It is an integral part of communication in healthcare to transfer critical information and the responsibility of the patient from one health care provider to another. Such transfer points are called handoff. “An effective handoff supports the transition of critical information and continuity of care and treatment.” These handoffs have been found to be particularly hazardous, and particularly involve missing, incomplete, or inaccurate information and are also associated with adverse events.
According to , medication errors are a major cause of injury to hospital patients, and it has been found that more than half of all the hospital medication errors occur at the time of an interface of care, like handoff. Handoff occurs across the entire spectrum of healthcare, and may differ from one healthcare provider to the other. Such as transfer from one location within the hospital, or between shift in the same unit. They also occur between the nurses and physicians, or interdisciplinary handoff between nurses or physicians.
In one such study, the nurse-to-nurse handoff allows the next nurse to visualize the patient and ask relevant questions. Therefore, it also allows the patient to get actively involved in the care and promote standardized communication. Even the Joint Commission is very particular the possibility of ADEs at the time of hand-offs. It is leading an effort to work with more than 20,000 accredited health care organizations.
The Model of Improvement is a simple yet powerful to speed up the process of improvement. It has two parts, asking the three fundamental questions to be addressed in any order, and then the PDSA cycle. It begins with the formation of a team and then followed by those three fundamental questions; setting up of aims; establishing measures, and then finally selecting the changes. This is followed by the PDSA cycles, which are followed by implementing change, and finally spreading changes.
We began with the setting up of aims. These aims should be time-specific and measurable. They should also define the target population of patients who will be impacted. In the case of our hospital, we have set up a reasonable aim of reducing the percentage of unreconciled medications at admission, discharge, and transfer to 25% of current level within the next 12 months. We will first begin working at the point of admission at the emergency department (ED). Then, we will be implementing changes across the rest of the point of transition at the hospital. Lastly, we will be spreading the change to other hospitals of our system.
An effective team comprises of members having three kinds of expertise; system leadership, technical expertise; and day-to-day leadership. In this context, we would like to form a team comprising of one ED physician who will form an effective clinical leader. He or She understands the clinical implications of the changes as well as the consequences. A nurse manager of ED will act as a technical expertise as they know the subject thoroughly and also understand the process of care. They would also be expert in improvement methods. A triage nurse and few other nurses will act as day-to-day leadership. They would understand the also understand the details of the system and would have observed the challenges from the front. Finally, the project sponsor will be the Director or the Vice President responsible for the ED.
Establishing Measures & Selecting Changes
Measures form an important part of the process as they tell us whether the changes we are making will lead to improvement or not. They bring with them the new knowledge into daily operational practice. They gather just enough data to learn from one PDSA cycle. Here will be observing both the process and outcome measure. Outcome measures the impact on the values of patient and their health outcomes. In the case of our studies, it will be the impact due to reduced potential adverse drug events (ADEs). And we have decided that the percentage of unreconciled medications at the time of hand offs to 25% by the end of the year. The process measures would include identify and to eliminate the barriers to reconciliation. They may include the staffing issues so that nurses have enough time to do the reconciliation. To determine process measures, we will be collecting random samples. And then, we will be plotting the outcomes over the time.
We will be selecting the changes that are consistent with and promote better communication at the time of hand-off: such that, there are reduced chances of ADEs. These changes will be selected by upon the recommendations by the team members. The changes will pertain to the nature and the content of the communication.
Now, the next step would be to test the change. This PDSA cycle broadly involves – planning, trying, observing the result, and acting on what we have learnt – from the change. This increases our belief on the change that will result from the improvement. It will also help in deciding among the several proposed changes, which are expected to lead to the desired outcome. It will also help us quantify how much can be expected from the change. And before spread the new measures, it will allow us to test whether it will work in the actual environment or not. This PDSA cycle or the pilot project will also allow us to determine whether the changes will have desired effect on the quality measures. Further, it will also help us evaluate the costs, social impact, and the side effects from the change. Lastly, we are involving the staff upfront; it will help minimize the resistance to change.
plan. Here will be broadly taking the following steps; defining the objective of the test; making predictions and projections about what will happen, and developing plan to test the change.
First, we will begin with selecting a team for the pilot project and will comprise of the medicine nursing unit. The patients will be getting admitted from everywhere to that nursing unit, and there are more than one nurse taking care of the patients. Consequently, we will be selecting five nursing beds of a particular nursing unit for our study. We plan to note down the conversation between the two nurses at the time of hand-off. This will involve the outgoing nurse to note down what all she dictated to the incoming nurse. The note should be in electronic format so that it can be assimilated and evaluated later. For this, we will be using tablet devices that will be installed besides the nursing beds. Notes will be timed and dated, and along with the name of the incoming and outgoing nurse. This will not only provide us with the data to evaluate later, but also a written note to the incoming nurse in case she forgets. So, this is not only a data collection tool, but also a means of improving quality of care.
As we know that for patient safety, the main reason for the shift handoff is to convey essential information about the patient. Also, to promote the continuity of care to, so as to meet the therapeutic goals and to ensure safe transfer to qualified clinician. To, promote this initiative, we will include education of nurses. Also, the part of the training would be debriefing, socialization, planning and organization, enhancement of teamwork, and other supportive funtions.
The duration of the plan is expected to be 2 weeks.
do. This will involve doing interview of the nurses involved. If for some reason, the outgoing nurse was unable to give proper medication instructions to the incoming nurse; we should explore the reasons why he or she was unable to do so. The interview will help bring out reasons for the same. The interview would have a few open and closed ended questions. This will ensure the validity of the process. These questions shall be in relation to the medication related information to be transmitted at the time of hand-off. In case the hand-off is between the departments, it will involve the discharge nurse. And they ensure that the discharge summary is properly documented or not.
This will help us document both the process and outcome measures at the time of hand-off. Here we will ask the outgoing nurse to note down on the tablet the detailed description of the medications being given to the patients, particularly any changes that might have been made at the time the patient was under the supervision. It is advisable that this nurse is verbally communicating at the time of writing down. This will not only save time, but also avoid any discrepancy. This will also entail the incoming nurse to repeat back what all she has just been told. At the same time, involve the whole team in documenting any of the problems they may face in the process of communicating at the time of hand-off.
As a part of the pilot project, we will be following the strategy that involves 17 broad steps.
consider different types of handoffs and places where they occur. Hand-offs occur in many different clinical areas. Some of the typical one includes nursing shift; physician-physician reports, such as consults, case-transfer, or on-call responsibility; within or in between speciality areas; nurse-physician hand-off in an inpatient unit; critical lab or diagnostic imaging report; transfer between hospitals; emergency or crisis interventions; or medical school staff.
standardized handoffs – reduce variations. This process includes conducting a detailed verbal handoff including tasks like read-back or repeat-back. It will also include creating a standard protocol tool for hand handoffs. This would imply that all the staff will follow the standardized procedures. This structured tool or a handoff checklist can vary depending upon what is being communicated.
mapping the handoff process. The mapping of the handoff process involves an assessment of the current process and the idealized situation. This
will also involve all the key stakeholders that in routinely involved in the handoff process, to review the newly recommended process. Also, it is important to make a small beginning. In that context, one should make a small process in this one unit. In this small but critical step, it is important to assess the critical element in that process. Our plan is also to involve the non-clinical staff, such as porters, in the process.
employ six principles of error-free handoffs. First of the principle will be to “communicate interactively, thereby allowing and promoting questions between the giver and the receiver of the information”. Second would be a need to communicate up-to-date information regarding care, treatment, services, condition, and recent or anticipated changes. Third, would be limiting the scope of interruptions to avoid losing the information. Fourth, there should be sufficient time to complete the handoff. Fifth, there should a verification process such as, repeat-back or read-back. Sixth, and final, the reviewer of the information has had a chance to review the historical data.
employ SBAR or other communication checklists. There are easy to remember acronyms – SBAR or ANTIcipate – that can be educated to the staff. SBAR stands for situation, background, assessment, and recommendation. Similarly, ANTIcipate will imply; administrative, new information, tasks, illness, and contingency plan.
manage change-of-shift communications. This will involve some overlap in change of shift times so that incoming shift begins approximately 30 minutes before the end of the previous shift. A standardized change-of-shift report is prepared the outgoing nurse. It will be better if it is electronic. At the change of shift, both incoming and outgoing nurse make beside rounds on all the patients in the unit. And in the process do the handover communication besides the patient.
standardize the patient discharge process. This would involve providing the discharge summary to patients in written form. These would include the diagnosis, summary of the tests performed, medications prescribed upon discharge, follow-up instructions, and other info. It is important to involve the patient and the family in the discharge process. Also, address their questions. Special care must be taken for critically ill patients.
provide clear medication instructions at discharge. We are aware that the medication errors are the most-common discharge events. So, it is important to develop clear instructions and provide key information on the medications to be continued at discharge.
use briefing or huddles. They are quick conversations among some or all the nurses of the unit to discuss the new or transferred patients. This may also involve sharing of information that is important for the next shift.
use forms, whiteboards, and checklists. To use, such educational tools toward training of nursing staff, and also to make discharge plan.
use facsimile reports to transfer information to receiving units. In this case the medical staff member faxes the reports to facilitate the movement of patients from unit to another. This faxed report can be sent to the nursing unit for ED, while the patient is still in transit.
study. This stage would involve analysis of date to examine if there have been any reduction in ADEs. We would also examine if the results were in line with the predictions made earlier. Once the progress is confirmed, we will summarize the knowledge gained so far.
After the testing has been done on a small cycle, the changes may be implemented on a broader scale.
“After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes to other parts of the organization or in other organizations.”
It has been observed that the chances of having adverse drug events are greatest at the time of handoff of patients. This necessitates improved patient protocol at the time of handoff at any situation. Therefore, to formulate and to test the protocol we have performed a Plan-Do-Study-Act cycle. As a part of planning process our team created a protocol. We tested it out in a particular unit, under the ‘do’ phase. Later, we studied the changes in adverse events in the ‘study’ phase. Based on that study, we made further changes under the ‘act’ phase. These will be tested in the next phase of the cycle. Once we have a reasonable amount of confidence, we plan to apply the new protocol to the rest of the hospital.
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