Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey

Assessing current handover practices in surgery: A survey of non-consultant hospital doctors in Ireland

BACKGROUND

Handovers of care are potentially hazardous moments in the patient journey and can lead to harm if conducted poorly. Through a national survey of surgical doctors in Ireland, this paper assesses contemporary surgical handover practices and evaluates barriers and facilitators of effective handover.

METHODS

After ethical approval and pre-testing with a representative sample, a cross-sectional, online survey was distributed to non-consultant hospital doctors (NCHDs) working in the Republic of Ireland. A mixed-methods approach was used, combining data using triangulation design.

MAIN FINDINGS

A total of 201 responses were received (18.5%). Most participants were senior house officers or senior registrars (49.7% and 37.3%). Most people (85.1%) reported that information received during handover was missing or incorrect at least some of the time. One-third of respondents reported that a near-miss had occurred as a result of handover within the past three months, and handover-related errors resulted in minor (16.9%), moderate (4.9%), or major (1.5%) harm. Only 11.4% had received any formal training. Reported barriers to handover included negative attitudes, a lack of institutional support, and competing clinical activities. Facilitators included process standardisation, improved access to resources, and staff engagement.

CONCLUSIONS

Surgical NCHDs working in Irish hospitals reported poor compliance with international best practice for handover and identified potential harms. Process standardisation, appropriate staff training, and the provision of necessary handover-related resources is required at a national level to address this significant patient safety concern.

Optimizing Transfer of Postcesarean Patients to Postoperative Ward Through a Quality Improvement (QI) Project: Curtailing Delays, Improving Care

BACKGROUND AND OBJECTIVES

Close monitoring of patients in the first 2 hours after cesarean delivery (CD) is crucial. Delays in shifting of the post-CD patients led to a chaotic environment in the postoperative ward, suboptimal monitoring, and inadequate nursing care. Our aim was to increase the percentage of post-CD patients shifted from transfer trolley to bed within 10 minutes of arrival in the postoperative ward from a baseline of 64% to 100%, and to maintain that rate for more than 3 weeks.

METHODS

A quality improvement team including physicians, nurses, and workers was constituted. Problem analysis revealed lack of communication among the caregivers as the main cause of delay. The percentage of post-CD patients shifted from trolley to bed within 10 minutes of being wheeled into the postoperative ward out of the total number of post-CD patients transferred from the operation theater to the postoperative ward was taken as the outcome indicator for the project. Multiple Plan-Do-Study-Act cycles based on the Point of Care Quality Improvement methodology were undertaken to achieve the target. Main interventions were: 1) written information of patient being transferred to operation theater for CD sent to the postoperative ward; 2) stationing of a duty doctor in the postoperative ward; and 3) keeping a buffer of 1 vacant bed in the postoperative ward. The data were plotted weekly as a dynamic time series chart and signals of change were observed.

RESULTS

Eighty-three percent (172 out of 206) of women were shifted in time by 3 weeks. After Plan-Do-Study-Act 4, the percentages kept improving leading to a median shift from 85.6% to 100% after 10 weeks post-initiation of the project. Sustainment was confirmed by continuing observations for 6 more weeks to ensure that the changed protocol was assimilated in the system. We found that all women were shifted within 10 minutes of their arrival in postoperative ward from trolley to bed.

CONCLUSION

Providing high-quality care to patients must be a priority for all health care providers. High-quality care is timely, efficient, evidence based, and patient-centric. Delays in transfer of postoperative patients to the monitoring area can be detrimental. The point of Care Quality Improvement methodology is useful and effective in solving complex problems by understanding and fixing the various contributory factors one by one. Reorganization of processes and available manpower without any extra investment in terms of infrastructure and resources is pivotal for long term success of a quality improvement project.

Patient handoffs among general surgery residents in Saudi Arabia: a cross-sectional study

BACKGROUND

Communication failure is a common cause of adverse events. An essential element of communication among health care providers is patient handoff. Patient handoff is defined as a practice whereby a health care provider transfers a patient's care information to another health care provider to ensure the patient's safety and continuity of care. To explore this practice, we assessed patient handoffs among general surgery residents in Saudi Arabia.

METHODS

A cross-sectional survey was conducted with individuals in accredited general surgery residency programs in Saudi Arabia between 2020 and 2021.

RESULTS

Participants comprised 118 general surgery residents: 66 (57.3%) were female; 67 (72.8%) did not receive any formal training on patient handoff; and 35 (38.8%) reported that they were sometimes interrupted during the patient handoff process. The most common reason for such interruptions was medical personnel paging. Furthermore, 60 (68.1%) general surgery residents stated that these interruptions led to a decreased quality of effective communication, 39 (44.3%) believed it led to decreased quality of patient care, 63 (71.5%) believed it led to the loss of some information related to patient handoff, and 16 (18.1%) believed it led to patient harm. Finally, 31 (34.4%) general surgery residents believed that the existing handoff system at their institutions neither adequately protected the patients' safety nor allowed for continuity of care, and 51 (68%) reported that their institution did not have a standardized protocol for the verbal patient handoff process. There was a higher proportion of patients with minor harm among residents who did not, rarely or sometimes received verbal or written hand off instructions compare to those who did so always or most of the time (67% vs. 49%, respectively).

CONCLUSION

The patient handoff process among general surgery residents in Saudi Arabia is subjective and is not standardized, and if not addressed, may lead to patient harm. Standardizing this process is paramount to improve patient safety.

Efficacy of a blended learning programme in enhancing the communication skill competence and self-efficacy of nursing students in conducting clinical handovers: a randomised controlled trial

BACKGROUND

A clinical handover is an essential nursing practice that ensures patient safety. However, most newly graduated nurses struggle to conduct clinical handovers as they lack sufficient communication skill competence and self-efficacy in this practice. This study aimed to examine the efficacy of a blended learning programme on the communication skill competence and self-efficacy of final-year nursing students in conducting clinical handovers.

METHODS

A randomised controlled design was used. A convenience sample of 96 final-year baccalaureate nursing students at a local university. Data were collected in 2020. Participants were randomly assigned to either an experimental group (n = 50) that received a blended learning programme with face-to-face training and an online module on handover practice, or a waitlist control group (n = 46) that received only face-to-face handover training during the study period and an online module immediately after the completion of data collection. The primary outcome was the communication skill competence and the secondary outcome was the self-efficacy of the participants in conducting clinical handovers. An analysis of covariance was used to examine the between-subjects effects on self-efficacy and communication skill competence in conducting clinical handovers after controlling for the significantly correlated variables. A paired sample t-test was used to determine the within-subjects effects on self-efficacy.

RESULTS

The participants in the experimental group had significantly higher communication skill competence (p < 0.001) than those in the waitlist control group. Although both groups showed a significant improvement in self-efficacy, the mean scores of the experimental group were higher than those of the waitlist control group (p < 0.001).

CONCLUSIONS

This study demonstrated the efficacy of a blended learning approach in improving the communication skill competence and self-efficacy of final-year nursing students in conducting clinical handovers. Nurse educators should incorporate a blended learning approach into the nursing curriculum to optimise the content of training programmes for teaching nursing students in conducting clinical handovers.

TRIAL REGISTRATION

The study protocol was registered in the Registration ClinicalTrials.gov ( NCT05150067 ; retrospective registration; date of registration 08/12/2021).

Newly graduate nurse perception and experience of clinical handover

BACKGROUND

Clinical handover is challenging for newly graduated nurses. Previous studies have showed that many new graduates perform handover ineffectively and unsystematically; however, our knowledge of newly graduated nurse perceptions of handover, including barriers and challenges to handover, is incomplete.

OBJECTIVES

The study aimed to explore newly graduated nurse experience of clinical handover in Hong Kong public hospitals.

DESIGN

This was a descriptive phenomenological study.

SETTING

Participants were recruited from 11 public acute care hospitals in Hong Kong.

PARTICIPANTS

The participants were a convenience sample of 20 nurses who had graduated within the previous 12 months.

METHODS

Individual semi-structured interviews were conducted, and the data were analysed using content analysis.

RESULTS

Three themes emerged from the data: 'significance of clinical handovers,' 'feelings of frustration about clinical handover,' and 'perceived barriers to handover.' Participants perceived clinical handover as an essential nursing practice in the provision of continuous patient care. Further, some new graduates experienced stress and anxiety in clinical handover, which severely affected their quality of life. Perceived barriers to handover included inadequate professional judgement, poor ability to synthesize the important information, and unsystematic reporting.

CONCLUSIONS

Newly graduated nurses face challenges and encounter difficulties in performing clinical handover. Handover theory and, in particular, skills training should be introduced into the undergraduate nursing curriculum, to arm students with the confidence and competence to perform appropriate clinical handover.

Assessing the Influence of Attending Surgeon Continuity on Free Flap Outcomes Following Unplanned Returns to the Operating Room

BACKGROUND

 Unplanned returns to the operating room (OR) may be necessary at times to salvage a compromised free flap. The aim of this study was to assess the influence of attending surgeon continuity on free flap outcomes following a return to the OR.

METHODS

 We retrospectively reviewed patients who underwent free flap reconstruction and experienced an unplanned return to the OR within 30 days from 2002 to 2017. Logistic regression modeling was used to determine factors that predict unplanned returns to the OR.

RESULTS

 Of the 1,177 patients were identified, 267 (22.5%) had an unplanned return to the OR. Of these, 69 (5.9%) patients experienced total flap loss. Overall, 216 take-back procedures were performed by the primary surgeons (80.2%), while 50 were performed by covering surgeons (18.8%). Flap loss occurred more frequently during a weekend procedure (p = 0.013). Additionally, when the take-back procedure was performed within 5 days of the original surgery by the primary as opposed to a covering surgeon, patients experienced lower estimated blood loss (75 vs. 150 cc, p = 0.04). Overall, there was a significantly lower incidence of flap loss when the take-back procedure was performed by the primary, as opposed to the covering, surgeon (20 vs. 47%, p = 0.0001).

CONCLUSION

 Higher rates of flap loss occur when a covering surgeon performs a take-back procedure in comparison to the primary surgeon. It is important to ensure the availability of the primary surgeon in the first few postoperative days following free flap reconstruction. When transfer of care is necessary, photographic or video documentation of the microvascular anastomosis may be helpful in addition to a verbal sign out.

Weekend surgical handover enhances early management of acute clinical changes using a red flag system

INTRODUCTION

Recent implementation of the European Working Time Directive in Ireland has resulted in a change from thetraditional model of patient care to a system characterised by shift work among clinicians. Effective handover ofpatient information is essential for transfer of responsibility between clinicians and maintaining continuity of care. The weekend has been identified as a particularly vulnerable transition of patient care.

AIMS AND METHODS

Our study aims to determine if implementing a formal face-to-face handover accompanied by an electronictemplate in our surgical department can improve the number of adverse events reported back to the primary teamafter a weekend on call. Data was collected over 12 weekends between February and May 2016. A list of adverseevents was established, and during an initial observation period of 6 weeks, we documented the number of adverseevents that were informally handed over. A 6-week intervention was then performed, involving a formal face-to-facehandover on Monday morning supported by an electronic patient census using a red-flag system to highlightpatients who experienced an adverse event over the weekend.

RESULTS

Our results showed the mean number of adverse events recorded pre-intervention was 3.17 ± 0.6 over the 6-week period. Following the introduction of weekend face-to-face handover, there was 147% increase in the number of adverse events recorded with a mean of 7.83 ± 1.2.

CONCLUSION

The introduction of a formal face-to-face weekend handover with a red-flag system resulted in increased reporting of patient adverse events, allowing earlier recognition and management.

Meta-Analyses of the Effects of Standardized Handoff Protocols on Patient, Provider, and Organizational Outcomes

OBJECTIVE

The overall purpose was to understand the effects of handoff protocols using meta-analytic approaches.

BACKGROUND

Standardized protocols have been required by the Joint Commission, but meta-analytic integration of handoff protocol research has not been conducted.

METHOD

The primary outcomes investigated were handoff information passed during transitions of care, patient outcomes, provider outcomes, and organizational outcomes. Sources included Medline, SAGE, Embase, PsycINFO, and PubMed, searched from the earliest date available through March 30th, 2015. Initially 4,556 articles were identified, with 4,520 removed. This process left a final set of 36 articles, all which included pre-/postintervention designs implemented in live clinical/hospital settings. We also conducted a moderation analysis based on the number of items contained in each protocol to understand if the length of a protocol led to systematic changes in effect sizes of the outcome variables.

RESULTS

Meta-analyses were conducted on 34,527 pre- and 30,072 postintervention data points. Results indicate positive effects on all four outcomes: handoff information (g = .71, 95% confidence interval [CI] [.63, .79]), patient outcomes (g = .53, 95% CI [.41, .65]), provider outcomes (g = .51, 95% CI [.41, .60]), and organizational outcomes (g = .29, 95% CI [.23, .35]). We found protocols to be effective, but there is significant publication bias and heterogeneity in the literature. Due to publication bias, we further searched the gray literature through greylit.org and found another 347 articles, although none were relevant to this research. Our moderation analysis demonstrates that for handoff information, protocols using 12 or more items led to a significantly higher proportion of information passed compared with protocols using 11 or fewer items. Further, there were numerous negative outcomes found throughout this meta-analysis, with trends demonstrating that protocols can increase the time for handover and the rate of errors of omission.

CONCLUSIONS

These results demonstrate that handoff protocols tend to improve results on multiple levels, including handoff information passed and patient, provider, and organizational outcomes. These findings come with the caveat that publication bias exists in the literature on handoffs. Instances where protocols can lead to negative outcomes are also discussed.

APPLICATION

Significant effects were found for protocols across provider types, regardless of expertise or area of clinical focus. It also appears that more thorough protocols lead to more information being passed, especially when those protocols consist of 12 or more items. Given these findings, publication bias is an apparent feature of this literature base. Recommendations to reduce the apparent publication bias in the field include changing the way articles are screened and published.