Brendan Esposito CNSCancer Care and Haematology Unit

The Tweed Hospital

October 2015

Handover Utilising MOSAIQ EMR

Optimising the Model of Care for Patient Management at The Tweed Cancer Care and Haematology Unit

Where’d he say he’s from?

The Tweed Cancer Care and Haematology Unit (CC&HU) is an ambulatory day treatment unit within The Tweed Hospital (TTH).

An initial implementation of a handover process was attempted by nursing staff in November 2011.

Coinciding at this time was the implementation of the dedicated oncology specific, electronic patient record system (EMR), MOSAIQ.

Sequenced process of patient handover utilising MOSAIQ EMR was begun on 7th May 2012

Handover – What’s the big deal

The commonly understood model of shift to shift

nursing handover does not apply to most ambulatory

day treatment units. Most ‘tailor made’ handover

process and checklists are not readily applicable .

None-the-less, ‘handover’ of patient clinical

information remains quintessential to safe clinical

practice.

Handover - What’s it got to do with EMR?

With the recent increased use of computer systems, electronic

medical record keeping and electronic devices that enable

communication, there has been a corresponding increase in

interest concerning how these innovations are impacting on

the transfer of clinical information and patient handover.

MOSAIQ – What is it?

Electronic Medical Record System

Dedicated Multi-Departmental Oncology Management System

Interfaces with external systems

All patients accessible to all disciplines

What does it do? EMR-patient notes

Assessments tools

Documents, letters, reports

Chemo orders

Generates blood test and investigation orders

Laboratory and investigative results

Appointment scheduling

Daily basis-patient ‘queuing’ and staff allocation

Medicare code capture and billing

Statistical analysis – crystal reports

What’s it look like?

CINSW Project Grant

The aims of the project where seen to be relevant to the

CINSW Strategic Plan 2011-2015

The project was funded through a successful application

for a CI NSW Cancer Services Development grant

Aim of the Project

To demonstrate the effectiveness of morning

handover utilising MOSAIQ EMR within Cancer

Care and Haematology Unit at The Tweed

Hospital and its impact on patient care delivery 

Methods Used

A comparison of morning handover using MOSAIQ to local and national standards

Benchmarking local handover practices

Comparison of Essentials of Care observations and Staff Satisfaction Surveys

Examination of Incidence Reports

Interrogative EMR Patient Chart Audit

Comparisons to Standards National standards (NSQHS standard 6)

Australian Commission on Safety and Quality in Health Care

Australian Resource Centre for Healthcare Innovations

Clinical Excellence Commission

NSW Safe Clinical Handover Program

NSW Health Policy directive PD2009_60 Clinical Handover - Standard Key Principles

Northern NSW Local Health District Procedure, Nursing/Midwifery Shift Clinical Handover – Point of Care/Bedside NC-NNSW-PRO-6361-12

Results of this Comparison

Handover utilising MOSAIQ EMR meets local and

national standards with limited exceptions:

No documentation of ‘handover’ present

Patient involvement in the process could be

greater or more explicit

Benchmarking

Six similar ambulatory units in the Northern NSW Local Health district and geographical proximal to TTH were canvassed.

The Nursing Unit Managers of these units were provided a copy of the SAFE CLINICAL HANDOVER-KEY PRINCIPLES FOR SAFE AND EFFECTIVE HANDOVER and a modified questionnaire taken from the same document

Results of Benchmarking

5/6 response rate

‘Handover’ practices vary widely locally

All units experienced similar circumstances and intrinsic problems

Standard handover formats devised for ‘shift to shift’ settings did not suit

Very few units (1/5) document ‘handover’

4/5 units employ EMR

EOC and Staff Surveys

CC&HU began engagement with the EOC program in October 2010. This cyclic process begins with data collection. Data is collected in various ways, one of which is observational studies of ward processes and activities

This qualitative data consisted of observations of the environment and staff interactions and also included the application and interpretation of a Questionnaire about Clinical Handover (QCH) in August 2012 and Nursing Workplace Satisfaction Questionnaire (Fairbrother, Jones and Rivas, 2010) in 2010

EOC and Staff Surveys (Hang in there… He gets interesting in about 3 more slides)

Aspects of the previously applied QCH (2012) were compared with results from an expanded QCH in 2014

Results from the 2014 NWSQ were compared to the previous results from the same questionnaire applied in 2010

A compared sick leave 12 months prior and then after implementation of handover

Results of Surveys and Observations

EOC observations and staff satisfaction surveys indicate that handover using MOSAIQ is valued by staff and has resulted in greater staff satisfaction and a perception of safer and better co-ordinated patient care.

A reduction in staff sick leave has also been observed in the period after the implementation of handover utilising MOSAIQ.

An examination of Incidence Reports

A total of 61 incident reports (Incident Information Management System) were examined

Incidents between 16 Aug 2010 and 24 Jan 2014 were examined

Four incidents were noted to concern the communication of clinical information

Results of this Examination

Two incidents prior to implementation resulted in patients being treated with low neutrophil counts (despite a checking procedure being in place) because this clinical information had not been communicated

Handover inserts another ‘group’ check into existing procedures. No further incidents of this nature have been noted

A third report revealed partially completed chemotherapy orders were discovered during handover for a patient booked for Tx. The potential for chemotherapy to be inadvertently administered was detected

A similar report described incorrect dosages of chemotherapy being discovered during the handover procedure.

These incidents lend support to the handover having improving patient safety

Chart Audit 50 EMR audited: 25 before implementation and 25 after

Is there evidence a review of blood results by nursing staff occurred on the day of treatment?

Has the patient been previously delayed chemotherapy treatment? Was this because of information discovered during handover?

Is there evidence the patient received chemotherapy education?

Is there evidence these orders/plans were acted upon? • Are there specific medical orders associated with the treatment in place prior

to the scheduled appointment?• Is there evidence of a nursing plan associated with the treatment in place prior

to scheduled appointment?• Is there evidence these orders/plans were acted upon?

Results of Chart Audit (Nearly there guys…)

An increase was seen in the nursing assessment of patient blood results and the number of patients receiving chemotherapy education, prior to the patient receiving chemotherapy

The handover process has resulted in an increase number of medical instructions being actioned nursing staff

A similar increase is shown in the number of nursing plans being actioned nursing staff

Conclusions

There now exists a dedicated, formalised, embedded and sequenced process of patient handover utilising MOSAIQ EMR to review patients, which is considered essential and valuable to the nursing practice within the CC&HU. This has positively impacted on the safety and care of patients and lead to improvements in staff satisfaction and feelings of collegiality. This process meets National and local standards and is readily applicable to the local circumstances within the unit described and may possibly prove applicable in other ambulatory settings utilising EMR systems.

Recommendations1. NSQHS standard 6.2 Establishing and maintaining structured and

documented processes for clinical handover

2. NSQHS standard 6.5.1 Mechanisms to involve patients and, where relevant carers in the clinical handover are in use.

3. This report to be made available to other ambulatory care units

4. Develop quantitative measures/KPIs– Wastage of chemotherapy– Patients OOS– Time in motion– Number of documented ‘handovers’

Acknowledgements

The hard working CC&HU Nursing Team

Lily Fenech - EOC Coordinator Northern NSW LHD

Stephen Manley – Cancer Systems Innovations Manager, CINSW

Greg Fairchild – Post Doctoral Research Fellow, NaMO

Sue Brooks - NUM, CC&HU TTH