Teamwork and mental workload in postsurgical pediatric patient handovers: Prospective effect evaluation of an improvement intervention for OR-PICU patient transitions

Postsurgical handover of pediatric patients from operating rooms (OR) to pediatric intensive care units (PICU) is a critical step. This transition is susceptible to errors and inefficiencies particularly if poor multidisciplinary teamwork occurs. Despite wide adoption of standardized handover interventions, comprehensive investigations into joint effects for patient care and provider outcomes are scarce. We aimed to improve OR-PICU handovers quality and sought to evaluate the intervention with particular attention to patient care effects and provider outcomes. A prospective, before-after-study design with an interrupted-series and a multi-source, mixed-methods evaluation approach was established. Drawing upon a participative plan-do-study-act approach, a standardized, checklist-based handover process was designed and implemented. For effect assessments, we observed OR-PICU handovers on site (pre implementation: n = 31, post: n = 30), respectively, with standardized expert observation and provider self-report tools (n = 111, n = 110). Setting was a tertiary Pediatric University Hospital. Supplementary qualitative, semi-structured interviews were conducted, and a general inductive content analysis approach was used to identify key facilitators and barriers on implementation. Improvement efforts focused on stepwise implementation of (1) standardized handover process and (2) a checklist for multi-professional OR-PICU handover communication. We observed significant increases in team and patient setup (pre: 79.3%, post: 98.6%, p < .01), enhanced team engagement (pre: 50%, post: 81.7%, p < .01), and comprehensive information transfer by the anesthesia sub-team (pre: 78.6%, post: 87.3%, p < .01). Expert-rated teamwork outcomes were consistently higher, yet self-reported teamwork did not change over time. Provider perceived stress and disruptions did not change, mental workload tended to decrease over time (pre: M = 3.2, post: 2.9, p = .08). Comprehensiveness of post-operative patient information reported by PICU physician increased significantly: pre: 65.9%, post: 76.2%, p < .05. After implementation, providers acknowledged the importance of standardized handover practices and associated benefits for facilitation of information transfer and comprehensiveness. Among reported barriers were obstacles during implementation as well as insufficient consideration of professionals' individual workflow after surgery.

CONCLUSION

 A multidisciplinary intervention for postsurgical pediatric patient handovers was associated with improved expert-rated teamwork and fewer omissions of key patient information over time. Inconsistent results were obtained for provider-rated mental workload and teamwork outcomes. The findings contribute to a better understanding concerning the interplay of teamwork and provider cognitions in the course of establishing safe patient transitions in pediatric care.

WHAT IS KNOWN

• Transfer of critically ill children conveys significant challenges for interprofessional communication and teamwork. Prospective research into interventions for safe and efficient handover practices of OR PICU patient transitions is necessary. • Checklists are assumed to facilitate cognitive load among providers in acute clinical environments.

WHAT IS NEW

• A standardized, checklist-based handover intervention was associated with improvements in team set-up and information transfer. Provider outcomes such as mental workload and stress did not change over time. • The combination of teamwork and provider assessments allows a more nuanced understanding of implementation barriers and sustainable effects in course of OR-PICU handover interventions.

Safe handoff practices and improvement of communication in different paediatric settings

Inadequate information management, especially during patient handoff, contributes to a large part of health care-related adverse events. The Committee for Quality of Care and Patient Safety of the Asociación Española de Pediatría has developed this document to provide an overview of handover practices in different paediatric care settings (emergency, inpatient, intensive care, neonatal and primary care). It describes resources to achieve safe and effective communication in all these settings, such as standardised handoff tools. It also proposes recommendations for the prevention of medication errors during the handover process, to improve safety in interhospital and intrahospital patient transfer, and to optimise communication and continuity of care in chronically ill and medically complex children.

Implementing the IMIST-AMBO tool for paramedic to trauma team handovers: a video review analysis

OBJECTIVE

Patient handover between paramedics and the trauma team is vulnerable to communication errors that may adversely affect patient care. This study assesses the feasibility of a handover tool, IMIST-AMBO (acronym of categories), implementation in the trauma bay and evaluates the degree to which it improves handover metrics.

METHODS

This is a prospective observational cohort study conducted at Canada's largest level-one trauma center. Feasibility of the tool implementation and improvement in handover metrics were assessed. Strategies for implementation included distribution of an educational video and posters, and point-of-care reminders in the trauma bay. Two reviewers independently assessed video recordings of handovers to evaluate handover metrics. Findings were compared to data obtained during a knowledge gap analysis conducted prior to the initiation of this study at the same institution.

RESULTS

Over 13 weeks (August to November 2020), 140 videos were recorded, of which 80 used the IMIST-AMBO tool (compliance of 57%). Paramedic adherence to the handover structure occurred in 70.4% of cases, with greater adherence to the IMIST (82.2%) compared to the AMBO (47.1%) section. The mean (± standard deviation) handover duration was shorter (1 min:58 s ± 0:44 s during implementation vs. 2 min:47 s ± 1:14 s pre-implementation, [p < 0.001]). Frequency of parallel conversations and informal handovers improved (61% to 30% and 65% to 13%, [p < 0.001], respectively). Interruptions during the handover decreased from 3.05 (± 1.95) to 1.5 (± 1.7), p < 0.001. The tool was received favorably among study participants.

CONCLUSION

The IMIST-AMBO tool reduced the frequency of interruptions, parallel conversations, and informal handovers during paramedic-trauma team handovers at our institution. The quality and amount of information communicated per handover improved, all with a decrease in handover duration. The IMIST-AMBO tool may be applied to other trauma centers across Canada, or more broadly on an international scale.

Evaluating the Association of a Core EPA-Oriented Patient Handover Curriculum on Medical Students' Self-reported Frequency of Observation and Skill Acquisition

INTRODUCTION

"Giving or receiving a patient handover to transition patient care responsibility" is one of the thirteen Core Entrustable Professional Activities (Core EPAs) for Entering Residency. However, implementing a patient handover curriculum in undergraduate medical education (UME) remains challenging. Educational leaders in the multi-institutional Core EPA8 pilot workgroup developed a longitudinal patient handover UME curriculum that was implemented at two pilot institutions.

MATERIALS AND METHODS

We utilized multi-school graduation questionnaire data to assess the association of our patient handover curriculum on self-reported frequency of observation/feedback and skill acquisition by comparing data from the shared curriculum schools to data from other Core EPA pilot schools (three schools with school-specific curriculum; five without a dedicated handover curriculum). Questionnaire data from 1,278 graduating medical students of the class of 2020 from all ten Core EPA pilot schools were analyzed.

RESULTS

Graduates from the two medical schools that implemented the shared patient handover curriculum reported significantly greater frequency of handover observation/feedback compared to graduates at the other schools (school-specific curriculum (p < .05) and those without a handover curriculum (p < .05)). Graduates from the two shared approach schools also more strongly agreed that they possessed the skill to perform handovers compared to graduates from the other eight pilot schools that did not implement this curriculum.

CONCLUSION

The findings of this study suggest that the implementation of a multi-institutional Core EPA-based curricular model for teaching and assessing patient handovers was successful and could be implemented at other UME institutions.

[On the safe side? Safety culture and patient safety in German anesthesiology clinics-A nationwide survey on the status quo]

BACKGROUND

A good safety culture may be predominantly defined by an open and unsanctioned communication about critical and erroneous courses. In an effort to improve patient safety various instruments, such as the critical incident reporting system (CIRS) or in terms of patient handover, the use of the situation, background, assessment, recommendation (SBAR) system patient handover, have been developed and are recommended by the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). This study aimed at identifying how anesthesiologists perceive the safety culture in their current department and whether CIRS or SBAR are already established or not.

MATERIAL AND METHODS

All registered members of the DGAI and the Professional Association of German Anaesthesiologists (BDA, n = 19,042) were invited to participate in an online survey on patient safety. In this survey there was a focus on the perceived safety culture and the experience with CIRS and SBAR.

RESULTS

Of the participants 76.6% (n = 1372) stated that their department of anesthesiology has a good safety culture, while in 23.4% (n = 419) there was not. For the whole hospital the safety culture was only rated as being positive by 54.3% (n = 949) of the respondents. An open communication about critical and erroneous courses occurred in 76.5% (n = 1375) according to the participants, 23.0% (n = 408) had the impression that in the case of errors the respective person was being denounced. In one third of the participants' departments (n = 630, 36.6%) there were no morbidity and mortality conferences. The acronym CIRS was familiar to 98.9% (n = 1801) of the participants, 84.8% (n = 1544) of the surveyed anesthesiologists reported that CIRS was established in their departments. Critical incidents have been reported via CIRS by 54.4% (n = 839) of the respondents. Only 29.4% (n = 462) of the participants received regular feedback on CIRS reports. The acronym SBAR as a handover tool is unknown to the majority of the surveyed participants (n = 1181, 63.7%) and 86.1% (n = 1554) consider using an instrument in order to improve handover quality as possibly being beneficial.

CONCLUSION

Anesthesiologists rate the quality of the safety culture of their own anesthesiology department to be higher compared to their hospital in general. In some hospitals there is denouncement in cases of erroneous courses according to the respondents. In the patients' point of view morbidity and mortality conferences should be established more often. CIRS is known to almost every surveyed anesthetist but feedback on a regular basis is sparse. This contradicts the claims of the German Coalition for Patient Safety. The acronym SBAR is unknown to the majority of surveyed participants despite the recommendation of the DGAI to implement it. There is a wish for tools in order to enhance the quality of handovers.

Evaluation of emergency service nurses' patient handover and affecting factors: A descriptive study

AIM

The aim of the study was to determine the patient handover efficacy level of emergency room nurses and the influencing factors.

METHOD

This descriptive, cross-sectional study was completed with (n = 120) emergency room nurses of two different state hospitals from April 26 to May 26, 2021. The "Nurses descriptive information form" and "Handover Evaluation Scale" were used as data collection forms.

RESULTS

The mean age of the nurses was 29.53(6.327 years, 70.8% of them were female, and 76.7% of them had a bachelor's degree. The mean number of handovers was 3.25 (SD = 3.17) for one nurse in a shift, and the mean handover duration for a patient was 10.16 (SD = 9.23) minutes. More than half of the nurses (61.7%) carried out oral handover at the bedside. The mean score of the handover evaluation scale was 53.31 (SD = 9.55). The mean score of the nurses who performed the handover with all the nurses on the shift (spelling and relieving) together was 56.47 (SD = 9.21) and higher than that of the nurses who performed the handover in small groups 49.84 (SD = 9.70), (p = 0.012).

CONCLUSION

The results of this study may contribute to promoting patient safety and improving patient handover processes in emergency rooms. It is recommended that standardized and comprehensive written handover forms be used, that all emergency room nurses should attend the handover process, and that further observational and interventional studies should be conducted.

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).

Completeness of the operating room to intensive care unit handover: a matter of time?

BACKGROUND

Handovers of post-anesthesia patients to the intensive care unit (ICU) are often unstructured and performed under time pressure. Hence, they bear a high risk of poor communication, loss of information and potential patient harm. The aim of this study was to investigate the completeness of information transfer and the quantity of information loss during post anesthesia handovers of critical care patients.

METHODS

Using a self-developed checklist, including 55 peri-operative items, patient handovers from the operation room or post anesthesia care unit to the ICU staff were observed and documented in real time. Observations were analyzed for the amount of correct and completely transferred patient data in relation to the written documentation within the anesthesia record and the patient's chart.

RESULTS

During a ten-week study period, 97 handovers were included. The mean duration of a handover was 146 seconds, interruptions occurred in 34% of all cases. While some items were transferred frequently (basic patient characteristics [72%], surgical procedure [83%], intraoperative complications [93.8%]) others were commonly missed (underlying diseases [23%], long-term medication [6%]). The completeness of information transfer is associated with the handover's duration [B coefficient (95% CI): 0.118 (0.084-0.152), p<0.001] and increases significantly in handovers exceeding a duration of 2 minutes (24% ± 11.7 vs. 40% ± 18.04, p<0.001).

CONCLUSIONS

Handover completeness is affected by time pressure, interruptions, and inappropriate surroundings, which increase the risk of information loss. To improve completeness and ensure patient safety, an adequate time span for handover, and the implementation of communication tools are required.

Patient handover between ambulance crew and healthcare professionals in Icelandic emergency departments: a qualitative study

Background

Ambulance services play an important role in the healthcare system when it comes to handling accidents or acute illnesses outside of hospitals. At the time of patient handover from emergency medical technicians (EMTs) to the nurses and physicians in emergency departments (EDs), there is a risk that important information will be lost, the consequences of which may adversely affect patient well-being. The study aimed to describe healthcare professionals’ experience of patient handovers between ambulance and ED staff and to identify factors that can affect patient handover quality.

Methods

The Vancouver School’s phenomenological method was used. The participants were selected using purposive sampling from a group of Icelandic EMTs, nurses, and physicians who had experience in patient handovers. Semi-structured individual interviews were conducted and were supported by an interview guide. The participants included 17 EMTs, nurses, and physicians. The process of patient handover was described from the participants’ perspectives, including examples of communication breakdown and best practices.

Results

Four main themes and nine subthemes were identified. In the theme of leadership, the participants expressed that it was unclear who was responsible for the patient and when during the process the responsibility was transferred between healthcare professionals. The theme of structured framework described the communication between healthcare professionals before patient’s arrival at the ED, upon ED arrival, and a written patient report. The professional competencies theme covered the participants’ descriptions of professional competences in relation to education and training and attitudes towards other healthcare professions and patients. The collaboration theme included the importance of effective teamwork and positive learning environment.

Conclusions

A lack of structured communication procedures and ambiguity about patient responsibility in patient handovers from EMTs to ED healthcare professionals may compromise patient safety. Promoting accountability, mitigating the diffusion of responsibility, and implementing uniform practices may improve patient handover practices and establish a culture of integrated patient-centered care.

Team performance during postsurgical patient handovers in paediatric care

Postsurgical handover of paediatric patients from operating rooms to intensive care units is a critical moment. This process is susceptible to errors and inefficiencies particularly if poor teamwork in this multidisciplinary and ad hoc collaboration occurs. Through combining provider- and observer-rated team performance, we aimed to determine agreement levels on team performance and associations with mental demands, disruptions, and stress. An observational and multisource study of provider and concomitant expert-observer ratings was established. In an Academic Paediatric Hospital, we conducted standardized observations of postsurgical handovers to PICU. We applied established observational and self-reported teamwork tools. Nested fixed and mixed models were established to estimate agreement within teams, between providers' and observer's ratings, as well as for estimations between team performance and mental demands, disruptions, and stress outcomes. Thirty-one postsurgical patient handovers were included with overall 109 ratings of involved providers. Provider-perceived team performance was rated high. Within the receiving sub-team, situation awareness was perceived lower compared to the handoff sub-team [F(df = 1) = 4.41, p = .04]. Inter-provider agreement on handover team performance was low for the overall team yet higher within handover sub-teams. We observed that high level of distractions during the handover was associated with inferior team performance rated by observers (B = - 0.72, 95% CI = - 1.44, - 0.01).Conclusion: We observed substantial disagreements on how involved professionals as well as observers rated teamwork during patient transfers. Investigations into paediatric teamwork and particular team-based handovers should carefully consider if concurrent provider and observer assessments are a valid and reliable way to evaluate teamwork in paediatric care. Common handover language should be established and mandatory before jointly evaluating this process. Our findings advocate also that handovers should be performed under low levels of distractions.What is Known:• Efficient teamwork during transfers of critically ill children is fundamental to quality and safety of handover practice.• Postoperative handovers are often performed by ad hoc teams of caregivers with multiple backgrounds and are prone to suboptimal team performance, communication, and information transfer.What is New:• Our provider and expert evaluations of team performance during OR-PICU handovers showed poor agreement for team performance. Our findings challenge previous results drawing upon single source assessments and inform future studies to carefully consider what approach of team performance assessments is required.• We further demonstrate that high levels of disruptions are associated with poor team performance during patient handovers and that efforts to ensure undisrupted handover practices in clinical care are necessary.

Challenges for conducting and teaching handovers as collaborative conversations: an interview study at teaching ICUs

INTRODUCTION

Whereas medical shift handovers are increasingly recognized to fulfil important functions beyond information transfer, studies suggest that shift handovers continue to be variably used for reflection, learning or discussion. Little is known of the dynamics of incorporating such functions into ICU shift handovers, resulting in a challenge for the design of educational programs whose underlying philosophies align with the specific requirements of the ICU.

METHODS

Intensivists, residents and fellows (n = 21) from three ICUs were interviewed to determine perceptions of handover functionality and the boundaries to what must or can be achieved in handover conversations. Interviews were analyzed to isolate training requirements and factors that challenge interactions.

RESULTS

The analysis revealed that ICU physicians value three functions for shift handovers: information transfer, enhancing shared understanding and decision-making, and learning. The functions towards which physicians are oriented were found to be affected by situational characteristics of cases, individuals, teams, and the unit workflow. Whereas some factors are helpful cues for determining communication needs, others raise dilemmas and misaligned expectations with regards to what can be achieved in the handover.

DISCUSSION

Our findings add to the growing case for the education of handovers in complex settings to involve more than information transfers. As residents gain experience, training should be gradually shifted towards more fluid and adaptable approaches to the handover and residents' ability to engage in joint reflections and discussions. Challenges for engaging in such interactions need to be alleviated, in order to allow the redefinition of handovers as potential sources of safety and learning, rather than error.

Practical strategies for increasing efficiency and effectiveness in critical care education

Technological advances and evolving demands in medical care have led to challenges in ensuring adequate training for providers of critical care. Reliance on the traditional experience-based training model alone is insufficient for ensuring quality and safety in patient care. This article provides a brief overview of the existing educational practice within the critical care environment. Challenges to education within common daily activities of critical care practice are reviewed. Some practical evidence-based educational approaches are then described which can be incorporated into the daily practice of critical care without disrupting workflow or compromising the quality of patient care. It is hoped that such approaches for improving the efficiency and efficacy of critical care education will be integrated into training programs.

Impact of Adding a Pictorial Display to Enhance Recall of Cancer Patient Histories: A Randomized Trial

CONTEXT

Current health care delivery models have increased the need for safe and concise patient handover. Handover interventions in the literature have focused on the use of structured tools but have not evaluated their ability to facilitate retention of patient information.

OBJECTIVES

In this study, mock pictorial displays were generated in an attempt to create a snapshot of each patient's medical and social circumstances. These pictorial displays contained the patient's photograph and other disease- and treatment-related images. The objective of this randomized trial was to assess the ability of these snapshots to enhance delayed information recall by care providers.

METHODS

Participating physicians were given four advanced cancer patient histories to review, two at a time over two weeks. Pictorial image displays, referred to as the Electronic Whiteboard (EWB) were added, in a randomized manner to half of the textual histories. The impact of the EWB on information recall was tested in immediate and delayed time frames.

RESULTS

Overall, patient information recall declined significantly over time, with or without the EWB. Still, this trial demonstrates significantly higher test scores after 24 hours with the addition of pictures to textual patient information, compared with textual information alone (P = 0.0002). A more modest improvement was seen with the addition of the EWB for questionnaires administered immediately after history review (P = 0.008). Most participants agreed that the EWB was a useful enhancement and that seeing a patient's photograph improved their ability to retain information.

CONCLUSION

Most studies examining the institution of handover protocols in the health care setting have failed to harness the power of pictures and other representative images. This study demonstrates the ability of pictorial displays to improve both immediate and delayed recall of patient histories without increasing review time. These types of displays may be amenable to generation by software programs and have the potential to enhance information transfer in various settings.

Patient handoffs in surgery: Successes, failures and room for improvement

Patient handoffs are transitions where communication failures may lead to errors in patient care. Face-to-face handoffs are preferred, however may not always be feasible. Different models and strategies have been described, yet there are few experimental studies. Expanding the problem, the on-call surgeon may be responsible for many patients, few or none that they admitted. Effective handoffs improve the quality of care and result in fewer errors. Herein we review different models of patient handoffs, comment on common pitfalls, and suggest areas for new research.

The effect of a checklist on the quality of patient handover from the operating room to the intensive care unit: A randomized controlled trial

PURPOSE

Handover of patient care is a potential safety risk for the patient due to loss of information which may result in adverse outcome. We hypothesized that a checklist for handover from the operating room (OR) to the intensive care unit (ICU) will lead to an increase of quality regarding information transfer compared with a nonstandardized handover procedure.

MATERIALS AND METHODS

The study was conducted as a prospective, randomized trial in a university hospital. The quality of handovers with checklist was compared with handovers without checklist. Handovers were recorded by digital voice recorder and analyzed using an individual rating sheet for each patient. This enabled to discriminate between items that "must be handed over" (red items) and items that "should be handed over" (yellow items).

RESULTS

A total of 121 patient handovers from OR to ICU were included. Significantly more red items were handed over in the study group compared with the control group (study group: median 87.1%, 25-27 percentile 77.1%-90.0%; control group: median 75.0%, 25-75 percentile 66.7%-88.6%; P < .01).

CONCLUSIONS

This study gives first evidence that the use of a standardized checklist for patient handover from OR to ICU increases the quantity and quality of transmitted medical information.