Transcript of Interactive Handover – What should I be worried about ? Quality Measurement in ICU – Feasibility...
Slide 1
Interactive Handover What should I be worried about ? Quality
Measurement in ICU Feasibility study & knowledge translation
Wrae Hill & Lenora Marcellus BC-PSQC Quality Forum 2015
Slide 2
Context : 80 % of serious adverse events related to poor
communication We know surprisingly little about something we do all
the time
Slide 3
Problems: Critical incidents associated with handovers No
standard for handover processes No expectation of interaction
Nursing shift change overlap not funded Common Hill, W. (2012) Time
for a Change in Change of Shift Report QI study conducted across
Interior Health and presented at the 2012 BC Quality Forum
Rare
Slide 4
How do experts communicate ? Hill, W (2010) Cognitive Human
Factors in ICU Techniques clinicians report that they use to
develop their anticipation, intuition and foresight at change of
shift report (CoSR). CJRT 46.4 ICU Receivers ask anticipatory
questions : What are you worried about ? What should I be worried
about ? Expert Physicians/ Nurses/Respiratory Therapists ask
anticipatory questions and learn ; Interdependence Brevity vs.
Relevance for receiver How to perceive each others subtle signals.
Shared mental model of evolving risk to get On the same page
Hollnagel 2010 - Resilience Engineering
Slide 5
HISTORY ANTICIPATE WHAT MIGHT OCCUR WHAT SHOULD I WATCH OUT FOR
??
Slide 6
Hill, W., Marcellus, L. Et al (2014) Interactive Handover -
What should I be worried about? Quality Measurement in ICU Measures
: Interactive Handover Quality Score (IHQS) Pre : Post CoSR 69 RNs,
32 RRTs 15 Charge RN 2 ICU settings
Slide 7
High PreHigh Post Improved Post IDRAW Low Pre IDRAW Modest
improvement
Slide 8
Interactive Handover (4:22)
https://www.youtube.com/watch?v=GSHcub4K-uk Interactive Handover KT
/ Implementation Handover Quality Feasibility Study: 1.Measurable
by direct observation using IHQS 2.Where it is low, it may be
improved using IDRAW, (Increased quality in less time) 3.Structured
interaction : quality / less time ? Next Steps : Research Safe
Communication Curriculum + Sim Labs (UBC/UBC-O/UVIC/BCIT)
http://www.cw.bc.ca/onlinecourses/development/ubc/sph2014/http://www.cw.bc.ca/onlinecourses/development/ubc/sph2014/.
Implementation: Effective Verbal Communication CPGs (2 pgs ea)
Verbal Handovers ID / Relevant concise story/ Active receiver
Urgent Communication (SBAR) appropriate assertion / Clear request
iLearn videos Peer to Peer - Social Contagion Physicians &
Nurses co-create their videos to model behaviours
Slide 9
AVIATION SAFETY Standard phraseology 15 sec Verbal burst @
transitions Active receiver Type/ Identity/speed/ Direction/
Altitude/ ETA HEALTHCARE COMMUNICATION SAFETY Standard phraseology
(IDRAW ?) Short Verbal burst @ transitions 1.Identity (Pt &
MRP) 2.Relevant concise story 3.Active Receiver (What should I be
worried about ?) Implement by peer-peer spread Role model
(Hospitalists/ Nurse Educators/ TLNs) Teach in orientation/ CME
& Simulations Contact: Wrae Hill MSc RRT FCSRT
[email protected] / Lenora Marcellus PhD RN
[email protected]@[email protected]
Slide 10
1.Alvarado,K., (2006) Transfer of Accountability: Transforming
Shift Handover to Enhance Patient Safety, Healthcare Quarterly,
9(Sp) 2006: 75-79Alvarado,K., Healthcare Quarterly, 9(Sp) 2006:
75-79 2.Berger,J. (2013) Contagious: Why Things Catch On (Simon
& Schuster) 3.Foster, S. & Manser, T. (2012a). Effects of
patient handover characteristics on subsequent care: A systematic
review and implications for future research. Academic Medicine, 87
(8), 1105-1124. 4.Frankel, R.M. (2012) Context, culture and
(non-verbal) communication affect handover quality BMJ. BMJ Qual
Saf 21:i121i127 5.Handoff of Care 2012 Frequently Asked Questions -
Virginia Health System
http://www.healthsystem.virginia.edu/internet/e-learning/handoff_faq.pdfhttp://www.healthsystem.virginia.edu/internet/e-learning/handoff_faq.pdf
6.Hill W., Nyce,J. (2010a) Human Factors in Clinical Shift Handover
Communication (Review) Canadian Journal of Respiratory Therapy 46.1
Spring 7.Hill,W. (2010b) Cognitive Human Factors in ICU Techniques
clinicians report that they use to develop their anticipation,
intuition and foresight at change of shift report (CoSR) Canadian
Journal of Respiratory Therapy 46.4 Winter 8.Hill (2012c) -
Handover Communication - Direct observation of Change of Shift
Report (CoSR) Assessment of current state on 26 units at 11
hospitals in Interior Health Interior Health Patient Safety Report
2011, Poster BC Quality Forum 2012 9.Hilligoss B, Moffatt-Bruce,
S.D. (2014) The limits of checklists; Handoff and Narrative
thinking, Downloaded from qualitysafety.bmj.com on April 12, 2014
10.Hollnagel, E. (2010). Exploring resilience: What is it? Why is
it important for healthcare? How resilience can point to critically
needed solutions in healthcare. Beyond High Reliability: Improving
Patient Safety Through Organizational Resilience. June 3-4,
Vancouver, Canada. 11.Horwitz,
L,I,.Moin,T.,Krumholz,H..,Wang,L.,Bradley,E.H. (2009) What are
covering doctors are told about their patients? Analysis of
sign-out among internal medicine house staff. Quality and Safety in
Health Care 18:248-255 12.Jeffcott,S.A., Ibrahim,J.E., Cameron,P.A.
(2009) Resilience in healthcare and clinical handover Quality and
Safety in Health Care ;18 pp. 256-260 13.Kemper,P.F., van Noord,
I., de Bruijne,M.,Knol,D.L., Wagner,C., van Dyck,C. (2013)
Development and reliability of the explicit professional oral
communication tool to quantify the use of non- technical skills in
healthcare BMJ Qual Saf;22:586-595 14.Kicken W, Van der Klink M,
Barach P, Boshuizen H.(2012) Handover training: does one size fit
all? The merits of mass customization. BMJ Qual Saf. 2012 Oct
30.Kicken WVan der Klink MBarach PBoshuizen HBMJ Qual Saf.
15.Landrigan,C.P., Lyons,A. (2012) I-PASS: Development of an
Evidence-Based Handoff Improvement Program for Physicians and
Nurses, First do no harm / Newsletter of the Quality & Patient
Safety Division of the Massachusetts Board of Registration of
Medicine. December 2012 16.Manser (2011) Minding the Gaps; moving
handover research forward European Journal of Anaesthesia 17.Morley
2002 Error Reduction and Performance Improvement in the Emergency
Department through Formal Teamwork Training: Evaluation results of
the MedTeams project, Health Service Results 2002; 37:1553.
18.MacDougall,E.,Marcellus,L., Hill, W. Marck,P.,Clark,J.
Campbell,S.,Ryan, M.M.,Reid,C.R.,Wong,S. Dempster, L.K.,Pamplin,C.,
Evans.C. (2015) Safe Patient Handover Communication Curriculum -
Research proposal BC Health Simulation Education. 19.Nemeth,C.
Wears,R.,Woods, D., Hollnagel,E.,Cook, R. (2008) Minding the Gaps:
Creating Resilience in Health Care (2008) Agency for Healthcare
Research and Quality. 20.Olvera,M. (2011) DRAW 3 Handover - IHI
Expedition on Handover March 23,2010 21.Park,B., Mishkin,A. (2005)
Best Practices in Shift Handover Communication : Mars Explorer
Rover Surface Operations Proceedings of the International
Association for the Advancement of Space Safety Conference,
sponsored by the ESA, NASA, and JAXA, Nice France. 25-27 October
2005 22.Patterson,E.S., Wears, R.L. (2010) Patient Handoffs :
Standardized and Reliable Measurement Tools Remain Elusive. The
Joint Commission Journal on Quality and Patient Safety Vol 36/ 2
p.51 23.Petersen LA, Brennan TA, ONeil AC, et al. Does housestaff
discontinuity of care increase the risk for preventable adverse
events? Ann Intern Med 1994;121:86672 24.Philibert,I. (2009) Use of
strategies from high reliability organizations to the patient
hand-off by resident physicians: practical implications Qual Saf
Health Care 18:261-266 25.2012 Safer Healthcare Crew Resource
Management in Healthcare
http://www.saferhealthcare.com/crew-resource-management/crew-resource-management-healthcare/http://www.saferhealthcare.com/crew-resource-management/crew-resource-management-healthcare/
26.Solet, D.J., Norvell, M., Rutan,G.H.,Frankel,R.M. Lost in
Translation: Challenges and Opportunities in Physician-to-Physician
Communication During Patient Handoffs Academic Medicine, Vol. 80,
No. 12 / December 2005 27.Sturgeon, D, Maclaren,J.,Stewart,M.,Cole,
D., Ratnarajan,E.,Letwin,S. (2013) Team TransFERmation: Leadership
LINX - Patient Handover /Transfer of Accountability action learning
project BC Health Authorities. (Interior Health Report) 28.Woods,
D.D., Sarter,N.B. (2010) Capturing the dynamics of attention
control from individual to distributed systems: the shape of models
to come. Theoretical Issues in Ergonomics Science Vol. 11, Nos. 12,
JanuaryApril 2010, 728. 2010 Taylor & Francis,
http://www.informaworld.comhttp://www.informaworld.com 29.Handoff
of Care 2012 Frequently Asked Questions - Virginia Health System
(http://www.healthsystem.virginia.edu/internet/e-learning/handoff_faq.pdf)http://www.healthsystem.virginia.edu/internet/e-learning/handoff_faq.pdf
30.Wohlauer MV, Arora VM, Horwitz LI, Bass EJ, Mahar SE, Philibert
I; (2012) The patient handoff: a comprehensive curricular blueprint
for resident education to improve continuity of care. Acad Med.
2012 Apr;87(4):411-8.Wohlauer MVArora VMHorwitz LIBass EJMahar
SEPhilibert IAcad Med. 31.Zavalkoff SR, Razack SI, Lavoie J, Dancea
AB Handover after pediatric heart surgery: a simple tool improves
information exchange. Pediatr Crit Care Med. 2011
May;12(3):309-13.Zavalkoff SRRazack SILavoie JDancea ABPediatr Crit
Care Med.