The Clinical Issue and Research Questions Developed Using PICOT

EVIDENCE- BASED CARE SHEET

Authors Carita Caple, RN, BSN, MSHS

Cinahl Information Systems, Glendale, CA

Tanja Schub, BS Cinahl Information Systems, Glendale, CA

Reviewers Darlene Strayer, RN, MBA

Cinahl Information Systems, Glendale, CA

Arsi L. Karakashian, RN, BSN Armenian American Medical Society of

California

Nursing Practice Council Glendale Adventist Medical Center,

Glendale, CA

Editor Diane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

February 9, 2018

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Hand Off: Patient Safety

What We Know › Transfer of responsibility between clinicians for patient care is commonly referred to

as “hand off,” “sign over,” or “shift report.” The objective of a hand off is to provide accurate and effective communication about the patient’s health status, prescribed treatment, and anticipated clinical events, as appropriate, in order to maintain patient safety and promote continuity of care(4,8)

• Types of transfer include intra-hospital and inter-facilitytransfers(4,8,9)

–The most common type of intra-hospital clinician hand offs are those related to(4,9)

- a change in nursing personnel between work shifts(4)

- change in physician care(4)

- interdisciplinary personnel changes (e.g., anesthesiologist hand off to the post-anesthesiacare unit [PACU] nurse)(4,9)

- intra-facility changes in level of care (e.g., hand off when patients are transported from the emergency department [ED] to an inpatient unit or the operating room [OR])(4)

–Common inter-facility transfers include those occurring between hospitals, to or from a skilled nursing facility, or from care in the inpatient setting to home health care(4)

› The nature of hand offs exposes patients to increased safety risk and the potential for adverse events, including patient misidentification, inappropriate and delayed treatment; delayed medical diagnosis; medication errors; wrong-site surgery (i.e., a term used to encompass surgery performed on the wrong body part, wrong surgical procedure performed, or surgery performed on the wrong patient); and insufficient monitoring, all of which could lead to life-threatening complications(1,4,6,13)

• Researchers who conducted a 6-month prospective study identified the occurrence of 66 adverse events during 290 intra-facility hand offs of critically ill patients from the ED to the intensive care unit (ICU)(6)

• In a study of malpractice claims from five insurers, investigators concluded that problems that occurred during hand off between physician trainees were the most common contributing factor in 167 out of 240 malpractice claims(14)

› Errors associated with patient hand off are most often attributed to miscommunication. Other barriers to effective hand off are system, organizational, and individual factors(1,8)

• The Joint Commission (TJC) has attributed 80% of serious medical errors to miscommunication during transfer of patients(8)

• System barriers include the hierarchical nature of health care, ineffective communication during transition of physician and nurse clinicians, background noise and interruptions, insufficient staffing, the increasingly complex care environment, and insufficient time devoted to hand offs(1,19)

• Organizational barriers include lack of standardized hand off protocols or forms, lack of verbal and written communication during hand off, and poor evaluation of patient transfer events and procedures(1,19)

–In a survey of 82 anesthesia providers (including nurse anesthetists, student registered nurse anesthetists, anesthesiologists, and anesthesia residents), 64% reported that they did not currently use a systematic process during anesthesia hand off(5)

• Individual barriers include inadequate communication skills and lack of training regarding the minimum information that is necessary to perform an effective hand off(1)

› Each hospital department has unique challenges related to patient hand offs(7,9,12,13,20)

• Perioperative (i.e., surgical area) clinicians perform multiple, closely-timed hand offs of patients who are anesthetized, recovering from anesthesia, or are otherwise vulnerable. The risk for adverse events increases due to rapid, multidirectional hand offs (e.g., from the preoperative area to the OR, from the OR to the post-anesthesia care unit (PACU), from the PACU to the ICU or an inpatient care unit)(9)

–Perioperative nurses receive frequent verbal and telephone orders from surgeons and implement changes in patient treatment that might not be documented or communicated completely during hand off(9)

• In the ED, the high volume of patient visits and the collaborative nature of performing triage and providing treatment increase risk for hand off errors(12)

–Information can be lost or miscommunicated when ED nurses and physicians participate in rapid hand offs when sending patients for urgent diagnostic procedures (e.g., CT scan) or emergency interventional treatments(12)

• Patients transferred from ICUs to a lower level of care are at increased risk because clinicians can misjudge the necessary level of information to sufficiently communicate the patient’s medical history and clinical status during hand offs(7)

–Investigators in a 2007 study that examined 47 patient transfers from a pediatric ICU to a general medical floor reported that in 25% of cases, hand off communication did not include relating information about clinically significant episodes of hemodynamic or respiratory instability(7)

–After analyzing 20 bedside ICU hand-offs using an observational tool based on 10 key principles for hand offs, researchers concluded that four principles—resuscitation status, discharge and long-term plans, use of a read-backsystem, and cross-checking medication orders—were minimally addressed or absent. The researchers recommended that development of a hand off tool specific to the ICU would assist in minimizing hand-off errors associated with miscommunication in this setting(16)

• In general medical units, where nurses are responsible for larger numbers of patients, researchers reported that hand off errors are more related to misidentification of patients. Because care of non-ICU patients is often released to unlicensed staff during transport to diagnostic and interventional areas, the subsequent communication to the receiving nurse can be insufficient(13,20)

–Adverse events that commonly occur during patient transport include loss of intravenous access, depleted oxygen supply, and equipment failure (e.g., infusion pump malfunction or loss of power)(13,20)

› In the case of multiple patient hand offs being communicated, the order in which patients are discussed appears to affect patient care practices(3)

• Researchers who analyzed video recordings of 262 patient discussions in 23 hand offs between ICU physicians concluded that more communication time and patient information were allocated to patients who were discussed early in the hand off. They suggested that the sickest or newest patients should be discussed first during hand offs(3)

› The following guidelines and recommendations have been established to improve the safety of critical care patients during hand offs(2,8,9,10,20,22)

• According to guidelines established by the Society of Critical Care Medicine (SCCM) and the American College of Critical Care Medicine (ACCCM) for transport of critically ill patients, the presence of two critical care team members during hand off is recommended to provide adequate monitoring and face-to-face verbal communication(22)

• Both TJC and the United States Department of Health and Human Services Agency for Healthcare Research and Quality recommend the use of verbal and written communication during hand offs, limiting interruptions during hand offs, reconciling patient medications, and implementing a standardized hand off protocol that includes the opportunity to ask and respond to questions(4,8)

• Formal training programs regarding performing hand offs are recommended. A simulation-based workshop about hand offs improved nurse communication of important patient information during shift change, such as confirming patient names, events that occurred during the previous shift, and treatment goals for the oncoming shift(2)

• Communication techniques recommended for use during hand off include

–SBAR, which stands for situation, background, assessment, and recommendation, is a framework for standardizing communication during hand offs(10)

- The authors of a recent systematic review concluded that use of SBAR during hand off is improves patient safety by creating a common language for communication of important patient care information, increasing the speaker’s and receiver’s confidence in the hand off report, and improving the efficiency and accuracy of the report(19)

–ISBAR, which stands for identity, situation, background, assessment, and recommendation, is a framework for standardizing communication during hand offs(11)

- Seventeen senior registered nurses involved in team leader handovers in the ICU agreed that the ISBAR tool is an effective tool for guiding clinical handover. They identified the following as the minimum dataset that should be included: Identity (name, age, days in ICU), Situation (diagnosis, surgical procedure), Background (significant events, management of significant events), Assessment (relevant observations and treatment within each body system), and Recommendation (patient plan for next shift, tasks to follow up for next shift)(15)

–“read-back,” a protocol for repeating verbal orders(4,9)

–use of a transport communication checklist (e.g., called “ticket-to-ride”) or similar form containing information regarding patient status, including his/her level of stability (e.g., orientation, oxygen requirements)(20)

• Implementation of a hand off bundle (i.e., a set of interventions that, when performed together, significantly improve patient outcomes) can reduce rates of medical errors(17,18)

–Investigators in a study conducted in nine hospitals concluded that the implementation of a standardized resident hand off bundle resulted in a 23% reduction in the medical error rate, a 30% reduction in preventable adverse events, and improved communication, without impeding workflow. Features of the program included a mnemonic to standardize hand offs, hand off and communication training, a faculty development and observation program, and a sustainability campaign(18)

–Implementation of a nursing hand off bundle in a pediatric ICU resulted in improvements in verbal hand off communication and a decrease in interruption frequency without significantly increasing the median hand off duration or affecting the amount of time spent in direct or indirect patient care activities. The bundle included educational training, a mnemonic to standardize hand offs, and visual materials(17)

• Patient participation in hand offs is recommended, but not always implemented in practice(21,23)

–The authors of a recent systematic review of 21 studies and 25 quality improvement projects identified barriers to patient involvement in bedside hand off, including nurses’ worries related to sharing confidential and sensitive information and reluctance to change their hand over methods(21)

–Researchers in Australia surveyed 401 patients and 200 nurses from medical wards and found that, although all participants favored patient involvement in hand off, patient and nurse preferences for certain components of the hand off process differ. For example, patients expressed a preference for having a family member/caregiver/friend present, while nurses did not consider this to be important. Similarly, patients had a weak preference for having sensitive information handed over quietly at the bedside while nurses had a relatively strong preference for verbal hand over of sensitive information to occur away from the bedside(23)

What We Can Do › Learn about effective strategies for transferring information regarding patient care during hand offs to provide accurate

and effective communication about the patient’s health status, prescribed treatment, and anticipated clinical events, as appropriate, in order to maintain patient safety and promote continuity of care; share this knowledge with your colleagues

› Adhere to facility/unit-specific protocols for effective communication during hand offs, including hand offs for patient transport, transfer of patient responsibility, and shift change for nurses

Coding Matrix References are rated using the following codes, listed in order of strength:

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster presentations or other such materials

CP Conference proceedings, abstracts, presentation

References 1. Association of periOperative Registered Nurses (AORN). (n.d.). Patient hand off tool kit. Retrieved January 17, 2018, from

http://www.aorn.org/aorn-org/guidelines/clinical-resources/tool-kits/patient-hand-off-tool-kit (GI)

2. Berkenstadt, H., Haviv, Y., Tuval, A., Shemesh, Y., Megrill, A., Perry, A., ... Ziv, A. (2008). Improving handoff communications in critical care: Utilizing simulation-based training toward process improvement in managing patient risk. Chest, 134(1), 158-162. doi:10.1378/chest.08-0914 (R)

3. Cohen, M. D., Ilan, R., Garret, L., LeBaron, C., & Christianson, M. K. (2012). The earlier the longer: Disproportionate time allocated to patients discussed early in attending physician handoff sessions. Archives of Internal Medicine, 172(22), 1762-1764. doi:10.1001.2013.jamainternmed.65 (R)

4. Friesen, M. A., White, S. V., & Byers, J. F. (2008). Chapter 34. Handoffs: Implications for nurses. Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Volume 2. Retrieved January 17, 2018, from http://www.ncbi.nlm.nih.gov/books/NBK2649/pdf/ch34.pdf (G)

5. Gibney, C. (2017). A needs assessment for development of the TIME Anesthesia Handoff tool. AANA Journal, 85(6), 431-437. (R)

6. Gillman, L., Leslie, G., Williams, T., Fawcett, K., Bell, R., & McGibbon, V. (2006). Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit. Emergency Medicine Journal, 23(11), 858-861. doi:10.1136/emj.2006.037697 (R)

7. Grant, M. J. C., & Larsen, G. Y. (2007). Clinical information transfer and medication reconciliation in patients transferred from the pediatric intensive care unit. Journal of Patient Safety, 3(4), 195-199. doi:10.1097/pts.0b013e31815a83bb (R)

8. Joint Commission on Accreditation of Healthcare Organizations. (2012). Joint Commission Perspectives, 32(8), 1-3. Retrieved from https://www.jointcommission.org/assets/1/6/ tst_hoc_persp_08_12.pdf (GI)

9. Joy, J. (2009). Nurses: The patient's first--and perhaps last--line of defense. AORN Journal, 89(6), 1133-1136. doi:10.1016/j.aorn.2009.05.013 (GI)

10. Kaiser Permanente. (n.d.). SBAR toolkit. Institute for Healthcare Improvement. Retrieved January 17, 2018, from http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx (G)

11. Rhode Island Hospital. (n.d.). ISBAR trip tick. Institute for Healthcare Improvement. Retrieved January 17, 2018, from http://www.ihi.org/resources/Pages/Tools/ ISBARTripTick.aspx (G)

12. Roman, L. M., & Metules, T. J. (2007). Door-to-balloon time: The race is on. RN, 70(2), 34-40. (GI)

13. Safe intrahospital transport of the non-ICU patient using standardized handoff communication. (2009). Pennsylvania Patient Safety Advisory, 6(1), 16-19. (GI)

14. Singh, H., Thomas, E. J., Petersen, L. A., & Studdert, D. M. (2007). Medical errors involving trainees: A study of closed malpractice claims from 5 insurers. Archives of Internal Medicine, 167(19), 2030-2036. doi:10.1001/archinte.167.19.2030 (R)

15. Spooner, A. J., Aitken, L. M., Corley, A., & Chaboyer, W. (2018). Developing a minimum dataset for nursing team leader handover in the intensive care unit: A focus group study. Australian Critical Care, 31(1), 47-52. doi:10.1016/j.aucc.2017.01.005 (R)

16. Spooner, A. J., Chaboyer, W., Corley, A., Hammond, N., & Fraser, J. F. (2013). Understanding current intensive care unit nursing handover practices. International Journal of Nursing Practice, 19(2), 214-220. doi:10.1111/ijn.12058 (R)

17. Starmer, A. J., Schnock, K. O., Lyons, A., Hehn, R. S., Graham, D. A., Keohane, C., & Landrigan, C. P. (2017). Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow. BMJ Quality & Safety, 26(12), 949-957. doi:10.1136/bmjqs-2016-006224 (R)

18. Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., & Lanigran, C. P. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803-1812. doi:10.1056/NEJMa1405556 (R)

19. Stewart, K. R. (2017). SBAR, communication, and patient safety: An integrated literature review. MEDSURG Nursing, 26(5), 297-305. (SR)

20. Systems analysis. Transporting patients and information from here to there and back again, safely. (2007). Joint Commission Perspectives on Patient Safety, 7(1), 3-4. (GI)

21. Tobiano, G., Bucknall, T., Sladdin, I., Whitty, J. A., & Chaboyer, W. (2018). Patient participation in nursing bedside handover: A systematic mixed-methods review. International Journal of Nursing Studies, 77, 243-258. doi:10.1016/j.ijnurstu.2017.10.014 (SR)

22. Warren, J., Fromm, R. E., Orr, R. A., Rotello, L. C., & Horst, H. M. (2004). Guidelines for the inter- and intrahospital transport of critically ill patients. Critical Care Medicine, 32(1), 256-262. doi:10.1097/01.CCM.0000104917.39204.0A (G)

23. Whitty, J. A., Spinks, J., Bucknall, T., Tobiano, G., & Chaboyer, W. (2016). Patient and nurse preferences for implementation of bedside handover: Do they agree? Findings from a discrete choice experiment. Health Expectations, 20(4), 742-750. doi:10.1111/hex.12513 (R)