Improving hospital weekend handover: a user-centered, standardised approach

Improving weekend handover in a teaching hospital elective general surgery department

Background

Effective documentation and transfer of clinical information are vital for the continuity of care, patient safety, and maintaining medico-legal records, as outlined by the Royal College of Surgeons "Safe Handover: Guidance from the Working Time Directive working party". Our elective surgery weekend team cross-covers both Colorectal and Upper Gastrointestinal surgical specialties across multiple wards, which poses a significant challenge. The aim of this study was to improve the documentation of patients' weekend plans through the introduction of a weekend handover proforma.

Method

We reviewed the weekend plans of 199 patients overall. 41 records were initially reviewed over a 2-week period. The surgical multidisciplinary team was then surveyed to establish the need for an improved weekend handover. Following this, a weekend handover proforma was introduced as part of the Friday ward round and education on the expectations were provided at a local Surgery Clinical Governance meeting. The documentation of the weekend plan was reviewed for 158 patients over a 6-week period and a post-intervention survey was disseminated.

Results

The preliminary survey highlighted concerns for delayed discharges and patient safety over the weekend, with 88.2% of respondents agreeing a weekend handover proforma would be beneficial. The initial data confirmed inadequate documentation of diagnosis (19.5%), operation/procedure (28.1%), and weekend plans for blood tests (19.5%), discharge planning (2.4%), diet (46.3%), antibiotics (19.5%), intravenous (IV) fluids (22.0%), mobility (19.5%) and drain/wound care (37.5%). After education and implementing a weekend handover proforma, these results increased for documentation of diagnosis (61.2%), operation/procedure (83.2%), blood tests (59.7%), and discharge planning (85.8%). However, there was little improvement in diet (53.0%) and no improvement in the weekend plans for antibiotics (14.2%), IV fluids (17.2%), mobility (14.9%) and drain/wound care (20.2%). The post-intervention survey showed an improvement across all areas, notably continuity of care and patient safety, with 95.5% of individuals finding the weekend handover proforma aided in patient care over the weekend.

Conclusion

Education of the ward team and implementation of a weekend handover proforma resulted in a marked improvement in the documentation of patients' weekend plans, which is essential to ensure the continuation of safe and effective patient care.

Investigating Weekend Effect in the Management of Upper and Lower Extremity Degloving Injuries

Background

Weekend presentation has been associated with adverse outcomes in emergent conditions, including stroke, myocardial infarction, and critical limb ischemia. We examine whether a weekend effect exists in the management of and outcomes after extremity degloving injuries.

Methods

The cohort included adults presenting with open extremity degloving injuries to a tertiary level one trauma center between June 2018 and May 2022. We collected demographics, comorbidities, injury information, interventions, and complications. Propensity score weighting was used to minimize confounding differences between those presenting on weekends (Sat-Sun) versus weekdays (Mon-Fri). Weighted regressions were used to examine differences in interventions by day of presentation. Multivariable weighted regressions accounting for differences in interventions received were used to examine whether weekend presentation was associated with amputation risk, complications, or functional deficits.

Results

Ninety-five patients with 100 open extremity degloving injuries were included. In total, 39% of injuries were weekend-presenting. There was a higher rate of noninsulin-dependent diabetes among patients presenting on weekends (P = 0.03). Weekend-presenting injuries had higher median Injury Severity Scores (P = 0.04). Propensity-weighted regression analysis revealed differences in interventions received on weekends, including lower rates of pedicled and free flaps and bone graft, and increased rates of negative-pressure wound therapy (P ≤ 0.02). Multivariable regression analysis revealed weekend presentation was a significant independent risk factor for amputation of the affected extremity [odds ratio 2.27, 95% CI (1.01-5.33), P = 0.05].

Conclusion

Weekend presentation may impact interventions received and amputation risk in patients presenting with open extremity degloving injuries.

Weekend handover: Improving patient safety during weekend services

Clinical Handover has been identified as one of the most high-risk processes within medicine. Inadequate handover is a significant cause of avoidable adverse events across many hospitals. A likert-survey of the weekend handover system at a district general hospital demonstrated significant dissatisfaction amongst junior doctors. Intending to improve patient safety and reduce stress for on-call junior doctors, a weekend handover proforma was compiled according to the Royal College of Physicians and Surgeons guidelines. The proforma was trialed on six medical wards for six months with a before and after questionnaire being sent to doctors on the wards involved to determine the proforma’s merits on a scale of 1 (least effective) to 10 (most effective). Reports subsequent to implementation demonstrated a 67% increase ease of identifying outstanding weekend jobs. 57% of doctors reported better understanding of their patient’s diagnosis and management plan and 53% stated it was easier to identify the patients that required regular medical review over the weekend. Results also highlighted a 55% reported an increase in safety of weekend handovers (p<0.01). A closed loop audit of handover practice through the use of a standardised proforma showed improved quality, detail and consistency of handovers. The reduction in stress for junior doctors managing unknown patients with a clear concise plan, directed by a senior from the parent team during the week, has improved patient safety and doctor satisfaction.

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Weekend handovers are a valuable tool to increase patient safety.

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Weekend handovers can reduce stress levels in junior doctors.

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Weekend handovers have been shown to reduce the financial and operational burden.

Development of a proforma to improve quality of handover of surgical patients at the weekend

RATIONALE, AIMS, AND OBJECTIVES

The introduction of shift pattern of working in the medical profession has led to an increase in reliance on effective handover of patient information. We evaluated the use of a weekend handover proforma in General Surgical patients at a University Teaching Hospital.

METHODS

A standardized weekend handover proforma was implemented. A pre-post survey of medical staff and prospective observational study on the use of the proforma was carried out. The impact of three strategies to reinforce change in clinical practice was investigated at random time-points. These were (1) presentation at a clinical governance meeting; (2) email; and (3) induction training on handover combined with one-to-one interactive training. The two outcome measures were compliance with the proforma, and "handover score," which was the amount of data transferred per patient.

RESULTS

The survey highlighted inadequate provision for handover at the weekend. National guidelines were used to design the weekend handover proforma. There was 70% compliance with the new standardized proforma with a median handover score of 83% (IQR = 0-100). The results were presented at a clinical governance meeting, and the proforma was refined. After this change, the proforma was used in 71% of patients, and the median score was 65% (IQR = 0-80, P = 0.0516). Compliance after an email reminder was 69%, and median handover score was 80% (IQR = 0-90, P = 0.1037). After induction training, there was a significant improvement in proforma compliance (94%) and median score (90%, IQR = 80-90, P = 0.013).

CONCLUSION

Effective transfer of handover information can be achieved over the weekend with the use of a standardized proforma. Use of the proforma was greatest after providing junior doctors with didactic training on handover combined with interactive guidance on completing the proforma.

Impact of an integrated electronic handover tool on pediatric junior medical staff (JMS) handover

BACKGROUND

Clinical medical handover between doctors forms a critical part of the patient care process. However, with the evolution of junior medical staff (JMS) working conditions, time pressure and increasing clinical and administrative loads mean that quality clinical handover is increasingly important yet more challenging to achieve. This study evaluated the impact of a newly integrated electronic handover tool on JMS adoption and usage of the tool, as well as impacts on the quality (accuracy and redundancy) of handover data, JMS perceived workflow (time management and communication) and JMS satisfaction.

FINDINGS

The majority of JMS surveyed used the tool at 1 (87.0%) and 3 (67.4%) months post implementation. After the introduction of the electronic handover tool, 67.5% of users spent less than 15min updating handover data in the electronic handover tool, compared to just 6.7% prior to the introduction. 28.3% of respondents noted that there was >25% redundant data, compared to more than half (52.2%) prior to introduction of the electronic tool. Overall JMS satisfaction with their handover process was significantly higher post implementation of the integrated electronic handover report (17.4% pre, 80.4% at 1 month, 67.4% at 3 months).

CONCLUSION

A newly introduced integrated electronic medical record handover tool had a high uptake amongst JMS, and resulted in improvement in perceived handover efficiency, a reduction in redundant data entry and improved JMS handover satisfaction.

Introduction of a Microsoft Excel-based unified electronic weekend handover document in Acute and General Medicine in a DGH: aims, outcomes and challenges

On-call weekends in medicine can be a busy and stressful time for junior doctors, as they are responsible for a larger pool of patients, most of whom they would have never met. Clinical handover to the weekend team is extremely important and any communication errors may have a profound impact on patient care, potentially even resulting in avoidable harm or death. Several senior clinical bodies have issued guidelines on best practice in written and verbal handover. These include: standardisation, use of pro forma documents prompting doctors to document vital information (such as ceiling of care/resuscitation status) and prioritisation according to clinical urgency. These guidelines were not consistently followed in our hospital site at the onset of 2014 and junior doctors were becoming increasingly dissatisfied with the handover processes. An initial audit of handover documents used across the medical division on two separate weekends in January 2014, revealed high variability in compliance with documentation of key information. For example, ceiling of care was documented for only 14-42% of patients and resuscitation status in 26-72% of patients respectively. Additionally, each ward used their own self-designed pro forma and patients were not prioritised by clinical urgency. Within six months from the introduction of a standardised, hospital-wide weekend handover pro forma across the medical division and following initial improvements to its layout, ceiling of therapy and resuscitation status were documented in approximately 80% of patients (with some minor variability). Moreover, 100% of patients in acute medicine and 75% of those in general medicine were prioritised by clinical urgency and all wards used the same handover pro forma.

Implementing an electronic patient handover system

BACKGROUND

Clear communication among health-care teams is paramount for safe patient care and effective handover. Advances in information technology have led to an increased use of electronic systems within modern health care. This quality improvement project introduced an electronic patient handover system that was intended to improve the accuracy of patient handover lists and be readily available to all members of the health-care team.

METHODS

A quality improvement project was undertaken to assess the effect of introducing an electronic patient handover system on maintenance workload and list accuracy.

RESULTS

List errors were common before the introduction of the electronic patient handover system, commonly patient location or a patient being incorrectly omitted from the list. These errors decreased significantly after the introduction of the electronic system (P<0.005 and 0.04 respectively). The workload associated with its maintenance also decreased (P<0.005) because many data fields were pre-populated by the software. This resulted in fewer instances of patients being missed on ward rounds (P<0.04).

CONCLUSIONS

Through modifying existing information technology infrastructure, a centrally maintained, widely accessible electronic handover system was introduced. This reduced the workload associated with maintaining handover lists and the rate of errors.

Introduction of a new electronic medical weekend handover at Tunbridge Wells Hospital

Effective handover between shifts is vital to protect patient safety and assist doctors with clinical governance. Poor quality, or inadequate handover can lead to serious harm for both patients and doctors. The weekend medical handover system among junior doctors at Tunbridge Wells Hospital in Pembury, UK was cumbersome, inadequate and poor, restricting the ability to provide good patient care. 78.6% of doctors felt that the introduction of an electronic weekend handover system would address the issues in order to improve communication between the medical teams and thus improve patient care. A five week trial of an excel based electronic weekend handover system was conducted. 87.5% of the doctors surveyed felt that the new electronic weekend handover was better or significantly better than the old paper based handover system. The effectiveness rating of the weekend medical handover, with 1 (least effective) - 10 (most effective), rose from 6.14 to 7.31 after introduction of the electronic weekend medical handover system. As a result, this project has become part of the junior doctors medical induction, ensuring permanence of electronic weekend medical handover. This project takes a step towards improved patient safety as well improving the working conditions for junior doctors in a busy acute medical unit. There is always a need to refine and optimise systems and though this project is not perfect, it is a step toward electronic handover that is available now and free of cost.

Improving the quality of weekend handover at Yeovil District Hospital

"Handover of care is one of the most perilous procedures in medicine" (British Medical Association, Safe Handover, Safe Patients). The system in place for weekend handover at YDH was deemed disorganised, unstructured and frequently missing key pieces of information, leaving the on-call Foundation Year 1 (FY1) doctor with only vague jobs and management plans. Baseline surveys demonstrated that junior doctors felt the system was inadequate, potentially compromised patient safety and increased their stress levels. In order to improve this problem a structured weekend handover proforma was created, comparable with the "Out of hours handover record keeping standards: template" from the Royal College of Physicians. This was made readily accessible on the local intranet. Education sessions were organised for the FY1 and FY2 doctors. The impact of the newly introduced proforma was measured using feedback surveys each week from the FY1 on ward cover for six months. A further change implemented was the introduction of a Friday Ward Round proforma. The aim was to reduce the time required to review notes by the on-call doctor, to minimise avoidable weekend jobs and to improve compliance with the management plans. The results demonstrated 100% compliance with the new proformas. There were notable improvements in the presence of a plan (37.5% to 91.7%, max. 100%), a minimum of two patient identifiers (68.8% to 100%) and relevant background information (62.5% to 100%). Qualitative data showed a much higher level of satisfaction with the new system. Future plans include rolling out electronic handover to improve problems such as illegible handwriting and missing data (enable 'compulsory' fields), and also for this system to be implemented Trust-wide.

Improving the quality of patient handover on a surgical ward

The European Working Time Directive means safe patient hand over is imperative. It is the responsibility of every doctor and an issue of patient safety and clinical governance [1]. The aims of this project were to improve the quality of patient handover between combined assessment unit (CAU) and surgical ward FY1 doctors.

The Royal College of Surgeons England (RCSEng) guidelines on surgical patient handover [1] were used as the standard. Data was collected throughout November 2013. A handover tool was then introduced and attached to the front of patient notes when a patient was transferred from CAU to the surgical ward. The doctor handing over the patient and the ward doctor receiving the handover signed this document. Policy was also changed so that handover should take place once the patient had received senior review on the CAU and was deemed appropriate for transfer to the surgical ward. Data from the handover tool was collated and checked against the list of surgical admission for February 2014.

The number of patients handed over improved from 15 % to 45%. The quality of patient handover also improved. 0 patient handovers in November 2013 included all of the information recommended by the RCSEng guidelines. 100% of the patient handovers in February 2014 contained all the recommended information.

Introduction of a handover tool and formalisation of timing of patient handover helped to improve quality and number of patients being handed over. Further work needs to be done to improve safe handover of surgical patients, particularly out of hours.

Improving handover of patient care using a new weekend proforma with a focus on ceiling of care

Patient handover is paramount for effective patient care and is often poorly documented or incomplete. North Bristol NHS Trust weekend handover proformas identify medical patients requiring weekend review. Many patients seen during on-call shifts are not handed over. Our aim was to develop Friday ward round proforma sheets for medical patients, to encourage clear documentation of management plans in order to improve handover of important information, particularly ceiling of care decisions.

Questionnaires were completed by F1 doctors regarding current handover systems. Baseline data collected by on-call F1s included time of understanding a patient's ceiling of care decision, and difficulty of comprehension of medical notes. Repeat data were collected with novel proformas in situ. Multiple cycles were performed to refine the sheets and target problems arising in their use.

Ninety-three percent of F1s wanted improved patient handover, with ceiling of care (87%) and management plans (73%) being the most difficult areas to understand. Time taken to ascertain ceiling of care decisions improved with the introduction of Friday handover proformas; mean time 153 seconds before and 5 seconds after. Clarity and documentation of management plans improved, with 50% improvement in ease of understanding medical notes.

Results demonstrate that introducing Friday ward round proformas for medical patients improves communication between weekday and on-call teams, highlights current escalation of care plans, and leads to faster decision-making. Future plans include the introduction of a short educational session to the new F1 doctors and continued progress with introduction into hospital stationary.