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DevelopmentofaStandardizedNursingHandoffWithTabletTechnology_AQualityImprovementInitiative1.pdf

Development of a Standardized Nursing Handoff With Tablet Technology: A Quality Improvement Initiative

Briana R. Miller, DNP, FNP-C, AGACNP-BC, RNFA, CSSBB ▄ Kimberly A. Maye, RN, MSN, CCRN ▄ Frances D. Charlton, DNP, MBA, MHA, RN, NE-BC

BACKGROUND: Nursing handoff of complete and accurate information is critical for patient safety yet is often difficult to achieve with consistency between nursing departments.

OBJECTIVE: This quality improvement project aims to describe the development and piloting of a standardized handoff tool for administration by computer tablet for nursing report.

METHODS: This descriptive quality improvement initiative was conducted in an 885-bed Level I trauma center in the Southeast Region of the United States. The study was completed in three phases. First, emergency department and trauma intensive care unit nurses were surveyed to determine handoff barriers and best practices. Second, the survey information was used to develop a standardized handoff tool incorporating tablet technology. Third, staff pilot testing was performed, followed by a final survey to ascertain staff feedback on the tool.

RESULTS: A total of n = 120 nurses completed the surveys, and pilot testing was conducted on n = 177 patient handoffs. Ninety-five percent of nurses expressed satisfaction with the tool and 65% with the tablet.

CONCLUSION: This study supported using a standardized handoff tool between the emergency department and trauma intensive care unit and substantiated the benefits of using a tablet for face-to-face communication.

KEYWORDS: Communication, Emergency department, Handoff tool, Handover, Reporting tool, Standardized handoff, Standardized report, Tablet, Trauma intensive care unit Cite as: Miller, BR., Maye, KA., & Charlton, FD. (2024). Development of astandardized nursing handoff with tablet technology: aquality improvement initiative. Journal of Trauma Nursing, 31(4), 218-223. https://doi.org/10.1097/JTN.0000000000000801

Handoff of patient information occurs more than 4,000 times daily in various contexts in a large

academic medical center (Blazin et al., 2020). The potential for adverse events during hospitalization can happen at any moment for a patient; however, handoff communication between the emergency department (ED) and the intensive care unit (ICU) marks an oppor- tunity for avoidable adverse events (Fleharty & Freel, 2021). Patients transferring from the ED to the ICU are often complex, with various high acuities (Kessler et al., 2014). A persistent problem with handoff communica- tion focuses on the inconsistencies regarding unbalanced expectations among registered nurses (RNs) in the ED and the ICU (Sasso et al., 2015). Time limitations, awareness of the other unit’s present state, lack of stan- dardization, cultural differences, lack of established relationships, and a vast amount of patient information

represent some of the challenging barriers faced by staff (Nasarwanji et al., 2016).

Communication failure is a root cause of most hospital sentinel events (The Joint Commission, 2017). Adverse patient events related to handoffs are often a result of multiple accumulating factors due to the fast-paced workflow in the ED (Mamalelala et al., 2023). A lack of standardized structure for patient handoff creates a space for a handoff with inaccurate information, delayed treatments, and decision-making that significantly decreases patient safety (Clarke et al., 2012). Developing a standardized handoff tool is vital to patient safety and continuity of care. Lewin’s model of change provides a solid framework for nurses from the ED and ICU to approach the issues with handoff, develop modifications to the handoff process, and refreeze newly implemented measures (Wojciechowski et al., 2016). General handoff tools have been created; however, no specific tools are established for specialty areas such as the ED and ICU.

A standardized handoff tool directly aids in com- municating pertinent patient information while redu- cing confusion within the workflow (Wolak et al., 2020). The ED’s workflow is ever-changing, including new patient assignments every four hours to reduce burnout. While this system optimizes the ED RN’s workflow, it was found to interrupt the ability to per- form a traditional bedside report as the receiving ED RN

Dates: Submitted October 5, 2023; Revised: May 3 2024; Accepted: May 4 2024

Author Affiliation: Department of Nursing Administration and Trauma Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina.

The authors declare no conflicts of interest. Correspondence: Briana R. Miller, DNP, FNP-C, AGACNP-BC, RNFA, CSSBB, Department of Nursing Administration and Trauma Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Blvd, Winston-Salem, NC 27157 ([email protected]).

QUALITY IMPROVEMENT

218 Journal of Trauma Nursing 2024 Volume 31, Number 4

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http://orcid.org/https://orcid.org/0009-0006-4299-4391

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was often not transporting the trauma intensive care unit (TICU) patient to the ICU.

The development of a standardized handoff tool would promote a streamlined process between the ED and ICU nurses utilizing a tablet to achieve face-to-face interaction. Leadership support with the use of Lewin’s change theory has the potential to highlight a standardized handoff tool that can enhance staff satisfaction, exchange of patient information without omissions, continuity of care, and, most importantly, patient safety.

OBJECTIVE

This quality improvement project aims to describe the development and piloting of a standardized handoff tool for administration by computer tablet for nursing report.

METHODS

Study Design This descriptive quality improvement initiative

was utilized to gauge the staff’s needs regarding a standardized reporting tool and the opinions sur- rounding the use of tablets in lieu of a phone call for direct patient report. The inclusion criteria for the study included all bedside staff RNs within the ED and TICU departments. Exclusion criteria included ancillary staff, providers, and RNs from units outside the ED and TICU. This study was deemed exempt by the Atrium Health Wake Forest Baptist Institutional Review Board (IRB), IRB approval number IRB00095850.

Presurvey An anonymous paper presurvey (Figure 1) was

distributed to gauge staff feedback surrounding the lack of a standardized process and handoff tool as it pertained to giving or receiving report on patients being admitted from the ED to the TICU. The qualitative survey included seven questions based on concerns ED and TICU nursing staff reported regarding the handoff process over the last 12 months. Survey questions focused on the challenges faced when giving or receiving a handoff, consequences of a poor handoff, common

information missed during handoff, thoughts surround- ing an ideal handoff, and ensuring the accuracy of infor- mation. Surveys were distributed at preshift huddles and asked to be returned to the nurse manager or nurse educator’s office to ensure staff’s privacy within one month of the distribution date. There were no incentives associated with participation in the survey. Based on these presurvey themes (Table 1), a standardized hand- off tool was developed to encompass ED and TICU staff requests and feedback (Figure 2). This tool and a new tablet reporting process were implemented on both units simultaneously.

Implementation Once the staff feedback had been received from the

presurvey results and the standardized tool was created, staff were educated on the new handoff tool (Figure 2). The computer tablets were brought to both units, and the reporting app was successfully downloaded. The standardized reporting tool was laminated and placed in the ED trauma bays and at the nurse’s station within the TICU for easy accessibility. A step-by-step in-app process for the tablet use was printed, laminated, and clipped to the tablet stands for staff to reference when needed. Staff were trained to use the innovative technol- ogy and show their ability to access their patient’s infor- mation within the tablet app and connect to the receiving units’ tablets. Multiple tests over two weeks were trialed before the formal go-live date. Staff demon- strated competency in using the standardized reporting form and the tablets before go-live.

Postimplementation After two months, all staff received an anonymous

postimplementation paper survey to measure their satis- faction with the standardized reporting tool and the new tablet communication process. The postimplementation surveys were returned no later than one month after distribution. The feedback for the standardized handoff tool was overwhelmingly positive, while the feedback on using tablets was mixed. However, the TICU staff who had previously used tablets for handoff with opera- tive reporting were satisfied overall. Given that tablets were new to the ED RNs, the feedback reflected a need for more time to acclimate to this new technology in their daily workflow. Based on the survey results, it was determined that no additional changes were required for the new handoff tool (Figure 2), and it was decided to continue with the use of the tablets as well as the hand- off tool as the new standard of practice between the ED and TICU departments.

RESULTS

In total, the study had 120 participants from both departments. During the study period, there were 177

KEY POINTS ● Lack of standardized patient handoff can result in inconsistent information-sharing.

● Standardized reporting tools can improve consistent staff communication and time management.

● Nursing handoffs delivered by computer tablet produced mixed results and opinions among staff nurses.

Journal of Trauma Nursing 2024 Miller et al. Volume 31, Number 4

admissions from the ED to the TICU. The preproject survey was submitted and completed anonymously by both RN groups. These results demonstrated a poor perception of the existing handoff practices, with many areas identified for improvement (Table 1). The pre- existing handoff practices were not observed as unsafe but rather inconsistent, with notable omissions of perti- nent patient data and lack of knowledge about the patient, leading to dissatisfaction among both groups.

Postsurvey results revealed around 95% staff satis- faction with using the new standardized handoff tool (Table 2). Feedback included a positive take on standar- dizing the report between the two groups, staff being more engaged with one another, and pertinent informa- tion being consistently included during handoff with the use of the new tool. The TICU RN feedback revealed that 74% were satisfied with using tablets, while 26% preferred a traditional phone call report. Emergency department RN feedback demonstrated that 59% were satisfied with the tablet, while 41% preferred a traditional phone call report. The overall results

revealed that 35% of the 120 staff members preferred the traditional phone call report, while 65% preferred the tablet for face-to-face reporting (Table 2). Utilizing a standardized handoff tool created by immediate

Table 1. Presurvey Results: Challenges with Current Process

Common Themes When Giving/Receiving Handoff Consequences of a Poor Handoff

Primary nurse unable to transfer patient

Delay in patient care/interventions

Inconsistent reporting layout Unknown patient-specific precautions (code status, spine precautions, infection isolation, etc.)

Information missed during handoff

Patient injury due to lack of information provided

Patient and staff dissatisfaction

Poor time management

Note. These were the most common theses noted between both the emergency department and trauma intensive care unit registered nurses.

Figure 1. Emergency department to trauma intensive care unit handoff presurvey.

Miller et al. Journal of Trauma Nursing 2024 Volume 31, Number 4

stakeholders increased satisfaction with reporting efforts when patients were admitted from the ED to the TICU, and the nurses achieved an overall compli- ance of 70% over the study period. Some concerns surrounding noncompliance included patients who were emergently transferred to procedural areas from the ED, resulting in emergent reporting via phone calls or at the bedside. Although no changes were made to the handoff tool based on the staff’s positive feedback, edu- cation and support were provided to increase profi- ciency and compliance.

DISCUSSION

Our study demonstrates that the use of a standar- dized handoff tool improves communication among staff, increases time management, and enhances the quality of patient care provided. Additionally, we observed an increase in the overall clinician experience in the TICU due to having complete information before beginning the next phase of care. Wolak et al. (2020) concluded that team members can have a more productive conversation about the patient and care needs when ambiguities in the handoff process are prevented.

The standardized handoff tool was well received by staff in both departments. A standardized handoff process prevents omitted information, reduces treat- ment errors, ensures staff availability, and prevents delays in treatment (Desmedt et al., 2020). While we received positive feedback on the tool, we had mixed reviews on incorporating the tablet into the handoff process. Initially, we felt that adding this type of tech- nology would be well-received. Potts et al. (2018) noted that an electronic handoff process had many benefits, including decreased boarding time and improved transi- tion of care directly from the ED to inpatient units. However, we found that it sometimes added time to the process due to difficulty finding the equipment, ensuring the battery was charged in both units and the overall “clunkiness” of incorporating it into the handoff process. Tablet communication for handoff can directly improve communication of pertinent patient information (Jelacic et al., 2020). The teams still believe it is a practical option for the handoff

process and offers benefits that the existing process does not, such as incorporating the patient and visualiz- ing wounds or other pertinent areas of care before the patient arrives in the TICU. However, further process improvements are needed to streamline the workflow to reduce delays and the number of steps involved when using the tablet to provide an effective handoff experience.

The goal of implementing a standardized handoff tool was to eliminate information gaps between two departments and create a seamless transfer of informa- tion, thus improving patient care, which proved success- ful based on the feedback. A standardized handoff reporting tool correlates with positive staff perceptions, improved patient outcomes, and enhanced information sharing between departments (Bell et al., 2023). The integration of the tablet was introduced to improve com- munication and aid in face-to-face handoff. Tablet-based handoffs directly correlate with improved communica- tion and accuracy of patient information discussed (Sparling et al., 2023). Since RNs from both units parti- cipated in creating the standardized handoff tool, it will be important to continue with front-line engagement as information needs change and tool revisions are needed.

LIMITATIONS

Limitations included budgetary restrictions for ordering tablets for the departments, the initial number of surveys returned, staff education surrounding the new tablet handoff, and capturing the report needs of two units. We initially used research tablets from the Information Technology department until the nursing units could bud- get and order the required tablets for long-term use. Discussions of the QI project were included in daily hud- dles, and the survey return period was extended by two weeks to encourage staff engagement and increase preim- plementation survey completion. Educators and clinical nurse specialists provided one-on-one staff education via in-services to capture all staff during the four weeks before the go-live date. Lastly, staff concerns were mitigated with the anonymous presurvey (Figure 1) to ensure that both groups’ needs, expectations, and non-negotiable handoff components were met on the new handoff tool.

CONCLUSION

Using a standardized handoff reporting tool between the ED and TICU resulted in less confrontation, improved patient care, staff satisfaction, and better time manage- ment. Using the tablet communication tool to replace a traditional phone call produced mixed results. Future research should be focused on more unit-based standar- dized tools and the advancement and integration of in-app technologies to allow for more seamless handoff reporting.

Table 2. Postsurvey Results

TICU ED Total

n % n % n %

Total Staff 49 41 71 49 120 100

Satisfaction with handoff tool 97 94 95

Satisfaction with tablet 74 59 65

Satisfaction with phone report 26 41 35

Note. Percentages were rounded to the nearest whole number.

Journal of Trauma Nursing 2024 Miller et al. Volume 31, Number 4

Orcid iDs

Briana R. Miller https://orcid.org/0009-0008-6779-2678 Kimberly A. Maye https://orcid.org/0009-0006-4299-4391 Frances D. Charlton https://orcid.org/0009-0009-1992- 1743

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