A national survey of obstetric anaesthetic handovers

Obstetric shift-to-shift handover in Kerala, India: A cross-sectional mixed method study

INTRODUCTION

Beyond the provision of services, quality of care and patient safety measures such as optimal clinical handover at shift changes determine maternity outcomes. We aimed to establish the proportion of women handed over and the content of clinical handovers and communication between shifts within 3 diverse obstetrics units in Kerala, India, and to describe the handover environment.

METHODS

A cross sectional study was conducted for six weeks during February and March 2015at three hospitals in Kerala, India, during nurses obstetric handover in one tertiary private, one tertiary government and one secondary government hospital. Nursing handovers in obstetric post-operative, in-patient and labour wards were sampled. An SBAR-based (situation, background, assessment and recommendation) data schedule was completed whilst observing handover at nursing shift changes. Since obstetricians had no scheduled handover, qualitative interviews were conducted with obstetricians in two hospitals to establish how they acquire information when beginning a shift.

RESULTS

Data was obtained on 258 patients handed over, within 67 shift changes. The median percentage of women handed over was 100% in two of the hospitals and 27.6% in the other. The median number of information items included out of a possible 25 was 11, 5 and 4,and did not change significantly for women with high-risk status. Important items regarding assessment and recommendation for care were often missed, including high-risk status. The median number of environment items achieved was good at 7 out of 10 in all hospitals. Obstetricians sought information in various ways when required. All supported the development of structured tools, face-to-face and team handovers.

CONCLUSIONS

Maternity unit handovers for doctors and nurses were inadequate. Ensuring handover of all women and including critical information, between shifts as well as between doctors, needs to be improved to increase patient safety.

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.

Differences in the handover process and perception between nurses and residents in a critical care setting

AIMS AND OBJECTIVES

To identify the differences in practices and perceptions of handovers between nurses and residents in the critical care setting, so as to improve the quality of the process.

BACKGROUND

Critically ill patients with complex problems are ideal for the study of handovers. However, few handover studies have been conducted in intensive care units.

DESIGN

Descriptive study using questionnaires.

METHODS

We interviewed all nurses and residents involved in handovers of patients admitted to and discharged from a medical intensive care unit over a period of one month. Interviews were guided by a questionnaire and conducted between 24-48 hours of handovers.

RESULTS

Out of 672 eligible participants, 580 (290 nurses and 290 residents) agreed to participate in the study (86·3% response rate). Compared to residents, nurses received more training on handovers, covered issues specific to allied health specialties more frequently during handovers, and reviewed patients earlier after handovers. The perceived importance of the different components of handover varied significantly: donor residents, donor nurses, recipient residents and recipient nurses emphasised the overall management plan, case complexity, management plan over the next 48 hours and past medical history, including allergies, respectively. Satisfaction in the handover was related to pre-handover review of electronic medical records, handover training and clarity level in the management plan following the handover, with only the last factor remaining significant on multivariate analysis.

CONCLUSIONS

More nurses than residents received prior training in handovers. Nursing handovers were more inclusive of allied health specialties. The perceived importance of the components of handover varied. Greater clarity in management plans was associated with better satisfaction.

RELEVANCE TO CLINICAL PRACTICE

Deficiencies in the handover process (lack of prior training in handovers, not including allied health specialties and not reviewing electronic records before handover) were identified, thus providing opportunities for mutual learning between nurses and residents.

An audit of the efficacy of a structured handover tool in obstetric anaesthesia

INTRODUCTION

The SAFE handover tool was developed to reduce critical omissions during handovers in obstetric anaesthesia. It comprises a simple proforma onto which the outgoing team documents patients who fall into one of four anaesthetically relevant categories: Sick patients; At-risk patients (of emergency caesarean section, major haemorrhage or anaesthetic problems); Follow-ups; and Epidurals. We hypothesised that its use would reduce the number of critical omissions at handover.

METHODS

The efficacy of the SAFE handover tool was assessed through several audit cycles in a single maternity unit. The four SAFE categories were considered the gold standard, since they encompassed the consensus opinion of senior obstetric anaesthetists with respect to parturients they most wanted to know about at handover. Against these criteria it was possible to compare the number of cases that should have been handed-over against the number that were actually handed-over.

RESULTS

After implementation of the handover tool, patients were four times more likely to be handed-over than without the use of the tool: an increase from 49% to 79% of relevant cases (P<0.0001, OR 4.1, 95% CI 2.19-7.6). The handover tool was particularly effective at increasing the handover rates of Sick and At-risk parturients, which increased from 21% to 67% (P<0.0001, OR 7.7, 95% CI 2.7-21.7) and 25% to 78% (P<0.01, OR 9.9, 95% CI 1.6-61.6), respectively.

CONCLUSION

The SAFE handover tool significantly increased handover rates of anaesthetically relevant parturients. It is easy to remember and consistent with UK National Health Service Litigation Authority's guidance on risk management in maternity units.

Standardizing and Evaluating Transitions of Care in the Era of Duty Hour Reform: One Institution's Resident-Led Effort

BACKGROUND

Compliance with the Accreditation Council for Graduate Medical Education duty hour standards may necessitate more frequent transitions of patient responsibility.

INTERVENTION

We created a multidisciplinary Patient Safety and Quality Council with a Task Force on Handoffs (TFH), engaging residents at a large, university-based institution.

METHODS

The TFH identified core content of effective handoffs and patterned institutional content on the SIGNOUTT mnemonic. A web-based module highlighting core content was developed for institutional orientation of all trainees beginning summer 2011 to standardize handoff education. The TFH distributed handoff material and catalogued additional program initiatives in teaching and evaluating handoffs. A standard handoff evaluation tool, assessing content, culture, and communication, was developed and "preloaded" into the institution-wide electronic evaluation system to standardize evaluation. The TFH developed questions pertaining to handoffs for an annual institutional survey in 2011 and 2012. Acceptability of efforts was measured by program participation, and feasibility was measured by estimating time and financial costs.

RESULTS

Programs found the TFH's efforts to improve handoffs acceptable; to date, 13 program-specific teaching initiatives have been implemented, and the evaluation tool is being used by 5 programs. Time requirements for TFH participants average 2 to 3 h/mo, and financial costs are minimal. More residents reported having education on handoffs (58% [388 of 668] versus 42% [263 of 625], P < .001) and receiving adequate signouts (69% [469 of 680] versus 61% [384 of 625], P  =  .004) in the 2012 survey, compared with 2011.

CONCLUSIONS

Use of a multispecialty resident leadership group to address content, education, and evaluation of handoffs was feasible and acceptable to most programs at a large, university-based institution.

Timing is everything-colectomy performed on Monday decreases length of stay

BACKGROUND

Perioperative care of patients undergoing colon resection requires a multidisciplinary approach by the operating surgeon, residents, and nurses. Operations performed on Monday take full advantage of hospital resources throughout the week to meet expected discharge by Friday. In a current health care environment of diminishing means, improving the timing of surgery in relation to expected length of stay may play an important role in preserving health care resources.

METHODS

A retrospective review of a prospectively collected colorectal surgical database identified all patients who underwent segmental colon resection at a single tertiary care referral center from 2004 to 2010. Length of stay for patients undergoing elective open and minimally invasive segmental colectomy was compared for Monday versus Tuesday through the weekend. Patient and surgeon demographics were recorded as well as postoperative outcomes and complications.

RESULTS

A total of 868 segmental colectomies were performed during the study period. Length of stay was significantly decreased by .73 days (P < .01) for all segmental colectomies performed on Monday compared with those performed Tuesday through Sunday. There was also a significant decrease in length of stay looking independently at right (.96 days, P < .01) and left or sigmoid colectomies (.56 days, P < .01). There was no significant difference in patient or surgeon demographics to account for this difference.

CONCLUSIONS

Segmental colectomies have a significantly decreased length in stay when performed on Monday compared with the rest of the week. The decrease is independent of surgeon, comorbidities, and complications. This difference may be the result of patients' taking full advantage of hospital resources and ancillary support. Cost-effective measures may be evaluated and directed at adjustment of resources available throughout the week to reduce length of stay.

The effect of a checklist on the quality of post-anaesthesia patient handover: a randomized controlled trial

OBJECTIVE

Patient handover is an important element of continuity, quality and safety in patient care. Handover without standardized protocols is prone to information loss and might be a possible danger to patient safety. Checklists are established methods that help to structure complex processes in other high-risk fields such as aviation. In the past few years, their implementation has attracted research interest in medicine. We hypothesize that a checklist for handover between anaesthesiologist and post-anaesthesia care unit nurse will increase the amount of information transfer during patient handover after anaesthesia.

DESIGN AND SETTING

A total of 120 post-anaesthesia patient handovers were recorded on video and analyzed. Forty handovers before the implementation of the checklist and 80 after the implementation of the checklist, randomized into two groups: with and without the use of the checklist.

MAIN OUTCOME MEASURES

An overall number of items handed over, handover of specific items and duration of the handover were analyzed.

RESULTS

With the use of the written checklist, the overall items handed over increased significantly from a median of 32.4-48.7%. The duration of handover increased from a median of 86-121 s. Instructions about items that should be included in handovers, but without the use of a written checklist, was not associated with an increase in the number of items handed over or duration of the interview.

CONCLUSIONS

This study suggests that the use of a checklist for post-anaesthesia handover might improve the quality of patient handover by increasing the information handed over.

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements

With changes in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements related to transitions in care effective July 1, 2011, sponsoring institutions and training programs must develop a common structure for transitions in care as well as comprehensive curricula to teach and evaluate patient handoffs. In response to these changes, within the Duke University Health System, the resident-led Graduate Medical Education Patient Safety and Quality Council performed a focused review of the handoffs literature and developed a plan for comprehensive handoff education and evaluation for residents and fellows at Duke. The authors present the results of their focused review, concentrating on the three areas of new ACGME expectations--structure, education, and evaluation--and describe how their findings informed the broader initiative to comprehensively address transitions in care managed by residents and fellows. The process of developing both institution-level and program-level initiatives is reviewed, including the development of an interdisciplinary minimal data set for handoff core content, training and education programs, and an evaluation strategy. The authors believe the final plan fully addresses both Duke's internal goals and the revised ACGME Common Program Requirements and may serve as a model for other institutions to comprehensively address transitions in care and to incorporate resident and fellow leadership into a broad, health-system-level quality improvement initiative.

The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department

Objectives

This study identifies best practice for shift handover and introduces a new tool used to hand over clinical and operational issues at the end of a shift in the emergency department (ED).

Methods

Literature review, semi-structured interviews and observations of handover were used to develop a standardised process for handover. Participants were ED middle grades, consultants and senior nurses. Interviews were used to identify agreed best practice and derive a tool to classify the information into relevant sections.

Results

Interviews identified a variety of perceived current deficits in handover including a lack of standardised practice and structure. Participants provided examples of poor handover that were thought to have led to adverse events; these included delay in investigations and treatment for patients who were handed over with brief or inaccurate information. There was wide variation in the understanding of the meaning and purpose of shift handover, and differences were apparent according to the level of experience of the middle grades interviewed. The experts' responses were used to reach a unifying ‘best practice’ for the content of handover. This was then grouped under ABCDE headings to develop the ABC of handover tool.

Conclusions

A simple tool was developed to provide the basis for medical shift handover, which includes clinical and operational information necessary for efficiency and organisation of the next shift. The ABC of handover classifies shift information to be handed over under the ABCDE headings, which are easy to remember and highly relevant to emergency medicine.

Transferring responsibility and accountability in maternity care: clinicians defining their boundaries of practice in relation to clinical handover

OBJECTIVE

This exploratory study reports on maternity clinicians' perceptions of transfer of their responsibility and accountability for patients in relation to clinical handover with particular focus transfers of care in birth suite.

DESIGN

A qualitative study of semistructured interviews and focus groups of maternity clinicians was undertaken in 2007. De-indentified data were transcribed and coded using the constant comparative method. Multiple themes emerged but only those related to responsibility and accountability are reported in this paper.

SETTING

One tertiary Australian maternity hospital.

PARTICIPANTS

Maternity care midwives, nurses (neonatal, mental health, bed managers) and doctors (obstetric, neontatology, anaesthetics, internal medicine, psychiatry).

PRIMARY OUTCOME MEASURES

Primary outcome measures were the perceptions of clinicians of maternity clinical handover.

RESULTS

The majority of participants did not automatically connect maternity handover with the transfer of responsibility and accountability. Once introduced to this concept, they agreed that it was one of the roles of clinical handover. They spoke of complete transfer, shared and ongoing responsibility and accountability. When clinicians had direct involvement or extensive clinical knowledge of the patient, blurring of transition of responsibility and accountability sometimes occurred. A lack of 'ownership' of a patient and their problems were seen to result in confusion about who was to address the clinical issues of the patient. Personal choice of ongoing responsibility and accountability past the handover communication were described. This enabled the off-going person to rectify an inadequate handover or assist in an emergency when duty clinicians were unavailable.

CONCLUSIONS

There is a clear lack of consensus about the transition of responsibility and accountability-this should be explicit at the handover. It is important that on each shift and new workplace environment clinicians agree upon primary role definitions, responsibilities and accountabilities for patients. To provide system resilience, secondary responsibilities may be allocated as required.

Patients' perceptions of safety and quality of maternity clinical handover

Background

Maternity clinical handover serves to address the gaps in knowledge existing when transitions between individuals or groups of clinicians occur throughout the antenatal, intra-partum and postnatal period. There are limited published studies on maternity handover and a paucity of information about patients' perceptions of the same. This paper reports postnatal patients' perceptions of how maternity handover contributes to the quality and safety of maternity care.

Methods

This paper reports on a mixed-methods study consisting of qualitative interviews and quantitative medical record analysis. Thirty English-speaking postnatal patients who gave birth at an Australian tertiary maternity hospital participated in a semi-structured interview prior to discharge from hospital. Interview data were coded thematically using the constant comparative method and managed via NVivo software; this data set was supplemented by medical record data analysed using STATA.

Results

Almost half of the women were aware of a handover process. Clinician awareness of patient information was seen as evidence that handover had taken place and was seen as representing positive aspects of teamwork, care and communication by participants, all important factors in the perception of quality health care. Collaborative cross-checking, including the use of cognitive artefacts such as hand held antenatal records and patient-authored birth plans, and the involvement of patients and their support people in handover were behaviours described by participants to be protective mechanisms that enhanced quality and safety of care. These human factors also facilitated team situational awareness (TSA), shared decision making and patient motivation in labour.

Conclusions

This study illustrates that many patients are aware of handover processes. For some patients, evidence of handover, through clinician awareness of information, represented positive aspects of teamwork, care and communication.

Cross-checking and cognitive artefacts were observed to support handover. Patient-authored birth plans were described by some to enhance the quality and safety of the handover by providing a 'voice' to the patient in this process. This was a novel and potentially important perspective.

Future research involving patients and their support people in supporting and evaluating handover should be considered.

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.

Improving handoffs in the emergency department

Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.

SHARED maternity care: enhancing clinical communication in a private maternity hospital setting

Midwives and visiting medical officers have a unique relationship within private hospital maternity settings. The effective exchange of accurate information between them is a fundamental element of patient safety and is vital to the success of the clinical handover process. The SHARED (situation, history, assessment, risk, expectation, documentation) project developed, implemented and evaluated a framework and support tools for improving clinical handover in two private maternity hospitals. The project included a pre- and post-study design using clinician surveys, chart audits, patient satisfaction surveys and a review of clinical incident data. A standardised approach to handover, using the SHARED framework with a standardised minimum dataset, improves the accuracy and appropriateness of information.

Can medical simulation and team training reduce errors in labor and delivery?

Patient safety is one of the most pressing challenges in health care today, and there is no question that medical errors occur and that patients are worried about them. Currently, there is a belief that the availability of medical simulations and the knowledge gained from the science of team training may improve patient outcomes, and there is a paradigm shift occurring in many universities and training programs. This article discusses two strategies that, when combined, may reduce medical error in the labor and delivery suite: team training and medical simulation.