Clinical Handovers

A
No standardization
 
No written template
 
No checklists
B
Communication problems
 
Omission
 
No face-face discussions
C
Time constraints
 
Lack of allotted time
D
Physical barriers
 
Lack of assigned space
 
Interruptions
 
Noisy environment
E
Staffing problems
 
Overworked physicians (too many patients
F
Lack of training
 
No formal lectures on handovers
 
Lack of formal curriculum
G
Lack of trainee supervision
 
Senior physicians absent during handovers

Strategies to Improve Physician Handovers

In recent years there has been an increase in the awareness about importance of effective handovers to improve clinical outcomes and reduce medical errors. Various strategies can be employed to achieve this goal (Table 13.2).
Table 13.2

Strategies to improve physician handovers
A
Training and education
 
Development of curriculum
 
Formal lectures
B
Physical environment
 
Allocation of time and space
 
Minimize interruptions
C
Standardization
 
Written guidelines, templates
 
Electronic (IT) solutions
 
Mnemonics
D
Communication
 
Face to face handover
 
Clarification
 
Reconciliation
E
Supervision by senior physicians
F
Policy and regulatory requirements
 
Residency training to incorporate handovers
Increased awareness about importance of handovers in improving patient safety can be achieved by education and involvement of the leadership team. Allotting designated time and place for a formal handover process is essential. Strategies towards standardization including written templates, handover cards, electronic tools, and information technology (IT) solutions improve consistency and accuracy of handovers. Senior physicians should be present to observe and guide handovers . Lastly, mnemonics are helpful as useful tools to improve the handover process.

Electronic Handover Solutions

Electronic systems can be utilized to improve the handover process .Existing medical record systems can be utilized for handover purposes [32]. Alternatively, stand -alone IT tools are available to aid the handover process [33, 34]. Use of a computerized handover tool has led to improved quality and completeness of physician handover, increased physician efficiency [35] and resulted in fewer adverse events [36]. Patient identifiers and medications are accurately extracted from medical record after implementation of a computerized handover tool [37]. A recent systematic review of interventions improving patient handovers by Arora et al. [38] reported that implementation of IT handover solutions was associated with an improvement in handover quality, healthcare team satisfaction and reduction in adverse events. However, though these electronic tools improve the accuracy of handover information , they do not influence the behavioural aspects of the handover process and may not improve communication between the health care providers [39].

Non-Electronic Handover Solutions

Various non-electronic solutions have been tried to improve quality of handovers. These could be hand-out templates, simulation techniques or mnemonics [1]. Lee et al. [40] used a standardized handover cards to facilitate handover process. Interns in the study group had fewer omissions in their handovers as compared to controls. Junior physicians can be trained using simulation techniques . Bhabra et al. [41] compared three handover styles over five consecutive handover cycles: oral only, oral with note taking, oral with written instructions using handover simulation scenarios performed by senior house officers. After five handover cycles, only 2.5 % of patient information was retained using the verbal-only handover method, 85.5 % was retained when using the verbal with note taking method and 99 % was retained when a printed hand-out containing all patient information was used .

Mnemonics

Mnemonics are increasingly becoming popular to facilitate handover process. Mnemonics aid health care staff in memorizing important steps in the handover process. Joint Commission has added “Implement a standardized approach to hand-off communications” to its National Patient Safety Goal in 2006. Mnemonics have evolved according to the needs of particular health care setting. SBAR has been, by far, most utilized and studied mnemonic in the literature. It can be used by physicians as well as nurses in diverse clinical settings It has been modified to suit a particular health-care setting (i.e. SBARR, SBAR-T) [42]. Porteous et al. [43] reported on use of a similar mnemonic iSoBAR in Western Australia. They found that iSoBAR form and accompanying tool-kit was widely accepted in this region owing to extensive clinician involvement and leadership. Horwitz et al. [44] developed an oral handover curriculum for medical students and residents emphasizing a structured handover format with the help of mnemonic HANDOUT. The participants demonstrated statistically significant increase in perceived comfort with providing sign-out after the intervention. Strimmer et al. have recently reported on development of mnemonic I-PASS, which is currently being evaluated in a multi-centre study [45]. Some authors have cautioned that handoffs , especially in some settings like critical care, can be very complex. Catchy mnemonics may not be adequate to deal with the complexity and nuances of the process [42] (Table 13.3).
Table 13.3

List of mnemonics used to facilitate handovers
Mnemonic
Description
ANTICipate [30]
A Administrative data
N New information
T Tasks
I Illness
C Contingency planning/code status
I PASS [45]
I Illness severity
P Patient summary
A Action list
S Situation awareness and contingency planning
S Synthesis by receiver
I PASS the BATON [46]
I Introduction: introduce yourself, your role
P Patient: name, identifiers, age, sex, location
A Assessment: chief complaint, vital signs, symptoms, diagnosis
S Situation: current status, code status, recent changes, response to treatment
S Safety concerns: critical lab values, allergies, alerts, socioeconomic status
B Background: co-morbidities, previous episodes, family history
A Actions: which were taken or required, providing brief rationale
T Timing: level of urgency, explicit action and prioritization of actions
O Ownership: who is responsible (e.g. nurse, doctor, team) including patient and family
N Next: anticipated changes in condition or care
SBAR [4649]
S Situation (identify the patient, why is the patient here
B Background (history, lab findings, test results
A Assessment (assessment of the course of care and patient condition
R Recommendation (recommendation for continuation of care
iSoBAR [43, 50]
I Identify: introduce yourself and your patient
S Situation: why are you calling? briefly state your problem
O Observations: recent vital signs and clinical assessment
B Background: pertinent information related to the patient
A Agreed plan: what needs to happen? assessment of the situation
R Read back: clarify and check for shared understanding
SHAREQ [46]
S Situation: describe the situation
H History: medical history, allergies, home medications
A Assessment: current medications intake, output, status
R Recommendations: results, discharge planning
Q Questions: opportunity to ask questions
SIGNOUT [44]
S Sick or DNR? (highlight sick or unstable patients, identify DNR/DNI patients
I Identifying data (name, age, gender, diagnosis
G General hospital course
N New events of the day
O Overall health status/clinical condition
U Upcoming possibilities with plan, rationale
T Tasks to complete

Nursing Handovers

Nursing hand-offs occur multiple times a day as nurses exchange information typically at the time of shift change [51]. Nurses seldom receive any formal training for this important aspect of patient care. Errors in nursing handoffs are an important contributing factor to adverse clinical events. Furthermore, nurses also share the legal liability in case of a malpractice suit resulting from an adverse clinical event due to improper hand-offs. Traditionally, nursing handovers fit into one of the following models:
1.

Verbal handovers (face-face
 
2.

Tape recorded handovers
 
3.

Bedside handovers
 
4.

Written handovers [5254]
 
In a review of these handover styles , McKenna did not identify one style superior to another. The author recommended written guidelines for nursing handovers to improve consistency and clinical outcomes [52]. In an observational study comparing verbal, taped and bedside handovers, O’Connell and Penney identified strengths and weaknesses of each style. Verbal handovers provide an opportunity for the staff to debrief, and clarify information and are narrative in nature. However, verbal handovers run the risk of becoming too subjective and superfluous, omitting vital information. Tape-recorded handovers can be to the point and less time consuming. There is no opportunity to clarify information, education and debriefing. Bedside handovers provide opportunity to clarify information, reconcile medications and involve patients, fostering individualized care. These, however can be time consuming and prone to interruptions [55]. In a study comparing taped versus face to face nursing reports, taped reports were found to have more omissions (information left out during hand-off leading to increased inefficiency) and less incongruence (information relayed during a hand-off that differs from the medical record) than the latter [56].

Patients’ Participation During Nursing Handovers

Nursing handover at the patient’s bedside is an important component of patient-centred care. It provides an opportunity for the patients to participate in their care and encourages their active involvement in their health-care decisions. In a descriptive study from Australia, McMurray reported on ten patients’ views about bedside nursing handovers. Most patients appreciated to be acknowledged as partners in their care, viewed it as an opportunity to correct mistakes and appreciated nurse-patient interaction [57]. Anderson et al. [58] reported on a shift in nursing policy at a US Hospital from a traditional handover towards a patient-centric bedside report. Several benefits were realized by patients as well as the health-care team. The patients’ satisfaction improved significantly as they were better informed and felt involved in making their health-care decisions. This change in policy translated into several benefits including financial savings for the health care institution and increased satisfaction for the hospital nursing staff, patients and physicians.

Barriers to Effective Nursing Handovers

Communication problems including irrelevant information, lengthy reports, problems with recall, language barriers, inadequate communication between physician, and nursing teams account for majority barriers to effective nursing handovers . Other barriers include lack of standardization of hand-off process, lack of training , environmental issues such as too many interruptions, poor lighting, and human factors including inadequate staffing and overworked nurses [51].

Strategies to Improve Nursing Handovers

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Nov 16, 2015 | Posted by in General Dentistry | Comments Off on Clinical Handovers
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