Effectiveness of handover practices between emergency department and intensive care unit nurses

Background

Nurses from the emergency department (ED) and the intensive care unit (ICU) must interact during the handover procedure. Factors such as unit boundaries, the interaction between different specialities, patient acuities, and treatment adjustments generate specific negotiating and teamwork problems during the transition of patients from ED to ICU.

Objective

This study aimed to describe the opinions of nurses regarding the effectiveness of handover practices between nurses in the ED and ICU in a major academic hospital in Gauteng province, South Africa.

Method

An analytical cross-sectional survey design was used. Data were collected using a 16-item handover evaluation tool. It comprises two sections (1) biographical details and (2) 16 statements about handover quality divided into five constructs, namely information transfer, shared understanding, working atmosphere, overall handover quality, and circumstances of handover. Data analysis was done utilising descriptive and non-parametric statistics.

Results

The majority (51.8%; n = 115) of the handovers occurred during the day. Out of 171 nurses, there were specialist practice emergency (19.2%; n = 33) and intensive care (28.0%; n = 48) nurses. There was statistical significance in information transfer between the ED and ICU nurses. (Me = 4.0, p < 0.05), compared to ICU nurses (Me = 3.0). Nurse specialist and non-specialist nurses' handovers differed statistically significantly on 12 of the 16 items on the rating scale, compared to 10 for non-specialist nurses' handovers.

Conclusion

The study showed that ED and ICU nurses have significantly different requirements and expectations for handover procedures. In addition to completed documentation, subtle interpretations of the information provided and received also impact the need. The ED and ICU nurses would need to agree on the contents of a structured handover framework because different specialities and departments have varied expectations to achieve an effective handover.

Interdependencies or integration? A qualitative evaluation of a national emergency department improvement programme

Purpose

In Wales (United Kingdom (UK)), a programme known as the emergency department quality and delivery framework (EDQDF) was launched in 2018 with the purpose of designing a framework of what good looks like for emergency care and then implementing this framework in a measurable and sustainable way.

Design/methodology/approach

A gatekeeper emailed attendees of the EDQDF launch event (n = 70), providing recipients with an information sheet and inviting them to contact the researcher (KJ) if they agreed to be interviewed. The authors conducted semi-structured interviews with all respondents (n = 8) after three invitation rounds sent between August and October 2021. The authors used a thematic analysis approach (Braun and Clarke, 2006).

Findings

Participants agreed with the aims and design of the framework, and the authors identified four themes relating to barriers and to facilitators of implementation. Participants perceive a softening of geographical boundaries through the project, but findings correspond with evidence generated elsewhere regarding emergency departments’ (EDs') system-wide interdependencies and a need for cross-organisational collaboration.

Research limitations/implications

A quality improvement method for health services known as CAREMORE® is found to be a useful approach for the collaborative design of service improvements. Participants perceive a softening of geographical boundaries through the project, but the interviews correspond with evidence generated elsewhere regarding EDs' system-wide interdependencies and a need for cross-organisational collaboration.

Practical implications

This evaluation relies on a relatively small number of participants, but as a qualitative evaluation it does not aim towards broadly generalisable findings but rather contributes to broad field concerned with the production of knowledge on the implementation of health service improvements. The project under evaluation is also on-going, and the findings reflect the period from inception to December 2021, but not beyond that date.

Originality/value

This evaluation builds upon previous work in relation to the application of CAREMORE to design a quality improvement framework in a complex area (see Nelson et al., 2018), but this evaluation considers the implementation process. The findings echo research elsewhere and add to a growing body of research that underlines system interconnectivities that impact upon the emergency department.

Investigating a Participatory Intervention in Multidisciplinary Cancer Care Teams Using an Integrative Organizational Model: A Study Protocol

Multidisciplinary teams encounter many challenges that can lead to higher levels of distress and burnout. This trend is acutely prevalent among multidisciplinary cancer care teams who frequently contend with increased task complexity and numbers of patients. Resilience is emerging as a critical resource that may optimize team members’ psychological health and wellbeing, work efficiency, and organizational agility, while reducing burnout. Accordingly, the proposed study aims to implement and evaluate a promising participatory interventional approach that fosters team resilience. Specifically, the effects of the intervention on participating team members will be compared to a control group of non-participating team members. This intervention’s core components include skills training, patient-centered meetings, talking spaces, and an agile problem-solving approach. The proposed study also seeks to determine whether enhanced resilience improves team mental health status and organizational outcomes. A participatory interventional approach will be implemented and assessed at three-time intervals [i.e., pre-intervention deployment (N = 375), 12 months post-deployment (N = 236), and 24 months post-deployment (N = 146)] across five cancer care teams in three Quebec healthcare institutions. A mixed methods design will be used that includes observations, semi-structured interviews, focus groups, and self-report questionnaires. Direct observation will document team functioning and structural resources (e.g., meetings, conflict management, and leadership). Semi-structured interviews will explore participants’ experience with activities related to the participatory interventional approach, its perceived benefits and potential challenges. Focus groups will explore participants’ perceptions of their team’s resilience and the effectiveness of the intervention. Questionnaires will assess support, recognition, empowerment, organizational justice, individual resilience, psychological safety, work climate, team resilience, workplace burnout, engagement, quality of work life, wellbeing, and organizational citizenship behaviors, and sociodemographic variables. Moreover, objective measures including absenteeism and staff turnover will be obtained via human resource records. Structural equation modeling will be used to test the study’s hypotheses. The proposed protocol and related findings will provide stakeholders with quantitative and qualitative data concerning a participatory interventional approach to optimize team effectiveness. It will also identify critical factors implicated in favorable organizational outcomes in connection with multidisciplinary cancer care teams. Expected results and future directions are also presented herein.

Process mapping in healthcare: a systematic review

INTRODUCTION

Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare.

METHODS

We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach.

RESULTS

The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions.

CONCLUSION

The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM.

TRIAL REGISTRATION

Prospero ID: CRD42017082140.

Patient handover between ambulance crew and healthcare professionals in Icelandic emergency departments: a qualitative study

Background

Ambulance services play an important role in the healthcare system when it comes to handling accidents or acute illnesses outside of hospitals. At the time of patient handover from emergency medical technicians (EMTs) to the nurses and physicians in emergency departments (EDs), there is a risk that important information will be lost, the consequences of which may adversely affect patient well-being. The study aimed to describe healthcare professionals’ experience of patient handovers between ambulance and ED staff and to identify factors that can affect patient handover quality.

Methods

The Vancouver School’s phenomenological method was used. The participants were selected using purposive sampling from a group of Icelandic EMTs, nurses, and physicians who had experience in patient handovers. Semi-structured individual interviews were conducted and were supported by an interview guide. The participants included 17 EMTs, nurses, and physicians. The process of patient handover was described from the participants’ perspectives, including examples of communication breakdown and best practices.

Results

Four main themes and nine subthemes were identified. In the theme of leadership, the participants expressed that it was unclear who was responsible for the patient and when during the process the responsibility was transferred between healthcare professionals. The theme of structured framework described the communication between healthcare professionals before patient’s arrival at the ED, upon ED arrival, and a written patient report. The professional competencies theme covered the participants’ descriptions of professional competences in relation to education and training and attitudes towards other healthcare professions and patients. The collaboration theme included the importance of effective teamwork and positive learning environment.

Conclusions

A lack of structured communication procedures and ambiguity about patient responsibility in patient handovers from EMTs to ED healthcare professionals may compromise patient safety. Promoting accountability, mitigating the diffusion of responsibility, and implementing uniform practices may improve patient handover practices and establish a culture of integrated patient-centered care.

Transition in Care from EMS Providers to Emergency Department Nurses: A Systematic Review

Background: Transitions in care between emergency medical services (EMS) providers and emergency department (ED) nurses are critical to patient care and safety. However, interactions between EMS providers and ED nurses can be problematic with communication gaps and have not been extensively studied. The aim of this review was to examine (1) factors that influence transitions in care from EMS providers to ED nurses and (2) the effectiveness of interventional strategies to improve these transitions. Methods: We conducted a mixed-methods systematic review that included searches of electronic databases (DARE, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, Joanna Briggs Institute EBP), gray literature databases, organization websites, querying experts in emergency medicine, and the reference lists cited in included studies. All English-language studies of any design were eligible for inclusion. Two reviewers independently screened titles/abstracts and full-texts for inclusion and methodological quality, as well as extracted data from included studies. We used narrative and thematic synthesis to integrate and explore relationships within the data. Results: In total, 8,348 studies were screened and 130 selected for full text review. The final synthesis included 20 studies. Across 15 studies of moderate-to-high methodological quality, 6 factors influenced transitions: different professional lenses, operational constraints, professional relationships, information shared between the professions, components of the transition process, and patient presentation and involvement. Three interventions were identified in 6 methodologically weak studies: (1) transition guideline (DeMIST, Identification, Mechanism/Medical complaint, Injuries/Information related to the complaint, Signs, Treatment and Trends - Allergies, Medication, Background history, Other information [IMIST-AMBO]) with training, (2) mobile web-based technology (EMS smartphone and geographic information system location data), and (3) a new clinical role (ED ambulance off-load nurse dedicated to triaging and assessing EMS patients). There were mixed findings for the effectiveness of transition guidelines and the new clinical role. Mobile technology was seen positively by both EMS providers and ED nurses as helpful for better describing the pre-hospital context and for planning flow in the ED. Conclusion: While multimedia applications may potentially improve the handoff process, future intervention studies need to be rigorously designed. We recommend interdisciplinary training of EMS and ED staff in the use of flexible structured protocols, especially given review findings that interdisciplinary communication and relationships can be challenging.

Barriers to effective EMS to emergency department information transfer at patient handover: A systematic review

BACKGROUND

Handovers of care are necessary, yet a vulnerable time for patient safety. They can either reduce the risk of medical error during transitions of care or cause direct medical or financial harm to patients due to poor communication.

OBJECTIVE

To review (1) observational studies that quantify the frequency of transfer of specific data points or clinician retention of information provided in prehospital verbal handoff to assess the state of EMS-to-ED handoffs; (2) surveys and interviews of prehospital and ED staff perceptions of the handover process and any perceived barriers to optimal handover found therein; (3) interventional studies that have aimed to improve the quality of EMS to ED handoffs.

METHODS

A systematic review of the literature was performed using Pubmed, Web of Science, Google Scholar, and Cochrane Database of Systematic Reviews and by hand-searching references of relevant articles. Articles were selected that focused on verbal and/or written handover of patient care from EMS to ED providers and that addressed the above goals. Qualitative data was extracted from the articles and assessed using thematic synthesis.

RESULTS

78 articles were identified for full text review, 60 of which met inclusion criteria. Four categories of barriers emerged on thematic synthesis: educational, operational, cultural, and cognitive. Within these categories, 12 initial descriptive themes and 9 suggested interventions were identified.

CONCLUSIONS

Descriptive themes of disrespect & disinterest, environmental factors, redundancy, poor recall, conflicting goals and perspectives, technological issues, information degradation, information loss, lack of standardization, lack of training, delays, and lack of feedback were identified as barriers to effective EMS to ED handovers. Three categories of interventions were identified across the included interventional studies, namely technological, educational, and changes to cultural customs.

Triage emergency nurse decision-making: Incidental findings from a focus group study

INTRODUCTION

Emergency Department (ED) triage decision-making is a complex process. Triage scales are used to determine patient acuity level, however, they do not provide information on how nurses make triage decisions. This focus group study was part of a larger project to develop a psychometrically sound instrument to measure triage decision-making by nurses; the Triage Decision-Making Instrument. We report important incidental findings that emerged during the study that the participants identified as factors impeding triage decision-making.

METHODS

Three focus groups were conducted with 11 triage Registered Nurses. They commented on the instrument items and identified factors that influence triage decision-making. Transcripts were analyzed using thematic analysis.

RESULTS

Three powerful inter-related themes emerged central to encumbering triage decision-making: competing systems (pre-hospital versus the ED), fluctuating patient volume resulting in 'intra-Canadian Triage and Acuity Scale' triaging, and personal capacity including experience and 'triage fatigue'.

DISCUSSION

The findings demonstrate how interrelated system factors impede nurses triage decision-making. Triage nurses require support in their role and initiatives are needed to reduce the pressure they feel in relation to resolving system issues. Larger system issues and the capacity of the individual decision-makers must be accounted for within the context of increasing effectiveness and safety of ED triage.

Advantages and disadvantages of between unit hand-off policies in Iranian hospitals: a qualitative study

Introduction: Currently in emergency department (ED) of educational medical centers of Iran there are generally two models for between unit hand-off process based on the time of transferring the responsibility (during stay vs. while departure). There is no comprehensive study available to compare the policies. Thus, the present qualitative study was designed to compare these two methods of hand-off via performing interviews by specialist physicians who involving the process in the hospitals to express the advantages and disadvantages of the two policies from their point of view. Methods: This qualitative study was done by using opinions of experts throughout 2015 and 2016. Interviews were performed using a one-on-one and in-depth semi-structured approach. Before asking the questions, the definitions of the two models of hand-off as well as the aims of the study were briefly explained to the interviewee. Thematic and content analysis strategies were used to identify core concepts and to develop categories. Qualitative content analytical approaches focus on analyzing both the explicit content of a text and the latent content that can be extrapolated from the text. Results: In the present study, a total of 25 individuals were interviewed. The mean age of the participants was 34 years and their mean working experience was 7 years. By analyzing the interviews performed, the results were categorized in four main themes including 'resident training', 'patient management in ED', 'quality and process of diagnosis and treatment of patients' and finally, 'satisfaction with the process among specialist'. Conclusion: Although the two methods have advantages and disadvantages, it is likely that during stay, model was more favorable than while departure model from the viewpoints of interviewees. However, it seems that choosing any of the methods depends on various situations such as workload, academic matters, availability of resources, etc.

A Safety-II Perspective on Organisational Learning in Healthcare Organisations Comment on "False Dawns and New Horizons in Patient Safety Research and Practice"

In their recent editorial Mannion and Braithwaite provide an insightful critique of traditional patient safety improvement efforts, and offer a powerful alternative vision based on Safety-II thinking that has the potential to radically transform the way we approach patient safety. In this commentary, I explore how the Safety-II perspective points to new directions for organisational learning in healthcare organisations. Current approaches to organisational learning adopted by healthcare organisations have had limited success in improving patient safety. I argue that these approaches learn about the wrong things, and in the wrong way. I conclude that organisational learning in healthcare organisations should provide deeper understanding of the adaptations healthcare workers make in their everyday clinical work, and that learning and improvement approaches should be more democratic by promoting participation and ownership among a broader range of stakeholders as well as patients.

The use of process mapping in healthcare quality improvement projects

Introduction Process mapping provides insight into systems and processes in which improvement interventions are introduced and is seen as useful in healthcare quality improvement projects. There is little empirical evidence on the use of process mapping in healthcare practice. This study advances understanding of the benefits and success factors of process mapping within quality improvement projects. Methods Eight quality improvement projects were purposively selected from different healthcare settings within the UK's National Health Service. Data were gathered from multiple data-sources, including interviews exploring participants' experience of using process mapping in their projects and perceptions of benefits and challenges related to its use. These were analysed using inductive analysis. Results Eight key benefits related to process mapping use were reported by participants (gathering a shared understanding of the reality; identifying improvement opportunities; engaging stakeholders in the project; defining project's objectives; monitoring project progress; learning; increased empathy; simplicity of the method) and five factors related to successful process mapping exercises (simple and appropriate visual representation, information gathered from multiple stakeholders, facilitator's experience and soft skills, basic training, iterative use of process mapping throughout the project). Conclusions Findings highlight benefits and versatility of process mapping and provide practical suggestions to improve its use in practice.

Managing the patient safety risks of bottom-up health information technology innovations: Recommendations for healthcare providers

Health information technology (IT) offers exciting opportunities for providing novel services to patients, and for improving the quality and safety of care. Many healthcare professionals are already improving services through the development of numerous bottom-up local health IT innovations. Such innovations from the ground up are to be welcomed, but healthcare providers are struggling to develop processes for managing the risks that come with the introduction of health IT into clinical processes. I argue that too often the main strategy appears to be one of organisational ignorance. This puts patients at risk, and it threatens the successful adoption of health IT. I recommend that healthcare providers focus on strengthening their processes for organisational learning, promoting proactive risk management strategies, and making risk management decisions transparent and explicit.

Psychometric Evaluation of the Hospital Culture of Transitions Survey

BACKGROUND

Ineffective or inefficient transitions threaten patient safety, hinder communication, and worsen patient outcomes. The Hospital Culture of Transitions (H-CulT) survey was designed to assess a hospital's organizational culture related to within-hospital transitions in care involving patient movement. In this article, psychometric properties of the H-CulT survey were examined to assess and refine the hospital culture of transitions.

METHODS

A cross-sectional, multicenter, multidisciplinary correlational design and survey methods were used to examine the psychometric properties of the H-CulT survey. Exploratory factor analysis was used to quantify the accuracy of the previously identified structure. Specifically, the analysis involved the principal axis factor method with an oblique rotation, based on a polychoric correlation matrix.

RESULTS

A sample of 492 respondents from 13 diverse hospitals participated. Cronbach's alpha for the instrument was 0.88, indicating strong internal consistency. Seven subscales emerged and were labeled: Hospital Leadership, Unit Leadership, My Unit's Culture, Other Units' Culture, Busy Workload, Priority of Patient Care, and Use of Data. Correlations between subscales ranged from 0.07 to 0.52, providing evidence that the subscales did not measure the same construct. Subscale correlations with the total score were near or above 0.50 (p <0.001). Use of a factor-loading cutoff of 0.40 resulted in the elimination of 12 items because of weak associations with the topic.

CONCLUSION

The H-CulT is a psychometrically sound and practical survey for assessing hospital culture related to patient flow during transitions in care. Survey results may prompt quality improvement interventions that enhance in-hospital transitions and improve staff satisfaction and patient satisfaction with care.

A safety culture assessment by mixed methods at a public maternity and infant hospital in China

Objective

To assess safety culture at a public maternity hospital in Shanghai, China, using a sequential mixed methods approach. The study was part of a bigger study looking at the application of the mixed methods approach to assess safety culture in health care in different organizations and countries.

Methodology

A mixed methods approach was utilized by first distributing the Safety Attitudes Questionnaire measuring six safety culture dimensions and five independent items to all hospital staff (n=1482) working in 18 departments at a single hospital. Afterward, semistructured interviews were conducted using convenience sampling, where 48 hospital staff from nine departments at the same hospital were individually interviewed.

Results

The survey received a response rate of 96%. The survey findings show significant differences between the hospital departments in almost all safety culture dimensions and independent items. Similarly, the interview findings revealed that there were different, competing priorities between departments perceived to result in a reduced quality of collaboration and bottlenecks in care delivery. Another major finding was that staff who worked more hours per week would perceive working conditions significantly more negatively. Issues related to working conditions were also the most common concerns discussed in the interviews, especially the issue on high workload. High workload was also reflected in the fact that 91.45% of survey respondents reported that they worked 40 hours or longer per week. Finally, interview findings complemented survey findings, thus providing a more complete and accurate picture of safety culture.

Conclusion

Hospital leaders need to prioritize interventions focused on improving the quality of cross-department collaboration and reducing workload. A mixed methods assessment of safety culture provides more meaningful, targeted results, enabling leaders to prioritize and tailor improvement efforts to increase the impact of an intervention.

Developing an Australian health and aged care research agenda: a systematic review of evidence at the subacute interface

Objective The aim of the present study was to systematically review articles describing recent interventions that aimed to improve access and outcomes for older people at the interface between health and aged care, with a focus on subacute care programs of palliative care, rehabilitation, geriatric evaluation and management (GEM) and psychogeriatrics. Methods Australian studies published between 2008 and 2013were evaluated using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and National Health and Medical Research Council of Australia (NHMRC) guidelines. Included studies were summarised according to focus areas and results discussed in the current Australian subacute health care context. Results Eleven Australian research articles were identified. Three did not achieve any NHMRC rating level because of methodological approach. Focus areas included: discharge planning; information management or communication; rehabilitation; hospital treatment in residential care; screening and intervention; and Telehealth. Interventions were primarily system centred; only three studies featured patient-level outcome measures. Conclusions There is limited high-quality research investigating the effectiveness of interventions at the health and aged care interface of subacute care. Further research is needed. What is known about the topic? Subacute care offers important healthcare programs for older people, operating at the interface between health and aged care. However, for the most part this has not been subject to research scrutiny. What does this paper add? Identified studies were predominantly hospital oriented and designed to avoid hospital admission and associated costs. Locally integrated, collaborative and multidiscipline based interventions improve system-level outcomes. Alternative and individualised models of care, particularly when provided in their home setting, yields positive outcomes for older people. What are the implications for practitioners? Health and aged care reforms and related research agenda must include the perspectives and experiences of patients and/or carers accessing subacute care programs, yet these are under-reported. The present review highlights opportunities to improve the quality of existing evidence and create a research agenda for the future.

Lost information during the handover of critically injured trauma patients: a mixed-methods study

BACKGROUND

Clinical information may be lost during the transfer of critically injured trauma patients from the emergency department (ED) to the intensive care unit (ICU). The aim of this study was to investigate the causes and frequency of information discrepancies with handover and to explore solutions to improving information transfer.

METHODS

A mixed-methods research approach was used at our level I trauma centre. Information discrepancies between the ED and the ICU were measured using chart audits. Descriptive, parametric and non-parametric statistics were applied, as appropriate. Six focus groups of 46 ED and ICU nurses and nine individual interviews of trauma team leaders were conducted to explore solutions to improve information transfer using thematic analysis.

RESULTS

Chart audits demonstrated that injuries were missed in 24% of patients. Clinical information discrepancies occurred in 48% of patients. Patients with these discrepancies were more likely to have unknown medical histories (p<0.001) requiring information rescue (p<0.005). Close to one in three patients with information rescue had a change in clinical management (p<0.01). Participants identified challenges according to their disciplines, with some overlap. Physicians, in contrast to nurses, were perceived as less aware of interdisciplinary stress and their role regarding variability in handover. Standardising handover, increasing non-technical physician training and understanding unit cultures were proposed as solutions, with nurses as drivers of a culture of safety.

CONCLUSION

Trauma patient information was lost during handover from the ED to the ICU for multiple reasons. An interprofessional approach was proposed to improve handover through cross-unit familiarisation and use of communication tools is proposed. Going beyond traditional geographical and temporal boundaries was deemed important for improving patient safety during the ED to ICU handover.