Development and implementation of electronic medical handovers across psychiatric hospitals: quality improvement initiative

NCHD handover in the acute mental health setting: a quality improvement initiative implementing an electronic handover tool

BACKGROUND

Cork University Hospital, Ireland's largest teaching hospital, faced challenges in maintaining consistent handover processes in its Acute Mental Health Unit (AMHU). Prior to 2019, handovers relied on informal methods, risking information loss and compromising patient care. This quality improvement (QI) initiative aimed to standardise handover practices using an electronic tool integrated with the ISBAR communication protocol.

OBJECTIVES

The project aimed to ensure accurate clinical information recording, improve patient care and safety, centralise handover material, enhance clinical transparency and accountability, and measure handover quality using the electronic tool.

METHODS

Using a Plan-Do-Study-Act (PDSA) model, the initiative began with a critical incident in July 2020, prompting the creation and piloting of an electronic 'handover tool' aligned with ISBAR. Subsequent PDSA cycles included mandatory policy implementation and educational interventions to reinforce tool usage and adherence to communication standards.

RESULTS

The electronic handover tool improved handover practices, with increased compliance to recommended criteria and enhanced tool utilisation. Notable improvements followed targeted educational interventions, leading to more comprehensive and standardised handover entries. These improvements enhanced communication and information transfer among NCHDs, contributing to better continuity of care and patient safety.

CONCLUSIONS

The QI initiative successfully standardised handover processes and improved communication among NCHDs in the AMHU. While improvements were observed, ongoing efforts are needed to address challenges and sustain effectiveness. Continuous training, feedback mechanisms and further refinement of the handover tool are essential for long-term success. Future directions include exploring additional technological solutions and reinforcing a culture of effective communication.

Physician inpatient handoffs-Patient and physician outcomes: A systematic review

BACKGROUND

Prior reviews have shown that interventions to improve inpatient handoffs are inconsistently associated with improvement in patient outcomes. This systematic review examines the effectiveness of inpatient handoff interventions on outcomes affecting patients and physicians, including objective measures when reported (PROSPERO ID: CRD42022309326).

METHODS

Pubmed, Embase, and Cochrane Central Register of Controlled Trials were searched on January 13th, 2022. We included experimental or quasi-experimental studies that examined handoff communication between inpatient physicians and reported patient clinical, patient experiential, physician experiential, or cost and utilization outcomes. Studies were excluded if they examined handoffs between facilities or levels of care, or only reported subjective measures of patient safety or physician experience. Risk of bias was assessed using the ROBINS-1 and RoB-2 tools.

RESULTS

Of the 42 included studies, six were randomized controlled trials. Most studies were conducted at academic centers (67%) and involved only residents (64%). An educational intervention was used in 52% of studies and a structural intervention was used in 43%, with 9% using both. Adverse events were significantly improved in three of 16 studies, medical errors in three of seven studies, and length of stay in three of seven studies. Four studies examined mortality, and none reported a significant improvement. Studies that used both structural and educational components reported significant improvements more frequently.

CONCLUSIONS

The literature is mixed on the impact of efforts to improve handoffs, though there are few randomized trials. Few studies reported patient experiential or cost/utilization outcomes, or involved hospitalist physicians, which represent potential areas for future research.

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.

Evaluating Psychometric Properties of the Sultan Bin Abdulaziz Humanitarian City (SBAHC) Nurses' Electronic Handover Tool

INTRODUCTION

Handover is crucial during the transfer of patient care between healthcare professionals.Successful handover maintains patients' safety and high-quality care. The electronic handover of patients' information is achievable, feasible, and potentially improves the quality of patient care. However, the introduction of the electronic handover is relatively recent and challenging for healthcare providers, especially nurses.

OBJECTIVES

Since Sultan Bin Abdulaziz Humanitarian City (SBAHC) has recently implemented an electronic handover system among nurses, the main aim of the current study was to develop a tool to assess the perception and barriers to electronic handover systems among nurses working at SBAHC and evaluate its psychometric properties.

METHODS

The tool content and face validity were assessed by the content validity ratio (CVR). Exploratory and confirmatory factor analysis were used as validity methods, while the test-retest and inter-item consistency were used as reliability measures. The sample size was planned as five times the number of questions and a total of 200 nurses participated in the study.

RESULTS

The criteria required for factor analysis were met as indicated by the results of the Kaiser-Mayer-Olkin test and Bartlett's test of sphericity. The reliability results showed a Cronbach's alpha coefficient ranging from 0.858 to 0.910 for the perception subscale and from 0.564 to 0.789 for the barrier subscale, and an overall interclass correlation of 0.986, p<0.001.

CONCLUSIONS

The developed SBAHC electronic handover tool was valid and reliable, and it is advisable to consider it at the initial stages of implanting an electronic handover system to identify obstacles that are faced by the staff to be considered and addressed by the higher management.

The effects of electronic nursing handover on patient safety in the general (non-COVID-19) and COVID-19 intensive care units: a quasi-experimental study

BACKGROUND

The unprecedented increase in the nurses' workload is one of the issues affecting the quality and safety of patient care in the Intensive Care Units (ICUs). The electronic nursing handover can share sufficient, relevant, and necessary data about patients with greater efficiency and accuracy and prevent their information from being deleted. Therefore, this study aimed to determine and compare the effect of the Electronic Nursing Handover System (ENHS) on patient safety in General ICU and COVID-19 ICU.

METHOD

This is a quasi-experimental study conducted during an 8-month period from 22 to 2021 to 26 June 2022 using a test-retest design. A total of 29 nurses working in the General and COVID-19 ICUs participated in this study. Data were collected using a five-part questionnaire consisting of demographic information, handover quality, handover efficiency, error reduction, and handover time. Data analysis was conducted in IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA) using the chi-squared test, paired t-test, and Analysis of Covariance (ANCOVA).

RESULTS

The results showed that the mean scores of handover quality and efficiency, reduction of clinical error, and handover time in the electronic handover were significantly higher than those obtained in the paper-based method. The results showed that the mean score of patient safety in the COVID-19 ICU was 177.40 ± 30.416 for the paper-based handover and 251.40 ± 29.049 for the electronic handover (p = .0001). Moreover, the mean score of patient safety in the general ICU was 209.21 ± 23.072 for the paper-based handover and 251.93 ± 23.381 for the electronic one (p = .0001).

CONCLUSION

The use of ENHS significantly improved the quality and efficiency of shift handover, reduced the possibility of clinical error, saved handover time, and finally increased patient safety compared to the paper-based method. The results also showed the positive perspectives of ICU nurses toward the positive effect of ENHS on the patient safety improvement.

Implementation of Electronic Medical Records in Mental Health Settings: Scoping Review

BACKGROUND

The success of electronic medical records (EMRs) is dependent on implementation features, such as usability and fit with clinical processes. The use of EMRs in mental health settings brings additional and specific challenges owing to the personal, detailed, narrative, and exploratory nature of the assessment, diagnosis, and treatment in this field. Understanding the determinants of successful EMR implementation is imperative to guide the future design, implementation, and investment of EMRs in the mental health field.

OBJECTIVE

We intended to explore evidence on effective EMR implementation for mental health settings and provide recommendations to support the design, adoption, usability, and outcomes.

METHODS

The scoping review combined two search strategies that focused on clinician-facing EMRs, one for primary studies in mental health settings and one for reviews of peer-reviewed literature in any health setting. Three databases (Medline, EMBASE, and PsycINFO) were searched from January 2010 to June 2020 using keywords to describe EMRs, settings, and impacts. The Proctor framework for implementation outcomes was used to guide data extraction and synthesis. Constructs in this framework include adoption, acceptability, appropriateness, feasibility, fidelity, cost, penetration, and sustainability. Quality assessment was conducted using a modified Hawker appraisal tool and the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses.

RESULTS

This review included 23 studies, namely 12 primary studies in mental health settings and 11 reviews. Overall, the results suggested that adoption of EMRs was impacted by financial, technical, and organizational factors, as well as clinician perceptions of appropriateness and acceptability. EMRs were perceived as acceptable and appropriate by clinicians if the system did not interrupt workflow and improved documentation completeness and accuracy. Clinicians were more likely to value EMRs if they supported quality of care, were fit for purpose, did not interfere with the clinician-patient relationship, and were operated with readily available technical support. Evidence on the feasibility of the implemented EMRs was mixed; the primary studies and reviews found mixed impacts on documentation quality and time; one primary study found downward trends in adverse events, whereas a review found improvements in care quality. Five papers provided information on implementation outcomes such as cost and fidelity, and none reported on the penetration and sustainability of EMRs.

CONCLUSIONS

The body of evidence relating to EMR implementation in mental health settings is limited. Implementation of EMRs could benefit from methods used in general health settings such as co-designing the software and tailoring EMRs to clinical needs and workflows to improve usability and acceptance. Studies in mental health and general health settings rarely focused on long-term implementation outcomes such as penetration and sustainability. Future evaluations of EMRs in all settings should consider long-term impacts to address current knowledge gaps.