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Professor Rick Iedema Director of the Centre for Health Communication, UTS Dr Robert Herkes, Director of Intensive Care Services RPA Sydney Eamon Merrick RN MHSM, Research Fellow Centre for Health Communication, University of Technology Sydney Royal Prince Alfred Hospital Intensive Care Services, Sydney South West Area Health Service

•  Objectives, participants will be able to: –  View, from a different perspective, how handovers are conducted in intensive care. –  Discuss the functions of handover in a intensive care service. –  Reflect on the difficulties that can confront ‘good’ handover. –  Articulate & Plan strategies for the improvement of handovers.

•  Outcomes, participants will be able to: –  Articulate the issues that confront effective handover in their own clinical settings. –  Discuss types of handover improvement strategies and how these may be applied practically. –  Communicate to their colleagues about contemporary approaches to handover improvement and feel able to implement these in their own clinical setting.

“ … the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis”1. “… to provide accurate information about a [patients] care, treatment, services, current condition and any recent or anticipated changes….. The information communication during handoff must be accurate in order to meet [patient] safety goals”2.

(1) Australian Medical Association. (2006). Safe Handover: Safe Patients. Canberra: Australian Medical Association. (2) The Joint Commission. (2007). Hospital/ Critical Access National Patient Safety Goals.: The Joint Commission.

180

A 24hr cross-sectional observational study.

160 140

n= 205 ICUs, 1,913 adult patients. 584 Sentinel events affecting 391 patients.

120 100 80 60 40 20 0 Medication

Lines, catheters, drains

Euip Fail

Airway

(3) Valentin, A., Capuzzo, M., Guidet, B., Moreno, R., Dolanski, L., Bauer, P., et al. (2006). Patient Safety in Intensive Care: Results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care Medicine, 32, 1591-1598.

Alarms

n=2966 root cause analyses

Pt. Assessment

Three leading factors are: 1.  Communication 2.  Orientation 3.  Pt. Assessment

Orientation

Communication

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10

20

30

40

(4) http://www.jcaho.org/accredited+organizations/ambulatory+care/ sentinel+events/root+causes+of+sentinel+event.htm

50

60

70

In your groups discuss the challenges inherent in maintaining accurate handover: People involved in handover skill levels, expertise, professional types The types of information required by participants? Where, who synthesizes this information? Where, what, are potential sources of error? How would you improve these situations?

C1

(4) Coiera, E., Jayasuriya, R. A., Hardy, J., Bannan, A., & Thorpe, E. C. (2002). Communication loads on clinical staff in the emergency department. Medical Journal of Australia, 176, 415-176.

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Content standardisation – 

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Listing of specific information that should always be mentioned in a handover

Topic standardisation – 

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Specification of general topic areas that should be covered in handover

Process standardisation – 

The process that work groups develop/deployed for the ongoing evaluation of handover performance

Understanding levels of clinical expertise Understanding clinical roles Understanding (intuitively) team dynamics Skill mix Organisational dynamics Service dynamics Understanding & synthesizing clinical need

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Level of care uncertainty

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(Non) standard time(s) for handover

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(Variable) location where handover is conducted

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(Different) participants in the handover (mono- vs multi-disciplinary interaction)

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(Different) informational needs of participants

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(Changing) length of time devoted to handover

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Spatial organisations and arrangements (where is handover conducted?)

In your groups articulate a strategy to improve this handover: Would you use content, topic, or process standardisation? What would this strategy look like, describe the: Planning Implementation Evaluation How might you ensure local relevance? How might you maintain buy in?

C2

Content Standardisation

Topic Standardisation

•  Participation •  Observation •  Filming •  Reflexive Sessions •  Implementation •  Ongoing self-evaluation

• Lack of clinical ‘ownership’ of patient care (nursing) • Planning of care inadequately implemented due to lack of interdisciplinary communication • Dangers of discontinuity of care • Nurse led (facilitated by senior medical staff) handovers at ward round • Improved continuity of care • Educational opportunities • Clinical team building

• Communication is prone to interruptions • Out-dated information • Time intensive >45mins • Handover at the patients bedside led by the senior registrar • Visual verification of information • Precise • Concise • Professional format • Time reduced <15-30, mins

• Opportunities for dialogic education • Coordination between disciplines • Availability of contemporaneous information • Early insight into emerging, potential, or previously unrecognised problems • Opportunity for the negotiation of supervisory support

“We must be alert to all the functions of handoff activity”

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Bedside patient check Multi-disciplinary handover Cross-hierarchy communication Checklist support Agreed interruption rules Systematized documentation process