A Standardized Electronic Handover Report for Anesthesia Providers

Background: Despite numerous studies and agencies recommending the standardization of handovers to improve the quality and safety of patient care, intraoperative anesthesia handovers have remained unstandardized at many institutions. Objectives: The purposes of this study were to 1) develop the preliminary Anesthesia Handover Report (AHR) and evaluate its accessibility, layout, and content using feedback from an Expert Sampling Group; 2) create the finalized AHR and evaluate the impact it had on the perceived quality of handover among anesthesia providers; and 3) to assess the uptake of the finalized AHR. Methods: This study was implemented at NorthShore University Health System (NSUHS), Evanston, Highland Park and Glenbrook locations. In Phase 1, an Expert Sampling Group of ten experienced anesthesia providers evaluated the preliminary AHR for its accessibility, layout and content using the Expert Sampling Group Questionnaire. In Phase 2, using feedback from this questionnaire, the finalized AHR was created and all 140 anesthesia providers at the three study locations were invited to utilize and evaluate the AHR during intraoperative anesthesia handover, additionally, during Phase 3 the use of the AHR was queried every two weeks for the duration of Phase 2 to assess uptake. Results: Five anesthesia providers completed the Expert Sampling Group Questionnaire in Phase 1. Changes made to the preliminary AHR in response to feedback from the Expert Sampling Group Questionnaire included the removal of redundant information, more appropriate layout of information in the sidebar, the addition of total drug dose given in the medications panel, an additional hyperlink to anesthesia nerve block reports, and corrections to wrong information being pulled into the AHR. During Phase 2, 21 anesthesia providers completed the Anesthesia Handover Survey. The overall mean Likert score for handover conduct was 3.72 with a SD of .475 (minimum 2, maximum 4), this indicated that overall the majority of the respondents perceived that the AHR improved the conduct component of handover. The overall mean Likert score for teamwork was 3.76, with a SD of .432 (minimum 3, maximum 4), which indicated that respondents felt the AHR improved teamwork during handover. Lastly, the mean Likert score for the handover quality was 3.64 with a SD of .611 (minimum 1, maximum 4), this indicated respondents felt the AHR improved overall handover quality. Results of Phase 3 indicated the uptake did not increase as expected over the six-week monitoring window, but rather peaked during week four and quickly dropped off thereafter. The mean number of times the “Anesthesia Handoff” event button was clicked each week was 3.17. Conclusions: Use of the AHR improved the perceived conduct, teamwork, and quality of intraoperative anesthesia handovers. The use of the AHR did not improve over time. Overall, use of the AHR improved the perceived quality of anesthesia handovers. Future studies should be done to determine if use of the AHR would result in the standardization of anesthesia handovers

Handoff Communication in the Emergency Department

The communication of patient information through use of handoff ensures continuity of care and patient safety. A study of hand-off reports between pre-hospital personnel and staff in the emergency department revealed a lack of complete or formal information dialogue. Nurses play a vital role in the process of communication and information exchange through the use of handoff despite minimal guidelines for that exchange in current nursing practice. The pre-hospital hand-off informational exchange impacts patient safety as well as the planning and implementation of nursing care based upon that information. The sample used was from a convenience sampling of patients arriving in the Emergency Department via ambulance over all days, shifts, and from all ambulance services that deliver patients who chose to participate in the study. The sample size was to observe hand offs occurring over a one month period of time equally distributed over all shifts and days of the week. The data was analyzed using a percentage distribution to classify the data related to hand off report content. This data was then divided and compared according to the categories of information transferred through utilization of the protocol and analyzed for frequency of occurrence. There are indications for nursing educational needs in relation to the importance of handoff documentation and how that documentation of the handoff report contents impacts nursing practice. There may also be implications for the standard format for handoff reporting and technology solutions to improve handoff content

The Design, implementation and Evaluation of a Technology Solution to Improve Discharge Planning Communication in a Complex Patient Population

Unnecessary delays in discharge planning can extend the length of stay (LOS) and add non-reimbursable days for socially and medically complex patients thereby increasing the financial burden to healthcare organizations. The literature supports enhanced discharge communication strategies and the use of checklists to facilitate safe and timely discharges. Following root cause analyses of significant discharge delays, one hospital identified gaps in communication as key precursors associated with discharge planning breakdown when discharging patients to skilled nursing facilities. Review of these events demonstrated the need for concurrent communication strategies between multidisciplinary care team members in planning for complex discharges. Following a complete assessment of the current discharge planning process, a web-based interactive discharge checklist was designed, implemented and evaluated in the attempt to provide guided communications to the essential partners of the patient’s team in an effort to reduce LOS and readmissions. After a six-month rollout of the new technology and concomitant procedures, the analyses revealed improvement in both the patient’s perception of discharge planning and the ability to discharge patients by noon. Results for LOS and readmission demonstrated inconsistent improvement. The use of an electronic checklist as a communication tool did reduce variability in discharge procedures and provided for continuity in handoff communication between team members. Staff agreed it promoted continuity and improved efficiency

Improving IT Enabled Continuity of Care Across Pre- Hospital and Hospital Settings

Pre-hospital Emergency Medical Services (EMS) are often the patients’ first contact with the health care system. These services are a collaborative effort between several organizations providing different levels of care. These services are also multi-organizational, process oriented, and information dependent. As a result, a significant challenge exists in these fastpaced environments in terms of collecting and handing-off accurate and timely patient information from one care provider to the next. Consequently, there is a significant need for technology-enabled process improvement initiatives and guiding frameworks for streamlining information hand-offs across pre-hospital and hospital settings. This multi-method study explores the current state and potential improvements of technology-enabled pre-hospital to hospital information hand-offs in the State of California (CA). A questionnaire was administered to EMS leaders across the State. Qualitative interviews and focus group discussions were then conducted on two CA county EMS systems to explore potential improvements and to construct a set of principles to guide system development to support emergency care processes. A set of design principles, guidelines, themes, and end-user needs are presented and future research directions discussed

Comparison of the effectiveness of traditional nursing medication administration with the Color Coding Kids system in a sample of undergraduate nursing students

The problem of medication errors in hospitals and the vulnerability of pediatric patients to adverse drug events (ADE) was investigated and well substantiated. The estimated additional cost of inpatient care for ADE’s in the hospital setting alone was conservatively estimated at an annual rate per incident of 400,000 preventable events each incurring an extra cost of approximately $5,857. The purpose of the researcher was to compare the effectiveness of traditional nursing medication administration with the Color Coding Kids (CCK) system (developed by Broselow and Luten for standardizing dosages) to reduce pediatric medication errors. A simulated pediatric rapid response scenario was used in a randomized clinical study to measure the effects of the CCK system to the traditional method of treatment using last semester nursing students. Safe medication administration, workflow turnaround time and hand-off communication were variables studied. A multivariate analysis of variance was used to reveal a significant difference between the groups on safe medication administration. No significant difference between the groups on time and communication was found. The researcher provides substantial evidence that the CCK system of medication administration is a promising technological breakthrough in the prevention of pediatric medication errors

A Team-Based Approach to Studying Complex Healthcare Processes

Communication is a critical aspect of clinical work. In 2010, the Joint Commission (JC) found that gaps in communication were among leading factors contributing to medical errors. Healthcare processes, such as patient discharge, depend on interdisciplinary communication to be successful. Electronic health records (EHRs) have the potential to facilitate communication and information sharing between interdisciplinary care team members; however, challenges remain in designing tools for team-based care and questions remain in understanding how EHRs impact interdisciplinary team communication. This dissertation focuses on understanding how EHRs can be designed to support communication and information sharing within interdisciplinary patient care teams. The first aim of the dissertation investigated how EHRs impact interdisciplinary clinical teams’ communication, shared mental models, and information sharing activities. The results showed that implementing new EHR tools appeared to have little impact on communication and shared mental models, but new information sharing activities mediated by EHR developed. These changes and lack thereof suggest that new EHR tools will be specifically needed to facilitate interdisciplinary team information sharing activities. The second aim of the dissertation investigates the information sharing activities and information needs of interdisciplinary team members during patient discharge. The results showed that the information clinicians sought out during discharge depended on the roles that person played as well as the progress of the discharge process. Future EHR tools should be aware of how patient care teams are progressing through the patient discharge process in order to provide information contextualized to their current tasks. In conclusion, interdisciplinary team communication and information sharing remain poorly supported by current EHRs and new tools designed specifically for interdisciplinary teams should provide information based on the completion of team activities

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

Program Evaluation of a Bundled Educational Intervention to Enhance Implementation of Professional Exchange Report

Communication handover is a source of potential error and risk to patient safety. Electronic-based tools may reduce errors and mitigate risks to patient safety. Electronic tools have been successfully implemented using multiple methods of education and training. Electronic tools vary in functionality and integration with the electronic health record (EHR). A large West Michigan Regional Health System (RHS) implemented a new EHR containing an embedded tool for communication handover called Professional Exchange Report (PER). There was inconsistency in the practice of bedside report by nurses. The RHS planned to use a bundled approach of educational interventions to implement the new tool and report structure including communications, video demonstration, in-seat training and at the elbow support during the go-live. This project systematically evaluated the interventions to implement PER using evidence based methodology. Evaluation was based on collection of data and evidence through interviews, pre- and post-implementation surveys, observations of the report process, and review of documents related to planning, implementing and evaluating the program. Organizational leaders engaged in robust planning. Educational interventions were evidence-based. Implementation was carried out effectively. The organization did not have a detailed, specific plan for evaluation of educational interventions or PER outcomes. Change in length of report could not be attributed to the process change, and nurse perceptions of the process and consistency of practice at bedside did not change. Observed opening of the EHR during report increased by 68%. There were statistically significant increases in yes responses to awareness of, understanding why, knowledge of specific, and ability to make practice changes

Master of Science

thesisThere is a high risk for communication failures at the hospital discharge. Discharge summaries (DCS) can mitigate these risks by describing not only the hospital course but also follow-up plans. Improvement in the DCS may play a crucial role to improve communication at this transition of care. This research identifies gaps between the local standard of practice and best practices reported in the literature. It also identifies specific components of the DCS that could be improved through enhanced use of health information technology. A manual chart review of 188 DCS was performed. The medication reconciliations were analyzed for completeness and for medical reasoning. The pending results reported in the DCS were compared to those identified in the enterprise data warehouse (EDW). Documentation of follow-up arrangements was analyzed. Report of patient preferences, patient goals, lessons learned, and the overall handover tone were also noted. Patients were discharged on an average of 9.8 medications. Only 3% of the medication reconciliations were complete regarding which medications were continued, changed, new, and discontinued; 94% were incomplete and medical reasoning was frequently absent. There were 358 pending results in 188 hospital discharges. 14% of those results were in the DCS while 86% were only found in the EDW. Less than 50% iv of patients had clear documentation of scheduled follow-up. Patient preferences, patient goals, and lessons learned were rarely (6%, 1%, and 3% respectively) included. There was a handover tone in only 17% of the DCS. The quality gaps in the DCS are consistent with the literature. Medication reconciliations were frequently incomplete, pending results were rarely available, and documentation of follow-up care occurred less than half of the time. Evaluating the DCS primarily as a clinical handover is novel. Information necessary for safe handovers and to promote continuity of care is frequently missing. Future improvements should reshape the DCS to improve continuity of care

Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clinic

Background Transitions of care from specialty and acute settings to primary care abound. Compared to the continuity in end-of-shift handoffs, care transitions involve provider communication between practices and facilities with their own cultures and bureaucracies. Using the transition from acute care to outpatient primary care for stroke/transient ischemic attack (TIA) patients as a case study, this qualitative research explored communication practices and institutional arrangements among clinical providers responsible for longitudinal management of hypertension. In this study, researchers investigated the barriers and facilitators of effective communication between acute stroke/TIA inpatient and primary care providers at a Veterans Affairs Medical Center. Methods A multidisciplinary team conducted consensus-based coding and thematic analysis of semistructured interviews with 21 clinical providers (9 with primary responsibilities for inpatient care and 12 with primary responsibilities in outpatient, primary care). Results Thematic analysis of responses identified three factors that influenced communication between clinical providers: (1) consistent, concise but complete medication and treatment plans; (2) reliable, standardized discharge documentation; (3) use of multiple modes of communication. Participants identified cultural barriers, including challenges with rotating providers at a teaching hospital and local discharge practices. Conclusion Ambiguity about who is being handed off to and time pressures in the acute setting may lead inpatient providers to give lower priority to discharge communication, leaving outpatient providers with low-quality information. While electronic templates have standardized key components of discharge documentation, improvement opportunities remain. Increased awareness of the challenges and opportunities on each side of the care transfer could foster communication practices that systematically account for the information needs of inpatient and outpatient providers