EFFECTIVE COMMUNICATION DURING POSTOPERATIVE HANDOVER · EFFECTIVE COMMUNICATION DURING...
Transcript of EFFECTIVE COMMUNICATION DURING POSTOPERATIVE HANDOVER · EFFECTIVE COMMUNICATION DURING...
27.04.2011
Tanja Manser, Industrial Psychology & Human Factors
EFFECTIVE COMMUNICATION DURING POSTOPERATIVE HANDOVER This research was funded by the European Commission, Marie Curie Intra-European Fellowship (PIEF-GA-2009-236668) and carried out in collaboration with Aberdeen Royal Infirmary (Dr. Rona Patey & Dr. Paul Holder), the Industrial Psychology Research Group (Prof. Rhona Flin), University of Aberdeen, and Simon Foster, Organizational and Occupational Sciences, ETH Zurich.
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Mechanism for transferring information, responsibility & authority
Contributes to informational, relational & management continuity (Haggerty et al., 2003)
Important “audit-point” essential for potential recovery from failure (Clancy, 2006; Perry, 2004)
Ideally “a moment of shared cognition” (Perry, 2004)
Related to organizational learning (Haggerty et al., 2003; Patterson et al., 2004) Training, socialization, encouraging / maintaining group cohesion
Patient handover
Status quo impedes good practice necessary to maintain high standards of clinical care (BMA, NPSA & NHS Modernisation Agency, 2005; Harvey et al., 2007) Lack of training on effective communication & team
coordination Lack of formal systems for patient handover
Patient handover as key process to investigate in order to improve patient safety (Australian Council for Safety and
Quality in Health Care, 2005; Committee on quality of health care in America, 2001)
Human factors research as integral part (Harvey et al., 2007)
Patient handover as a research priority
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In contrast to other high-risk industries, patient handover has seldom been studied (Patterson, et al. 2004)
Most studies focus on shift handover
Few studies investigate patient handover at postoperative care transitions to recovery or ICU (Horn & Jacobi, 2006; Catchpole et al.,
2007; Smith et al., 2008; Nagpal et al., 2010; Thieme Groen et al., 2010)
take place in an environment that is event-driven, time pressured, and prone to concurrent distractions
while the patient is in an “at risk” state (Smith et al., 2008)
Studies of patient handover
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Observational studies (Catchpole et al., 2007; Thieme Groen et al., 2010)
Ideosyncratic handover practices Information transfer often unstructured and
not supported by documentation Concurrent clinical tasks
Development of standardised protocols (Catchpole et al., 2007; Nagpal et al., 2010)
Evaluation of standardized handover protocols Improvements in quality of handover* and in teamwork
without increasing handover duration (Catchpole et al., 2007)
* Operationalised as adherence to protocols
Postoperative patient handover
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Research gap: Little in-depth information on the specific teamwork
activities and their effects on handover quality
Research questions: What is the current practice in postoperative handover ? Which factors influence handover practice
(e.g. clinical setting, level of training)? Which characteristics of current handover practice are
related to positive assessments of handover quality?
Research gap & questions
Methodological approach
Unit of analysis Patient handover at care transitions after surgery
Interview study Semi-structured interviews Ethnographic observations
Observation study Structured observations Assessment of handover quality
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Interview topics Participant's clinical experience Goal structure Factors influencing the quality and safety of patient handover Task structure Team structure / Leadership Information needs Decision making / Shared cognition Feedback and education
27 participants: 5 anaesthetists, 5 theatre nurses, 5 recovery room nurses, 5 ICU nurses, 5 ICU physicians, 2 surgeons
Transcription and qualitative analysis (i.e. emergent themes)
Interview study
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“Anaesthesia isn’t black and white so I think it’s easier to handover verbally. I would much prefer a verbal handover than a written handover.” (Anaesthesia consultant)
“I just try to make sure it’s maybe not too technical from the point of view of the whole patient story, it’s maybe how they’ve been in theatre and highlighting anything particular that I want them to know really at the end of the day. (..) So I think they have quite a lot of information coming in. I try to keep it reasonably brief (..) I try to tell them things outwith the standard. (..) That’s what is asked for by the nurses. They want to know what’s going to happen with the patient (..) anything I can predict that might happen.” (Anaesthesia consultant)
“I just want to ascertain what they’ve had in theatre any complications that they’re expected to have during their time in the recovery room and what our plan is for when the patient is in recovery. Just to make sure that the patient has a safe transition from theatre to recovery and there’re no gaps in information. Make sure of the important things are handed over to me. I want to know what their observations have been like in theatre and what their expectations are for the recovery room.” (Recovery room nurse)
Handover as information transfer
Transfer of responsibility for a patient
I take that bit where I say “Are you happy
with everything” and they say “Yes”, I take that as the end point of the handover. I’m now officially handing the patient over to you
and you’re taking prime responsibility for their care from that point onwards but I’ll be there as a backup. When the anaesthetist walks out of the door,
then it’s my patient and I will take responsibility for the patient.
If the anaesthetist and the scrub nurse come through with a patient,
the idea is that, until they’ve given handover to a recovery nurse, they’re responsible.
(…) there tends to be a point at which the theatre nurse (…) will share
the information and then from that point forward, the responsibility is ours (...) but, in real terms, you assume responsibility for the patient as soon as they come
in the door.
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“I certainly don’t feel I transfer the responsibility. Even if I’m... Certainly to a nurse or to a junior surgeon, I would never feel I was transferring responsibility. To a colleague, a consultant anaesthetist, to a degree you’re transferring responsibility. But it’s one of those things... If you’ve been involved with a patient, you have a sense of responsibility even quite far down the line.” (Anaesthesia consultant)
“I suppose in theory it should be exactly the same but I feel more comfortable usually taking a patient into ITU because both the nursing staff and the medical staff there are used to dealing with things that happen acutely. (..) So I think I’d probably give ITU responsibility a bit earlier, particularly if they know the patient. (..) Whereas I know that, in Recovery, I can’t suddenly give responsibility for the patient to the nurse because they’re trained totally differently and they won’t be able to deal with all the problems that come up, whereas intensive care will. I’m quite happy to give responsibility back to them. Get out of there as fast as possible.” (Anaesthesia consultant)
Handover as transfer of responsibility
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“I guess it’s whoever’s been the main person looking after the patient as well throughout the operation, whoever has developed the most understanding of the patient, it would make sense.
Occasionally, the person who’s in charge may ... occasionally you have a problem where they (consultant anaesthetists) pitch up just at the end so they’ll come through to recovery with you and (…), they’ll do the handover but not having been there for most of the time which is sometimes when the dangerous bits happen, they’ll say “Oh yes, his blood pressure’s been fine the whole way through” and you’re like “No, actually it’s been too high the whole way through”.
(...) so you may just stick around waiting for the other person to leave so that you can give a bit more information because you don’t want to embarrass them by saying “Actually that’s totally wrong” in front of somebody else unless it’s something very serious, very tactfully say “Well, yes, the blood pressure was fine but then it was really weird, during the operation it was really high all the time. So, if it’s high here, I think we should do X, Y, or Z”.
It’s something we’re not very good at, especially when there’s two anaesthetists working, we’re not very good at working out who’s in charge“
(Anaesthesia trainee)
Who should hand over?
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Structured observation of 117 handovers 50 theatre to recovery room 25 theatre to cardiac ITU 42 recovery room to ward (40 matching cases)
Audio recording of subset for reliability analysis Participants
31 anaesthetists, 36 scrub nurses, 21 recovery room nurses, 12 cardiac ITU nurses, 31 ward nurses
Maximum of 5 observations per clinician to avoid bias Quantitative analysis
(i.e. relative amount of time per category)
Observation study
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Mostly routine handovers
Situational handover characteristics
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Situational handover characteristics
Similar for all clinical settings
In line with interview data
Tendency of receiving clinicians to rate complexity and uncertainty lower
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Handover observation system
Development of observation categories Literature review, Interviews, Ethnographic observations
Second-by-second coding of handover activity
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Handover activity Ti
me
spen
t on
hand
over
act
iviti
es
in %
of
hand
over
dur
atio
n
75 72
198
7
70 63 58 86
34 34 18 43 5 5 4 5
0
50
100
150
200
250
Overall Theatre to recovery (n=50)
Theatre to Cardiac ITU (n=25)
Recovery to ward (n=42)
Clinical work (% of t) HO Com (% of t) HO Doc (% of t) Soc Com (% of t)
Significant difference between settings for Clinical work (ANOVA with setting = factor, p < 0.001, Eta² = 0.91)
HO communication (ANOVA with setting = factor, p < 0.001, Eta² = 0.44)
Concurrent activities (ANOVA with setting = factor. p < 0.001, Eta² = 0.80)
Concurrent A. 1.84, ±0.57
Concurrent A. 1.41, ±0.14
Concurrent A. 2.78, ±0.40
Concurrent A. 1.73, ±0.25
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Handover communication
Time spent on subcategories of handover communication in % of handover duration across clinical settings and handover roles
22.15 (±8.8) 2.62 (±2.9) 0.23 (±1.4) 19.74 (±12.3) 9.13 (±5.8) 12.79 (±5.2) 2.92 (±2.8)
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Handover communication
Time spent on subcategories of handover communication in % of handover duration across clinical settings comparing handover roles
Transferring clinician(s): Information giving, Assessment and Planning & decision making
Receiving clinician(s): Acknowledgement and Information seeking
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Handover communication
Theatre to recovery
Recovery to ward
Theatre to Cardiac ITU
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Clinical work & handover communication
Kendall tau correlations between Clinical work (Setup/Patient care) and handover communication for the three clinical settings. ͣIn setting 2 “Information verifying" did not occur * p < 0.05, ** p < 0.01, *** p < 0.001
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Literature claims problems with trainee handover – but often only includes data on trainee handover
What is different? Trainee handovers take longer
(277.9 sec; ±111 vs. 222.7sec; ±70.5, p<0.05, Eta²=0.08)* Receiving staff’s ratings of handover quality slightly
lower for trainees (3.2; ±0.94 vs. 3.5; ±0.73, n.s.)* Differences in handover communication?
* Due to sample size only calculated for Theatre to recovery handovers.
Trainee vs. consultant handover
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Trainee vs. consultant handover
Handovers from theatre to recovery by trainee (n=12) or consultant level anaesthetists (n=38)
Information giving Information seeking Information verifying
Planning & Decision making Acknowledgement Handover organisation
Assessment
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Trainee vs. consultant handover
Handovers from theatre to CITU by trainee (n=4) or consultant level anaesthetists (n=21)
Information giving Information seeking Information verifying
Planning & Decision making Acknowledgement Handover organisation
Assessment
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Ratings of handover quality
Rating by transferring and receiving clinician(s)
Analysis Item quality Factor structure Predictive validity Link to handover
activities Manser et al., 2010 QSHC
Factor structure of handover quality
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Patient care information
Shared understanding
Handover organisation
Conduct
Factors predicting handover quality
Patient care information r = 0.45, p < 0.001
Shared understanding r = 0.32, p < 0.001
Handover organisation r = 0.37, p < 0.001
Conduct r = -0.13, p < 0.05
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Differences between clinical settings
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Overall handover quality Across clinical settings higher receiver rating when:
More Assessment (r = .312; p ≤ 0.001)
Less Information seeking by receiver (r = -.327; p ≤ 0.001)
No relationship for Information giving (r = .118; ns) and Planning & decision making (r = .095; ns)
Assessment (but not information giving and planning and decision making) negatively correlated with information seeking
Assessments are key to handover quality ratings
* Correlation analysis of handover activities with quality judgments of the receiving staff across all settings
What makes a „good handover“?*
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Handover communication
Patient care information
Handover organisation
Shared understanding
Conduct
Information giving
Information seeking r = -.205*
Information verifying
Assessment r = .224** r = .359** r =.193* r = -.298**
Planning & decision making
Acknowledgement r =.251**
Handover organisation r = -.182*
What makes a „good handover“?
* Significant at 0.05 level ** Significant at 0.01 level
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It’s more than facts and figures Assessments are key to high handover quality ratings Compensatory information seeking behaviour of
receiving staff
Implications for handover standardisation efforts Implications for education / training of handover Research challenges
Ethics – especially for ITU admissions Complexity of handover in different settings
Discussion