention, and programs and interventions have been implemented for patients and caregivers. The objective of this systematic review was to identify the types of interventions to improve patient safety that focused on engaging patients and their families, and the effectiveness of these interventions. Searching four electronic databases, 2019 articles were obtained; of these, 15 articles met the inclusion criteria. The studies used intervention strategies at the "information" and "involvement" engagement levels. Interventions with strategies only at the information level mostly measured safety perception and were mostly found to be effective. Interventions with both information and involvement strategies measured more diverse outcomes, but their effectiveness was inconsistent. Further studies using a range of intervention strategies and outcomes with more rigorous methodologies are needed.PROSPERO registration number CRD42018096162.

A 10-year evaluation of projects in a doctor of nursing practice programme

AIMS AND OBJECTIVES

The role of professional doctorates is receiving increased attention internationally. As part of building the rigour and scholarship of these programmes, we assessed projects undertaken as part of a doctor of nursing practice (DNP) programme at Johns Hopkins University. Recommendations for programme development in professional doctorates are provided.

BACKGROUND

Past research has described the methodologic limitations and dissemination of DNP projects. However, few studies have provided recommendations for strengthening these projects and alternative strategies for achieving scale in larger student cohorts.

DESIGN

A descriptive study reported in accordance with STROBE guidelines.

METHODS

From 2009-2018, 191 final DNP project reports were obtained from the DNP programme administrator. Essential project characteristics from the papers were extracted, including use of theoretical framework, design, setting, sample and dissemination through publication. To determine whether the results of the projects had been published, the title and student's name were searched in Google Scholar and Google.

RESULTS

Of the 191 projects, 83% focused on adults and 61% were conducted in the hospital setting. Sample sizes ranged from 7 to 24,702. Eighty per cent of the projects employed a pretest/post-test design, including both single and independent groups. The projects spanned six overarching themes, including process improvement, clinician development, patient safety, patient outcome improvement, access to care and workplace environment. Twenty-one per cent of the project findings were published in scholarly journals.

CONCLUSIONS

Conducting a critical review of DNP projects has been useful in refining a strategy shifting from incremental to transformative changes in advanced practice.

RELEVANCE TO CLINICAL PRACTICE

Programme evaluation is critical in order to sufficiently prepare nurses in advanced nursing practice to influence healthcare outcomes at the individual or population level.

A systematic review on the structured handover interventions between nurses in improving patient safety outcomes

AIM

This review aimed to elucidate the effectiveness of structured handovers in improving patient outcomes in the wards.

BACKGROUND

Studies have reported that the lack of quality handovers is one of the main causes of adverse effects.

EVALUATION

A search over six electronic databases: MEDLINE; CINAHL; Web of Science; EMBASE; Scopus; and CENTRAL via Ovid concluded nine studies and synthesized by two independent reviewers based on the Cochrane Handbook for Systematic Reviews of Interventions. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used to guide the undertaking of this review and meta-analysis. All studies published up to February 2019 were considered in this review.

KEY ISSUES

This review has demonstrated that structured handovers reduced the incidences of patient complications, medication errors and general adverse events. However, the results were not statistically significant.

CONCLUSION

Current structured handover formats were effective in reducing problematic handovers such as omission of information, inaccurate information and documentation errors.

IMPLICATIONS FOR NURSING MANAGEMENT

Although there is limited high-quality and rigorous research conducted to gain a clearer understanding of the impacts on patient-related outcomes in nursing care, structured handovers remained effective in reducing the number of mistakes in information transfer.

Interventions to reduce mortality from in-hospital cardiac arrest: a mixed-methods study

Background

Unchecked patient deterioration can lead to in-hospital cardiac arrest (IHCA) and avoidable death. The National Cardiac Arrest Audit (NCAA) has found fourfold variation in IHCA rates and survival between English hospitals. Key to reducing IHCA is both the identification of patients at risk of deterioration and prompt response. A range of targeted interventions have been introduced but implementation varies between hospitals. These differences are likely to contribute to the observed variation between and within hospitals over time.

Objective

To determine how interventions aimed at identification and management of deteriorating patients are associated with IHCA rates and outcomes.

Design

A mixed-methods study involving a systematic literature review, semistructured interviews with 60 NHS staff, an organisational survey in 171 hospitals and interrupted time series and difference-in-difference analyses (106 hospitals).

Setting

English hospitals participating in the NCAA audit.

Participants

NHS staff (approximately 300) and patients (13 million).

Interventions

Education, track-and-trigger systems (TTSs), standardised handover tools and outreach teams.

Main outcome measures

IHCA rates, survival and hospital-wide mortality.

Data sources

NCAA, Hospital Episode Statistics, Office for National Statistics Mortality Statistics.

Methods

A literature review and qualitative interviews were used to design an organisational survey that determined how interventions have been implemented in practice and across time. Associations between variations in services and IHCA rates and survival were determined using cross-sectional, interrupted time series and difference-in-difference analyses over the index study period (2009/10 to 2014/15).

Results

Across NCAA hospitals, IHCAs fell by 6.4% per year and survival increased by 5% per year, with hospital mortality decreasing by a similar amount. A national, standard TTS [the National Early Warning Score (NEWS)], introduced in 2012, was adopted by 70% of hospitals by 2015. By 2015, one-third of hospitals had converted from paper-based TTSs to electronic TTSs, and there had been an increase in the number of hospitals with an outreach team and an increase in the number with a team available at all times. The extent of variation in the uses of educational courses and structured handover tools was limited, with 90% of hospitals reporting use of standardised communication tools, such as situation, background, assessment and recommendation, in 2015. Introduction of the NEWS was associated with an additional 8.4% decrease in IHCA rates and, separately, a conversion from paper to electronic TTS use was associated with an additional 7.6% decrease. However, there was no associated change in IHCA survival or hospital mortality. Outreach teams were not associated with a change in IHCA rates, survival or hospital mortality. A sensitivity analysis restricted to ward-based IHCAs did not alter the findings but did identify an association between increased outreach team intensity in 2015 and IHCA survival.

Limitations

The organisational survey was not able to explore all aspects of the interventions and the contextual factors that influenced them. Changes over time were dependent on respondents’ recall.

Conclusions

Standardisation of TTSs and introduction of electronic TTSs are associated with a reduction in IHCAs. The apparent lack of impact of outreach teams may reflect their mode of introduction, that their effect is through providing support for implementation of TTS or that the organisation of the response to deterioration is not critical, as long as it is timely. Their role in end-of-life decision-making may account for the observed association with IHCA survival.

Future work

To assess the potential impact of outreach teams at hospital level and patient level, and to establish which component of the TTS has the greatest effect on outcomes.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

An observational study of patient handover communications among nurses on an oncology critical care unit

BACKGROUND

Breakdown in communication is a common cause of errors in hospitals. Aim/Objectives: To evaluate the feasibility and utilization of evidence-based recommendations for nurse-to-nurse shift handover on an oncology critical care unit.

DESIGN

Observational study.

METHODS

Nurses were provided education that integrated evidence-based recommendations for handover of care. Nursing shift report was observed for one month in 2015 and for one month in 2016. Results were evaluated for inclusion of 24 evidence-based essential elements for handover communication.

RESULTS

Total completeness of handover increased with 86.64% (N = 38) in 2015 and 88.68% (N = 35) in 2016. Interruptions during handover were positively correlated with length of handover (r = 0.587, n = 18, p = .010), thus confirming the need for structured, more effective handover methods.

CONCLUSIONS

Providing education, mentoring, and real-time feedback to motivated staff may lead to improvements in handover communication methods, yielding positive patient outcomes.

Effectiveness of ways to improve detection and rescue of deteriorating patients

A number of interventions has been introduced to improve recognition of and response to deterioration, but evidence for improved outcomes is mixed. Future evaluations need better articulation of intervention components and outcomes, longer run-in times and consideration of the interplay between concurrent interventions.

Meta-Analyses of the Effects of Standardized Handoff Protocols on Patient, Provider, and Organizational Outcomes

OBJECTIVE

The overall purpose was to understand the effects of handoff protocols using meta-analytic approaches.

BACKGROUND

Standardized protocols have been required by the Joint Commission, but meta-analytic integration of handoff protocol research has not been conducted.

METHOD

The primary outcomes investigated were handoff information passed during transitions of care, patient outcomes, provider outcomes, and organizational outcomes. Sources included Medline, SAGE, Embase, PsycINFO, and PubMed, searched from the earliest date available through March 30th, 2015. Initially 4,556 articles were identified, with 4,520 removed. This process left a final set of 36 articles, all which included pre-/postintervention designs implemented in live clinical/hospital settings. We also conducted a moderation analysis based on the number of items contained in each protocol to understand if the length of a protocol led to systematic changes in effect sizes of the outcome variables.

RESULTS

Meta-analyses were conducted on 34,527 pre- and 30,072 postintervention data points. Results indicate positive effects on all four outcomes: handoff information (g = .71, 95% confidence interval [CI] [.63, .79]), patient outcomes (g = .53, 95% CI [.41, .65]), provider outcomes (g = .51, 95% CI [.41, .60]), and organizational outcomes (g = .29, 95% CI [.23, .35]). We found protocols to be effective, but there is significant publication bias and heterogeneity in the literature. Due to publication bias, we further searched the gray literature through greylit.org and found another 347 articles, although none were relevant to this research. Our moderation analysis demonstrates that for handoff information, protocols using 12 or more items led to a significantly higher proportion of information passed compared with protocols using 11 or fewer items. Further, there were numerous negative outcomes found throughout this meta-analysis, with trends demonstrating that protocols can increase the time for handover and the rate of errors of omission.

CONCLUSIONS

These results demonstrate that handoff protocols tend to improve results on multiple levels, including handoff information passed and patient, provider, and organizational outcomes. These findings come with the caveat that publication bias exists in the literature on handoffs. Instances where protocols can lead to negative outcomes are also discussed.

APPLICATION

Significant effects were found for protocols across provider types, regardless of expertise or area of clinical focus. It also appears that more thorough protocols lead to more information being passed, especially when those protocols consist of 12 or more items. Given these findings, publication bias is an apparent feature of this literature base. Recommendations to reduce the apparent publication bias in the field include changing the way articles are screened and published.

Gaps in continuity of care: patients' perceptions of the quality of care during labor ward handover in Mulago hospital, Uganda

Background

Client satisfaction is a common outcome measure for quality of care and goal for quality improvement in healthcare. We assessed women’s perceptions of the structure, process and outcome of intrapartum care in Mulago hospital, specifically, labor ward duty shift handovers.

Methods

Data was collected through 40 in-depth interviews conducted on two occasions: during the time of hospitalization and within 4–6 months after childbirth. Participants were women who delivered at the hospital, of whom some had life-threatening obstetric complications. Data was analyzed by thematic analysis.

Results

Maternity duty handovers were associated with patient dissatisfaction, particularly the process of hand-over, the decision-making that follows handovers and failure of communication of information to patients and their caretakers. Consequently, duty handovers were perceived inadequate. They were described as gaps in the continuity of care, and contributed to poor quality of care, birth trauma and mothers’ dissatisfaction with the childbirth experience.

Conclusion

The handover process and practices should be standardized using protocols and checklists. Health workers need training on handover practices, team work and communication skills (so as to improve patient-health provider and provider-provider interaction.