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

Perceived Quality of Postoperative Handover by Saudi Nurses: A Single-Center Cross-Sectional Study

BACKGROUND

 Handover is considered a basic nursing practice in which a patient's care information is moved to another nurse. Handover of patients after surgery is critical due to a number of care transitions, the presence of a surgical procedure, and the influence of anesthesia. High-quality postoperative handover is essential to safe patient care. Few studies have been conducted to evaluate the quality of current postoperative handover practices and the factors contributing to the quality of such processes, especially in Saudi Arabia.

AIM

 The present research aimed at evaluating nurses' perceptions of postoperative handover quality and assessing factors impacting this process. This cross-sectional study targeted registered nurses with at least one year of professional experience who were actively involved in the conduction of postoperative handovers across various surgical departments. A total sample of 143 nurses was selected via a convenient sampling technique. Study instruments included Handover Quality Rating Form, patient status, and nurses' background characteristics.

RESULTS

 Overall, postoperative handover quality was perceived as high by handing over and receiving nurses. Generally, 55.2% of nurses agreed on the different items supporting the positive circumstance for handover, and 92.3% agreed on the good conduct of handover compared to only 7.69% disagreement (p˂0.001). Significant agreements were observed for teamworking (p˂0.001), as well as four indicators (out of five) measuring the overall handover quality (p<0.001). The type of involved departments impacted significantly the handover quality perception (p=0.004). The respondents' age had a significant effect on quality (p=0.036), as well as circumstances of postoperative handover (p=0.046). Moreover, significant statistical differences were found for the circumstance of handover (p=0.031), as well as teamwork (p=0.019) according to the nurses' roles. Finally, the patient's blood circulation and respiration had a significant effect (p=0.023, p=0.033, respectively), as did the patient's level of consciousness (p=0.006) in the nurses' perception of the overall postoperative handover quality.

CONCLUSION

 Postoperative handover quality was highly perceived by nurses. This research explored a multitude of factors such as patient health status and nurses' socio-demographic variables and their impact on nurses' perception of handover quality. Several nurse and patient-related factors were found to impact the handover process. This current research provided findings that could direct future improvements in nursing handover practice to ensure high-quality patient care.

How doctors build community and socialize into a clinical department through morning reports. A positioning theory study

PHENOMENON

The morning report is one of the longest surviving hospital practices. Most studies of the morning report focus on the effectiveness of formal medical training, while focus on social and communicative aspects is rarer. This study explores the social interactions and communication in morning reports, examining the ways in which they contribute to the construction of professional identity and socialization into the community of the clinical department.

APPROACH

We used a qualitative explorative design with video observations of morning reports. Our data consisted of 43 video-recorded observations (in all, 15.5 hours) from four different hospital departments in Denmark. These were analyzed using the theoretical framework of positioning theory.

FINDINGS

A key finding was that each department followed its own individual structure. This order was not articulated as such but played out implictly. Two alternative storylines unfolded in the elements of the morning report: 1) being equal members of the specialty and department, and 2) preserving the hierarchical community and its inherent positions.

INSIGHTS

The morning report can be seen as playing an important role in community making. It unfolds as a "dance" of repeated elements in a complex collegial space. Within this complexity, the morning report is a space for positioning oneself and others as a collegial "we", i.e., equal members of a department and specialty, at the same time as "having a place" in a hierarchal community. Thus, morning reports contribute to developing professional identity and socialization into the medical community.

The Use of the Situation, Background, Assessment, and Recommendation (SBAR) Form as a Tool for Handoff Communication in the Pediatrics Department in a Sudanese Teaching Hospital

PURPOSE

 Patient care transitions between healthcare providers are common in hospitals -- this project aimed to audit the use of Situation, Background, Assessment, and Recommendation (SBAR)-based handoff communication tool in the handoff process.

MATERIALS AND METHODS

This prospective audit was conducted at Ribat Teaching Hospital, Khartoum, Sudan. All handoff communications of pediatric inpatients who required close monitoring during the study period were included. Two cycles of data collection were conducted, each spanning a duration of two weeks. The data, whether in the first or second cycle, were collected using a checklist document containing the items of the SBAR form. After the end of the first cycle, regular training sessions about the content and importance of the SBAR form were conducted for one week. Additionally, doctors' perception regarding the form was assessed.

RESULTS

Some 48 doctors participated in this study, 29 females and 19 males. In the first cycle, the percentages of filled SBAR form components were as follows: Situation 7%, Background 0.00%, Assessment 0.00%, and Recommendation 0.00%. After conducting training sessions, the second cycle assessment was done and it showed improvement in all form components: Situation 88.8%, Background 83.6%, Assessment 66.3%, and Recommendation 69.5%. Regarding the doctors' perception assessment, the majority reported the usefulness of the SBAR form in patients' safety, physicians' communication, and accountability.

CONCLUSION

The SBAR form is a simple and effective tool for improving communication; it helps doctors capture all relevant patient information. Most importantly, the majority of doctors were satisfied with the use of this tool for handoff communication.

Facilitating educational experiences in a paediatric handover: A qualitative case study

AIM

Handovers have been established as a valuable educational tool; nevertheless, a paucity of literature exists evaluating contributors to the educational experience. Our study aimed to investigate participants' educational experiences based on a paediatric handover, and the facilitators and barriers towards teaching and learning during this process.

METHODS

A case study was conducted using semi-structured interviews. Data were collected exploring participants' perspectives of their educational experiences within a handover. An inductive, thematic content analysis was performed to identify key themes, assisted by nVivo software.

RESULTS

Four key themes contributing to the educational experience within a handover were identified related to the organisation of a handover, team dynamics, teaching and learning moments and tensions between the clinical tasks and education. A model is proposed aimed at optimising education within this context.

CONCLUSIONS

Our study identified contributing factors towards the educational experiences at handovers and provides strategies to optimise these.

Advantages and disadvantages of between unit hand-off policies in Iranian hospitals: a qualitative study

Introduction: Currently in emergency department (ED) of educational medical centers of Iran there are generally two models for between unit hand-off process based on the time of transferring the responsibility (during stay vs. while departure). There is no comprehensive study available to compare the policies. Thus, the present qualitative study was designed to compare these two methods of hand-off via performing interviews by specialist physicians who involving the process in the hospitals to express the advantages and disadvantages of the two policies from their point of view. Methods: This qualitative study was done by using opinions of experts throughout 2015 and 2016. Interviews were performed using a one-on-one and in-depth semi-structured approach. Before asking the questions, the definitions of the two models of hand-off as well as the aims of the study were briefly explained to the interviewee. Thematic and content analysis strategies were used to identify core concepts and to develop categories. Qualitative content analytical approaches focus on analyzing both the explicit content of a text and the latent content that can be extrapolated from the text. Results: In the present study, a total of 25 individuals were interviewed. The mean age of the participants was 34 years and their mean working experience was 7 years. By analyzing the interviews performed, the results were categorized in four main themes including 'resident training', 'patient management in ED', 'quality and process of diagnosis and treatment of patients' and finally, 'satisfaction with the process among specialist'. Conclusion: Although the two methods have advantages and disadvantages, it is likely that during stay, model was more favorable than while departure model from the viewpoints of interviewees. However, it seems that choosing any of the methods depends on various situations such as workload, academic matters, availability of resources, etc.

A Multidisciplinary Handoff Process to Standardize the Transfer of Care Between the Intensive Care Unit and the Operating Room

OBJECTIVE

Critically ill patients are at high risk for adverse events on transfer between intensive care unit and operating room. Patient safety concerns were raised within our institution during such transfers, and absence of a standardized patient handoff process was identified as an area of concern.

METHODS

The current state of the patient transfer processes between the intensive care units (ICUs) and the operating rooms (ORs) was mapped and failure modes were identified. A multidisciplinary team was convened and a standardized handoff process and tool (checklist) was developed. Adherence to the process and care team satisfaction was assessed at the end of a 60-day pilot period.

RESULTS

The process was successfully implemented hospital-wide covering all adult and pediatric ICUs. We observed a 90% compliance rate with ICU to the OR transfers and 95% compliance rate with transfers from OR to the ICU during the 60-day pilot period. The care team expressed overall satisfaction with the process and identified potential areas of improvement.

CONCLUSION

A standardized patient handoff process between the ICU and the ORs can be successfully implemented in a large academic medical center. Universal application of this quality improvement tool can reduce patient harm, improve communication between providers, and enhance patient safety.

"Do You Know What I Know?": How Communication Norms and Recipient Design Shape the Content and Effectiveness of Patient Handoffs

BACKGROUND

Poor communication during end-of-shift transfers of care (handoffs) is associated with safety risks and patient harm. Despite the common perception that handoffs are largely a one-way transfer of information, researchers have documented that they are complex interactions, guided by implicit social norms and mental frameworks.

OBJECTIVES

We investigated communication strategies that resident physicians report deploying to tailor information during face-to-face handoffs that are often based on their implicit inferences about the perceived information needs and potential harm to patients.

METHODS/PARTICIPANTS

We interviewed 35 residents in Medicine and Surgery wards at three VA Medical Centers (VAMCs).

MAIN MEASURES

We conducted qualitative interviews using audio-recorded semi-structured cognitive task interviews.

KEY RESULTS

The effectiveness of handoff communication depends upon three factors: receiver characteristics, type of shift, and patient's condition and perceived acuity. Receiver characteristics, including subjective perceptions about an incoming resident's training or ability levels and their assumed preferences for information (e.g., detailed/comprehensive vs. minimal/"big picture"), influenced content shared during handoffs. Residents handing off to the night team provided more information about patients' medical histories and care plans than residents handing off to the day team, and higher patient acuity merited more detailed information and the medical service(s) involved dictated the types of information conveyed.

CONCLUSIONS

We found that handoff communication involves a complex combination of socio-technical information where residents balance relational factors against content and risk. It is not a mechanistic process of merely transferring clinical data but rather is based on learned habits of communication that are context-sensitive and variable, what we refer to as "recipient design." Interventions should focus on raising awareness of times when information is omitted, customized, or expanded based on implicit judgments, the emerging threats such judgments pose to patient care and quality, and the competencies needed to be more explicit in handoff interactions.

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.

Nurses' shift reports: a systematic literature search and critical review of qualitative field studies

AIMS AND OBJECTIVES

To identify reporting practices that feature in studies of nurses' shift reports across diverse nursing specialities. The objectives were to perform an exhaustive systematic literature search and to critically review the quality and findings of qualitative field studies of nurses' shift reports.

BACKGROUND

Nurses' shift reports are routine occurrences in healthcare organisations that are viewed as crucial for patient outcomes, patient safety and continuity of care. Studies of communication between nurses attend primarily to 1:1 communication and analyse the adequacy and accuracy of patient information and feature handovers at the bedside. Still, verbal reports between groups of nurses about patients are commonplace. Shift reports are obvious sites for studying the situated accomplishment of professional nursing at the group level. This review is focused exclusively on qualitative field research for nuanced and contextualised insights into nurses' everyday shift reporting practices.

DESIGN

The study is a systematic literature search and critical review of qualitative field analyses of nurses' shift reports. We searched in the databases CIHAHL, PubMed and PsycINFO and identified and reviewed 19 articles published 1992-2014. Data were systematically extracted using criteria for the evaluation of qualitative research reports.

RESULTS

The studies described shift report practices and identified several factors contributing to distribution of clinical knowledge. Shift report practices were described as highly conventionalised and locally situated, but with occasional opportunities for improvisation and negotiation between nurses. Finally, shift reports were described as multifunctional meetings, with individual and social effects for nurses and teams.

CONCLUSION

Innovations in between-shift communications can benefit from this analysis, by providing for the many functions of handovers that are revealed in field studies.

RELEVANCE TO CLINICAL PRACTICE

Leaders and practising nurses may consider what are the best opportunities for nurses to work up clinical knowledge and negotiate care.

A multidisciplinary initiative to standardize intensive care to acute care transitions

QUALITY ISSUE

Transfers from intensive care units to acute care units represent a complex care transition for hospitalized patients. Within our institution, variation in transfer practices resulted in unpredictable processes in which patient safety concerns were raised.

INITIAL ASSESSMENT

Key stakeholders were engaged across the institution. Patient safety ('incident') reports and a staff survey identified safety concerns.

CHOICE OF A SOLUTION

Using lean methodology, current transfer processes were mapped for the four adult intensive care units and waste was identified. During a summit of key stakeholders an ideal transfer process was conceived and a structured handoff tool (checklist) was developed. A daily management system (DMS) was implemented to monitor adherence.

EVALUATION

The primary process outcome was adherence to the standardized workflow. Audits at 4, 8, and 12 months after implementation indicated that the checklist was used for 100% of transfers. Secondary outcomes included the percentage of transfers completed within a pre-specified time window of 120 minutes, provider notification of patient arrival on the acute care unit, and staff survey responses assessing adequacy of transfer communication.

LESSONS LEARNED

Prior work has shown that structuring handoffs can improve patient safety, but the novelty of this project was addressing the transfer process in its entirety, across silos of care. Factors leading to the success of this project were the involvement of key stakeholders across the entire institution early in the project development phase, employment of lean methodology, and implementation of tools to guide workflow adherence and track causes of deviation from the workflow.

Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture

Background

The context of the study is the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture (HSOPSC). The purpose of the study is to analyze how different elements of patient safety culture are associated with clinical handoffs and perceptions of patient safety.

Methods

The study was performed with hierarchical multiple linear regression on data from the 2010 Survey. We examine the statistical relationships between perceptions of handoffs and transitions practices, patient safety culture, and patient safety. We statistically controlled for the systematic effects of hospital size, type, ownership, and staffing levels on perceptions of patient safety.

Results

The main findings were that the effective handoff of information, responsibility, and accountability were necessary to positive perceptions of patient safety. Feedback and communication about errors were positively related to the transfer of patient information; teamwork within units and the frequency of events reported were positively related to the transfer of personal responsibility during shift changes; and teamwork across units was positively related to the unit transfers of accountability for patients.

Conclusions

In summary, staff views on the behavioral dimensions of handoffs influenced their perceptions of the hospital’s level of patient safety. Given the known psychological links between perception, attitude, and behavior, a potential implication is that better patient safety can be achieved by a tight focus on improving handoffs through training and monitoring.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1502-7) contains supplementary material, which is available to authorized users.

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

BACKGROUND

There is little evidence for solutions to improve the handoff process between units, particularly from the emergency department (ED) to the inpatient unit. A systematic approach was used to improve the handoff communication process between the ED and the four private physician groups serving Juneau, Alaska, that admit and deliver care to patients of a 73-bed, Level 4 trauma center community hospital.

METHODS

Data were collected in using the Joint Commission Center for Transforming Healthcare's Targeted Solutions Tool (®)(TST(®)) to determine the rate of defective handoff communications and the factors that contributed to those defective handoff communications. Targeted solutions were then implemented to specifically address the identified contributing factors.

RESULTS

A random sample of 107 handoff opportunities was collected during the baseline phase (November 4, 2011- January 12, 2012) to measure performance and identify the contributing factors that led to defective handoffs. The baseline handoff communications defective rate was 29.9% (32 defective handoffs/107 handoff opportunities). The top four contributing factors, together accounting for 69.8% of all the causes of defective handoffs, were inaccurate/incomplete information, method ineffective, no standardized procedures for an effective handoff, and the person initiating the handoff, known as the "sender," lacks knowledge about the patient. After implementation of targeted solutions to the identified contributing factors, the handoff communications defective rate for the "improve" phase (April 1, 2012-July 29, 2012) was reduced from baseline by 58.2% to 12.5% (13 defective handoffs/104 handoff opportunities), p = 0.002; 2-proportions test. The number of adverse events related to hand-off communications declined as the handoff communications defective rate improved.

CONCLUSION

Use of the TST was associated with improvement in the ED handoff communication process.

Handing Off Safety at the Bedside

The study purpose was to describe how bedside nurses can use nursing bedside shift report (NBSR) to keep patients safe. NBSR has been recommended as a means of increasing patient safety, but little is known about how or whether it does so. Grounded theory methods were used. Data were collected from 2014 to 2015 with bedside nurses in a pediatric unit with an established NBSR process. The primary process by which bedside nurses use NBSR to keep patients safe is reducing risk of harm through conveying the patient story from shift to shift. Having a perspective from the bedside is a key antecedent to reducing risk of harm, as it supports the nurses' ability to subsequently identify and address risks. Although often seen as a routine exchange of information, how nursing shift report is conducted can impact patient safety. The study reinforces the value of targeting nursing communication to improve patient safety.

Effect of hospital referral networks on patient readmissions

Previous studies have shown that referral networks encompass important mechanisms of coordination and integration among hospitals, which enhance numerous organizational-level benefits, such as productivity, efficiency, and quality of care. The present study advances previous research by demonstrating how hospital referral networks influence patient readmissions. Data include 360,697 hospitalization events within a regional community of hospitals in the Italian National Health Service. Multilevel hierarchical regression analysis tests the impacts of referral networks' structural characteristics on patient hospital readmissions. The results demonstrate that organizational centrality in the overall referral network and ego-network density have opposing effects on the likelihood of readmission events within hospitals; greater centrality is negatively associated with readmissions, whereas greater ego-network density increases the likelihood of readmission events. Our findings support the (re)organization of healthcare systems and provide important indications for policymakers and practitioners.

Electronic handoff instruments: a truly multidisciplinary tool?

The objective was to assess use of a physician handoff tool embedded in the electronic medical record by nurses and other non-physicians. We administered a survey to nurses, physical therapists, discharge planners, social workers, and others to assess integration into daily practice, usefulness, and accuracy of the handoff tool. 231 individuals (61% response) participated. 60% used the tool often or usually/always during a shift. Nurses (46%) used the tool for shift transitions and found it helpful for medical history (79%) but not for acquiring medication, allergy, and responsible physician information. Nurses (96%) and others (75%) rated the tool as accurate. Medical nurses rated the tool more useful than surgical nurses, and pediatric nurses rarely used the tool. The tool was integrated into the daily workflow of non-physicians despite being designed for physician use. Non-physicians should be included in the design and implementation of electronic patient handoff systems.

Chart biopsy: an emerging medical practice enabled by electronic health records and its impacts on emergency department-inpatient admission handoffs

OBJECTIVE

To examine how clinicians on the receiving end of admission handoffs use electronic health records (EHRs) in preparation for those handoffs and to identify the kinds of impacts such usage may have.

MATERIALS AND METHODS

This analysis is part of a two-year ethnographic study of emergency department (ED) to internal medicine admission handoffs at a tertiary teaching and referral hospital. Qualitative data were gathered and analyzed iteratively, following a grounded theory methodology. Data collection methods included semi-structured interviews (N = 48), observations (349 hours), and recording of handoff conversations (N = 48). Data analyses involved coding, memo writing, and member checking.

RESULTS

The use of EHRs has enabled an emerging practice that we refer to as pre-handoff "chart biopsy": the activity of selectively examining portions of a patient's health record to gather specific data or information about that patient or to get a broader sense of the patient and the care that patient has received. Three functions of chart biopsy are identified: getting an overview of the patient; preparing for handoff and subsequent care; and defending against potential biases. Chart biopsies appear to impact important clinical and organizational processes. Among these are the nature and quality of handoff interactions, and the quality of care, including the appropriateness of dispositioning of patients.

CONCLUSIONS

Chart biopsy has the potential to enrich collaboration and to enable the hospital to act safely, efficiently, and effectively. Implications for handoff research and for the design and evaluation of EHRs are also discussed.