Clinical handover in acute psychiatric and community mental health settings

Healthcare Professionals' Perspectives on Sepsis Care Pathways-Qualitative Pilot Expert Interviews

Background/Objectives: Despite recent decades' rapid advances in the management of patients with sepsis and septic shock, global sepsis mortality and post-acute sepsis morbidity rates remain high. Our aim was, therefore, to provide a first overview of sepsis care pathways as well as barriers and supportive conditions for optimal pre-clinical, clinical, and post-acute sepsis care in Germany. Methods: Between May and September 2023, we conducted semi-structured, video-based, one-to-one pilot expert interviews with healthcare professionals representing pre-hospital, clinical, and post-acute care settings. The interviews were audio-recorded, transcribed verbatim, and analyzed according to the principles of Mayring's content analysis. Results: The eight interviewed professionals identified perceived critical success factors along the entire care pathway with regard to early detection (e.g., disease awareness), early acute treatment (e.g., unknown origin of infection), rehabilitation/aftercare (e.g., availability of primary care actors), and patient transitions within and between sectors (e.g., advance notice of patient arrival). These critical factors comprised: (1) the characteristics of the staff providing care (e.g., available experience), (2) the aids/utilities used (e.g., SOPs), (3) the presentation of the disease (e.g., clear symptoms), (4) the workplace (e.g., high workload), and (5) the cooperation between the staff caring for the patient (e.g., announced and standardized handovers). Conclusions: Apart from the specific recommendations that can be derived from the individual factors presented, it can be summarized that all levels of care seem only to be purposeful if providers collaborate and communicate efficiently (i.e., correct triage, multiple-eye principle, transfer management, provision of content-rich medical/discharge letters).

Trauma Bay Evaluation and Resuscitative Decision-Making

The reader of this article will now have the ability to reflect on all aspects of high-quality trauma bay care, from resuscitation to diagnosis and leadership to debriefing. Although there is no replacement for experience, both clinically and in a simulation environment, trauma clinicians are encouraged to make use of this article both as a primer at the beginning of a trauma rotation and a reference text to revisit after difficult cases in the trauma bay. Also, periods of reflection seem appropriate in the busy but, of course, rewarding career in trauma care.

Initiative to improve handover notes in a tertiary psychiatric hospital

Clinical handover is an important process in hospital settings, but it is often carried out inadequately, posing potentially serious consequences for the patients. This project aimed to increase the effectiveness of handover notes when patients were transferred between a general psychiatric ward and other wards in a tertiary psychiatric hospital. Effective handover notes in this project were defined to have the following five components: brief psychiatric history, reason for the patient to be transferred, significant risk issues, reason for psychotropic medication change and active medical issues. Baseline measurement obtained from audits revealed that the completion rate of effective handover notes was only 27.27%, which could potentially compromise patient safety and staff work efficiency. To address this problem, a series of plan-do-study-act (PDSA) cycles was implemented to improve the handover process. The interventions included education to junior doctors, reminders to complete effective handover notes and implementation of a handover template. Following each PDSA cycle, data were gathered to assess whether an effect had been achieved and to identify ways to enhance interventions to maximise impact. After the final PDSA cycle, the percentage of effective handover notes among all transfer cases reached 90.50%. Postintervention feedback from inpatient team indicated that effective communication between different teams was ensured, and staff satisfaction and time savings were improved. This study highlights the importance of employing PDSA cycles to assess and refine interventions and the usefulness of structuring the content of key components of handover notes to obtain measurable improvements.

Improving the handover process in a psychiatry liaison setting

Efficient handover of patient care is integral to clinical safety. Barriers in communication can lead to adverse outcomes. The Integrated Liaison Assessment Team (ILAT) has a daily handover meeting which presents several challenges to the multidisciplinary liaison team (MDT including high patient turnover, differing staff shift-work patterns, presence of visitors/students and lack of a unified approach to structured discussion at times. Areas identified for improvement included optimising efficiency, structure and handover documentation. Lack of teaching and learning opportunities were also identified. The primary aim was to reduce handover time to 30 min. The secondary aims were to improve communication by introducing the Situation-Background-Assessment-Recommendation (SBAR) tool, improve team satisfaction and introduce a teaching programme in the time saved. The Model for Improvement methodology was used with MDT focus groups and questionnaires to explore change ideas. This informed our 'Plan, Do, Study, Act' cycles to design a structured handover. Daily measures looked at handover length and individual team member satisfaction. Weekly measures included semiqualitative questionnaires highlighting areas for improvement. Feedback was gathered from emails and MDT discussions. A structured handover format incorporating SBAR, key task allocation and a shift handover lead was introduced. A regular MDT teaching programme was initiated. Over 4 weeks, 'Good' handover ratings increased from 22% to 65%; 'Poor' ratings decreased from 25% to 8%. Mean handover time decreased from 47 min to 31.25 min; a decrease of 33.5%. Overall, the team viewed SBAR positively as an efficiency-promoting tool. Structured handover has promoted staff competencies, team morale and information sharing practices among ILAT. MDT teaching improved team communication and confidence. Sustaining motivation to keep up interventions and documentation of handover were identified as key areas for sustained improvement.

Improving Transfer of Care Between Psychiatrists and Residents: Participants' Perspective on the Implementation of a Handover Protocol in a Psychiatric Emergency

OBJECTIVES

Handover refers to the transfer of information from one professional to another during transitions of care. I-PASS is a mnemonic tool which stands for Illness severity; Patient summary; Action list; Situation awareness and contingency planning; and Synthesis by receiver. It was developed to standardize the handover process. Psychiatrists, nurses, and residents at the Montreal Jewish General Hospital psychiatric emergency were trained and the I-PASS handover model was implemented.

METHODS

Thirty-one psychiatrists, nurses, and residents participated in this quality improvement project. Participants filled a pre-training questionnaire to examine the baseline status of handovers before attending a training session on I-PASS. Participants then filled a second questionnaire assessing the perceived quality of the handover training session, as well as anticipated benefits and challenges of I-PASS prior to its implementation. Finally, following implementation, two focus groups were held to collect feedback from participants.

RESULTS

Pre-training, most participants reported that information provided during handovers was incomplete. Training was overall much appreciated. The most significant anticipated obstacle for implementing I-PASS was lack of time to properly fill out the form. Post-implementation, participants unanimously reported an improvement in the handover process. Handovers were perceived as faster, providing all key information about patients, and the perceived quality of the information was better.

CONCLUSION

Overall, the implementation of the I-PASS handover model was much appreciated by participants, who perceived that handovers were more comprehensive, efficient, and of better quality.

Teaching clinical handover with ISBAR

Clinical handover is one of the most critical steps in a patient's journey and is a core skill that needs to be taught to health professional students and junior clinicians. Performed well, clinical handover should ensure that lapses in continuity of patient care, errors and harm are reduced in the hospital or community setting. Handover, however, is often poorly performed, with critical detail being omitted and irrelevant detail included. Evidence suggests that the use of a structured, standardised framework for handover, such as ISBAR, improves patient outcomes. The ISBAR (Introduction, Situation, Background, Assessment, Recommendation) framework, endorsed by the World Health Organisation, provides a standardised approach to communication which can be used in any situation. In the complex clinical environment of healthcare today, ISBAR is suited to a wide range of clinical contexts, and works best when all parties are trained in using the same framework. It is essential that healthcare leaders and professionals from across the health disciplines work together to ensure good clinical handover practices are developed and maintained. Organisations, including universities and hospitals, need to invest in the education and training of health professional students and health professionals to ensure good quality handover practice. Using ISBAR as a framework, the purpose of this paper is to highlight key elements of effective clinical handover, and to explore teaching techniques that aim to ensure the framework is embedded in practice effectively.

Involving mental health consumers in nursing handover: A qualitative study of nursing views of the practice and its implementation

Nursing handover occurs between shifts and is an important means of communication and information exchange around consumer care. The involvement of consumers in nursing handover, known as 'bedside handover', is well established within general health settings and promotes a patient-centred approach to care. Bedside handover represents an opportunity for mental health settings to consolidate recovery-oriented principles, albeit with some unique challenges in the way that involving consumers in nursing handover is implemented. This qualitative descriptive study explores the views of nursing staff and nursing managers about involving consumers in nursing handover and the process of implementation across five mental health inpatient units in Australia. The study took place in a local health district covering regional and rural areas of New South Wales that had issued a directive to implement bedside handover. The consolidated criteria for reporting qualitative research (COREQ) checklist was applied to this study. Six focus groups were held with nursing staff (n = 22), and eleven individual interviews were undertaken with nursing managers to explore their perceptions of bedside handover and its implications for nursing practice. The data were analysed using thematic analysis. Data from focus groups and interviews were analysed separately and then combined to generate three themes: (i) the mental health context is different; (ii) protecting consumer privacy and confidentiality; and (iii) it might make things worse. The findings provide insights into both the challenges, and the process of involving consumers in nursing handover within mental health settings and provides guidance for future implementation.

Views of mental health consumers about being involved in nursing handover on acute inpatient units

The involvement of consumers in handover with nurses has been identified as reducing miscommunication and a reduction in adverse events in generalist nursing settings. Mental health (MH) care is complex, and handover practices need to fit with the philosophy of recovery-focussed practice. Recovery-focussed practice recognizes the person at the centre of care as an expert in their own treatment and decision-making. The aim of the present study was to explore the views of consumers with a mental illness, without prior involvement in nursing handover, about their need to be involved in nursing handover on an acute mental health inpatient unit. Using an exploratory descriptive, qualitative design (n = 11), participants who were receiving care in an acute inpatient unit were recruited using purposive convenience sampling. Data were collected using semistructured interviews and analysed using thematic analysis. Participants' diagnoses were schizophrenia (n = 6), bipolar affective disorder (n = 4), and depression (n = 1). Two themes emerged from the interviews: (i) behind closed doors; and (ii) being involved. Several subthemes were also identified. The first theme, behind closed doors, had two subthemes: (i) it is about us; and (ii) knowing their thoughts. The second theme had three subthemes: (i) clarifying issues; (ii) setting expectations; and (iii) when and how. Nursing handover on the acute inpatient unit offers a good opportunity for consumers to take an active role in the delivery of nursing care. There is a need to rethink the way nursing handover occurs to include consumers.

Developing a guideline for structured content and process in mental health nursing handover

The process of handover has received recent attention within Australian health care, as evidence linking patient safety with the quality of handover emerges. Such links between clinical handover and patient safety have been reported elsewhere in the literature, where it is posited that the safe care of patients relies not only on the expertise and judgment of individual clinicians, teamwork, and effective management, but hinges to a large extent on the quality of information transferred from team to team. The present qualitative, descriptive study used participant observations, focus groups, and interviews to investigate the nursing handover in two acute mental health inpatient units in New South Wales, Australia. Data collected as part of that investigation contributed to the development of a handover guideline that incorporates the key components of structure, content, and leadership. The research indicated a link between these components, and further revealed the necessity to have other forums, such as supervision and clinical review, to ensure that handover serves its intended purpose in an efficient manner.

Stories of change: the text analysis of handovers in an Italian psychiatric residential care home

WHAT IS KNOWN ON THE SUBJECT?: There is a growing emphasis on communication as a result of the move towards the more inclusive approach associated with the community-based rehabilitation model. Therefore, more importance is attached to handovers. Besides ensuring transfer of information, handovers enhance group cohesion, socialize staff members to the practices of the service and capture its organizational culture. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: While handovers are mainly used for information transfer and to manage the services' daily routine, this paper offers an insight on how handovers can be conceived as valuable instruments to document cultural and organizational change. Only a limited amount of studies has focused on handovers in mental healthcare settings, and most of them only consider the perspectives of psychiatric nurses, while embracing a broader perspective, this paper provides valuable insights into the perspectives of various service providers. The overcoming of the dichotomy deficit-based vs. recovery-oriented model is possible if professionals use handovers to reflect upon their practice and the ways in which their cultural models are affected by the environmental context. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Handovers are valuable instruments to document organizational change. It would be important for psychiatric and rehabilitation facilities to keep track of the handover records over time as they may provide insightful information about cultural change and the transformations in the core values and beliefs held by professionals.

ABSTRACT

Handovers assure a timely and correct information transfer while socializing workers to the service's culture; however, no study describes them as instruments to document organizational change and only a few have focused on psychiatric settings. Aim To investigate the change in the culture of an Italian psychiatric residential care home as perceived by its mental health workers (MHWs) over the course of two decades. Method Emotional text analysis (ETA) was used to analyse the MHWs' handovers completed from 1990 to 2011. Results The analysis generated four clusters and three main factors illustrating the change in the MHWs' representations of the residential care home and its occupants. The factors showed: (1) the shift from an individualistic, problem-focused view to an inclusive, community-based approach; (2) the presence of a descriptive as well as a specialized language; and (3) the presence of a double focus: on patients and professionals. Conclusions Handovers transcripts document the following changes: (1) a shift from a symptom-based to a recovery-oriented approach; (2) a modification of the MHWs values towards an holistic view of the patient; (3) a growing importance assigned to accountability, services integration and teamwork. The paper shows that handovers can be used diachronically to document organizational change.

Evaluation of a clinical handover simulation training session for junior doctors in psychiatry

Background

Clinical handover is an important aspect of patient care and medical education, as identified by trainee surveys. There is a need for robust, standardised handover systems. Situation, Background, Assessment and Recommendation (SBAR) is a communication and empowerment tool for standardised communication in healthcare. The purpose of this study was to evaluate the educational impact of a simulation-based educational session in clinical handover for trainees in psychiatry, using SBAR.

Method

A 3-hour session for trainees in psychiatry was designed with the North West Simulation Education Network and took place at the North Western Deanery School of Psychiatry. Presession and postsession questionnaires were completed, followed by a 6-week follow-up questionnaire.

Results

A significant improvement in participants' confidence and skills was demonstrated following the teaching session. Qualitative feedback also highlighted improved clinical application of the SBAR tool. Following the session, trainees reported an improvement in their appreciation of the role of other professionals in the handover process and a sense of empowerment when liaising with senior colleagues.

Conclusions

The training session potentially improved patient care by giving trainees structure, confidence and empowerment when talking to other colleagues while handing over. This may also help to meet the training requirements of the various Royal College curricula. This is the first study, to the best of our knowledge, which has evaluated a simulation session specifically designed to develop handover skills for trainees in psychiatry.

Handover of patient information from the crisis assessment and treatment team to the inpatient psychiatric unit

Handover, or the communication of patient information between clinicians, is a fundamental component of health care. Psychiatric settings are dynamic environments relying on timely and accurate communication to plan care and manage risk. Crisis assessment and treatment teams are the primary interface between community and mental health services in many Australian and international health services, facilitating access to assessment, treatment, and admission to hospital. No previous research has investigated the handover between crisis assessment and treatment teams and inpatient psychiatric units, despite the importance of handover to care planning. The aim of the present study was to identify the nature and types of information transferred during these handovers, and to explore how these guides initial care planning. An observational, exploratory study design was used. A 20-item handover observation tool was used to observe 19 occasions of handover. A prospective audit was undertaken on clinical documentation arising from the admission. Clinical information, including psychiatric history and mental state, were handed over consistently; however, information about consumer preferences was reported less consistently. The present study identified a lack of attention to consumer preferences at handover, despite the current focus on recovery-oriented models for mental health care, and the centrality of respecting consumer preferences within the recovery paradigm.

Improving handovers across a North London Mental Health Trust

The GMC Survey June 2011 highlighted that trainees in Barnet, Enfield and Haringey Mental Health Trust (BEH-MHT) were dissatisfied with the Trust's handover process. At this time there were no Trust guidelines on handovers.

A quality improvement project was developed to create a consistent out of hours handover process and to improve staff satisfaction thereafter. Handover guidelines were implemented throughout the Trust on 1/2/12. An audit was carried out to measure staff compliance with handovers. A questionnaire was sent out to staff before and after implementation of the guidelines to assess satisfaction with handovers.

The audit results highlighted that handovers occurred relatively consistently across the Trust following implementation of the guidelines. The questionnaire results showed an improvement in staff satisfaction with the handover process.

The clinical implication of this project is an improved process of out of hours handover across BEH-MHT.