Impact of an education session on clinical handover between medical shifts in an emergency department: A pilot study

Improved patient safety with a simplified operating room to pediatric intensive care unit handover tool (PATHQS)

Introduction

Patient handover is a crucial transition requiring a high level of coordination and communication. In the BC Children's Hospital (BCCH) pediatric intensive care unit (PICU), 10 adverse events stemming from issues that should have been addressed at the operating room (OR) to PICU handover were reported into the patient safety learning system (PSLS) within 1 year. We aimed to undertake a quality improvement project to increase adherence to a standardized OR to PICU handover process to 100% within a 6-month time frame. In doing so, the secondary aim was to reduce adverse events by 50% within the same 6-month period.

Methods

The model for improvement and a Plan, Do, Study, Act method of quality improvement was used in this project. The adverse events were reviewed to identify root causes. The findings were reviewed by a multidisciplinary inter-departmental group comprised of members from surgery, anesthesia, and intensive care. Issues were batched into themes to address the most problematic parts of handover that were contributing to risk.

Intervention

A bedside education campaign was initiated to familiarize the team with an existing handover standard. The project team then formulated a new simplified visual handover tool with the mnemonic "PATHQS" where each letter denoted a step addressing a theme that had been noted in the pre-intervention work as contributing to adverse events.

Results

Adherence to standardized handover at 6 months improved from 69% to 92%. This improvement was sustained at 12 months and 3 years after the introduction of PATHQS. In addition, there were zero PSLS events relating to handover at 6 and 12 months, with only one filed by 36 months. Notably, staff self-reporting of safety concerns during handover reduced from 69% to 13% at 6 months and 0% at 3 years. The PATHQS tool created in this work also spread to six other units within the hospital as well as to one adult teaching hospital.

Conclusion

A simplified handover tool built collaboratively between departments can improve the quality and adherence of OR to PICU handover and improve patient safety. Simplification makes it adaptable and applicable in many different healthcare settings.

Development and implementation of a standardised emergency department intershift handover tool to improve physician communication

BACKGROUND

Structured handover can reduce communication breakdowns and potential medical errors. In our emergency department (ED) we identified a safety risk due to variation in quality and content of overnight handovers between physicians.

AIM

Our goal was to develop and implement a standardised ED-specific handover tool using quality improvement (QI) methodology. We aimed to increase the proportion of patients having adequate handover information conveyed at overnight shift change from a baseline of 50%-75% in 4 months.

METHODS

We used published best practices, stakeholder input and local data to develop a tool customised for intershift ED handovers. Implementation methods included education, cognitive aids, policy change and plan-do-study-act cycles informed by end-user feedback. We monitored progress using direct observation convenience sampling.

MEASURES

Our outcome measure was proportion of adequate patient handovers (defined as >50% of handover components communicated per patient) per overnight handover session. Tool utilisation characteristics were used for process measurement, and time metrics for balancing measures. We report changes using statistical process control charts and descriptive statistics.

RESULTS

We observed 49 overnight handover sessions from 2017 to 2019, evaluating handovers of 850 patients. Our improvement target was met in 10 months (median=76.1%) and proportion of adequate handovers continued to improve to median=83.0% at the postimprovement audit. Written communication of handover information increased from a median of 19.2% to 68.7%. Handover time increased by median=31 s per patient. End-users subjectively reported improved communication quality and value for resident education.

CONCLUSIONS

We achieved sustained improvements in the amount of information communicated during physician ED handovers using established QI methodologies. Engaging stakeholders in handover tool customisation for local context was an important success factor. We believe this approach can be easily adopted by any ED.

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.