Lost information during the handover of critically injured trauma patients: a mixed-methods study

Design and construct of an assessment tool for the handover of critical patient the in urgent care and emergency setting

OBJECTIVES

To design and construct an assessment tool for the handover of critical patients in the urgent care and emergency setting.

RESEARCH METHODOLOGY

This metric and descriptive study comprised two phases in accordance with the Clinical practice guidelines for A Reporting Tool for Adapted Guidelines in Health Care: The RIGHT-Ad@pt Checklist. In the first phase, the identification and selection of items related to the handover of critical patients were performed by consensus of a group of experts. The second phase consisted of two stages. In the first stage, the items were selected by applying the e-Delphi technique across two assessment rounds and in the second stage, the items were subjected a pilot test in a real critical patient handover scenario. Professionals from different disciplines and work areas (hospital and prehospital) caring for critically ill patients in the urgency and emergency setting participated in each of the phases.

RESULTS

A total of 58 critical patient care, and urgent and emergency care professionals participated in the design and construction of the assessment tool. The initial list consisted of 14 categories and 57 items, which were reduced to 28 items grouped into five categories after the intervention of the participants. The content validity index (CVI) of the instrument was 0.966.

CONCLUSIONS

This study describes an assessment tool developed in Spanish-language designed to assess the handover of critical patients in the urgent care and emergency setting. This tool has a high CVI, and is the only currently available tool that consider all of the dimensions and characteristics of the handover process.

IMPLICATIONS FOR CLINICAL PRACTICE

The assessment tool developed in this study could enable critical care professionals in their clinical practice to work in a systematic way, universalizing the handover of critically ill patients in the urgent care and emergency setting through scientifically proven guidelines.

Psychometric Analysis of the Spanish-Language Version of the Instrument for the Evaluation of Handovers in Critically Ill Patients in Urgent and Emergency Care Settings

Background/Objectives: Patient handover is the process by which the responsibility for care is transferred from one health care professional to another. Given the lack of validated scales to assess the handover of critically ill patients, our aim was to evaluate the reliability and validity of the Instrumento de Evaluación de la Transferencia de Enfermos Críticos (IETEC) (English: Instrument for the Evaluation of Handovers in Critically Ill Patients). Methods: Psychometric analysis of the reliability and validity (construct, convergent, and discriminant) of the IETEC. This single-center study included professionals (nurses, physicians, and emergency medical technicians) involved in the care of the critically ill in urgent care and emergency situations. Results: We evaluated 147 handovers of critically ill patients. The KR-20 score was 0.87, indicting good internal consistency. Of the 147 handovers, 117 (79.6%) were classified as unsafe and 30 (20.4%) as safe. The model fit showed an acceptable construct validity (24 items and four factors: Identification, Communication, Quality, and Family). The Communication domain had the strongest correlation with the total scale (r = 0.876) while Family had the weakest (r = 0.706). The Communication and Family domains were closely correlated (r = 0.599). The IETEC reliably differentiated between safe and unsafe handovers, with a mean (SD) score of 26.3 (1.2) versus 19.0 (4.8), respectively. No significant differences (p = 0.521) in mean IETEC scores were observed between the physicians and nurses. Conclusions: These results show that the IETEC presents adequate psychometric properties and is, therefore, a valid, reliable tool to evaluate handovers in critically ill patients in urgent care and emergency settings.

Improved recall of handover information in a simulated emergency - A randomised controlled trial

Background

Handovers during medical emergencies are challenging due to time-critical, dynamic and oftentimes unorderly and distracting situations. We evaluated the effect of distraction-reduced clinical surroundings during handover on (1) the recall of handover information, (2) the recall of information from the surroundings and (3) self-reported workload in a simulated in-hospital cardiac arrest scenario.

Methods

In a parallel group design, emergency team leaders were randomly assigned to receive a structured handover of a cardio-pulmonary resuscitation (CPR) either inside the room ("inside group") right next to the ongoing CPR or in front of the room ("outside group") with no audio-visual distractions from the ongoing CPR. Based on the concept of situation awareness, the primary outcome was a handover score for the content of the handover (0-19 points) derived from the pieces of information given during handover. Furthermore, we assessed team leaders' perception of their surroundings during the scenario (0-5 points) and they rated their subjective workload using the NASA Task Load Index.

Results

The outside group (n = 30) showed significant better recall of handover information than the inside group (n = 30; mean difference = 1.86, 95% CI = 0.67 to 3.06, p = 0.003). The perception of the surroundings (n = 60; mean difference = -0.27, 95% CI = -0.85 to 0.32, p = 0.365) and the NASA Task Load Index (n = 58; mean difference = 1.1; p = 0.112) did not differ between the groups.

Conclusions

Concerning in-hospital emergencies, a structured handover in a distraction reduced environment can improve information uptake of the team leader.

Seasonality and temporal variation of pediatric trauma in Southern California

INTRODUCTION

Seasonality of pediatric trauma has been previously described, although the association of season with hour of presentation is less understood. Both factors have potential implications for resource allocation and team preparedness.

METHODS

A multicenter retrospective study was conducted to analyze the records of injured children <18 years-old who presented to one of the 15 trauma centers within Los Angeles County. Data from the County Trauma and Emergency Medicine Information System Registry was abstracted from 1/1/10 to 12/31/21. Patient demographics, mechanism of injury (MOI) and time of presentation by season were analyzed using Kruskal Wallis tests and chi-square tests.

RESULTS

A total of 30,444 pediatric trauma presentations were included. Both the time of presentation and the MOI differed significantly by season with p < 0.001. Autumn had a higher incidence of pedestrian injuries during hours of 08:00 and 15:0020:00, and sports injuries from 16:00 to 21:00. In the Summer there were more burns between 17:00 and 23:00 and falls from greater than 10 ft after 13:00. The mode of transport used was also different across seasons (p = 0.03), with the use of both air and ground EMS greatest during summer and least during winter. The hours of greatest utilization remained relatively constant for all seasons for air transport (18:00-19:00 h) and ground transport (19:00-20:00 h).

CONCLUSION

These data demonstrate the significant seasonal and temporal variation within pediatric trauma. These findings could be used to inform improvements in emergency response, and resource allocation in particular.

Improving the handover of complex trauma patients by implementing a standardised process

BACKGROUND

Patient handover continues to be an international health priority in the prevention of patient harm. Transitioning patients from the intensive care unit (ICU) to the ward is complex, particularly for trauma patients, due to the multifaceted aspects of their care requirements as a result of multiple injuries and different speciality teams.

OBJECTIVES/AIM

To design, implement, and evaluate the efficacy of a standardised handover process and tool for the transfer of ICU trauma patients.

METHODS

A multimethod before/after study design was used. This included observations before and after an implemented transfer process and semistructured interviews with ICU and ward nurses caring for trauma patients. Comparisons were made of data before and after the intervention.

RESULTS

Eleven patient handovers were observed, and 21 nurses (11 from the ICU and 10 from the ward) were interviewed. Patients and family members were included during the handover following the intervention (n = 0/10 [0%] vs n = 4/11 [36%]) and the ward nurses were asked if they had any concerns (n = 5/10 [50%] vs n = 10/11 [91%]). Improvements in patient observations handed over were reported following the intervention. However, omissions remained in some key areas including patient introduction, patient identity, fluid balance, and allergies/alerts. Thematic analysis of interviews revealed that the new handover process was perceived advantageous by both ICU and ward nurses because of its structured and comprehensive approach. Identified future improvements included the need for hospital service managers to ensure integration of ICU and ward electronic health record systems.

CONCLUSION

Precise, accurate, and complete handover remains a patient safety concern. Improvements were achieved using a standardised process and handover tool for the transfer of complex trauma patients. Further improvements are required to reduce the failure to hand over essential patient information.

Effectiveness of handover practices between emergency department and intensive care unit nurses

Background

Nurses from the emergency department (ED) and the intensive care unit (ICU) must interact during the handover procedure. Factors such as unit boundaries, the interaction between different specialities, patient acuities, and treatment adjustments generate specific negotiating and teamwork problems during the transition of patients from ED to ICU.

Objective

This study aimed to describe the opinions of nurses regarding the effectiveness of handover practices between nurses in the ED and ICU in a major academic hospital in Gauteng province, South Africa.

Method

An analytical cross-sectional survey design was used. Data were collected using a 16-item handover evaluation tool. It comprises two sections (1) biographical details and (2) 16 statements about handover quality divided into five constructs, namely information transfer, shared understanding, working atmosphere, overall handover quality, and circumstances of handover. Data analysis was done utilising descriptive and non-parametric statistics.

Results

The majority (51.8%; n = 115) of the handovers occurred during the day. Out of 171 nurses, there were specialist practice emergency (19.2%; n = 33) and intensive care (28.0%; n = 48) nurses. There was statistical significance in information transfer between the ED and ICU nurses. (Me = 4.0, p < 0.05), compared to ICU nurses (Me = 3.0). Nurse specialist and non-specialist nurses' handovers differed statistically significantly on 12 of the 16 items on the rating scale, compared to 10 for non-specialist nurses' handovers.

Conclusion

The study showed that ED and ICU nurses have significantly different requirements and expectations for handover procedures. In addition to completed documentation, subtle interpretations of the information provided and received also impact the need. The ED and ICU nurses would need to agree on the contents of a structured handover framework because different specialities and departments have varied expectations to achieve an effective handover.

Does mortality after trauma team activation peak at shift change?

BACKGROUND

Prior institutional data have demonstrated trauma mortality to be highest between 06:00-07:59 at our center, which is also when providers change shifts (07:00-07:30). The objective was definition of patient, provider, and systems variables associated with trauma mortality at shift change among patients arriving as trauma team activations (TTA).

METHODS

All TTA patients at our ACS-verified Level I trauma center were included (01/2008-07/2019), excluding those with undocumented arrival time. Study groups were defined by arrival time: shift change (SC) (06:00-07:59) vs. non-shift change (NSC) (all other times). Univariable/multivariable analyses compared key variables. Propensity score analysis compared outcomes after matching.

RESULTS

After exclusions, 6020 patients remained: 229 (4%) SC and 5791 (96%) NSC. SC mortality was 25% vs. 16% during NSC (p < 0.001). More SC patients arrived with SBP <90 (19% vs. 11%, p < 0.001) or GCS <9 (35% vs. 24%, p < 0.001). ISS was higher during SC (43[32-50] vs. 34[27-50], p < 0.001). Time to CT scan (36[23-66] vs. 38[23-61] minutes, p = 0.638) and emergent surgery (94[35-141] vs. 63[34-107] minutes, p = 0.071) were comparable. Older age (p < 0.001), SBP <90 (p < 0.001), GCS <9 (p < 0.001), need for emergent operative intervention (p = 0.044), and higher ISS (p < 0.001) were independently associated with mortality. After propensity score matching, mortality was no different between SC and NSC (p = 0.764).

CONCLUSIONS

Early morning is a low-volume, high-mortality time for TTAs. Increased mortality at shift change was independently associated with patient/injury factors but not provider/systems factors. Ensuring ample clinical resource allocation during this high acuity time may be prudent to streamline patient care at shift change.

Listeria meningitis associated with tonsillar herniation in an immunocompetent school-aged child

Listeria monocytogenes can cause severe illnesses such as gastroenteritis, sepsis and neurolisteriosis, especially in infants, the elderly and immunocompromised patients. We report a case of a previously healthy school-aged girl presenting with severe neurological deficits found to have Listeria meningoencephalitis. Her potential exposure to L. monocytogenes was consumption of contaminated cheese. She had some clinical improvement after initiation of tailored Listeria anti-microbial coverage with ampicillin and gentamicin; however, she developed hydrocephalus requiring external ventricular drain placement and tonsillar herniation requiring emergent posterior fossa decompression. The patient made significant improvements after neurosurgical intervention, and along with continued antibiotics and subsequent rehabilitation services, she improved to near full recovery within a year. The case highlights that neurolisteriosis can affect even immunocompetent children, and aggressive neurosurgical interventions should be considered in patients who develop severe complications such as hydrocephalus and tonsillar herniation to improve outcomes.

Holistic strategy for promoting effective handoffs

Background

Handoffs are ubiquitous in modern healthcare practice, and they can be a point of resilience and care continuity. However, they are prone to a variety of issues. Handoffs are linked to 80% of serious medical errors and are implicated in one of three malpractice suits. Furthermore, poorly performed handoffs can lead to information loss, duplication of efforts, diagnosis changes and increased mortality.

Methods

This article proposes a holistic approach for healthcare organisations to achieve effective handoffs within their units and departments.

Results

We examine the organisational considerations (ie, the facets controlled by higher-level leadership) and local drivers (ie, the aspects controlled by the individuals working in the units and providing patient care).

Conclusion

We propose advice for leaders to best enact the processes and cultural change necessary to see positive outcomes associated with handoffs and care transitions within their units and hospitals.

Comprehensive Improvement of Cardiology Inpatient Transfers: A Bed-availability Triggered Approach

Introduction

Patient transfers pose a potential risk during hospitalizations. Structured communication practices are necessary to ensure effective handoffs, but occur amidst competing priorities and constraints. We sought to design and implement a multidisciplinary process to enhance communication between pediatric cardiovascular intensive care unit and cardiology floor teams with a comprehensive approach evaluating efficiency, safety, and culture.

Methods

We conducted a prospective quality improvement study to enact a bed-availability triggered bedside handoff process. The primary aim was to reduce the time between handoff and unit transfer. Secondary metrics captured the impact on safety (reported safety events, overnight transfers, bounce backs, and I-PASS utilization), efficiency (transfer latency, unnecessary patient handoffs, and cumulative time providers were engaged in handoffs), and culture (team members perceptions of satisfaction, collaboration, and handoff efficiency via survey data).

Results

Eighty-two preimplementation surveys, 26 stakeholder interviews, and 95 transfers were completed during the preintervention period. During the postintervention period, 145 handoffs were audited. We observed significant reductions in transfer latency, unnecessary handoffs, and cumulative provider handoff time. Overnight transfers decreased, and no negative impact was observed in reported safety events or bouncebacks. Survey results showed a positive impact on collaboration, efficiency, and satisfaction among team members.

Conclusions

Developing safer handoff practices require a collaborative, structured, and stepwise approach. Advances are attainable in high-volume centers, and comprehensive measurement of change is necessary to ensure a positive impact on the overall patient and provider environment.

Who's on your team? Specialty identity and inter-physician conflict during admissions

PURPOSE

Despite the implementation of professionalism curricula and standardised communication tools, inter-physician conflict persists. In particular, the interface between emergency medicine (EM) and internal medicine (IM) has long been recognised as a source of conflict. The social nuances of this conflict remain underexplored, limiting educators' ability to comprehensively address these issues in the clinical learning environment. Thus, the authors explored EM and IM physicians' experiences with negotiating hospital admissions to better understand the social dynamics that contribute to inter-physician conflict and provide foundational guidance for communication best practices.

METHODS

Using a constructivist grounded theory (CGT) approach, the authors conducted 18 semi-structured interviews between June and October 2020 with EM and IM physicians involved in conversations regarding admissions (CRAs). They asked participants to describe the social exchanges that influenced these conversations and to reflect on their experiences with inter-physician conflict. Data collection and analysis occurred iteratively. The relationships between the codes were discussed by the research team with the goal of developing conceptual connections between the emergent themes.

RESULTS

Participants described how their approaches to CRAs were shaped by their specialty identity, and how allegiance to members of their group contributed to interpersonal conflict. This conflict was further promoted by a mutual sense of disempowerment within the organisation, misaligned expectations, and a desire to promote their group's prerogatives. Conflict was mitigated when patient care experiences fostered cross-specialty team formation and collaboration that dissolved traditional group boundaries.

CONCLUSIONS

Conflict between EM and IM physicians during CRAs was primed by participants' specialty identities, their power struggles within the broader organisation, and their sense of duty to their own specialty. However, formation of collaborative inter-specialty physician teams and expansion of identity to include colleagues from other specialties can mitigate inter-physician conflict.

Safe handovers: Safe patients-why good quality structured handovers in the transfusion laboratory are important

BACKGROUND

Effective transfer of information relating to patient care is vital in healthcare. In the UK formal handover is an established and well reported process in the clinical setting but less so in transfusion laboratories. Blood transfusions occur within many hospital specialities and across clinical and laboratory staff shifts, making robust handover critical for safe practice. Failure to adequately transfer information relating to pending or ongoing provision of blood components during shift handover in the laboratory can have an adverse impact on patient care.

AIMS

To identify transfusion errors where laboratory handover was considered a contributory factor.

MATERIALS AND METHODS

Serious adverse events and reactions reported to the UK haemovigilance scheme, Serious Hazards of Transfusion (SHOT), involving handover in the transfusion laboratory were reviewed for a 6-year period.

RESULTS

Laboratory incidents involving handover were mainly associated with incorrect blood component transfused-specific requirements not met (IBCT-SRNM) and delays in provision of blood components transfusion, with 16.6% of these cases involving major haemorrhage situations. Handover was found to be insufficient in most cases, no handover was completed in 29.5% of cases, inadequate written handover accounted for 14.8% cases, and inadequate verbal for 5.7% of cases.

DISCUSSION

Poor handover can lead to laboratory errors, particularly delays in provision of blood components. Embedding effective handover processes in the laboratory and including handover time within the shift working pattern, may help reduce errors and ensure continuity of care.

CONCLUSION

Handover should be considered a task that is built into laboratory routine practices, ensuring effective transfer of information and appropriate follow up actions are taken. SHOT have created a handover template which can be adopted in laboratories to formalise this process.

Assessing the quality of patient handovers between ambulance services and emergency department – development and validation of the emergency department human factors in handover tool

Background

Patient handover between prehospital care and the emergency department plays a key role in patient safety. Therefore, we aimed to create a validated tool for measuring quality of communication and interprofessional relations during handover in this specific setting.

Methods

Based on a theoretical framework a comprehensive item pool on information transfer and human factors in emergency department handovers was created and refined in a modified Delphi survey involving clinical experts. Based on a pre-test, items were again revised. The resulting Emergency Department Human Factors in Handover tool (ED-HFH) was validated in a field test at the emergency department of a German university hospital from July to December 2017. The ED-HFH was completed by emergency department and ambulance service staff participating in handovers and by an external observer. Description of item characteristics, exploratory factor analysis, analyses on internal consistency and interrater reliability by intraclass-correlation. Construct validity was analysed by correlation with an overall rating on quality of the handover.

Results

The draft of the ED-HFH contained 24 items, 90 of 102 eligible staff members participated in the field test completing 133 questionnaires on 38 observed handovers. Four items were deleted after analysis of item characteristics. Factor analysis supported a single factor explaining 39% of variance in the items. Therefore, a sum-score was calculated with a possible range between 14 and 70. The median value of the sum-score in the sample was 61.5, Cronbach’s α was 0.83, intraclass-correlation was 0.52, the correlation with the overall rating of hand-over quality was ρ = 0.83 (p ≤ 0.001).

Conclusions

The ED-HFH showed its feasibility, reliability and validity as a measure of quality of information transfer and human factors in handovers between ambulance services  and the emergency department. It promises to be a useful tool for quality assurance and staff training.

Handover of Critical Patients in Urgent Care and Emergency Settings: A Systematic Review of Validated Assessment Tools

The emergency handover of critical patients is used to describe the moment when responsibility for the care of a patient is transferred from one critical patient care healthcare team to another, requiring the accurate delivery of information. However, the literature provides few validated assessment tools for the transfer of critical patients in urgent care and emergency settings. To identify the available evaluation tools that assess the handover of critical patients in urgent and emergency care settings in addition to evaluations of their psychometric properties, a systematic review was carried out using PubMed, Scopus, Cinahl, Web of Science (WoS), and PsycINFO, in accordance with PRISMA guidelines. The quality of the studies was assessed using the COSMIN checklist. Finally, eight articles were identified, of which only three included validated tools for evaluating the handover of critical patients in emergency care. Content validity, construct validity, and internal consistency were the most studied psychometric properties. Three studies evaluated error and reliability, criterion validity, hypothesis testing, and sensitivity. None of them considered cross-cultural adaptation or the translation process. This systematic psychometric review shows the existing ambiguities in the handover of critically ill patients and the scarcity of validated evaluation tools. For all of these reasons, we consider it necessary to further investigate urgent care and emergency handover settings through the design and validation of an assessment tool.

Emergency handover of critical patients. A systematic review

BACKGROUND

Emergency handover of critical patients is used to describe the moment of union between prehospital and hospital health team. However, the literature shows several definitions leading to great heterogeneity.

PURPOSE

To study the emergency handover of critical patients between two critical-emergency care wards performed by emergency nurses worldwide and to identify the features of these processes.

METHODS

We conducted an integrative review in eleven databases published from 2010 to 2019. Quality criteria and PRISMA checklist were applied. The protocol is registered with PROSPERO (CRD42020182335).

RESULTS

A total of 22 studies included and the following factors were identified: variability vs standardization, identification, professionals' behavior, localization, environmental factors, patient participation, clinical records, education/training, responsability, and communication.

CONCLUSIONS

The actual emergency handover occurs under conditions quite contrary to those recommended by experts so that it is neither safe nor effective, leading a serious problem for patient safety and quality care.

Critical care nurses' communication challenges during handovers: A systematic review and qualitative meta-synthesis

AIMS

To review and synthesize qualitative studies to gain a deeper understanding of critical care nurses' inter-departmental and shift-to-shift handover challenges.

BACKGROUND

Good-quality nurse-to-nurse handover promotes patient safety, while poor handover has been associated with medical errors. However, systematic reviews of qualitative approaches for better understanding the handover experiences of critical care nurses are lacking.

EVALUATION

Systematic review methods incorporating meta-synthesis were used. A comprehensive search of seven databases was conducted. Two independent reviewers performed data extraction and evaluated ten studies using the Critical Appraisal Screening Program. Findings were analysed and synthesized using thematic analysis. The transactional model of communication was used to guide the analysis.

KEY ISSUES

A total of 10 qualitative studies were included. Seven major handover themes were identified: (a) expectations of perfection, (b) need for partnership, (c) unilateral communication, (d) obstacles to information acquisition, (e) lack of pertinent patient information, (f) need for a structured handover and (g) interruptions/distractions.

CONCLUSIONS

Handovers should be considered an essential part of patient-centred care for ensuring continuity of care.

IMPLICATIONS FOR NURSING MANAGEMENT

Poor communication during a handover could increase the nurse's burden or stress and adversely affect patient care. Therefore, training should be provided on explicit handover communication.

Information concerning ICU patients' families in the handover-The clinicians' «game of whispers»: A qualitative study

AIMS AND OBJECTIVES

To explore how information concerning ICU patients´ families is included in the ICU clinicians' daily handover.

BACKGROUND

Handover refers to the transfer of information and care responsibility between clinicians. An effective and precise handover are of great importance to ensure quality of care. Although improvements in handovers have received increasing attention in recent decades, little is known about how information about ICU patients' family members is included in handovers.

DESIGN

A qualitative study using Charmaz' constructivist grounded theory approach.

METHODS

Data were gathered through participant observation, focus groups, dyadic and individual interviews of physicians and nurses from four ICUs in different Norwegian hospitals. The data consist of 270 observation hours, seven focus groups, three dyadic interviews and two individual interviews. Field notes and transcribed interview data were analysed using constructivist grounded theory approach. COREQ checklist was applied as reporting guideline for this study.

FINDINGS

"A game of whispers" emerged as the core category, representing missing information about the patient's family during the handover. Together with three subcategories: "documentation dilemmas," "being updated" and "talking together," the core category explains how transfer of family-related information between clinicians is continually processed and resolved.

CONCLUSIONS

This study indicates challenges related to appropriate and high-quality handover concerning ICU patients´ families. Oral handovers are essential in terms of clinicians' need to elaborate on written information and update each other. However, oral transmission involves a high risk of information loss during the handover. Written documentation about the family seems to be inadequate and poorly structured.

RELEVANCE TO CLINICAL PRACTICE

The study findings suggest a need for increased awareness in practice and research of the importance of transferring appropriate and reliable information about patients' families between ICU clinicians. User-friendly handover tools and patient records that include information on patients' family members should be developed.

Missed hand and forearm injuries in multiple trauma patients: An analysis from the TraumaRegister DGU®

PURPOSE

Multiple trauma patients have a high risk of missed injuries. The main point of our study was to provide new epidemiological data on hand and forearm injuries in multiple trauma with a focus on those that were missed. Therefore, we used the database of the TraumaRegister DGU®.

METHODS

In this study, we evaluated anonymous data from 139931 patients aged 1-100 years with multiple trauma in the TraumaRegister DGU® of the German Society for Trauma Surgery from 2007 to 2017. Patients with hand and forearm injuries documented during hospital stay were identified and analyzed. We included fractures, dislocations, tendon injuries, nerve injuries and vessel injuries. Patients with missed hand and forearm injuries were compared with patients with primary diagnosed injuries in view of gender, age, ISS, Abbreviated Injury Score (AIS), Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), trauma mechanism type of injury, hospital stay, RISC II and mortality rate. Missed injuries were defined as injuries that were recently diagnosed and documented in the intensive care unit (ICU).

RESULTS

A total of 50459 multiple trauma patients (36.1%) had hand or forearm injuries, and 89472 patients (63.9%) had neither. Patients with hand injuries were younger and were more often involved in car and motorcycle accidents. Severe head trauma was evaluated less frequently, and severe thorax trauma was evaluated more often in patients with hand injuries. The times of diagnosis of hand injuries were documented in 10971 cases. A total of 727 patients (6.6%) with missed hand injuries were registered. The most commonly missed injuries in multiple trauma were 104 carpal fractures/dislocations (11.2%), 195 nerve injuries (25.4%) and 54 tendon injuries (11.4%). Predisposing factors for missing injuries were multiple diagnoses, primary care in the first hospital and direct from emergency room transfer to the ICU.

CONCLUSION

In contrast to previous findings, severely injured patients, especially those with head injuries and GCS of ≤8, were not predisposed to have missed hand injuries compared to patients without severe head trauma. Special attention should be paid to younger patients after traffic accidents with multiple diagnoses and direct transfer to the ICU.

Nurse-to-nurse communication about multidisciplinary care delivered in the emergency department: An observation study of nurse-to-nurse handover to transfer patient care to general medical wards

BACKGROUND

Little is known about how Australian national safety standards for communicating multidisciplinary care are operationalised during high-risk care transitions. We examined transfer of care for complex patients from the emergency department (ED) to medical wards to explore nurse-to-nurse communication about multidisciplinary care provided in the ED.

METHODS

Using naturalistic, mixed-methods design, observation, audit and interview data were collected from a convenience sample of 38 nurses during transfer of care for 19 complex patients from the ED to medical wards at a tertiary hospital. A focus group with 19 clinicians from multiple disciplines explored explanations for findings and recommendations. Quantitative data were analysed using frequencies and descriptive statistics; the Connect, Observe, Listen, Delegate (COLD) framework informed qualitative content analysis.

RESULTS

Nurses seldom communicated multidisciplinary care at patient transfer. Most handovers included Connect and Observe (63-95%) and Listen (90%); Delegate (42%) behaviours were infrequent. Behaviours consistent with good practice recommendations (90%) and known to increase communication risk (53%) were observed. Tensions between policies and clinical processes, and information quality negatively impacted transfers.

CONCLUSIONS

This study revealed gaps in nurse-to-nurse communication about patients' multidisciplinary care. Complex factors negatively impact nurses' handover communication necessitating workarounds, and highlighting nurses' role as patient safety advocates.

Information flow during pediatric trauma care transitions: things falling through the cracks

Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Every year, nearly 10 million children are evaluated in emergency departments (EDs) for traumatic injuries, resulting in 250,000 hospital admissions and 10,000 deaths. Pediatric trauma care in hospitals is distributed across time and space, and particularly complex with involvement of large and fluid care teams. Several clinical teams (including emergency medicine, surgery, anesthesiology, and pediatric critical care) converge to help support trauma care in the ED; this co-location in the ED can help to support communication, coordination and cooperation of team members. The most severe trauma cases often need surgery in the operating room (OR) and are admitted to the pediatric intensive care unit (PICU). These care transitions in pediatric trauma can result in loss of information or transfer of incorrect information, which can negatively affect the care a child will receive. In this study, we interviewed 18 clinicians about communication and coordination during pediatric trauma care transitions between the ED, OR and PICU. After the interview was completed, we surveyed them about patient safety during these transitions. Results of our study show that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, important patient care information is often lost when transitioning patients between units. To safely manage the transition of this fragile and complex population, we need to find ways to better manage the information flow during these transitions by, for instance, providing technological support to ensure shared mental models.

Critical incident reporting systems (CIRS) in trauma patients may identify common quality problems

BACKGROUND

Critical incident reporting systems (CIRS) are considered to be a valid instrument to identify typical errors in various clinical settings as well as in prehospital emergency medicine. Our aim was to review incidents and errors in the care of trauma patients during the period of emergency trauma room treatment before their transfer to the intensive care unit or the operation room.

METHODS

We screened six open access and German language-based CIRS-platforms on the internet.

RESULTS

We identified 78 critical incidents. They could be divided into four groups: organization related (n = 30), communication related (n = 6), equipment related (n = 28), and medical error (n = 23). Within the category, typical, common, or frequent clusters were identified, such as incomplete trauma team, malfunctioning equipment, or a lack of communication skills. In 12 cases (15.4%), patients were reported to have been harmed, mostly by medical errors. Three reported incidents (3.6%) were considered near-incidents.

CONCLUSIONS

Our results demonstrate that using CIRS is able to reveal individual or rare errors and allows for the identification of systematic errors and deficiencies in the acute care of trauma patients in the trauma room. This may guide quality control and quality improvement measures to be focused on the most common fields of demand.

The impact of standardised perioperative handover protocols

The handover of the care of patients is acknowledged as a vulnerable period in the perioperative patient journey, and handovers given within the perioperative environment present the risk of potentially harmful errors occurring. These errors can result from poor communication and inaccurate information transfer, and may be avoided through the implementation of standardised protocols. This article presents an in depth literature review and discussion allowing for the examination of best practice in the delivery of a handover within the perioperative environment, drawing clear conclusions and presenting recommendations for best practice.

Barriers and facilitators of appropriate vancomycin use: prescribing context is key

PURPOSE

Audit studies reveal frequent non-compliance with dosing and monitoring guidelines for vancomycin. This study aimed to qualitatively explore the barriers and facilitators of compliance with vancomycin dosing and monitoring guidelines.

METHODS

Interviews were conducted with 16 prescribers in a large tertiary teaching hospital in Sydney, Australia. Questions explored knowledge, attitudes, and perceived complexities associated with vancomycin use. Interviews were analysed using thematic analysis.

RESULTS

Prescribers reported utilising vancomycin guidelines, citing familiarity with guidelines, a positive perception of guidelines, awareness of poor guideline compliance, and assistance from specialist staff as facilitators of the uptake of guideline recommendations. Barriers existing within the prescribing environment such as the prescribing culture, a lack of time, and poor communication and coordination of therapeutic drug monitoring processes were identified as hindrances to guideline compliance.

CONCLUSIONS

The provision of guidelines may not be sufficient in ensuring appropriate prescribing and monitoring of vancomycin when barriers relating to the prescribing environment exist. Developing interventions targeted toward these barriers, such as having dedicated phlebotomists for vancomycin blood sampling, fostering better handover processes, and educating staff on poorly understood aspects of guidelines, is likely to improve the uptake of guideline recommendations for vancomycin and other medications requiring therapeutic drug monitoring.

Strategies to Improve Information Transfer for Multitrauma Patients

The aim of this multiphase mixed-method study was to improve access, flow, and consistency of information transfer for multitrauma patients leaving the Emergency Department. Methods included literature review, focus group interviews, chart audits, staff surveys, and a review of international trauma forms to inform an intervention developed with a researcher-led, clinician stakeholder group. Analysis included descriptive and inferential statistics. Baseline data revealed variability existed in patient-care documentation, showing little standardization. Improvement strategies implemented included a gold standard for information embedded in handover tools, raising staff awareness of complexities for information transfer. Improvement was seen in communication between wards coordinating transfer, improved documentation, decreased information duplication, improved legibility, and increased ease and efficiency in navigating to key information. Improvement in communication at patient transition is essential to continuity of safe, effective care, and is impacted by complex interactions between multiple factors. Difficulty increases for patients with high acuity.

Mapping the Flow of Pediatric Trauma Patients Using Process Mining

BACKGROUND

Inhospital pediatric trauma care typically spans multiple locations, which influences the use of resources, that could be improved by gaining a better understanding of the inhospital flow of patients and identifying opportunities for improvement.

OBJECTIVES

To describe a process mining approach for mapping the inhospital flow of pediatric trauma patients, to identify and characterize the major patient pathways and care transitions, and to identify opportunities for patient flow and triage improvement.

METHODS

From the trauma registry of a level I pediatric trauma center, data were extracted regarding the two highest trauma activation levels, Alpha (n = 228) and Bravo (n = 1,713). An event log was generated from the admission, discharge, and transfer data from which patient pathways and care transitions were identified and described. The Flexible Heuristics Miner algorithm was used to generate a process map for the cohort, and separate process maps for Alpha and Bravo encounters, which were assessed for conformance when fitness value was less than 0.950, with the identification and comparison of conforming and nonconforming encounters.

RESULTS

The process map for the cohort was similar to a validated process map derived through qualitative methods. The process map for Bravo encounters had a relatively low fitness of 0.887, and 96 (5.6%) encounters were identified as nonconforming with characteristics comparable to Alpha encounters. In total, 28 patient pathways and 20 care transitions were identified. The top five patient pathways were traversed by 92.1% of patients, whereas the top five care transitions accounted for 87.5% of all care transitions. A larger-than-expected number of discharges from the pediatric intensive care unit (PICU) were identified, with 84.2% involving discharge to home without the need for home care services.

CONCLUSION

Process mining was successfully applied to derive process maps from trauma registry data and to identify opportunities for trauma triage improvement and optimization of PICU use.

A multi-center prospective cohort study of patient transfers from the intensive care unit to the hospital ward

PURPOSE

To provide a 360-degree description of ICU-to-ward transfers.

METHODS

Prospective cohort study of 451 adults transferred from a medical-surgical ICU to a hospital ward in 10 Canadian hospitals July 2014-January 2016. Transfer processes documented in the medical record. Patient (or delegate) and provider (ICU/ward physician/nurse) perspectives solicited by survey 24-72 h after transfer.

RESULTS

Medical records (100%) and survey responses (ICU physicians-80%, ICU nurses-80%, ward physicians-46%, ward nurses-64%, patients-74%) were available for most transfers. The median time from initiation to completion of transfer was 25 h (IQR 6-52). ICU physicians and nurses reported communicating with counterparts via telephone (78 and 75%) when transfer was requested (82 and 24%) or accepted (31 and 59%) and providing more elements of clinical information than ward physicians (mean 4.7 vs. 3.9, p < 0.001) and nurses (5.0 vs. 4.4, p < 0.001) reported receiving. Patients were more likely to report satisfaction with the transfer when they received more information (OR 1.32, 95% CI 1.18-1.48), had their questions addressed (OR 3.96, 95% CI 1.33-11.84), met the ward physician prior to transfer (OR 4.61, 95% CI 2.90-7.33), and were assessed by a nurse within 1 h of ward arrival (OR 4.70, 95% CI 2.29-9.66). Recommendations for improvement included having a documented care plan travel with the patient (all stakeholders), standardized face-to-face handover (physicians), avoiding transfers at shift change (nurses) and informing patients about pending transfers in advance (patients).

CONCLUSIONS

ICU-to-ward transfers are characterized by failures of patient flow and communication; experienced differently by patients, ICU/ward physicians and nurses, with distinct suggestions for improvement.

Handing over patients from the ICU to the general ward: A focused ethnographical study of nurses' communication practice

AIM

To explore nursing practice and perception of engaging in communicative interaction when handing over multi-morbid patients from the ICU to general medical or surgical wards.

BACKGROUND

Communication failures impose risks to patient safety. ICU and general ward nurses communicate in writing and verbally when handing over patients from one setting to another. A deeper understanding of nurses' communicative interaction and of nurses' perception of their interaction is crucial to facilitate clinical interventions focusing to improve patient safety.

DESIGN

An explorative, qualitative design using focused ethnography was applied to the study.

METHODS

Participant observation of 22 clinical situations of handing over patients from the ICU to general wards was conducted in November and December 2015, followed by five focus group interviews, three interviews with general ward nurses and two with ICU nurses in January-February 2016. Observation notes and interview transcripts were analysed using content analysis.

FINDINGS

The theme "Communicative interaction as a process of sharing and adopting ownership" and the subtheme "Communicative interaction influenced by nurses individual expectations towards patient status and the handing over process" emerged from observation notes. From transcribed focus group interviews, the theme "Balancing and negotiating when passing on, consuming and adapting knowledge" was identified.

CONCLUSION

A lack of shared goals regarding handing over patients from a high monitoring unit to general wards causes communicative and collaborative difficulties, loss of information and potential risks to patients. Organizational attention in relation to ICU discharge is crucial to improve collaboration, communication and patient safety.

Local emergency medical response after a terrorist attack in Norway: a qualitative study

INTRODUCTION

On 22 July 2011, Norway suffered a devastating terrorist attack targeting a political youth camp on a remote island. Within a few hours, 35 injured terrorist victims were admitted to the local Ringerike community hospital. All victims survived. The local emergency medical service (EMS), despite limited resources, was evaluated by three external bodies as successful in handling this crisis. This study investigates the determinants for the success of that EMS as a model for quality improvement in healthcare.

METHODS

We performed focus group interviews using the critical incident technique with 30 healthcare professionals involved in the care of the attack victims to establish determinants of the EMS' success. Two independent teams of professional experts classified and validated the identified determinants.

RESULTS

Our findings suggest a combination of four elements essential for the success of the EMS: (1) major emergency preparedness and competence based on continuous planning, training and learning; (2) crisis management based on knowledge, trust and data collection; (3) empowerment through multiprofessional networks; and (4) the ability to improvise based on acquired structure and competence. The informants reported the successful response was specifically based on multiprofessional trauma education, team training, and prehospital and in-hospital networking including mental healthcare. The powerful combination of preparedness, competence and crisis management built on empowerment enabled the healthcare workers to trust themselves and each other to make professional decisions and creative improvisations in an unpredictable situation.

CONCLUSION

The determinants for success derived from this qualitative study (preparedness, management, networking, ability to improvise) may be universally applicable to understanding the conditions for resilient and safe healthcare services, and of general interest for quality improvement in healthcare.