Quality improvement of doctors' shift-change handover in neuro-critical care

Abstract

Background Clinical handover is a necessary process for the continuation of safe patient care; however, deficiencies in the handover process can introduce error. While the number of handover studies increases, few have validated implemented improvements with repeated audit. Objective To improve the morning handover round on a busy critical care unit and assess sustainability of improvement through repeated audit. Design/Methods A quality improvement process based on prospective observational assessment of the doctor's shift-change handover was carried out, assessing the content of clinical information and effects of distractions, location and timing. The effect of a training session for the junior doctors with the introduction of a standardised handover protocol was assessed. Results The content of clinical information improved after the training session with introduction of a standardised protocol, but returned to baseline with a new cohort of untrained doctors. Distractions were associated with increased handover times for individual patients and for total handover time. Overall, handover time was shortest in the coffee room compared with ward and lecture theatre handovers. Individual patient handover time was positively correlated with clinical content scores. Four indices of critical illness all positively correlated with increased handover time. Conclusions Early specific training is vital for quality clinical handover. Distractions during handover cause inefficiency and can adversely affect information transfer. Changing handover location according to local environment can yield improved efficiency, structure and ease of management. Adequate time must be allocated for clinical handover especially when dealing with very sick and complex patients.Clinical handover between shift changes is a necessary process to ensure seamless continuity of patient care. However, deficiencies in the handover process can introduce error. The accurate transfer of a necessary amount of clinical information to allow the continuation of safe care and, in addition, bring fresh intelligence to clinical problems, requires an efficient, clear and comprehensive system of communication.Despite awareness that handover systems were inadequate as long ago as 1996 in the UK, 1 it has taken several years for action to be taken, prompting the production of guidelines for handover. 2Despite the large number of handover studies conducted in the past two decades ( We wished to improve the morning handover round on our 21-bed Neurosciences Critical Care Unit (NCCU), a busy unit with a bed occupancy rate of approximately 90%, caring for neurosurgical/neurology and general patients requiring intensive care. Our specific aim was to improve the quality of the whole process. We felt that a goodquality handover would use the most appropriate setting, where the environment enhanced information transfer in addition to maximising the time utilised so that pertinent and complete clinical information was presented and discussed without unnecessary ...

Are weekend handovers of adequate quality for the on-call general medical team?

“…Training may improve the quality of the meetings. 16,17 Handover is more than just relaying patient details -it requires assessing what information might be needed by the on-call team without handing over excessive amounts of distracting information. It needs to be relayed in a structured and succinct manner.…”

Quality and safety of handover in intensive care

“…Ideally a standardized format of presentation should be used to ensure key information is not omitted. 2 Inadequate handover carries risks for patients, individual clinicians and the organizations within which they work. 1,3,4 Current handover practices are often not standardized and are highly variable.…”

Development of an orthopedic surgery trauma patient handover checklist

“…It has been previously suggested that handover should involve dedicated locations and access to laboratory values, radiographs and clinical information; occur in an open, friendly environment facilitating discussion and void of interruptions and distractions (e.g., phones/pagers); comprise 2-way communication involving feedback; have dictated leadership from a senior doctor; involve attendance by the entire team (may be multidisciplinary); and have an adequate, yet fixed duration. 1,8,34,35 Our respondents agreed with many of these criteria. They consider ed it important that the handover procedure follow the same process each day, that all appropriate laboratory work and diagnostic imaging is available, that there is adequate time for the handover and that they could spend more time on the handovers of patients whose conditions are more severe.…”

“…The topics covered on our checklist include those used in previously developed checklists, including diagnosis, comorbidities, history, mechanism of injury and outstanding injuries. 5,[7][8][9]12 It is important to remember that our checklist is not exclusive; it contains a column for "other pertinent information" to address the variability among patients who present with traumatic injuries. The checklist provides a starting point for information that should not be missed, but as seen in Table 2, most of the information has been deemed important by a panel of orthopedic surgeons and trainees across the country and any can be added at the discretion of the admitting physician.…”

“…1 The risks to patient care associated with handover have been extensively studied among health care workers, including personnel from prehospital care, emergency department, nursing, intensive care unit (ICU), anesthesiology, general surgery, plastic surgery, neurosurgery and orthopedic surgery. [2][3][4][5][6][7][8][9][10][11][12] Many groups have proposed handover checklists as a manner to improve information retention and handover safety. [13][14][15][16][17] Medical errors are common, occurring in 3.2%-10.6% of patients, 18,19 and it is estimated that 58%-66% of these errors will result in patient injury.…”