Improving Transitions of Care, Handoffs and Coordination Across Units

Dr. Ayse Gurses & Dr. Mahiyar Nasarwanji

Armstrong Institute for Patient Safety and Quality

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Objective

• To highlight the importance of smooth care transitions and handoffs

• To provide a list of good practices during transitions of care

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Overview

• Background • Define

– Care transitions – Handoffs

• Good practices – For each stage of the transition

• Handoffs• Other pieces of the intervention package

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Significance of Care Transitions

• 46% to 56% of all medication errors during transitions (Pippins et al 2008, Barnsteiner 2005)

• Hazards (Horwitz 2009)– Inadequate support for situation

awareness– Inaccurate / inadequate information

transfer– Unstructured / non-standardized

handoff – Responsibility / Role ambiguity– High workload

Communication Breakdowns are frequently the root cause of…undesirable outcomes

Improving Handoff Communications: Meeting National Patient Safety Goal 2E, Joint Comm Perspectives on Patient Safety, 2006.

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Handoff reports

• Patients are particularly vulnerable during handoffs – Incorrectly communicated information– Information not communicated at all

• Appropriate measures for evaluating effectiveness of handoffs still need to be established and validated1

1. Solet DJ, Norvell JM, Rutan GH, et al., Acad Med, 2005.

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Part of the larger care process…

Pre transfer care

Prepare patient for transfer at

sending endPhysically transfer patient

Stabilize patient at receiving

end

Handoff

Post transfer care

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Care transitions

“Set of actions designed to ensure the coordination and continuity of health care as patients transfer (move) between different locations or different levels of care. Care transitions encompass both the sending and the receiving aspects of the transfer”

American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557.

Patient

ER

ICU

OR

FloorRehab center

Home

Home care

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Handoffs

“The transfer of information (along with authority and responsibility) during transitions in care across the continuum for the purpose of ensuring the continuity and safety of the patient’s care.”

Presentation for Standardizing Handoffs for Patient Safety AORN. 2012. Accessed April 8, 2013. Available at: http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=20863

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Care transitions intervention

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Evidence

• CSTS project (site visits)– Observations– Interviews– Tool analysis (handoff report

checklists)• Literature• Wisdom of crowds (Clinical

expertise and experiences)

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Systems Engineering Initiative for Patient Safety (SEIPS) Model

Carayon, P., Hundt, A.S., Karsh, B.-T., Gurses, A.P., Alvarado, C.J., Smith, M. and Brennan, P.F. “Work System Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i50-i58, 2006.

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How do we implement it?

• Leverage your CUSP teams• Covered in the face to face meeting

1. Identify executive leadership 2. Identify units involved 3. Identify team 4. Identify current practice and expectations Today

5. Assessment of current system6. Training program 7. Develop and roll out handoff tool8. Periodic assessment9. Continual improvement

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Good Practices

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Focus

• Concentrates on transfers from– OR ICU – ICU Floor

• List of good practices are generic – Some many not apply to specific transition

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Good practices

• Prior to patient transfer

• During patient transfer

• At receiving unit prior to verbal handoff

• During verbal handoff

• Following verbal handoff

At sending unit

At receiving unit

Hospital

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At the hospital level

• Handoff policy – That all staff are aware of– Or staff know where to locate

• Adequate and appropriate training on care transitions and handoffs• Coordination and teamwork between units should be regularly

evaluated and improved• Designated champions at various locations

– Can be contacted for questions – Can collect feedback

• Equipment should be functional and ready to use• Consider compatibility of devices across units when making

purchasing decisions

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• Prior to patient transfer

• During patient transfer

• At receiving unit prior to verbal handoff

• During verbal handoff

• Following verbal handoff

Good practices

At sending unit

At receiving unit

Hospital

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Prior to patient transfer

• Inform receiving unit of– Patient’s time of arrival– Patient related information (telephone handoff)– Specific equipment needs

• Inform sending unit of patient’s destination• All cables, lines and wires should be

– Clearly labeled – Organized and secured

• Patient should be stable and ready for transfer

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• Prior to patient transfer

• During patient transfer

• At receiving unit prior to verbal handoff

• During verbal handoff

• Following verbal handoff

Good practices

At sending unit

At receiving unit

Hospital

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During patient transfer

• Equipment should permit stable movement of the patient– Bed / wheelchairs used for transport should

have adequate and appropriate locations to place and secure all equipment required for transfer

• At least one individual should be aware of the exact destination at the sending unit

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During transfer of patient

• Remove all barriers – Provide an assigned or limited access

elevator for transfers – Path of travel should be a barrier free zone

• No equipment in the corridors• No movement past family waiting areas

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• Prior to patient transfer

• During patient transfer

• At receiving unit prior to verbal handoff

• During verbal handoff

• Following verbal handoff

Good practices

At sending unit

At receiving unit

Hospital

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At receiving unit prior to verbal handoff

• At least one nurse in addition to the primary nurse should be present to receive the patient (dependent on patients condition)

• The cables and monitors in from the sending unit should be compatible with those in the receiving unit

• When transferring cables and lines– Cables and lines should be transferred sequentially– Warning should be provided prior to disconnecting– No more than a 30s disruption

• Patient should be stable and comfortable

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• Prior to patient transfer

• During patient transfer

• At receiving unit prior to verbal handoff

• During verbal handoff

• Following verbal handoff

Good practices

At sending unit

At receiving unit

Hospital

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Verbal handoff (1 of 3)

• At least the primary nurse and/or the provider from the receiving unit (e.g., intensivist) should be present

• The environment should– Be free of noise– Provide adequate space for all the key players– Not interfere with other clinical workflow

• Adequate time should be provided to complete the handoff

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Verbal handoff (2 of 3)

• There should be an identified leader that initiates and directs the verbal handoff

• The primary nurse or provider should be asked and explicitly acknowledge readiness for the handoff

• There should be no distractions and interruptions other than for– Clarifications– Questions – To take care of critical patient related issues in the unit

• Nurses and providers should be able to pause the handoff • Everyone should feel comfortable asking questions

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Verbal handoff (3 of 3)

• A standardized handoff checklist or tool – Should be consistently used – Kept as a temporary record

• Primary nurse and provider should make notes of what is being discussed

• The primary nurse or practitioner at the receiving unit should explicitly acknowledge assumption of care

• Principles of good teamwork should be followed– Empowerment– No role or responsibility ambiguity– Appropriate conflict resolution – Clear, complete, brief and timely communication

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• Prior to patient transfer

• During patient transfer

• At receiving unit prior to verbal handoff

• During verbal handoff

• Following verbal handoff

Good practices

At sending unit

At receiving unit

Hospital

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Following verbal handoff

• The nurses and physicians at the receiving units – Should be aware of the short-term and long-term

goals for the patient– Know who to contact after the handoff for questions

and concerns• How to contact them

– Should verify critical information communicated during the handoff

• Should be a mechanism to provide immediate informal feedback

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Lets concentrate a little more on the verbal handoffs …

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Handoffs

Why?

When?

Where?

Who?

How?

What?

• Successful transfer of information

• Dedicated time• Sufficient length

• Close to work area• Large enough

space• Free from

distractions• Access to required

information and technology

• Key personnel / players• Active involvement of

senior physicians

• Clear leadership • Good

communication• Team involvement • Avoid interruptions • Discussion and

questions• With the aid of

checklists, tools and technology

• Provider information • Patient information• Plan of care • Discussion and

questions

Adapted from: AMA Clinical Handover Guide - Safe Handover: Safe Patients: https://ama.com.au/ama-clinical-handover-guide-safe-handover-safe-patients

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Primary objective of handoffs

• “The primary objective of a “hand off ” is to provide accurate information about a [patient’s] care, treatment, and services, current condition and any recent or anticipated changes.”

Meeting the Joint Commission 2008 National Patient Safety Goals, Joint Commission, 2007.

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What information?

• Customized to hospital and setting • Use pre-existing format and Mnemonics• Some guidelines

– Introduction of all care providers and their roles– Identifiable patient information– Past medical history/ comorbidities of the patient – Current situation / state of patient – Current assessment and diagnosis– Plan of care – Anticipated problems and contingency plans– Read-back and / or synthesis by receiver– Questions– A genuine invitation to call for additional clarifications

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Standards of effective communication

Brief

Clear

Complete Timely

Verify & validate

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Teamwork

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Toolkit

• New material – Assessment of Care Transitions (ACT) Upcoming– Participatory user centered design approach Upcomingto tool / checklist development

• Reinforcement– Teamwork across unit tool Upcoming– Barrier identification and mitigation tool

• Currently implemented– Transitions of care survey – Part of HSPOS – Relational Coordination

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You will need to ACT soon… Assessment of Care Transitions

Yes No N/aPre verbal handoff assessment      

Was there at least one nurse present in addition to the primary nurse when the patient arrived at the receiving unit to help stabilize the patient?

Were the monitors and or cables, sent with the patient compatible with the monitors and / or cables at the receiving unit?

Was equipment (e.g. monitors) needed for the patient at the receiving unit      

a. Available a. Functional a. Appropriate / adequate

If lines, tubes and cables were transferred to a new monitor,      

a. Were all key parameters visible throughout, with less than a 30s disruption? a. Was a verbal warning provided prior to disconnecting the key line, tube,

wire or cable?

How long did take to stabilize the patient (from the time the patient first arrived at the receiving unit to the time the verbal handoff started)?

min     

Did a patient related issue increase the overall time stabilize the patient? Was the patient situated, stable and comfortable at the receiving unit prior to the

verbal handoff?

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Participatory user centered design approach to tool / checklist development

Identify needs

Identify requirement

Needs analysis

Design

Iterative testing

Finalize design

• Development of a team communication tool

• Information needs from all players considered

• Standardized form– Shared and used by all

team members

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Thank you!

Ayse Gurses, Ph.D. agurses1@jhmi.edu

Mahiyar Nasarwanji, Ph.D. mnasarw1@jhmi.edu