Using the Targeted Solutions Tool® to Improve Emergency Department Handoffs in a Community Hospital

Der Übergabeprozess in der zentralen Notaufnahme

Hintergrund

Die Weitergabe von Informationen in einer stressbesetzten, hoch dynamischen Arbeitsumgebung wie der zentralen Notaufnahme (ZNA) stellt eine Risikoquelle für die Entstehung von Behandlungsfehlern dar und ist somit mortalitätsbeeinflussend.

Ziel der Arbeit

In der Arbeit wird untersucht, welchen Stellenwert dem Übergabeprozess durch die beteiligten Berufsgruppen beigemessen wird und welche strukturellen Merkmale bzw. Rahmenbedingungen dem Übergabeprozess von diesen zugeschrieben werden.

Material und Methoden

Bei der vorliegenden Studie handelte es sich um eine anonyme, freiwillige, webbasierte (Online‑)Umfrage, die mittels eines strukturierten elektronischen Fragebogens durchgeführt wurde.

Ergebnisse

Insgesamt haben 2728 Teilnehmer an der Onlineumfrage teilgenommen. Nahezu alle Teilnehmer-/innen benennen die Übergabe als outcomerelevanten Parameter für die Patienten, allerdings sehen 3 von 4 Teilnehmern den Übergabeprozess als verbesserungswürdig an. Bei der Selbsteinschätzung meinen 4 von 5 Teilnehmer-/innen, die Übergabe zu beherrschen. Es lässt sich unter den Teilnehmern kein favorisiertes Übergabeschema erkennen, die Mehrheit benutzt entweder ein eigenes oder gar kein Übergabeschema. Eine hohe Übereinstimmung zwischen Rettungsdienst und ZNA-Mitarbeitern liegt in Bezug auf Kerninhalte und Rahmenbedingungen der Übergabe vor. Mit großer Mehrheit zeigt sich der Wunsch nach einem einheitlichen Übergabeschema sowie nach Integrierung in Aus- und Fortbildungskonzepte.

Diskussion

Als Konsequenz der Umfrage sollte zügig auf nationaler Ebene mit allen an der Übergabe beteiligten Strukturen ein standardisiertes Übergabeverfahren etabliert werden. Die Bereitstellung entsprechender finanzieller und personeller Ressourcen für die Umsetzung dieses gesundheitspolitischen Ziels ist allerdings Voraussetzung.

Developing an Interfacility Transfer Handoff Intervention: Applying the Person-Based Approach Method

OBJECTIVE

To develop an interfacility transfer handoff intervention by applying the person-based approach method.

METHODS

We conducted a qualitative study that used nominal group technique (NGT) and focus groups to apply the person-based approach for intervention development. NGT methods were used to determine prioritized pediatric transfer handoff elements to design the initial intervention prototype. Five focus group sessions were then held to solicit feedback on the intervention, perceptions on implementing the intervention, and outcomes for evaluating the intervention. Data were analyzed by using content analysis. Iterative improvements were made to the intervention prototype as data emerged.

RESULTS

Forty-two clinical providers in total participated in NGT and focus group sessions, including physicians, advanced practitioners, nurses, and a respiratory therapist. The initial intervention prototype was a handoff mnemonic tool, "SHARING" (short introduction, how the patient appeared, action taken, responses and results, interpretation, next steps, gather documents). Perceived benefits of the intervention included clarifying handoff expectations, reducing handoff deficits, supporting less experienced clinical providers, and setting the stage for ongoing effective communication. Outcomes perceived to be meaningful were related to triage appropriateness, workflow and use, and communication and information sharing. The final version of the intervention consisted of a SHARING reference card and a SHARING electronic medical record note template.

CONCLUSIONS

Using qualitative methods to apply the person-based approach to intervention development, we developed a transfer handoff intervention. Future research is needed to examine impacts of this tool; outcomes can include those identified as meaningful by participants in our present study.

Debunking the myth that the majority of medical errors are attributed to communication

CONTEXT

Many articles, book chapters and presentations begin with a declaration that the majority of medical errors are attributed to communication. However, this statement may not be supported by the research reported in the literature.

OBJECTIVES

The purpose of this systematic review is to identify where errors are reported in the research literature.

METHODS

A systematised review was conducted of research articles over the last 20 years (1998-2018) indexed in PubMed/MEDLINE and the Cumulative Index to Nursing and Allied Health (CINAHL) using term combinations: medical errors, research and communication. Inclusion was based on reported generalised primary research of medical error and the reported causes.

RESULTS

This systematised review resulted in 2881 research articles, which produced 42 that met the inclusion criteria. Although there was some overlap, three categories of errors were dominant in this research: errors of commission (20 articles; 47.6%), errors of omission (six articles; 14.2%) and errors through communication (four articles; 9.5%). There were 12 (28.5%) articles in which all three categories together significantly contributed to error. Of these 12 articles, errors of commission or omission were dominant in nine articles (21.4%) and errors of communication were prevalent in only three articles (7%).

CONCLUSIONS

The assertion that the majority of medical errors can be attributed to miscommunication is not supported by this systematic review. Overwhelmingly, most reported errors are attributed to errors of omission or commission. Intentionally or unintentionally providing misinformation may mislead patient safety initiatives, and research and funding agency priorities.

The Admission Conference Call: A Novel Approach to Optimizing Pediatric Emergency Department to Admitting Floor Communication

Optimizing information sharing at transfer of care between teams is an important target for the improvement of patient safety. Traditional emergency department (ED)-to-floor handoffs do not support a shared mental model between physicians, residents, and nurses. This report describes and evaluates acceptance of a novel process for coordinating physician and nursing handoff calls for patients being admitted to an inpatient floor from a children's hospital ED.

METHODS

The Admission Conference Call (ACC) is a single conference call including attendings, residents, and nurses from the ED and inpatient teams, currently used for 29.8% of admissions from one ED. Physicians and nurses were surveyed to assess perception of its effects on patient care.

RESULTS

A total of 653 ACCs were conducted during 2017. The survey was completed by 43 nurses and 89 physicians. Mean Likert scale findings were in favor of the process supporting safe patient care (4.5/5; standard deviation [SD], 0.6); none said it increased risk. Ratings favored the process improving interdisciplinary alignment (4.0/5; SD, 0.8) and the benefits outweighing the inconvenience (3.9/5; SD, 0.9). Respondents were neutral on the effect of the ACC on throughput time (3.0/5; SD, 1.0). Logistical concerns were expressed; mean satisfaction was 6.8/10 (SD, 2.1). Free text comments varied widely, from pride to frustration.

CONCLUSION

The Admission Conference Call is a well-accepted alternative to a traditional multiple call process. Most participants believe it supports safe patient care. Further research is necessary to confirm measurable effects on patient outcomes, but this project provides encouragement to institutions considering innovative approaches.

Triaging Inpatient Admissions: an Opportunity for Resident Education

In the context of internal medicine, "triage" is a newly popularized term that refers to constellation of activities related to determining the most appropriate disposition plans for patients, including assessing patients for admissions into the inpatient medicine service. The physician or "triagist" plays a critical role in the transition of care from the outpatient to the inpatient settings, yet little literature exists addressing this particular transition. The importance of this set of responsibilities has evolved over time as health systems become increasingly complex to navigate for physicians and patients. With the emphasis on hospital efficiency metrics such as emergency department throughput and appropriateness of admissions, this type of systems-based thinking is a necessary skill for practicing contemporary inpatient medicine. We believe that triaging admissions is a critical transition in the care continuum and represents an entrustable professional activity that integrates skills across multiple Accreditation Council for Graduate Medical Education (ACGME) competencies that internal medicine residents must master. Specific curricular competencies that address the domains of provider, system, and patient will deliver a solid foundation to fill a gap in skills and knowledge for the triagist role in IM residency training.

Measuring the quality of inpatient specialist consultation in the intensive care unit: Nursing and family experiences of communication

RATIONALE

Critically ill patients in the intensive care unit (ICU) often require the care of specialist physicians for clinical or procedural expertise. The current state of communication between specialist physicians and families and nurses has not been explored.

OBJECTIVES

To document the receipt of communication by nurses and family members regarding consultations performed on their patient or loved one, and to quantify how this impacts their overall perceptions of the quality of specialty care.

METHODS

Prospective survey of 60 adult family members and 90 nurses of 189 ICU patients who received a specialist consultation between March and October of 2015 in a single academic medical center in the United States. Surveys measured the prevalence of direct communication-defined as communication conducted in person, via telephone, or via text-page in which the specialist team gathered information about the patient from the nurse/family member and/or shared recommendations for care-and perceived quality of care.

RESULTS

In about two-thirds of family surveys (40/60) and one-half of nurse surveys (75/160), respondents had no direct communication with the specialist team that performed the consultation. Compared to nurses who had no direct communication with the specialists, those who did were 1.5 times more likely to rate the consultation as "excellent" (RR 1.48, 95% CI 1.2-1.8, p<0.001). Nearly 40% (22/60) of families knew so little about the consultation that they felt incapable of evaluating it.

CONCLUSIONS

Most ICU families and nurses have no interaction with specialist providers. Nurses' frequent exclusion from conversations about specialty care may pose safety risks and increase the likelihood of mixed messages for patients and families, most of whom desire some interaction with specialists. Future research is needed to identify effective mechanisms for information sharing that keep nurses and families aware of consultation requests, delivery, and outcomes without increasing the risk of mixed messages.

Using focused ethnography to explore and describe the process of nurses' shift reports in a psychiatric intensive care unit

AIMS AND OBJECTIVES

To explore and describe the cultural routine of shift reports among nursing staff in a psychiatric intensive care unit and further to develop a taxonomic, thematic and theoretical understanding of the process.

BACKGROUND

Lack of communication among healthcare staff is associated with risks for medical errors. Thus, handovers and shift reports are an essential and integral routine among nurses to pass on information about the patients' health status. Previous studies within the field have highlighted the benefits of structured reporting tools. However, shift reports as a cultural activity within the nursing tradition have been given less attention, not the least in psychiatric care.

METHODS

Focused ethnography was used. The data comprised 20 observational sessions. The observations ranged over a time span of 5 months and were conducted in a psychiatric intensive care unit in Sweden.

RESULTS

The process of shift reports encompassed the following three phases: (a) getting settled, (b) giving the report and (c) engaging in the aftermath. The results demonstrate that the phases entail different cultural activities, which take place in different areas of the ward and that the level of formality varied.

CONCLUSIONS

Shift reports are not an isolated event with clear boundaries. The study enriches the understanding of shift reports as a "fuzzy process". The individual phases were found to be tied to cultural connotations, such as activities, places and roles with certain meanings for staff members.

RELEVANCE TO CLINICAL PRACTICE

The new insights are useful for nurses in overcoming an uncritical adoption of the biomedical tradition regarding pace and tone during shift reports. The reporting nurse has the potential to transform shift reports from a monologue with a foreclosed style to a more dialogical interaction with colleagues that focuses on the patients' needs rather than the needs of staff.

Standardized Reporting System Use During Handoffs Reduces Patient Length of Stay in the Emergency Department

Background

Emergency department (ED) shift handoffs are potential sources of delay in care. We aimed to determine the impact that using standardized reporting tool and process may have on throughput metrics for patients undergoing a transition of care at shift change.

Methods

We performed a prospective, pre- and post-intervention quality improvement study from September 1 to November 30, 2015. A handoff procedure intervention, including a mandatory workshop and personnel training on a standard reporting system template, was implemented. The primary endpoint was patient length of stay (LOS). A comparative analysis of differences between patient LOS and various handoff communication methods were assessed pre- and post-intervention. Communication methods were entered a multivariable logistic regression model independently as risk factors for patient LOS.

Results

The final analysis included 1,006 patients, with 327 comprising the pre-intervention and 679 comprising the post-intervention populations. Bedside rounding occurred 45% of the time without a standard reporting during pre-intervention and increased to 85% of the time with the use of a standard reporting system in the post-intervention period (P < 0.001). Provider time (provider-initiated care to patient care completed) in the pre-intervention period averaged 297 min, but decreased to 265 min in the post-intervention period (P < 0.001). After adjusting for other communication methods, the use of a standard reporting system during handoff was associated with shortened ED LOS (OR = 0.60, 95% CI 0.40 - 0.90, P < 0.05).

Conclusions

Standard reporting system use during emergency physician handoffs at shift change improves ED throughput efficiency and is associated with shorter ED LOS.

Evaluation of a Novel Handoff Communication Strategy for Patients Admitted from the Emergency Department

Introduction

Miscommunication during inter-unit handoffs between emergency and internal medicine physicians may jeopardize patient safety. Our goal was to evaluate the impact of a structured communication strategy on the quality of admission handoffs.

Methods

We conducted a mixed-methods, pre-test/post-test study at a 560-bed academic health center with 60,000 emergency department (ED) patient visits per year. Admission-handoff best practices were integrated into a modified SBAR format, resulting in the Situation, Background, Assessment, Responsibilities & Risk, Discussion & Disposition, Read-back & Record (SBAR-DR) model. Physician handoff conversations were recorded and transcribed for the 60 days before (n=110) and 60 days after (n=110) introduction of the SBAR-DR strategy. Transcriptions were scored by two blinded physicians using a 16-item scoring instrument. The primary outcome was the composite handoff quality score. We assessed physician perceptions via a post-intervention survey.

Results

The composite quality score improved in the post-intervention phase (7.57 + 2.42 vs. 8.45 + 2.51, p=.0085). Three of the 16 individual scoring elements also improved, including time for questions (70.6% vs. 82.7%, p=.0344) and confirmation of disposition plan (41.8% vs. 62.7%, p=.0019). The majority of emergency and internal medicine physicians felt that the SBAR-DR model had a positive impact on patient safety and handoff efficiency.

Conclusion

Implementation of the SBAR-DR strategy resulted in improved verbal handoff quality. Agreement upon a clear disposition plan was the most improved element, which is of great importance in delineating responsibility of care and streamlining ED throughput. Future efforts should focus on nurturing broader physician buy-in to facilitate institution-wide implementation.