Variation in printed handoff documents: Results and recommendations from a multicenter needs assessment

Eastern association for the surgery of trauma - quality, patient safety, and outcomes committee - transitions of care: healthcare handoffs in trauma

BACKGROUND

Handoffs are defined as the transfer of patient information, professional responsibility, and accountability between caregivers. This work aims to clarify the current state of transitions of care related to the management of trauma patients.

METHODS

A PubMed database and web search were performed for articles published between 2000 and 2020 related to handoffs and transitions of care. The key search terms used were: handoff(s), handoff(s) AND healthcare, and handoff(s) AND trauma. A total of 55 studies were included in qualitative synthesis.

RESULTS

This systematic review explores the current state of healthcare handoffs for trauma patients. Factors found to impact successful handoffs included process standardization, team member accountability, effective communication, and the incorporation of culture. This review was limited by the small number of prospective randomized studies available on the topic.

CONCLUSION

Handoffs in trauma care have been studied and should be utilized in the context of published experience and practice. Standardization when applied with accountability has proven benefit to reduce communication errors during these transfers of care.

Addition of CORES to the I-PASS Handoff: A Resident-led Quality Improvement Study

Quality patient handoff is vital in patient care and attainable with structured handoff systems, such as the I-PASS mnemonic. This paper describes a continuous quality improvement study occurring after the implementation of the I-PASS handoff bundle. Our objectives were to (1) determine compliance with the inclusion of I-PASS elements during handoff and (2) determine whether the addition of CORES, an electronic tool that generates a patient list designed for use with I-PASS, would improve compliance and sustainability.

Communication at Transitions of Care

Communication errors during transitions of care are a leading source of adverse events for hospitalized patients. This article provides an overview of the role of communication errors in adverse events, describes the complexities of communication for hospitalized patients, and provides evidence regarding the positive effects of applying high-reliability principles to transitions of care and culture of safety. Elements of effective handoffs and a detailed approach for successful implementation of a handoff program are provided. The role of handoff communication in medical education at all levels, as well as for the interprofessional team, is discussed.

Leveraging Structural Changes in an Electronic Health Record Tool to Standardize Written Handoff

Miscommunications during patient handoff can lead to harm. The I-PASS bundle has been shown to improve safety outcomes. Although effective training reliably improves verbal handoffs, research has demonstrated a lack of effect on written handoffs. The objective was to compare written handoff before and after integration of a standardized electronic health record (EHR) tool. Interns at a large urban academic medical center underwent I-PASS handoff training. The EHR handoff tool was then revised to prompt the I-PASS components. Handoff documents were obtained before and after the intervention. More handoffs included Illness Severity (33% to 59%, P < .001) and Action List (65% to 83%, P = .005) after the intervention. There was no change in handoffs with miscommunications (12.5% to 10%, P = .566) or omissions (8% to 11%, P = .447). Handoffs including tangential or unrelated information decreased (20% to 4%, P = .001). A written handoff tool can reinforce the effect of training and increase adherence to I-PASS.

Chart stalking, list making, and physicians' efforts to track patients' outcomes after transitioning responsibility

CONTEXT

Transitions of patient care responsibility occur frequently between physicians. Resultant discontinuities make it difficult for physicians to observe clinical outcomes. Little is known about what physicians do to overcome the practical challenges to learning these discontinuities create. This study explored physicians' activities in practice as they sought follow-up information about patients.

METHODS

Using a constructivist grounded theory approach, semi-structured interviews with 18 internal medicine hospitalist and resident physicians at a single tertiary care academic medical center explored participants' strategies when deliberately conducting follow-up after they transitioned responsibility for patients to other physicians. Following open coding, the authors used activity theory (AT) to explore interactions among the social, cultural and material influences related to follow-up.

RESULTS

The authors identified three themes related to follow-up: (i) keeping lists to track patients, (ii) learning to create tracking systems and (iii) conducting follow-up. Analysis of participants' follow-up processes as an activity system highlighted key tensions in the system and participants' work adaptations. Tension within functionality of electronic health records for keeping lists (tools) to find information about patients' outcomes (object) resulted in using paper lists as workarounds. Tension between paper lists (tools) and protecting patients' health information (rules) led to rule-breaking or abandoning activities of locating information. Finding time to conduct desired follow-up produced tension between this and other activity systems.

CONCLUSION

In clinical environments characterised by discontinuity, lists of patients served as tools for guiding patient care follow-up. The authors offer four recommendations to address the tensions identified through AT: (i) optimise electronic health record tracking systems to eliminate the need for paper lists; (ii) support physicians' skill development in developing and maintaining tracking systems for follow-up; (iii) dedicate time in physicians' work schedules for conducting follow-up; and (iv) engage physicians and patients in determining guidelines for longitudinal tracking that optimise physicians' learning and respect patients' privacy.

Using mobile devices for inpatient rounding and handoffs: an innovative application developed and rapidly adopted by clinicians in a pediatric hospital

Objective

To describe the usage of a novel application (The FLOW) that allows mobile devices to be used for rounding and handoffs.

Materials and Methods

The FLOW provides a view of patient data and the capacity to enter short notes via personal mobile devices. It was deployed using a "bring-your-own-device" model in 4 pilot units. Social network analysis (SNA) was applied to audit trails in order to visualize usage patterns. A questionnaire was used to describe user experience.

Results

Overall, 253 health professionals used The FLOW with their personal mobile devices from October 2013 to March 2015. In pediatric and neonatal intensive care units (ICUs), a median of 26-26.5 notes were entered per user per day. Visual network representation of app entries showed that usage patterns were different between the ICUs. In 127 questionnaires (50%), respondents reported using The FLOW most often to enter notes and for handoffs. The FLOW was perceived as having improved patient care by 57% of respondents, compared to usual care. Most respondents (86%) wished to continue using The FLOW.

Discussion

This study shows how a handoff and rounding tool was quickly adopted in pediatric and neonatal ICUs in a hospital setting where patient charts were still paper-based. Originally developed as a tool to support informal documentation using smartphones, it was adapted to local practices and expanded to print sign-out documents and import notes within the medicolegal record with desktop computers. Interestingly, even if not supported by the nursing administrative authorities, the level of use for data entry among nurses and doctors was similar in all units, indicating close collaboration in documentation practices in these ICUs.

Information Needs Assessment for a Medicine Ward-Focused Rounding Dashboard

To identify the routine information needs of inpatient clinicians on the general wards for the development of an electronic dashboard. Survey of internal medicine and subspecialty clinicians from March 2014-July 2014 at Saint Marys Hospital in Rochester, Minnesota. An information needs assessment was generated from all unique data elements extracted from all handoff and rounding tools used by clinicians in our ICUs and general wards. An electronic survey was distributed to 104 inpatient medical providers. 89 unique data elements were identified from currently utilized handoff and rounding instruments. All data elements were present in our multipurpose ICU-based dashboard. 42 of 104 (40 %) surveys were returned. Data elements important (50/89, 56 %) and unimportant (24/89, 27 %) for routine use were identified. No significant differences in data element ranking were observed between supervisory and nonsupervisory roles. The routine information needs of general ward clinicians are a subset of data elements used routinely by ICU clinicians. Our findings suggest an electronic dashboard could be adapted from the critical care setting to the general wards with minimal modification.