Identifying Transfer of Care Gaps: Electronic Health Record Capture of Perioperative Handoff Communications

Transitions in patient care are held together by interdisciplinary handoff communications intended to coordinate the patient\u27s ongoing care requirements. Patients with complexity in care encumber the transfer of care process requiring a higher level of care coordination between the interdisciplinary team (Coleman, 2003; Naylor et al., 2004). While the literature is abundant on the characteristics and quality of handoff communications, it is limited on the requirements of what data is necessary for ongoing care following transfer communications (Galatzan & Carrington, 2018). This dissertation explores the verbal information transferred during Operating Room (OR) to Post Anesthesia Care Unit (PACU) nursing handoff communications and whether the data is captured in the electronic health record (EHR) to represent the information critical to ongoing patient care and care planning. the study builds on the Kennedy Integrated Theoretical Framework (KITF) (Kennedy, 2012) integrating cognition theory, patterns of knowledge theory, and clinical communication space theory to support the human-technology characteristics within perioperative handoffs. Evidence of wisdom was present in the KITF in addition to elements of non-verbal communication patterns emerging from shared common ground contributed to the framework\u27s expansion. to understand the contributions of the perioperative nursing interface terminology, the Perioperative Nursing Data Set (PNDS), makes to postsurgical care transitions, the study examines nursing diagnoses, interventions, interim outcomes and goals relationships to the handoff data communicated between OR and PACU Registered Nurses. Study findings revealed a complex fragmented process of verbal communications and electronic documentation for the handoff process. While the EHR is prominent in data procurement for the handoff process, the design of handoff artifacts (e.g., paper, electronic) significantly impact the value of information received. Incomplete handoff tools or missing EHR data adds to a cycle of information decay while contributing to increase cognitive load and potentiating opportunities for information and knowledge loss. the absence of nursing diagnoses in the automation of the PNDS challenges the integrity of the language within the documentation platform and raises considerations for hierarchical representation within interface terminologies. This study reinforces literature to reconsider user requirements in the design and functionality of healthcare information technology (HIT) to enable data and information flow and preserve knowledge development. the inclusion of mobile technology, cognitive support aids including clinical decision support tools, and other HIT will further enable the effectiveness of transfer communication, knowledge development, and the safety of ongoing patient care

Implementation of a Standardized Handoff During Transition of Care from the Emergency Department to the Intensive Care Unit

Patient safety and nursing communication are crucial to the nursing handoff during transition of care from the emergency department (ED) to the intensive care unit (ICU). The Institute of Medicine published To Err is Human: Building a Safer Health System (1999) and Crossing the Quality Chasm (2001) highlighting ED handoffs as a safety measure. In 2006, the Joint Commission recognized handoffs with the National Patient Safety Goal 2E. The purpose of this evidence-based practice project was to determine if implementation of a standardized handoff would improve nursing communication and patient safety during transition of care from the ED to the ICU. Rogers’ Diffusion of Innovation Theory was used as the theoretical framework. The Stetler Model guided this project at a non-profit, 205-bed hospital, in the Midwest. The intervention included the development of a standardized handoff that (a) utilized a specific handoff tool, (b) minimized interruptions and multitasking, (c) enabled nurses to ask questions when information was unclear, (d) included anticipatory changes in patient’s condition, (e) ensured timing of the patient transfer was appropriate, (f) and confirmed ancillary staff was notified and available. Data for demographics of ED and ICU nurses, pre- and post-implementation questionnaires, and patient transfer times from ED to ICU were collected. Descriptive analysis was used to investigate nursing demographics regarding age, gender, race, and education. Two identical questions were asked of the nurses in the pre-and post-implementation questionnaires. Paired t-tests analyzed the nurses’ responses and found significant improvements in nursing communication (t=7.23, df=46, p\u3c=0.00) and patient safety (t=5.76, df=46, p\u3c=0.00). An independent t-test analyzed the patient transfer times from the ED to ICU. Patient transfer time decreased significantly pre (M=82.85 minutes; SD = 18.24) to post (M=75.47 minutes; SD = 17.74) intervention (t=1.974, df=283, p=0.0049). The patient transfer time from ED to ICU decreased by more than seven minutes. The p value indicates strong evidence against the null hypothesis. The clinical site adopted aspects of this standardized handoff for implementation not only in transfer of care from the ED to the ICU, but for handoffs throughout the hospital

Identifying ICU patient safety priorities within a Northern Ontario setting : a delphi study

The purpose of this study was to explore patient safety priorities as perceived by clinical experts working in a northern Ontario adult ICU. A modified Delphi was used to elicit consensus regarding patient safety priorities from the perspective of an expert panel of registered nurses and intensivists. At the onset of the study, the consensus level was set at 70%. Data was collected through serials rounds with researcher-developed questionnaires. Descriptive statistical analysis was completed. No consensus was reached at Round 1. Three points of consensus regarding patient safety priorities were reached at Round 2: improving pain and agitation management; incorporating a checklist into the bullet round reporting tool; and implementing use of visual cues for high-risk lines. These strategies support the need for anticipation, recognition, and management of at risk situations. The results have the potential to guide the advancement of the patient safety mandate within an ICU setting.Master of Science (MSc) in Nursin

The Electronic Health Record's Impact on Labor and Delivery Nurses' Cognitive Work

The Electronic Health Record’s Impact on Labor and Delivery Nurses’ Cognitive WorkAbstractBackground and objective: Despite recognition that electronic health record (EHR) use has introduced cognitive challenges for clinicians, few studies have evaluated its impact on the cognitive dimension of nurses’ work. Labor and delivery nurses may encounter unique challenges when using the electronic health record since they also interact with an electronic fetal monitoring system. This study sought to explore labor and delivery nurses’ perceptions of the EHR’s impact on their cognitive work with the goal of identifying patient safety implications. Methods and setting: This was a grounded theory study using dimensional and situational analysis. Data were interviews and observations with 21 labor nurses at two community hospitals in the Western United States. Results: The ways that nurses configured care when using the EHR varied across participants and sites and depended on how easily they integrated it into their practice. Individual, group, and situational factors facilitated or constrained integration. This took place in a dynamic, high-acuity, specialty clinical environment while using EHRs that were not designed for pregnant women. Nurses used clinical decision support and other cognitive support features that rarely worked as intended due to the lack of EHR customization to account for pregnancy physiology and unique risk factors in the perinatal patient. Nurses viewed the quality of their relationships with patients and their families as an integral part of caring for laboring women and felt that interaction with the EHR sometimes threatened this dimension of their work. Conclusions: When nurses were unable to integrate the EHR into care it resulted in numerous consequences that have important safety implications. Available cognitive support features lacked the specialty-specific support needed to care for laboring women and instead required nurses to track information in other ways that added to their cognitive burden and work routines. As a result, nurses and patients were not benefitting from the intended decision support and patient safety protections offered by appropriate risk assessment screens or critical alerts. These findings have important implications for the configuration and design of EHRs in perinatal settings

Quality of handover assessment by registered nurses on transfer of patients from emergency departments to intensive care units

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg In partial fulfillment the requirements for the degree of Master of Science in Nursing Johannesburg, 2017Background: Continuity of quality care and patient safety depends mainly on the effective handover. Gaps in communication might lead to omissions of vital information affecting continuity and safety of care and leading to negative consequences and sentinel events. Purpose: The aim of this study was to describe the opinions of nurses regarding the effectiveness of handover practices between nurses in the Emergency Departments and Intensive Care Units in an academic hospital in Johannesburg using a handover rating tool. The recommendations for clinical practice and education were provided thereafter. Method: A descriptive quantitative cross sectional survey was used. Convenience sampling was used. A sample size of hundred and eleven handovers (n=111) was used. Data was collected using a 16 item handover evaluation tool developed by Manser et al. (2010). The handover rating tool is divided into two sections. The first section was the demographic data, the second section asks about the information transfer, shared understanding, working atmosphere, overall handover assessment and circumstances of handover. Data analysis was done by means of descriptive and non parametric statistics using graphs, frequency distributions, medians and interquartile ranges, Wilcoxon rank sum and logistic regression. Testing was done at the 0.05 level of significance. Results: A higher level of qualification and years of experience in trauma and Intensive Care Unit were significant factors related to information transfer, shared understanding and overall handover quality. Univariate ordinal model showed statistical that respondents handing over were more likely to agree with information transfer, shared understanding, working atmosphere, overall handover quality and circumstances of handover compared with those receiving. Univariate ordinal model showed statistical difference that non specialist handing over were likely to agree to overall handover quality whereas multivariate ordinal model also showed statistical difference that non specialist handing over were likely to agree with circumstances of handover. The study suggests that it is necessary for ED and ICU nurses to have an agreement on the content of the structured handover framework as different specialists have different expectations.MT201

Taking Note: A Design Solution for Physician Documentation to Balance the Benefits of Handwritten Notes and Electronic Health Records

Master of Design in Integrative DesignUniversity of Michiganhttps://deepblue.lib.umich.edu/bitstream/2027.42/136865/1/THo_2017_MDes-Thesis.pd

Clinical handover of patients between nurses in the emergency department and somatic wards – an explorative interview study.

Master's thesis in Health and social sciencesBackground: Leading international health organizations have focused on improving the quality of clinical handovers. Research demonstrates areas for improvement where clinical handovers in healthcare are essential for quality, safety, and continuity of patient care. One hospital had received many incident reports about the quality of interdepartmental handovers between the Emergency Department and somatic wards, and wanted to improve them. Aim: The aim of this study was to explore how clinical handovers are experienced between the ED and ward nurses, and gather suggestions for improvement. Method: This study pursued a qualitative, inductive, explorative approach with 6 focus group interviews of nurses (N=19) on both ends of the ED-Ward handover (2 ED, 1 surgical, 3 medical). The interdepartmental handover is by telephone from ED to ward nurses. Graneheim and Lundman’s (2004) content analysis method was used to analyze interview texts. Rasmussen’s system approach and Dynamic Safety Model formed the theoretical basis for interpretation. Results: Four bodies of data emerged from the interviews: Poor handovers and Successful handovers from ED or Wards’ perspectives. Poor handovers occurred in a busy ED without handover structure where efficiency trumps quality causing consequences for nurses and patients on the wards. Nursing assessments and documentation lacked, and patients’ status upon arrival on wards didn’t always match the handover description. Successful handovers were described as bridging needs of patients and nurses. Conclusion: The results provide evidence for improving the interdepartmental handover but will take organizational buy-in and collaboration over time to develop and implement evidence-based, locally suitable handover routines and protocols

Trauma leadership and ICU shift-handovers:Identification, observation and integration of key skills

Residents’ work in trauma and intensive care is centered on patients with complex and high-risk conditions and involves close collaboration and coordination within a multidisciplinary team. For two specific skills – trauma leadership and ICU shift-handovers –Nico Leenstra and his team identified the concrete behaviors by which they can be taught, observed and evaluated, and which factors affect their use in practice.Trauma leadershipThrough an interview study with trauma team members and leaders, Leenstra identified the key leadership behaviors of the trauma leader (i.e., information coordination, action coordination, decision making, communication management, and team development), and established the extensive Taxonomy of Trauma Leadership Skills (TTLS). It benefits the design of leadership training. Complementary, a second version (TTLS-SHORT) was developed and evaluated, specifically for its ability to benefit observations, note-taking and reflections on leadership performances. ICU shift-handoversRegarding shift-handovers, Leenstra explored two dimensions. First, he identified physicians’ perceptions regarding the various functions of shift-handovers and how handover conditions may alter the handover process. His findings add to the growing case for handovers in complex settings being educated as more than information transfers, but also revealed dilemmas for engaging in functions such as joint decision making or reflection.Second, Leenstra analyzed the various strategies for structuring handover communication by residents, and evaluated how differing structures affected the reception of handover information. Foremost, he found that stating the working diagnosis early in the handover (as opposed to more towards the end) was associated with more critical reflections and information seeking by the receiver

Supporting dynamic and distributed decision making in acute care environments: Insights from a cognitive ethnography

The way that medical decisions are carried out in hospital environments has undergone radical changes in recent years, in part as a result of the changing landscape of care. To make decisions, physicians are expected to keep abreast of a growing and changing body of medical and patient knowledge, collaborate more with clinical colleagues, and utilize more technologies to inform care than ever before. This dissertation reports on a five month cognitive ethnography in an ICU in Ontario Canada, and utilizes distributed cognition to understand the challenges that physicians face in making decision in modern acute care environments. It also seeks to elucidate the strategies used by ICU physicians to cope with the challenges associated with using information from social, material and technological sources in decision-making. My findings demonstrate how information resources are (1) Objectivist, in that too much attention is paid to supporting the formalized, outcome-centered aspects of medical thinking, without due regard to the processes involved in adapting decisions to their situation; (2) Fragmented, in that, while information resources are often well-designed when considered in isolation, they force physicians to bridge gaps in the logic of access or representation when working between resources; (3) Individualistic, in that information resources are often tailored to support the cognitive needs of individual physicians, leaving the cognitive needs associated with collaboration unsupported, and sometimes undermining them. To compensate for the challenges associated with using objectivist, fragmented and individualistic information resources, physicians employed a number techniques, including relying in paper and other flexible artifacts, interpersonal clinical communications, and engaging in mobility work. This research brings us a step closer to understanding how people, paper, and technologies function together to fulfill the complex and dynamic needs associated with making medical decisions