A theoretical framework and competency-based approach to improving handoffs

Sustainability of an Operating Room to Pediatric Postanesthesia Care Unit Handoff Tool

PURPOSE

The purpose of this quality improvement (QI) project was to reintroduce and assess the feasibility of a standardized, electronic health record (EHR) handoff tool and to evaluate the sustainability of a structured, team-based approach in a pediatric postanesthesia care unit (PACU).

DESIGN

This QI project used an observational pre-post design using two separate convenience samples of handoffs and perianesthesia providers.

METHODS

A standardized EHR handoff tool was reintroduced for operating room to pediatric PACU handoff communication. Handoffs between anesthesia providers, surgery team members, and PACU nurses were observed pre- and postreintroduction of the EHR handoff tool. Anesthesia providers and PACU RNs received training for giving and receiving handoffs and were provided directions on locating the EHR handoff tool. A bedside audit of items communicated for the six handoff phases (introductions, situation, background, assessment, recommendations, and questions), handoff duration, team member participation, and handoff tool utilization were performed for 149 handoffs pre- and 146 handoffs postimplementation. To evaluate sustainability, the audits were compared to postimplementation data from the 2014 pilot handoff project.

FINDINGS

Following reintroduction, EHR handoff tool use increased from 4% to 19%. There was a statistically significant increase in items communicated for three of the six handoff phases when using the EHR tool (P < .05). There was no statistically significant increase in handoff duration (mean = 3.66 minutes, SD = 1.57 minutes) with the EHR handoff tool. Surgical team member presence for the team-based handoff increased from 90.7% pre to 95.9% post. Provider compliance with the team-based handoff approach, which includes a PACU RN, surgical team member, and anesthesia team member present for handoff, was sustained and increased 6 years postimplementation. Feedback from anesthesia providers and PACU RNs indicated mixed reports of satisfaction with the EHR tool, perceived handoff efficiency, and consistency in both giving and receiving handoff. Adherence to five of the six structured handoff phases, except introductions, was sustained and even improved 6 years following implementation.

CONCLUSIONS

Evidence-based practice for handoff communication supports the use of a team approach and standardized EHR handoff tools. The reintroduction of a standardized EHR handoff tool improved the completeness of information transfer, yet did not lead to widespread adoption nor improved user satisfaction. There is an ongoing need to identify adoptable and sustainable perioperative handoff methods.

Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs

BACKGROUND

Safe and effective physician-to-physician patient handoffs are integral to patient safety. Unfortunately, poor handoffs continue to be a major cause of medical errors. Developing a better understanding of challenges faced by health care providers is critical to address this continued patient safety threat. This study addresses the gap in the literature exploring broad, cross-specialty trainee perspectives around handoffs and provides a set of trainee-informed recommendations for both training programs and institutions.

METHODS

Using a constructivist paradigm, the authors conducted a concurrent/embedded mixed method study to investigate trainees' experiences with patient handoffs across Stanford University Hospital, a large academic medical center. The authors designed and administered a survey instrument including Likert-style and open-ended questions to solicit information about trainee experiences from multiple specialties. The authors performed a thematic analysis of open-ended responses.

RESULTS

687/1138 (60.4%) of residents and fellows responded to the survey, representing 46 training programs and over 30 specialties. There was wide variability in handoff content and process, most notably code status not being consistently mentioned a third of the time for patients who were not full code. Supervision and feedback about handoffs were inconsistently provided. Trainees identified multiple health-systems level issues that complicated handoffs and suggested solutions to these threats. Our thematic analysis identified five important aspects of handoffs: (1) handoff elements, (2) health-systems-level factors, (3) impact of the handoff, (4) agency (duty), and (5) blame and shame.

CONCLUSIONS

Health systems, interpersonal, and intrapersonal issues affect handoff communication. The authors propose an expanded theoretical framework for effective patient handoffs and provide a set of trainee-informed recommendations for training programs and sponsoring institutions. Cultural and health-systems issues must be prioritized and addressed, as an undercurrent of blame and shame permeates the clinical environment.

The consequences of emotionally evocative patient behaviors on emergency nurses' patient assessments and handoffs: An experimental study using simulated patient cases

BACKGROUND

Engaging with human emotions is an integral but poorly understood part of the work of emergency healthcare providers. Patient factors (e.g., irritable behavior; mental illness) can evoke strong emotions, and evidence suggests that these emotions can impact care quality and patient safety. Given that nurses play a critical role in providing high quality care, efforts to identify and remedy factors that may compromise care are needed. Yet to date, few experiments have been conducted.

OBJECTIVE

To examine the effects of emotionally evocative patient behavior as well as the presence of mental illness on emergency nurses' emotions, patient assessments, testing advocacy, and written handoffs.

DESIGN

Experimental vignette research.

SETTING

Online experiment distributed via email between October and December 2020.

PARTICIPANTS

Convenience sample of 130 emergency nurses from seven hospitals in the Northeastern United States and one hospital in the mid-Atlantic region in the United States.

METHODS

Nurses completed four multimedia computer-simulated patient encounters in which patient behavior (irritable vs. calm) and mental illness (present vs. absent) were experimentally varied. Nurses reported their emotions and clinical assessments, recommended diagnostic tests, and provided written handoffs. Tests were coded for whether the test would result in a correct diagnosis, and handoffs were coded for negative and positive patient descriptions and the presence of specific clinical information.

RESULTS

Nurses experienced more negative emotions (anger, unease) and reported less engagement when assessing patients exhibiting irritable (vs. calm) behavior. Nurses also judged patients with irritable (vs. calm) behavior as more likely to exaggerate their pain and as poorer historians, and as less likely to cooperate, return to work, and recover. Nurses' handoffs were more likely to communicate negative descriptions of patients with irritable (vs. calm) behavior and omit specific clinical information (e.g., whether tests were ordered, personal information). The presence of mental illness increased unease and sadness and resulted in nurses being less likely to recommend a necessary test for a correct diagnosis.

CONCLUSIONS

Emergency nurses' assessments and handoffs were impacted by patient factors, particularly irritable patient behavior. As nurses are central to the clinical team and experience regular, close contact with patients, the effects of irritable patient behavior on nursing assessments and care practices have important implications. We discuss potential approaches to address these ill effects, including reflexive practice, teamwork, and standardization of handoffs.

TWEETABLE ABSTRACT

Experimental evidence links irritable patient behaviors to lower quality emergency department nurse handoffs, which may compromise patient safety @(lindamisbell) @(Nathan_Huff_1).

Discharge Communications for Older Patients Between Hospital Healthcare Providers and Home Healthcare Providers: An Integrative Review

The increasing volume of our aging population is dramatically affecting the need for home care services. The discharge process from hospital to home can be fraught with communication challenges if critical information is not provided. The transition process can threaten patient safety and incur adverse patient health outcomes. However, little is known about how the communication occurs between hospital and home health providers. Therefore, this integrative literature review was conducted to (1) describe the discharge communication that is occurring for older patients between hospital and home healthcare providers and (2) summarize the limitations of current discharge communication. A systematic search was conducted using CINAHL, PubMed, Web of Science, and PsycINFO databases. Findings were categorized to address each aim. Seven studies were included for full reviews. Healthcare providers used a variety of communication methods, including: written information, phone calls, or in-person meetings to exchange the discharge information of older patients. Limitations in communications included excessive and incomplete discharge documents, lack of provider’s contact information, lack of trust in each other, and lack of bidirectional communications. The quality of discharge communications can improve by utilizing mediators and implementing standardized discharge documentation requirements. Overall, there was a lack of literature that described the methods and limitations of discharge communication for older patients between hospital and home care services. Further studies can be conducted to generate more evidence. Healthcare providers may improve the quality of discharge communication by addressing the suggested areas.

Clinical handover and handoff in healthcare: a systematic review of systematic reviews

PURPOSE

The purpose of this systematic review is to appraise and summarize existing literature on clinical handover.

DATA SOURCES

We searched EMBASE, MEDLINE, Database of Abstracts of Reviews of Effects and Cochrane Database of Systematic Reviews.

STUDY SELECTION

Included articles were reviewed independently by the review team.

DATA EXTRACTION

The review team extracted data under the following headers: author(s), year of publication, journal, scope, search strategy, number of studies included, type of studies included, study quality assessment, used definition of handover, healthcare setting, outcomes measured, findings and finally some comments or remarks.

RESULTS OF DATA SYNTHESIS

First, research indicates that poor handover is associated with multiple potential hazards such as lack of availability of required equipment for patients, information omissions, diagnosis errors, treatment errors, disposition errors and treatment delays. Second, our systematic review indicates that no single tool arises as best for any particular specialty or use to evaluate the handover process. Third, there is little evidence delineating what constitutes best handoff practices. Most efforts facilitated the coordination of care and communication between healthcare professionals using electronic tools or a standardized form. Fourth, our review indicates that the principal teaching methods are role-playing and simulation, which may result in better knowledge transfer to the work environment, better health and patients' well-being.

CONCLUSIONS

This review emphasizes the importance of staff education (including simulation-based and team training), non-technical skills and the implementation process of clinical handover in healthcare settings.

Handoffs in Radiology: Minimizing Communication Errors and Improving Care Transitions

Handoffs are essential to achieving safe care transitions. In radiology practice, frequent transitions of care responsibility among clinicians, radiologists, and patients occur between moments of care such as determining protocol, imaging, interpreting, and consulting. Continuity of care is maintained across these transitions with handoffs, which are the process of communicating patient information and transferring decision-making responsibility. As a leading cause of medical error, handoffs are a major communication challenge that is exceedingly common in both diagnostic and interventional radiology practice. The frequency of handoffs in radiology underscores the importance of using evidence-based strategies to improve patient safety in the radiology department. In this article, reliability science principles and handoff improvement tools are adapted to provide radiology-focused strategies at individual, team, and organizational levels with the goal of minimizing handoff errors and improving care transitions.

How isolation of key information and allowing clarifying questions may improve information quality and diagnostic accuracy at case handover in paediatrics

Handover between colleagues is a complex task. The problem is that handovers are often inadequate because they are not structured according to theoretically grounded guidelines. Based on the cognitive load theory, we suggest that allowing a clarifying dialogue and thereby optimizing germane cognitive load enhances the information quality and diagnostic accuracy at handover, but may prolong handover duration. We also expect that mentioning key information first and thus decreasing intrinsic cognitive load improves information quality and diagnostic accuracy. We developed two representative paediatric cases for presentation in a factorial 2 × 2 design. Sixth-year medical students (N = 80) were randomly assigned to one of four groups that differed with regard to how the case histories were delivered to them (chronological order versus key information mentioned first) and direction of information exchange (unidirectional versus a clarifying dialogue). The receivers of the handover were asked to write a report of the cases and suggest the best diagnosis. Dependent variables were information quality of the written report (Information score), quality of the diagnosis (Diagnostic accuracy score) and the time it took to deliver the written handover case report (Handover report duration). Seen through the lens of cognitive load theory, allowing a clarifying dialogue at handover, and thus optimizing the germane cognitive load, significantly increased the Information score (p < 0.0005), Diagnostic accuracy score (< 0.05) and Handover report duration (p < 0.001).

Evidence for validity for the Cognitive Load Inventory for Handoffs

CONTEXT

Patient handovers remain a significant patient safety challenge. Cognitive load theory (CLT) can be used to identify the cognitive mechanisms for handover errors. The ability to measure cognitive load types during handovers could drive the development of more effective curricula and protocols. No such measure currently exists.

METHODS

The authors developed the Cognitive Load Inventory for Handoffs (CLIH) using a multi-step process, including expert interviews to enhance content validity and talk-alouds to optimise response process validity. The final version contained 28 items. From January to March 2019, we administered a cross-sectional survey to 1807 residents and fellows from a large health care system in the USA. Participants completed the CLIH following a handover. Exploratory factor analysis of data from one-third of respondents identified high-performing items; confirmatory factor analysis of data from the remaining sample assessed model fit. Model fit was evaluated using the comparative fit index (CFI) (>0.90), Tucker-Lewis index (TFI) (>0.80), standardised root mean square residual (SRMR) (<0.08) and root mean square of error of approximation (RMSEA) (<0.08).

RESULTS

Participants included 693 trainees (38.4%) (231 in the exploratory study and 462 in the confirmatory study). Eleven items were removed during exploratory factor analysis. Confirmatory factor analysis of the 16 remaining items (five for intrinsic load, seven for extraneous load and four for germane load) supported a three-factor model and met criteria for good model fit: the CFI was 0.95, TFI was 0.93, RMSEA was 0.074 and SRMR was 0.07. The factor structure was comparable for gender and role. Intrinsic, extraneous and germane load scales had high internal consistency. With one exception, scale scores were associated, as hypothesised, with postgraduate level and clinical setting.

CONCLUSIONS

The CLIH measures three types of cognitive load during patient handovers. Evidencefor validity is provided for the CLIH's content, response process, internal structure and association with other variables. This instrument can be used to determine the relative drivers of cognitive load during handovers in order to optimize handover instruction and protocols.

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.

Ensuring Effective Care Transition Communication: Implementation of an Electronic Medical Record-Based Tool for Improved Cancer Treatment Handoffs Between Clinic and Infusion Nurses

PURPOSE

Ineffective handoffs contribute to gaps in patient care and medication errors, which jeopardize patient safety and lead to poor-quality care. The project aims are to develop and implement a standardized handoff process using an electronic medical record (EMR)-based tool to ensure optimal communication of treatment-related information for patients receiving cancer treatment between oncology nurses.

METHODS

A multidisciplinary team convened to develop a standard and safe treatment handoff process. The intervention was developed over a series of phases using Plan-Do-Study-Act methodology, including current workflow process mapping; identifying gaps, limitations, and potential causes of ineffective handoffs; and prioritizing these using a Pareto chart. An EMR-based tool incorporating a standardized treatment handoff process was developed. Study outcomes included proportion of handoff-related medication errors, tool utilization, handoff completion, patient waiting time, and nurse satisfaction with tool. All outcomes were evaluated before and after the intervention over a 1-year period.

RESULTS

The proportion of medication errors as a result of ineffective handoffs was reduced from 10 of 17 (60%) pre-intervention to 11 of 34 (32%) postintervention (P = .07). The EMR-based handoff tool was used in 9,274 of 10,910 (85%) patient treatment visits, and the handoff completion rate increased from 32% pre-intervention to 86% postintervention. Patient waiting time showed an average reduction of 2 minutes/patient/month. A majority of nurses reported that the new tool conveyed necessary information (85% of nurses) and was effective in preventing errors (81% of nurses).

CONCLUSION

Multidisciplinary stakeholders guided the development and implementation of a standard handoff process and an EMR-based tool to optimize communication between nurses during patient transition. The intervention was associated with a reduction in the proportion of medication errors as the result of ineffective handoffs. In addition, the intervention improved communication between nurses.

How does training in anesthesia residency shape residents' approaches to patient care handoffs? A single-center qualitative interview study

BACKGROUND

Handoffs are a complex procedure whose success relies on mutual discussion rather than simple information transfer. Particularly among trainees, handoffs present major opportunities for medical error. Previous research has explored best practices and pitfalls in general handoff education but has not discussed barriers specific to anesthesiology residents. This study characterizes the experiences of residents in anesthesiology as they learn handoff technique in order to inform strategies for teaching this important component of perioperative care.

METHODS

In 2016, we conducted a semi-structured interview study of 30 anesthesia residents across all three postgraduate years at a major academic hospital. Interviews were coded by two coders using a grounded theory approach and an iterative process designed to enhance reliability and validity.

RESULTS

Residents cited lack of consistency as a major impediment to proper handoff education. They found the impact of lectures and written materials to be limited. The level of guidance and direction they received from one-to-one attendings was described as highly variable. Residents' comfort in executing handoffs was heavily dependent on location and situation. They felt that coordination among the parties involved in the handoff was difficult to achieve, causing confusion about the importance of handoffs as well as proper protocol. Finally, residents offered opinions on when handoff education should occur during the residency and had several recommendations for its improving, including standardization of key handoff topics.

CONCLUSIONS

In a single center study of anesthesiology resident handoff education, residents exhibited confusion related to a perceived disconnect between the stated importance of effective handoffs and a lack of consensus on proper handoff technique. Standardization of curriculum and framing expectations has the potential to enhance resident handoff training in academic anesthesia departments.

Emergency Patient Handoffs: Identifying Essential Elements and Developing an Evidence-Based Training Tool

BACKGROUND

Patient handoffs between care teams have been recognized as a major patient safety risk due to inadequate exchange or loss of critical information, especially during emergent patient transfers. The purpose of this literature review was to identify the essential elements of effective patient handoffs in emergency situations to develop a standardized tool to support a structured patient handoff procedure capable of guiding education and training.

METHOD

A literature search of handoff procedures and patient transfers was conducted using the Cumulative Index to Nursing and Allied Health Literature and PubMed between 2008 and 2015.

RESULTS

Two global themes were identified-Crew Interactions, and Essential Data Elements-resulting in a tool containing 30 objective and five subjective items.

CONCLUSION

Through the literature review, synthesis, and workgroup consensus, we developed a standardized tool to guide standardized education, training, and future inquiry in prehospital and emergent patient handoffs. J Contin Educ Nurs. 2018;49(1):34-41.

Echo: A Large Display Interactive Visualization of ICU Data for Effective Care HandOffs

One of the significant challenges of care transitions in Intensive Care Units (ICUs) is the lack of effective support tools for outgoing clinicians to find, filter, organize, and annotate information that can be effectively handed off to the incoming team. We present a large display interactive multivariate visual approach, aimed towards supporting clinicians during the transition of care. We first provide a characterization of the problem domain in terms of data and tasks, based on an observation session at the University of Illinois Hospital, and on interviews with several biomedical researchers and ICU clinicians. Informed by this experience, we design a scalable, interactive visual approach that supports both overview and detail views of ICU patient data, as well as anomaly detection, comparison, and annotation of the data. We demonstrate a large-display implementation of the visualization on an existing anonymized ICU dataset. Feedback from domain experts indicates this approach successfully meets the requirements of effective care transitions.

Similarity and accuracy of mental models formed during nursing handovers: A concept mapping approach

BACKGROUND

Shared mental models are crucial for constructing mutual understanding of the patient's condition during a clinical handover. Yet, scant research, if any, has empirically explored mental models of the parties involved in a clinical handover.

OBJECTIVES

This study aimed to examine the similarities among mental models of incoming and outgoing nurses, and to test their accuracy by comparing them with mental models of expert nurses.

DESIGN

A cross-sectional study, exploring nurses' mental models via the concept mapping technique.

PARTICIPANTS

40 clinical handovers.

DATA COLLECTION

Data were collected via concept mapping of the incoming, outgoing, and expert nurses' mental models (total of 120 concept maps). Similarity and accuracy for concepts and associations indexes were calculated to compare the different maps.

RESULTS

About one fifth of the concepts emerged in both outgoing and incoming nurses' concept maps (concept similarity=23%±10.6). Concept accuracy indexes were 35%±18.8 for incoming and 62%±19.6 for outgoing nurses' maps. Although incoming nurses absorbed fewer number of concepts and associations (23% and 12%, respectively), they partially closed the gap (35% and 22%, respectively) relative to expert nurses' maps. The correlations between concept similarities, and incoming as well as outgoing nurses' concept accuracy, were significant (r=0.43, p<0.01; r=0.68 p<0.01, respectively). Finally, in 90% of the maps, outgoing nurses added information concerning the processes enacted during the shift, beyond the expert nurses' gold standard.

DISCUSSION AND CONCLUSIONS

Two seemingly contradicting processes in the handover were identified. "Information loss", captured by the low similarity indexes among the mental models of incoming and outgoing nurses; and "information restoration", based on accuracy measures indexes among the mental models of the incoming nurses. Based on mental model theory, we propose possible explanations for these processes and derive implications for how to improve a clinical handover.

The impact of duty cycle workflow on sign-out practices: a qualitative study of an internal medicine residency program in Maryland, USA

OBJECTIVES

Although JCAHO requires a standardised approach to handoffs, and while many standardised protocols have been tested, sign-out practices continue to vary. We believe this is due to the variability in workflow during inpatient duty cycle. We investigate the impact of such workflows on intern sign-out practices.

DESIGN

We employed a prospective, grounded theory mixed-method design.

SETTING

The study was conducted at a residency programme in the mid-Atlantic USA. Two observers randomly evaluated three types of daily sign-outs for 1 week every 3 months from September 2013 to March 2014. The compliance of each observed behaviour to JCAHO's Handoff Communication Checklist was recorded.

PARTICIPANTS

Thirty one interns conducting 134 patient sign-outs were observed randomly among the 52 in the programme.

RESULTS

In the 06:00 to 07:00 sign-back, the night-cover focused on providing information on overnight events to the day interns. In the 11:00 to 12:00 sign-out, the night-cover focused on transferring task accountability to a day-cover intern before departure. In the 20:00 to 21:00 sign-out, the day interns focused on transferring responsibility of their patients to a night-cover.

CONCLUSION

Different sign-out periods had different emphases regarding information exchange, personal responsibility and task accountability. Sign-outs are context-specific, implying that across-the-board standardised sign-out protocols are likely to have limited efficacy and compliance. Standardisation may need to be relative to the specific type and purpose of each sign-out to be supported by interns.

Large-scale implementation of the I-PASS handover system at an academic medical centre

BACKGROUND

Healthcare has become increasingly complex and care delivery models have changed dramatically (eg, team-based care, duty-hour restrictions). However, approaches to critical communications among providers have not evolved to meet these new challenges. Evidence from safety culture surveys, academic studies and malpractice claims suggests that healthcare handover quality is problematic, leading to preventable errors and adverse outcomes. To address this concern, from 2013 to 2016 Massachusetts General Hospital completed phase I of a multifaceted programme to implement standardised, structured handovers across all departments, units and direct care providers.

METHODS

A multidisciplinary Handovers Committee selected the I-PASS handover system. Phase I implementation focused on large-scale training and shift-to-shift handovers. Important features included administrative and clinical leadership support; EHR templates for I-PASS; hospital handover policy revision; varied educational modalities, venues and durations; concomitant TeamSTEPPS training; unit-level I-PASS champions; handover observations; and solicitation of caregiver feedback and suggestions.

RESULTS

More than 6000 doctors, nurses and therapists have been trained. Trended observation scores demonstrate progressive but non-uniform adoption of I-PASS, with significant improvements in the correct sequencing and percentage of I-PASS elements included in handovers. Adoption of Synthesis (readback) has been challenging, with lower scores.

CONCLUSIONS

Comprehensive I-PASS implementation in a large academic medical centre necessitated major cultural change. I-PASS education is straightforward, whereas assuring consistent and sustained adoption across all services is more challenging, requiring adaptation of the basic I-PASS structure to local needs and workflows. EHR I-PASS templates facilitated caregiver acceptance. Initial phase I results are encouraging and the lessons learned should be helpful to other programmes planning handover initiatives. Phase II is ongoing, focusing on more uniform and consistent adoption, spread and sustainability.

A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication

BACKGROUND

Patient history-taking is an essential clinical skill, with effects on diagnostic reasoning, patient-physician relationships, and more. We evaluated the impact of using a structured, timeline-based format, the Chronology of Present Illness (CPI), to guide the initial patient interaction.

OBJECTIVE

To determine the feasibility and impact of the CPI on the patient interview, written notes, and communication with other providers.

DESIGN

Internal medicine residents used the CPI during a 2-week night-float rotation. For the first week, residents interviewed, documented, and presented patient histories according to their normal practices. They then attended a brief educational session describing the CPI, and were asked to use this method for new patient interviews, notes, and handoffs during the second week. Night and day teams evaluated the method using retrospective pre-post comparisons.

PARTICIPANTS

Twenty-two internal medicine residents in their second or third postgraduate year.

INTERVENTION

An educational dinner describing the format and potential benefits of using the CPI.

MAIN MEASURES

Retrospective pre-post surveys on the efficiency, quality, and clarity of the patient interaction, written note, and verbal handoff, as well as open-ended comments. Respondents included night-float residents, day team residents, and attending physicians.

KEY RESULTS

All night-float residents responded, reporting significant improvements in written note, verbal sign-out, assessment and plan, patient interaction, and overall efficiency (p < 0.05). Day team residents (n = 76) also reported increased clarity in verbal sign-out and written note, improved efficiency, and improved preparedness for presenting the patient (p < 0.05). Attending physician ratings did not differ between groups.

CONCLUSIONS

Resident ratings indicate that the CPI can improve key aspects of patient care, including the patient interview, note, and physician-physician communication. These results suggest that the method should be taught and implemented more frequently.

Learning health 'safety' within non-technical skills interprofessional simulation education: a qualitative study

BACKGROUND

Healthcare increasingly recognises and focusses on the phenomena of 'safe practice' and 'patient safety.' Success with non-technical skills (NTS) training in other industries has led to widespread transposition to healthcare education, with communication and teamwork skills central to NTS frameworks.

OBJECTIVE

This study set out to identify how the context of interprofessional simulation learning influences NTS acquisition and development of 'safety' amongst learners.

METHODS

Participants receiving a non-technical skills (NTS) safety focussed training package were invited to take part in a focus group interview which set out to explore communication, teamwork, and the phenomenon of safety in the context of the learning experiences they had within the training programme. The analysis was aligned with a constructivist paradigm and took an interactive methodological approach. The analysis proceeded through three stages, consisting of open, axial, and selective coding, with constant comparisons taking place throughout each phase. Each stage provided categories that could be used to explore the themes of the data. Additionally, to ensure thematic saturation, transcripts of observed simulated learning encounters were then analysed.

RESULTS

Six themes were established at the axial coding level, i.e., analytical skills, personal behaviours, communication, teamwork, context, and pedagogy. Underlying these themes, two principal concepts emerged, namely: intergroup contact anxiety - as both a result of and determinant of communication - and teamwork, both of which must be considered in relation to context. These concepts have subsequently been used to propose a framework for NTS learning.

CONCLUSIONS

This study highlights the role of intergroup contact anxiety and teamwork as factors in NTS behaviour and its dissipation through interprofessional simulation learning. Therefore, this should be a key consideration in NTS education. Future research is needed to consider the role of the affective non-technical attributes of intergroup contact anxiety and teamwork as focuses for education and determinants of safe behaviour.

ABBREVIATIONS

AUM: Anxiety/uncertainty management; NTS: Non-technical skills; TINSELS: Training in non-technical skills to enhance levels of medicines safety.

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

OBJECTIVE

To evaluate the impact of a medical education session on the implementation of a new change of shift medical clinical handover format in an urban hospital ED.

METHODS

This pilot study used a pre- and post-intervention design. The intervention consisted of a 1 h education session to teach a new handover format, SBARM (Situation, Background, Assessment, Recommendation, Medication). Data were collected through observations of doctors performing clinical handover and individual interviews with participants.

RESULTS

The educational intervention led to an increased focus on checking medication charts, but had minimal effect on changing other aspects of clinical handover at doctors' change of shift times. Perceived increased time spent on handover using the new system was seen as a major barrier to the implementation of SBARM. The addition of 'M' to 'SBAR' heightened awareness of checking medication and fluid charts.

CONCLUSION

Time pressures need to be taken into consideration when introducing changes to current processes. Also, it is recommended that, in addition to ongoing education, senior clinicians are engaged during the planning and execution stages of changes to practice.

Real-World Implementation of a Standardized Handover Program (I-PASS) on a Pediatric Clinical Teaching Unit

OBJECTIVE

A standardized handover curriculum (I-PASS) has been shown to reduce preventable adverse events in a large multicenter study. We aimed to study the real-world impact of the implementation of this curriculum on handover quality, duration, and identification of unstable patients.

METHODS

A prospective intervention study was conducted. We implemented the I-PASS curriculum via faculty education and resident workshops. Resident handover on the clinical teaching unit was videorecorded, and written handover documents were collected for 2 weeks before and after the intervention. We examined the inclusion of key elements on handover documents before and after intervention using logistic regression models accounting for multiple handovers per patient. Duration of handover was compared using a linear regression model adjusting for number of patients. Qualitative content analysis was used to describe observable differences in verbal handover recordings and written critical care consultations.

RESULTS

A total of 1275 handovers were included, comprising 364 inpatients. There was a significant increase (P < .05) in 7 of 11 key elements and a significant decrease in written physical examination findings after the intervention. No significant change was found in handover duration. Qualitative video analysis revealed observable differences in handover collaboration and organization. After the intervention, patients with critical care needs overnight were correctly identified as requiring close monitoring during handover.

CONCLUSIONS

Handover training resulted in consistent inclusion of key elements and was characterized by collaboration between participants and improved organization without significant increase in handover duration. Appropriate identification and response to clinically deteriorating patients was also found using the I-PASS model.

Revealing structures in narratives: A mixed-methods approach to studying interdisciplinary handoff in critical care

OBJECTIVE

To examine a novel mixed-methods approach for studying patterns of clinical communication that could inform future informatics solutions, with a specific focus on handoff within interdisciplinary teams.

MATERIALS AND METHODS

Researchers observed, recorded, and transcribed verbal handoff discussions of different members of critical care teams. The transcripts were coded qualitatively, and then analyzed quantitatively for emerging structural patterns using categorical cluster analysis, and for degree of shared mental models (SMM) using the modified Pyramid method.

RESULTS

An empirical study using the proposed mixed-methods approach suggested emerging patterns of communication among clinicians. For example, the temporal focus of handoff was often determined by the role of the clinician giving the handoff; the clinical content of handoff was consistent between clinicians, but varied between patients. The SMM index ranged from 0.065 (with the maximum possible overlap score of 1) to 0.007 with a median of 0.026; the overlap was higher in statements concerned with patient presentation (23.6% of these had overlap) and referring to the past (24% overlapped). This calculated SMM index was correlated with the assessment of coherence within the participating teams by independent physicians (r=0.63, p=0.038).

CONCLUSIONS

The proposed novel mixed-methods approach helped to reveal emerging patterns in content and structure of handoff communication and highlight differences due to the clinical context, and to the different priorities of clinicians on interdisciplinary patient care teams. The approach for calculating SMM is more ecologically sensitive as it relies on naturally occurring discourse and less intrusive than traditional ways of assessing SMM, and takes initial steps toward establishing empirical foundation for the design of electronic tools to support handoff in interdisciplinary teams.

Unpacking the Complexity of Patient Handoffs Through the Lens of Cognitive Load Theory

ISSUE

The transfer of a patient from one clinician to another is a high-risk event. Errors are common and lead to patient harm. More effective methods for learning how to give and receive sign-out is an important public health priority.

EVIDENCE

Performing a handoff is a complex task. Trainees must simultaneously apply and integrate clinical, communication, and systems skills into one time-limited and highly constrained activity. The task demands can easily exceed the information-processing capacity of the trainee, resulting in impaired learning and performance. Appreciating the limits of working memory can help identify the challenges that instructional techniques and research must then address. Cognitive load theory (CLT) identifies three types of load that impact working memory: intrinsic (task-essential), extraneous (not essential to task), and germane (learning related). The authors generated a list of factors that affect a trainee's learning and performance of a handoff based on CLT. The list was revised based on feedback from experts in medical education and in handoffs. By consensus, the authors associated each factor with the type of cognitive load it primarily effects. The authors used this analysis to build a conceptual model of handoffs through the lens of CLT.

IMPLICATIONS

The resulting conceptual model unpacks the complexity of handoffs and identifies testable hypotheses for educational research and instructional design. The model identifies features of a handoff that drive extraneous, intrinsic, and germane load for both the sender and the receiver. The model highlights the importance of reducing extraneous load, matching intrinsic load to the developmental stage of the learner and optimizing germane load. Specific CLT-informed instructional techniques for handoffs are explored. Intrinsic and germane load are especially important to address and include factors such as knowledge of the learner, number of patients, time constraints, clinical uncertainties, overall patient/panel complexity, interacting comorbidities or therapeutics, experience or specialty gradients between the sender and receiver, the maturity of the evidence base for the patient's disease, and the use of metacognitive techniques. Research that identifies which cognitive load factors most significantly affect the learning and performance of handoffs can lead to novel, contextually adapted instructional techniques and handoff protocols. The application of CLT to handoffs may also help with the further development of CLT as a learning theory.

Designing Learning Outcomes for Handoff Teaching of Medical Students Using Group Concept Mapping: Findings From a Multicountry European Study

PURPOSE

To develop, by consultation with an expert group, agreed learning outcomes for the teaching of handoff to medical students using group concept mapping.

METHOD

In 2013, the authors used group concept mapping, a structured mixed-methods approach, applying both quantitative and qualitative measures to identify an expert group's common understanding about the learning outcomes for training medical students in handoff. Participants from four European countries generated and sorted ideas, then rated generated themes by importance and difficulty to achieve. The research team applied multidimensional scaling and hierarchical cluster analysis to analyze the themes.

RESULTS

Of 127 experts invited, 45 contributed to the brainstorming session. Twenty-two of the 45 (48%) completed pruning, sorting, and rating phases. They identified 10 themes with which to select learning outcomes and operationally define them to form a basis for a curriculum on handoff training. The themes "Being able to perform handoff accurately" and "Demonstrate proficiency in handoff in workplace" were rated as most important. "Demonstrate proficiency in handoff in simulation" and "Engage with colleagues, patients, and carers" were rated most difficult to achieve.

CONCLUSIONS

The study identified expert consensus for designing learning outcomes for handoff training for medical students. Those outcomes considered most important were among those considered most difficult to achieve. There is an urgent need to address the preparation of newly qualified doctors to be proficient in handoff at the point of graduation; otherwise, this is a latent error within health care systems. This is a first step in this process.

Patient safety in ambulance services: a scoping review

Background

The role of ambulance services has changed dramatically over the last few decades with the introduction of paramedics able to provide life-saving interventions, thanks to sophisticated equipment and treatments available. The number of 999 calls continues to increase, with adverse events theoretically possible with each one. Most patient safety research is based on hospital data, but little is known concerning patient safety when using ambulance services, when things can be very different. There is an urgent need to characterise the evidence base for patient safety in NHS ambulance services.

Objective

To identify and map available evidence relating to patient safety when using ambulance services.

Design

Mixed-methods design including systematic review and review of ambulance service documentation, with areas for future research prioritised using a Delphi process.

Setting and participants

Ambulance services, their staff and service users in UK.

Data sources

A wide range of data sources were explored. Multiple databases, reference lists from key papers and citations, Google and the NHS Confederation website were searched, and experts contacted to ensure that new data were included in the review. The databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts, Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium (HMIC), NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED),Health Technology Assessment, the FADE library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE) and Zetoc (The British Library's Electronic Table of Contents) were searched from 1 January 1980 to 12 October 2011. Publicly available documents and issues identified by National Patient Safety Agency (NPSA), NHS Litigation Authority (NHSLA) and coroners’ reports were considered. Opinions and perceptions of senior managers, ambulance staff and service users were solicited.

Review methods

Data were extracted from annual reports using two-stage thematic analysis, data from quality accounts were collated with safety priorities tabulated and considered using thematic analysis, NPSA incident report data were collated and displayed comparatively using descriptive statistics, claims reported to NHSLA were analysed to identify number and cost of claims from mistakes and/or poor service, and summaries of coroners’ reports were assessed using thematic analysis to identify underlying safety issues. The depth of analysis is limited by the remit of a scoping exercise and availability of data.

Results

We identified studies exploring different aspects of safety, which were of variable quality and with little evidence to support activities currently undertaken by ambulance services. Adequately powered studies are required to address issues of patient safety in this service, and it appeared that national priorities were what determined safety activities, rather than patient need. There was inconsistency of information on attitudes and approaches to patient safety, exacerbated by a lack of common terminology.

Conclusion

Patient safety needs to become a more prominent consideration for ambulance services, rather than operational pressures, including targets and driving the service. Development of new models of working must include adequate training and monitoring of clinical risks. Providers and commissioners need a full understanding of the safety implications of introducing new models of care, particularly to a mobile workforce often isolated from colleagues, which requires a body of supportive evidence and an inherent critical evaluation culture. It is difficult to extrapolate findings of clinical studies undertaken in secondary care to ambulance service practice and current national guidelines often rely on consensus opinion regarding applicability to the pre-hospital environment. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Managing competing organizational priorities in clinical handover across organizational boundaries

Objectives

Handover across care boundaries poses additional challenges due to the different professional, organizational and cultural backgrounds of the participants involved. This paper provides a qualitative account of how practitioners in emergency care attempt to align their different individual and organizational priorities and backgrounds when handing over patients across care boundaries (ambulance service to emergency department (ED), and ED to acute medicine).

Methods

A total of 270 clinical handovers were observed in three emergency care pathways involving five participating NHS organizations (two ambulance services and three hospitals). Half-day process mapping sessions were conducted for each pathway. Semi-structured interviews were carried out with 39 participants and analysed thematically.

Results

The management of patient flow and the fulfilment of time-related performance targets can create conflicting priorities for practitioners during handover. Practitioners involved in handover manage such competing organizational priorities through additional coordination effort and dynamic trade-offs. Practitioners perceive greater collaboration across departments and organizations, and mutual awareness of each other’s goals and constraints as possible ways towards more sustainable improvement.

Conclusion

Sustainable improvement in handover across boundaries in emergency care might require commitment by leaders from all parts of the local health economy to work as partners to establish a culture of integrated, patient-centred care.

An entrustable professional activity (EPA) for handoffs as a model for EPA assessment development

Medical education is moving toward assessment of educational outcomes rather than educational processes. The American Board of Internal Medicine and American Board of Pediatrics milestones and the concept of entrustable professional activities (EPA)--skills essential to the practice of medicine that educators progressively entrust learners to perform--provide new approaches to assessing outcomes. Although some defined EPAs exist for internal medicine and pediatrics, the continued development and implementation of EPAs remains challenging. As residency programs are expected to begin reporting milestone-based performance, however, they will need examples of how to overcome these challenges. The authors describe a model for the development and implementation of an EPA using the resident handoff as an example. The model includes nine steps: selecting the EPA, determining where skills are practiced and assessed, addressing barriers to assessment, determining components of the EPA, determining needed assessment tools, developing new assessments if needed, determining criteria for advancement through entrustment levels, mapping milestones to the EPA, and faculty development. Following implementation, 78% of interns at the University of Minnesota Medical School were observed giving handoffs and provided feedback. The authors suggest that this model of EPA development--which includes engaging stakeholders, an iterative process to describing the behavioral characteristics of each domain at each level of entrustment, and the development of specific assessment tools that support both formative feedback and summative decisions about entrustment--can serve as a model for EPA development for other clinical skills and specialty areas.

Patient Handoffs: Is Cross Cover or Night Shift Better?

OBJECTIVES

Studies show singular handoffs between health care providers to be risky. Few describe sequential handoffs or compare handoffs from different provider types. We investigated the transfer of information across 2 handoffs using a piloted survey instrument. We compared cross-cover (every fourth night call) with dedicated night-shift residents.

METHODS

Surveys assessing provider knowledge of hospitalized patients were administered to pediatric residents. Primary teams were surveyed about their handoff upon completion of daytime coverage of a patient. Night-shift or cross-covering residents were surveyed about their handoff of the same patient upon completion of overnight coverage. Pediatric hospitalists rated the consistency of information between the surveys. Absolute difference was calculated between the 2 providers' rating of a patient's (a) complexity and (b) illness severity. Scores were compared across provider type.

RESULTS

Fifty-nine complete handoff pairs were obtained. Fourteen and 45 handoff surveys were completed by a cross-covering and a night-shift provider, respectively. There was no significant difference in information consistency between primary and night-shift (median, 4.0; interquartile range [IQR], 3-4) versus primary and cross-covering providers (median, 4.0; IQR, 3-4). There was no significant difference in median patient complexity ratings (night shift, 3.0; IQR, 1-5, versus cross cover, 3.5; IQR, 1-5) or illness severity ratings (night shift, 2.0; IQR, 1-4, versus cross-cover, 3.0; IQR, 1-6) when comparing provider types giving a handoff.

CONCLUSIONS

We did not find a difference in physicians' transfer of information during 2 handoffs among providers taking traditional call or on night shift. Development of tools to measure handoff consistency is needed.

Assessment of internal medicine trainee sign-out quality and utilization habits

Transfers of care have been associated with adverse events. High quality sign-out may help mitigate this risk. The authors sought to characterize the clinical questions asked of physicians covering patients overnight and to determine the adequacy of current sign-out practice to anticipate inquiries. The authors conducted a prospective, self-report study of interns' overnight experience at two hospitals. We collected data from novice interns (July 7-August 3, 2010) and experienced interns (March 2-March 29, 2011) in an Internal Medicine residency program. Interns recorded information about overnight inquiries regarding cross-covered patients. For each inquiry about a patient, the intern was asked to record what the situation was about, who initiated the contact, where the intern found the desired information, whether all required data was located, whether the call could have been anticipated by the primary team, if so, whether the call was anticipated, whether the sign-out was sufficient, the time required to address the question, and whether the patient was physically visited. Twenty-one interns (13 novice, 8 experienced) reported 167 overnight inquiries. Most were from nursing staff (87%) about a wide range of topics, with orders (25%) and plan of care (20%) being most common. Trainees used the oral or written sign-out to answer 56% of inquiries. The proportion of inquiries successfully anticipated (47% overall) significantly decreased as the academic year progressed (AOR = 0.4, 95% CI 0.2, 0.8). Trainees rely on sign-out to answer nearly half of overnight inquiries, but the quality of sign-out may decrease over the course of the academic year. The deterioration of sign-out quality from novice to experienced interns and the common use of sign-out as a reference by covering interns suggest continued education, support and oversight by supervising physicians may be beneficial.

A conceptual model to facilitate transitions from primary care to specialty substance use disorder care: a review of the literature

AIM

This article presents a conceptual model to help facilitate the transition from primary care to specialty substance use disorder (SUD) care for appropriate patients.

BACKGROUND

Substance misuse is a common health condition among patients presenting to primary care settings and may complicate the treatment of chronic health conditions such as diabetes and hypertension. It is therefore critical that primary care providers be prepared to identify and determine appropriate treatment options for patients presenting with substance misuse.

METHODS

We conducted a narrative review that occurred in three stages: literature review of health care transition models, identification of conceptual domains common across care transition models, and identification of SUD-specific model elements. Findings The conceptual model presented describes patient, provider, and system-level facilitators and barriers to the transition process, and includes intervention strategies that can be utilized by primary care clinics to potentially improve the process of transitioning patients from primary care to SUD care. Recognizing that primary care clinics vary in available resources, we present three examples of care practices along an intensity continuum from low (counseling and referral) to moderate (telephone monitoring) to high (intensive case management) resource demands for adoption. We also provide a list of common outcomes clinics might consider when evaluating the impact of care transition practices in this patient population; these include process outcomes such as patients' increased knowledge of available treatment resources, and health outcomes such as patients' reduced substance use and better quality of life.

Quality in transitional care of the elderly: Key challenges and relevant improvement measures

Introduction

Elderly people aged over 75 years with multifaceted care needs are often in need of hospital treatment. Transfer across care levels for this patient group increases the risk of adverse events. The aim of this paper is to establish knowledge of quality in transitional care of the elderly in two Norwegian hospital regions by identifying issues affecting the quality of transitional care and based on these issues suggest improvement measures.

Methodology

Included in the study were elderly patients (75+) receiving health care in the municipality admitted to hospital emergency department or discharged to community health care with hip fracture or with a general medical diagnosis. Participant observations of admission and discharge transitions (n = 41) were carried out by two researchers.

Results

Six main challenges with belonging descriptions have been identified: (1) next of kin (bridging providers, advocacy, support, information brokering), (2) patient characteristics (level of satisfaction, level of insecurity, complex clinical conditions), (3) health care personnel's competence (professional, system, awareness of others’ roles), (4) information exchange (oral, written, electronic), (5) context (stability, variability, change incentives, number of patient handovers) and (6) patient assessment (complex clinical picture, patient description, clinical assessment).

Conclusion

Related to the six main challenges, several measures have been suggested to improve quality in transitional care, e.g. information to and involvement of patients and next of kin, staff training, standardisation of routines and inter-organisational staff meetings.

Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research

Background and objectives

Handover and communication failures are a recognised threat to patient safety. Handover in emergency care is a particularly vulnerable activity owing to the high-risk context and overcrowded conditions. In addition, handover frequently takes place across the boundaries of organisations that have different goals and motivations, and that exhibit different local cultures and behaviours. This study aimed to explore the risks associated with handover failure in the emergency care pathway, and to identify organisational factors that impact on the quality of handover.

Methods

Three NHS emergency care pathways were studied. The study used a qualitative design. Risks were explored in nine focus group-based risk analysis sessions using failure mode and effects analysis (FMEA). A total of 270 handovers between ambulance and the emergency department (ED), and the ED and acute medicine were audio-recorded, transcribed and analysed using conversation analysis. Organisational factors were explored through thematic analysis of semistructured interviews with a purposive convenience sample of 39 staff across the three pathways.

Results

Handover can serve different functions, such as management of capacity and demand, transfer of responsibility and delegation of aspects of care, communication of different types of information, and the prioritisation of patients or highlighting of specific aspects of their care. Many of the identified handover failure modes are linked causally to capacity and patient flow issues. Across the sites, resuscitation handovers lasted between 38 seconds and 4 minutes, handovers for patients with major injuries lasted between 30 seconds and 6 minutes, and referrals to acute medicine lasted between 1 minute and approximately 7 minutes. Only between 1.5% and 5% of handover communication content related to the communication of social issues. Interview participants described a range of tensions inherent in handover that require dynamic trade-offs. These are related to documentation, the verbal communication, the transfer of responsibility and the different goals and motivations that a handover may serve. Participants also described the management of flow of patients and of information across organisational boundaries as one of the most important factors influencing the quality of handover. This includes management of patient flows in and out of departments, the influence of time-related performance targets, and the collaboration between organisations and departments. The two themes are related. The management of patient flow influences the way trade-offs around inner tensions are made, and, on the other hand, one of the goals of handover is ensuring adequate management of patient flows.

Conclusions

The research findings suggest that handover should be understood as a sociotechnical activity embedded in clinical and organisational practice. Capacity, patient flow and national targets, and the quality of handover are intricately related, and should be addressed together. Improvement efforts should focus on providing practitioners with flexibility to make trade-offs in order to resolve tensions inherent in handover. Collaborative holistic system analysis and greater cultural awareness and collaboration across organisations should be pursued.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Addressing the Mandate for Hand-off Education

The Accreditation Council for Graduate Medical Education requires that residency programs teach residents about handoffs and ensure their competence in this communication skill. Development of hand-off curricula for anesthesia residency programs is hindered by the paucity of evidence regarding how to conduct, teach, and evaluate handoffs in the various settings where anesthesia practitioners work. This narrative review draws from literature in anesthesia and other disciplines to provide recommendations for anesthesia resident hand-off curriculum development and evaluation.

A systematic review of the literature on the evaluation of handoff tools: implications for research and practice

OBJECTIVE

Given the complexities of the healthcare environment, efforts to develop standardized handoff practices have led to widely varying manifestations of handoff tools. A systematic review of the literature on handoff evaluation studies was performed to investigate the nature, methodological, and theoretical foundations underlying the evaluation of handoff tools and their adequacy and appropriateness in achieving standardization goals.

METHOD

We searched multiple databases for articles evaluating handoff tools published between 1 February 1983 and 15 June 2012. The selected articles were categorized along the following dimensions: handoff tool characteristics, standardization initiatives, methodological framework, and theoretical perspectives underlying the evaluation.

RESULTS

Thirty-six articles met our inclusion criteria. Handoff evaluations were conducted primarily on electronic tools (64%), with a more recent focus on electronic medical record-integrated tools (36% since 2008). Most evaluations centered on intra-departmental tools (95%). Evaluation studies were quasi-experimental (42%) or observational (50%), with a major focus on handoff-related outcome measures (94%) using predominantly survey-based tools (70%) with user satisfaction metrics (53%). Most of the studies (81%) based their evaluation on aspects of standardization that included continuity of care and patient safety.

CONCLUSIONS

The nature, methodological, and theoretical foundations of handoff tool evaluations varied significantly in terms of their quality and rigor, thereby limiting their ability to inform strategic standardization initiatives. Future research should utilize rigorous, multi-method qualitative and quantitative approaches that capture the contextual nuances of handoffs, and evaluate their effect on patient-related outcomes.

Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners

OBJECTIVE

Although there is a growing recognition of the importance of active communication behaviours from the incoming clinician receiving a patient handover, there are currently no agreed-upon measures to objectively describe those behaviours. This study sought to identify differences in incoming clinician communication behaviours across levels of clinical training for physicians and nurses.

METHODS

Handover observations were conducted during shift changes for attending physicians, resident physicians, registered nurses and nurse practitioners in three medical intensive care units from July 2011 to August 2012. Measures were the number of interjections from the incoming clinician and the communication mode of those interjections. Each collaborative cross-check, a specific type of interactive question, was subsequently classified by level of assertiveness.

RESULTS

133 patient handovers were analysed. Statistical differences were found in both measures. Higher levels of training were associated with fewer interjections, and a higher proportion of interactive questioning to detect erroneous assessments and actions by the incoming provider. All groups were observed to use the least assertive level of a collaborative cross-check, which contributed to misunderstandings. Nurses used less assertive collaborative cross-checks than physicians.

CONCLUSIONS

Differences across clinician type and levels of clinical training were found in both measures during patient handovers. The findings suggest that training could enable physicians and nurses to learn communication competencies during patient handovers which were used more frequently by more experienced practitioners, including interjecting less frequently and using interactive questioning strategies to clarify understanding, and assertively question the appropriateness of diagnoses, treatment plans and prognoses. Accompanying cultural change initiatives might be required to routinely employ these strategies in the clinical setting, particularly for nursing personnel.

[Patient participation in medical decision making within an integrated health care system in Germany: results of a controlled cohort study]

An integrated health care project called "Gesundes Kinzigtal" was conducted in a rural area in Germany. As part of the project, physicians were trained and other measures were taken to enhance patient involvement in medical decision making. As part of the external evaluation, various effects regarding patient involvement in medical decision making, patient involvement and information preference, decision confidence, patient satisfaction with ambulatory care and patient quality of life were examined. The data were gathered by means of a questionnaire on an annual basis between 2007 and 2009. Effects were compared between patients who were participating in the integrated care project and two control groups. Analyses are based on the data of 1,205 patients. Over time all outcomes decreased slightly, except for information preference and physical quality of life. No statistically significant intervention effects on patient involvement in medical decision making or any other outcome variable could be found. The intensity of the training was presumably too low to establish an enduring change in the physician-patient interaction.

Effectiveness of written hospitalist sign-outs in answering overnight inquiries

BACKGROUND

Hospitalists are key providers of care to medical inpatients, and sign-out is an integral part of providing safe, high-quality inpatient care. There is little known about hospitalist-to-hospitalist sign-out.

OBJECTIVE

To evaluate the quality of hospitalist/physician-extender sign-outs by assessing how well the sign-out prepares the night team for overnight events and to determine attributes of effective sign-out.

DESIGN

Analysis of a written-only sign-out protocol on a nonteaching hospitalist service using prospective data collected by an attending physician survey during overnight shifts.

SETTING

Yale-New Haven Hospital, a 966-bed, urban, academic medical center in New Haven, Connecticut with approximately 13,700 hospitalist discharges annually.

RESULTS

We recorded 124 inquiries about 96 patients during 6 days of data collection in 2012. Hospitalists referenced the sign-out for 89 (74%) inquiries, and the sign-out was considered sufficient in isolation to respond to 27 (30%) of these inquiries. Hospitalists physically saw the patient for 14 (12%) of inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]), and clinical changes (26 [21%]). Ninety-five (77%) inquiries were considered to be "somewhat" or "very" clinically important by the hospitalist.

CONCLUSIONS

Overall, we found that attending hospitalists rely heavily on written sign-out to address overnight inquiries, but that those sign-outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign-out is needed to help improve the safety of overnight care.

Improving shift report focus and consistency with the situation, background, assessment, recommendation protocol

OBJECTIVE

The Situation, Background, Assessment, Recommendation (SBAR) protocol was used to improve shift reports in 4 medical-surgical units.

BACKGROUND

The SBAR protocol is increasingly advocated for use during shift reports, but data on the efficacy are limited.

METHODS

Nurses were trained on SBAR in 4 medical-surgical units in a tertiary care hospital. Nurse tasks, tools, and locations were recorded during observation audits.

RESULTS

The average time for shift reports did not decrease using SBAR. Nurses spent significantly more time on tasks specific to report. There was significantly more dialogue and less writing with SBAR.

CONCLUSION

The introduction of SBAR made reports more focused, with more time spent discussing the patient and less on transcribing information. The SBAR protocol provides a concise and prioritized structure that enables consistent, comprehensive, and patient-centric reports.