Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO) : primary research

Background and objectives: Handover and communication failures are a recognised threat to patient safety. Handover in emergency care is a particularly vulnerable activity owing to the high-risk context and overcrowded conditions. In addition, handover frequently takes place across the boundaries of organisations that have different goals and motivations, and that exhibit different local cultures and behaviours. This study aimed to explore the risks associated with handover failure in the emergency care pathway, and to identify organisational factors that impact on the quality of handover. Methods: Three NHS emergency care pathways were studied. The study used a qualitative design. Risks were explored in nine focus group-based risk analysis sessions using failure mode and effects analysis (FMEA). A total of 270 handovers between ambulance and the emergency department (ED), and the ED and acute medicine were audio-recorded, transcribed and analysed using conversation analysis. Organisational factors were explored through thematic analysis of semistructured interviews with a purposive convenience sample of 39 staff across the three pathways. Results: Handover can serve different functions, such as management of capacity and demand, transfer of responsibility and delegation of aspects of care, communication of different types of information, and the prioritisation of patients or highlighting of specific aspects of their care. Many of the identified handover failure modes are linked causally to capacity and patient flow issues. Across the sites, resuscitation handovers lasted between 38 seconds and 4 minutes, handovers for patients with major injuries lasted between 30 seconds and 6 minutes, and referrals to acute medicine lasted between 1 minute and approximately 7 minutes. Only between 1.5% and 5% of handover communication content related to the communication of social issues. Interview participants described a range of tensions inherent in handover that require dynamic trade-offs. These are related to documentation, the verbal communication, the transfer of responsibility and the different goals and motivations that a handover may serve. Participants also described the management of flow of patients and of information across organisational boundaries as one of the most important factors influencing the quality of handover. This includes management of patient flows in and out of departments, the influence of time-related performance targets, and the collaboration between organisations and departments. The two themes are related. The management of patient flow influences the way trade-offs around inner tensions are made, and, on the other hand, one of the goals of handover is ensuring adequate management of patient flows. Conclusions: The research findings suggest that handover should be understood as a sociotechnical activity embedded in clinical and organisational practice. Capacity, patient flow and national targets, and the quality of handover are intricately related, and should be addressed together. Improvement efforts should focus on providing practitioners with flexibility to make trade-offs in order to resolve tensions inherent in handover. Collaborative holistic system analysis and greater cultural awareness and collaboration across organisations should be pursued

Reconceptualising clinical handover: Information sharing for situation awareness

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Safer clinical systems : interim report, August 2010

Safer Clinical Systems is the Health Foundation’s new five year programme of work to test and demonstrate ways to improve healthcare systems and processes, to develop safer systems that improve patient safety. It builds on learning from the Safer Patients Initiative (SPI) and models of system improvement from both healthcare and other industries. Learning from the SPI highlighted the need to take a clinical systems approach to improving safety. SPI highlighted that many hospitals struggle to implement improvement in clinical areas due to inherent problems with support mechanisms. Clinical processes and systems, rather than individuals, are often the contributors to breakdown in patient safety. The Safer Clinical Systems programme aimed to measure the reliability of clinical processes, identify defects within those processes, and identify the systems that result in those defects. Methods to improve system reliability were then to be tested and re-developed in order to reduce the risk of harm being caused to patients. Such system-level awareness should lead to improvements in other patient care pathways. The relationship between system reliability and actual harm is challenging to identify and measure. Specific, well-defined, small-scale processes have been used in other programmes, and system reliability has been shown to have a direct causal relationship with harm (e.g. care bundle compliance in an intensive care unit can reduce the incidence of ventilator-associated pneumonia). However, it has become evident that harm can be caused by a variety of factors over time; when working in broader, more complex and dynamic systems, change in outcome can be difficult to attribute to specific improvements and difficulties are also associated with relating evidence to resulting harm. The overall aim of Phase 1 of the Safer Clinical Systems programme was to demonstrate proof-of-concept that using a systems-based approach could contribute to improved patient safety. In Phase 1, experienced NHS teams from four locations worked together with expert advisers to co-design the Safer Clinical Systems programme

A pathway of care for vulnerable families (0-3): guidance

"The Scottish Government asked NHS Quality Improvement Scotland (NHS QIS) to lead the development of a national multi-agency, multidisciplinary programme of work to support vulnerable children and families from conception to age 3 as part of the implementation of the Early Years Framework. The guidance has been developed as part of that work. It is intended primarily for service managers across all agencies to use with their teams to support the specific aims of the Early Years Framework implementation... The overall aim is to ensure that vulnerable children (from conception to age 3) and families in all parts of Scotland receive support that is equitable, proportionate, effective and timely." - Page 6

Patients’ perspectives on the medical primary-secondary care interface : systematic review and synthesis of qualitative research

Funding NHS Highland Research, Development & Innovation Department, Aberdeen University, and Stirling University provided funds to meet publication costs.Peer reviewedPublisher PD

Development of a programme to facilitate interprofessional simulation-based training for final year undergraduate healthcare students

Original report can be found at: http://www.health.heacademy.ac.uk/publications/miniproject/alinier260109.pdfIntroduction: Students have few opportunities to practise alongside students from other disciplines. Simulation offers an ideal context to provide them with concrete experience in a safe and controlled environment. This project was about the development of a programme to facilitate interprofessional scenario-based simulation training for final year undergraduate healthcare students and explored whether simulation improved trainees’ knowledge of other healthcare discipline’s roles and skills. Methods: A multidisciplinary academic project team was created and trained for the development and facilitation of this project. The team worked on the development of appropriate multiprofessional scenarios and a strategy to recruit the final year students on a volunteer basis to the project. By the end of the project 95 students were involved in small groups to one of fifteen 3-hour interprofessional simulation sessions. Staff role played the relatives, doctor on call, and patient when it was more appropriate than using a patient simulator (Laerdal SimMan/SimBaby) in the simulated community setting and paediatric or adult emergency department. Each session had 3 to 4 of the following disciplines represented (Adult/Children/Learning Disability Nursing, Paramedic, Radiography, Physiotherapy) and each student observed and took part in one long and relevant high-fidelity scenario. Half the students were randomly selected to fill in a 40-item questionnaire testing their knowledge of other disciplines before the simulation (control group) and the others after (experimental group). Students were assessed on the questions relating to the disciplines represented in their session. Results: By the end of the project 95 questionnaires were collected of which 45 were control group students (Questionnaire before simulation) and 50 experimental group students (Questionnaire after simulation). Both groups were comparable in terms of gender, discipline and age representation. Participants were: Adult nurses (n=46), Children’s nurses (n=4), Learning Disability nurses (n=7), Nurses, Paramedics (n=8), Radiographers (n=20), Physiotherapists (n=8). 15 sessions were run with an average of around 7 participants and at least 3 disciplines represented. The knowledge test results about the disciplines represented was significantly different between the control and experimental groups (Control 73.80%, 95% CI 70.95-76.65; and Experimental 78.81%, 95% CI 75.76-81.87, p=0.02). In addition, there were sometimes reliable differences between the groups in their view of multidisciplinary training; confidence about working as part of a multidisciplinary team was 3.33 (SD=0.80, Control) and 3.79 (SD=0.90, Experimental), p=0.011; their anticipation that working as part of a multidisciplinary team would make them feel anxious was 2.67 (SD=1.17, Control) and 2.25 (SD=1.04, Experimental), p=0.073; their perception of their knowledge of what other healthcare professionals can or cannot do was 3.00 (SD=0.91, Control) and 3.35 (SD=0.93, Experimental), p=0.066; their view that learning with other healthcare students before qualification will improve their relationship after qualification was 3.93 (SD=1.14, Control) and 4.33 (SD=0.81, Experimental), p=0.055; their opinion about interprofessional learning helping them to become better team workers before qualification was 3.96 (SD=1.24, Control) and 4.42 (SD=0.77, Experimental), p=0.036. Conclusions: Although the difference is relatively small (~5%), the results demonstrate that students gained confidence and knowledge about the skills and role of other disciplines involved in their session. Through simulation, the positivism of students about different aspects of learning or working with other healthcare disciplines has significantly improved. Students gained knowledge of other disciplines simply by being given the opportunity to take part in a multiprofessional scenario and observe another one. The results of the test and their reported perception about multidisciplinary team working suggest that they are better prepared to enter the healthcare workforce. Discussions during the debriefings highlighted the fact that multidisciplinary training is important. The main challenges identified have been the voluntary student attendance and timetabling issues forcing us to run the session late in the day due to the number of disciplines involved in each session and their different placement rota. The aim is now to timetable formally this session within their curriculum. Introducing simulation in the undergraduate curriculum should facilitate its implementation as Continuing Professional Development once these students become qualified healthcare professionals

Evaluation of the organisation and delivery of patient-centred acute nursing care

In 2002, a team of researchers from the School of Nursing, University of Salford were commissioned by Bolton Hospitals NHS Trust to evaluate the delivery and organisation of patient-centred nursing care across the acute nursing wards within the Royal Bolton Hospital. The key driver for the commissioning of this study arose from two serious untoward incidents that occurred in the year 2000. Following investigation of both these events the Director of Nursing in post at that time believed that poor organisation and delivery of care may have been a contributory factor. Senior nurses in the Trust had also expressed their concern that care may not be organised in a way that made best use of the skills available

Textual Mediation in Simulated Nursing Handoffs: Examining How Student Writing Coordinates Action

In clinical nursing simulations, a group of students provide care for a robotic patient during a structured scenario. As care is transferred from one group to another, they participate in a patient handoff, with outgoing students passing key information onto incoming students. In healthcare, the nursing handoff is a critical and perilous communication moment that is mediated by a range of participants and texts. Drawing on observations and video recordings of 52 simulation handoffs in the United States, this article examines how two student-designed texts – a collaborative patient chart and individual notes – are leveraged during the handoff. I also consider how handoff talk and writing changes as student nursing knowledge increases over the course of a year. By focusing on textual mediation of the simulated nursing handoff, this article contributes to existing research on professional writing pedagogy and to nursing scholarship on the handoff. Ultimately, it argues that a textual mediation framework can help bridge class room and professional contexts by evaluating student writing not for how successfully it meets a set of imposed criteria but for how effectively it supports classroom activities

PATIENT WP4-Deliverable: Curriculum for Handover Training in Medical Education [Public Part]

What is handover? Handover is the accurate, reliable communication of task-relevant information between doctors and patients and from one care-giver to another. This occurs in many situations in healthcare. Why is handover important? Improperly conducted handovers lead to wrong treatment, delays in medical diagnosis, life threatening adverse events, patient complaints, increased health care expenditure, increased length of stay hospital and a range of other effects that impact on the health system(1). This is how accurate performed and well-structured handovers improve patient safety, i.e. “absence of preventable harm to a patient during the process of health care” (2). How to teach handover? The best way to teach practical skills is, to let students perform the skill. To decrease the risk for real patients simulation is the teaching method of choice. Therefore and on the basis of the project’s preceding results (3,4), this curriculum is divided into three modules: Module 1 – Risk and Error Management Module 2 – Effective Communication Module 3 – SimulationPATIEN