Are weekend handovers of adequate quality for the on-call general medical team?

Weekend handover: Improving patient safety during weekend services

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

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Weekend handovers are a valuable tool to increase patient safety.

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Weekend handovers can reduce stress levels in junior doctors.

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

Accuracy of inter-hospital transfer information in Australian hospital administrative databases

Inter-hospital transfers improve care delivery for which sending and receiving hospitals both accountable for patient outcomes. We aim to measure accuracy in recorded patient transfer information (indication of transfer and hospital identifier) over 2 years across 121 acute hospitals in New South Wales, Australia. Accuracy rate for 127,406 transfer-out separations was 87 per cent, with a low variability across hospitals (10% differences); it was 65 per cent for 151,978 transfer-in admissions with a greater inter-hospital variation (36% differences). Accuracy rate varied by departure and arrival pathways; at receiving hospitals, it was lower for transfer-in admission via emergency department (incidence rate ratio = 0.52, 95% confidence interval: 0.51-0.53) versus direct admission. Transfer-out data were more accurate for transfers to smaller hospitals (incidence rate ratio = 1.06, 95% confidence interval: 1.03-1.08) or re-transfers (incidence rate ratio > 1.08). Incorporation of transfer data from sending and receiving hospitals at patient level in administrative datasets and standardisation of documentation across hospitals would enhance accuracy and support improved attribution of hospital performance measures.

The Weekend Effect in Hospitalized Patients: A Meta-Analysis

BACKGROUND

The presence of a "weekend effect" (increased mortality rate during Saturday and/or Sunday admissions) for hospitalized inpatients is uncertain.

PURPOSE

We performed a systematic review to examine the presence of a weekend effect on hospital inpatient mortality.

DATA SOURCES

PubMed, EMBASE, SCOPUS, and Cochrane databases (January 1966-April 2013) were utilized for our search.

STUDY SELECTION

We examined the mortality rate for hospital inpatients admitted during the weekend compared with those admitted during the workweek. To be included, the study had to provide discrete mortality data around the weekends (including holidays) versus weekdays, include patients who were admitted as inpatients over the weekend, and be published in English.

DATA EXTRACTION

The primary outcome was all-cause weekend versus weekday mortality with subgroup analysis by personnel staffing levels, rates and times to procedures rates and delays, or illness severity.

DATA SYNTHESIS

A total of 97 studies (N = 51,114,109 patients) were examined. Patients admitted on the weekends had a significantly higher overall mortality (relative risk, 1.19; 95% confidence interval, 1.14-1.23). With regard to the subgroup analyses, patients admitted on the weekends consistently had higher mortality than those admitted during the week, regardless of the levels of weekend/weekday differences in staffing, procedure rates and delays, and illness severity.

CONCLUSIONS

Hospital inpatients admitted during weekends may have a higher mortality rate compared with inpatients admitted during the weekdays.

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

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

Evaluating Outcomes of Electronic Tools Supporting Physician Shift-to-Shift Handoffs: A Systematic Review

BACKGROUND

Multiple organizations have recognized that handoffs are prone to errors, and there has been an increase in the use of electronic health records and computerized tools in health care.

OBJECTIVE

This systematic review evaluates the current evidence on the effectiveness of electronic solutions used to support shift-to-shift handoffs.

METHODS

We searched the English-language literature for research studies published between January 1, 2008, and September 19, 2014, using National Library of Medicine PubMed, EBSCO CINAHL, OvidSP All Journals, and ProQuest PsycINFO. Included studies focused on the evaluation of physician shift-to-shift handoffs and an electronic solution designed to support handoffs. We assessed articles using a quality scoring system, conducted a review of barriers and strategies, and categorized study outcomes into self-report, process, and outcome measures.

RESULTS

Thirty-seven articles met inclusion criteria, including 20 single group pre- and posttest studies; 8 posttest only or cross-sectional studies; 4 nonrandomized controlled trials; 1 cohort study; 1 randomized crossover study; and 3 qualitative studies. Quality scores ranged from 3.5 to 14 of a possible 16. Most articles documented some positive outcomes, with 2 of the 3 studies evaluating patient outcomes yielding statistically significant improvements. The only other study that analyzed patient outcomes showed that interventions other than the electronic tool were responsible for most of the significant improvements.

CONCLUSIONS

The majority of studies supported using an electronic tool, yet few measured patient outcomes, and numerous studies suffered from methodology issues. Future studies should evaluate patient outcomes, improve study design, assess the role of faculty oversight, and broaden the focus to recognize the role of human factors.

Improving the quality of weekend handover at Yeovil District Hospital

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

Association of weekend continuity of care with hospital length of stay

OBJECTIVE

The purpose of this study was to evaluate the association of physician continuity of care with length of stay, likelihood of weekend discharge, in-hospital mortality and 30-day readmission.

DESIGN

A cohort study of hospitalized medical patients. The primary exposure was the weekend usual provider continuity (UPC) over the initial weekend of care. This metric was adapted from an outpatient continuity of care index. Regression models were developed to determine the association between UPC and outcomes.

SETTING

An academic medical center.

MAIN OUTCOME MEASURE

Length of stay which was calculated as the number of days from the first Saturday of the hospitalization to the day of discharge.

RESULTS

Of the 3391 patients included in this study, the prevalence of low, moderate and high UPC for the initial weekend of hospitalization was 58.7, 22.3 and 19.1%, respectively. When compared with low continuity of care, both moderate and high continuity of care were associated with reduced length of stay, with adjusted rate ratios of 0.92 (95% CI 0.86-1.00) and 0.64 (95% CI 0.53-0.76), respectively. High continuity of care was associated with likelihood of weekend discharge (adjusted odds ratio 2.84, 95% CI 2.11-3.83) but was not significantly associated with mortality (adjusted odds ratio 0.72, 95% CI 0.29-1.80) or readmission (adjusted odds ratio 0.88, 95% CI 0.68-1.14) when compared with low continuity of care.

CONCLUSIONS

Increased weekend continuity of care is associated with reduced length of stay. Improvement in weekend cross-coverage and patient handoffs may be useful to improve clinical outcomes.

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

Clinical Handover remains one of the most perilous procedures in medicine (1). Weekend handover has emerged as a key area of concern with high variability in handover processes across hospitals (1,2,4, 5-10). Studying weekend handover processes within medicine at an acute teaching hospital revealed huge variability in documented content and structure. A total of 12 different pro formas were in use by the medical day-team to handover to the weekend team on-call. A Likert-survey of doctors revealed 93% felt the current handover system needed improvement with 71% stating that it did not ensure patient safety (Chi-squared, p-value <0.001, n=32). Semi-structured interviews of doctors identified common themes including "a lack of consistency in approach" "poor standardization" and "high variability". Seeking to address concerns of standardization, a standardized handover pro forma was developed using Royal College of Physician (RCP) guidelines (2), with direct end-user input. Results following implementation revealed a considerable improvement in documented ceiling of care, urgency of task and team member assignment with 100% uptake of the new proforma at both 4-week and 6-month post-implementation analyses. 88% of doctors surveyed perceived that the new proforma improved patient safety (p<0.01, n=25), with 62% highlighting that it allowed doctors to work more efficiently. Results also revealed that 44% felt further improvements were needed and highlighted electronic solutions and handover training as main priorities. Handover briefing was subsequently incorporated into junior doctor induction and education modules delivered, with good feedback. Following collaboration with key stakeholders and with end-user input, integrated electronic handover software was designed and funding secured. The software is currently under final development. Introducing a standardized handover proforma can be an effective initial step in improving weekend handover. Handover education and end-user involvement are key in improving the process. Electronic handover solutions have been shown to significantly increase the quality of handover and are worth considering (9, 10).

Improving weekend patient handover

The Royal College of Physicians state that ‘handover, particularly of temporary ‘on-call’ responsibility, has been identified as a point at which errors are likely to occur’ [1].

Working a weekend on-call covering medical wards is often busy and stressful for all junior doctors, with added pressure in trying to identify patients and tasks amongst several different pieces of paper and making important care escalation.

All handover sheets from a random weekend were collected and studied. Only 57% of patients listed had the minimum expected 3 patient identifiers [2] included and just 11% had any indication of escalation planning. They were also often written on scrap pieces of paper and included varying levels of relevant patient background and information.

After liaison with junior doctors and the handover committee, involving senior medical clinicians, a new handover sheet was created and uploaded onto the trust intranet, to rectify some of the problems identified. Junior doctors were also educated about the changes to weekend handover.

At 2 months post-introduction, another set of weekend handover sheets were collected. All medical wards used the handover sheets for documentation of patients and tasks at a weekend and inclusion of 3 patient identifiers rose to 80%. There was also a big increase noted in clinical information and background included at weekend handover and anecdotally made weekend handover easier and less stressful. There was also increased consideration of escalation planning.

The handover sheet is now being rolled out trust-wide in medicine and introduced to surgical colleagues.

Handover in Trauma and Orthopaedic Surgery - A Human Factors Assessment

Handovers permeate healthcare delivery systems. They are critical for patient safety and continuity of care, but also for logistics and clinical efficiency. Poor handovers can cause reduced efficiency, delayed discharge or time to operation, and contributes to patient harm. The Objective was to conduct a human factors assessment (HFA) using a systems approach to study the handover process at an Orthopaedic unit, determine barriers to information transfer, and suggest improvements. A direct observation model was used to help provide insights on the evening handover process. A Systems Engineering Initiative for Patient Safety (SEIPS) model was used to provide a framework. A total of ten handover sessions were observed and the junior doctors were interviewed using a semi-structured approach. Participants had two chief centres of complaint: workspace and environmental issues (such as a small, hot, uncomfortable room), and the lack of the junior house officer at handover leading to 'signal loss' with respect to sick patients who may not be handed over fully. The process also lacked standardisation and structure compounding the potential loss of information.

CONCLUSION

Good handover remains a cornerstone of safe and effective clinical practice and continuity of care. This study has shown how an HFA can be useful in determining problems with the handover process locally. It suggests an approach for improvement and recommends better training at all levels in this aspect of patient care.