Barriers and facilitators to the implementation of an evidence-based electronic minimum dataset for nursing team leader handover: A descriptive survey

© 2017 Australian College of Critical Care Nurses Ltd. Introduction: There is widespread use of clinical information systems in intensive care units however, the evidence to support electronic handover is limited. Objectives: The study aim was to assess the barriers and facilitators to use of an electronic minimum dataset for nursing team leader shift-to-shift handover in the intensive care unit prior to its implementation. Methods: The study was conducted in a 21-bed medical/surgical intensive care unit, specialising in cardiothoracic surgery at a tertiary referral hospital, in Queensland, Australia. An established tool was modified to the intensive care nursing handover context and a survey of all 63 nursing team leaders was undertaken. Survey statements were rated using a 6-point Likert scale with selections from 'strongly disagree' to 'strongly agree', and open-ended questions. Descriptive statistics were used to summarise results. Results and discussion: A total of 39 team leaders responded to the survey (62%). Team leaders used general intensive care work unit guidelines to inform practice however they were less familiar with the intensive care handover work unit guideline. Barriers to minimum dataset uptake included: a tool that was not user friendly, time consuming and contained too much information. Facilitators to minimum dataset adoption included: a tool that was user friendly, saved time and contained relevant information. Identifying the complexities of a healthcare setting prior to the implementation of an intervention assists researchers and clinicians to integrate new knowledge into healthcare settings. Conclusion: Barriers and facilitators to knowledge use focused on usability, content and efficiency of the electronic minimum dataset and can be used to inform tailored strategies to optimise team leaders' adoption of a minimum dataset for handover

The pitfalls of postoperative theatre to intensive care unit handovers: a review of the current literature

Postoperative handovers present a critical step in the management of intensive care unit (ICU) patients. There are many challenges in the transportation of unstable patients with complex medical histories from theatre to the ICU, and the subsequent transfer of responsibility for care from one group of caregivers to another. Communication between the providers of the handover report (anaesthetists, surgeons and theatre nursing staff) and receivers of the report (ICU physicians and ICU nursing staff) is often poor. The unstructured presentation of information, the noisy ICU environment, and discussions between healthcare workers from different disciplines at different levels of training adds to the burden of communication. The handover report may be seen as a sentinel event in the ICU patient’s stay. ICU staff use the handover process as an important source of information to coordinate management input from multiple disciplines. Despite its importance, the practice of a structured postoperative handover protocol in our region’s hospitals is non existent. The authors reviewed the current literature to better understand the challenges facing proper handover processes and suggest some interventional strategies

ICU handover procedure: the Greek perspective

Background: Passing the right information poses a challenge in clinical practice. This is the first study in Greece that tries to describe the handover procedure in an intensive care unit to a tertiary hospital.Methods: A two phase study was conducted during a 155 days period. It included a blind and open observational study which examined the quality and content of clinical handover by night shift doctor to the medical team and a survey about the process. Retrospective cross-checking of the information handed over with one written down in the actual patient record was also conducted.Results: A total of 800 set of patients’ daily records were examined. A structure of system-based approach of the handover was recorded, with system coverage varying from 21% (nutrition) to 86% (respiratory system) and good relation with the actual record in most areas of interest. Other areas, such as comorbidities, and relatives’ issue were poorly covered. Education meeting that was held between the two phases did ameliorate the content and the quality of information passed over, and in some areas, proved to have a positive effect on certain aspect of handover like e.g. frequency of interruptions, infection status, relatives’ issues and proposed management plan coverage.Conclusions:Handoverprocess is vital for maintaining stability and quality of care in intensive care unit. Its continual efficiency reevaluation is at least as important as the handover itself for preserving it as a valuable tool in everyday practice.

Team working in intensive care:current evidence and future endeavors

Purpose of review: It has recently been argued that the future of intensive care medicine will rely on high quality management and teamwork. Therefore, this review takes an organizational psychology perspective to examine the most recent research on the relationship between teamwork, care processes, and patient outcomes in intensive care. Recent findings: Interdisciplinary communication within a team is crucial for the development of negotiated shared treatment goals and short-team patient outcomes. Interventions for maximizing team communication have received substantial interest in recent literature. Intensive care coordination is not a linear process, and intensive care teams often fail to discuss how to implement goals, trigger and align activities, or reflect on their performance. Despite a move toward interdisciplinary team working, clinical decision-making is still problematic and continues to be perceived as a top-down and authoritative process. The topic of team leadership in intensive care is underexplored and requires further research. Summary: Based on findings from the most recent research evidence in medicine and management, four principles are identified for improving the effectiveness of team working in intensive care: engender professional efficacy, create stable teams and leaders, develop trust and participative safety, and enable frequent team reflexivity

Potential uses of AI for perioperative nursing handoffs: A qualitative study

OBJECTIVE: Situational awareness and anticipatory guidance for nurses receiving a patient after surgery are keys to patient safety. Little work has defined the role of artificial intelligence (AI) to support these functions during nursing handoff communication or patient assessment. We used interviews to better understand how AI could work in this context. MATERIALS AND METHODS: Eleven nurses participated in semistructured interviews. Mixed inductive-deductive thematic analysis was used to extract major themes and subthemes around roles for AI supporting postoperative nursing. RESULTS: Five themes were generated from the interviews: (1) nurse understanding of patient condition guides care decisions, (2) handoffs are important to nurse situational awareness, but multiple barriers reduce their effectiveness, (3) AI may address barriers to handoff effectiveness, (4) AI may augment nurse care decision making and team communication outside of handoff, and (5) user experience in the electronic health record and information overload are likely barriers to using AI. Important subthemes included that AI-identified problems would be discussed at handoff and team communications, that AI-estimated elevated risks would trigger patient re-evaluation, and that AI-identified important data may be a valuable addition to nursing assessment. DISCUSSION AND CONCLUSION: Most research on postoperative handoff communication relies on structured checklists. Our results suggest that properly designed AI tools might facilitate postoperative handoff communication for nurses by identifying specific elevated risks faced by a patient, triggering discussion on those topics. Limitations include a single center, many participants lacking of applied experience with AI, and limited participation rate

Nursing Team Leader handover in the intensive care unit contains diverse information and lacks structure: An observational study

Background: Despite a proliferation of evidence and the development of standardised tools to improve communication at handover, evidence to guide the handover of critical patient information between nursing team leaders in the intensive care unit is limited. Objective: The study aim was to determine the content of information handed over during intensive care nursing team leader shift-to-shift handover. Design: A prospective observational study. Setting: A 21-bed medical/surgical adult intensive care unit specialising in cardiothoracic surgery at a tertiary referral hospital in Queensland, Australia. Participants: Senior nurses (Grade 5 and 6 Registered nurses) working in team leader roles, employed in the intensive care unit were sampled. Method: After obtaining consent from nursing staff, team leader handovers were audiotaped over 20 days. Audio recordings were transcribed and analysed using deductive and inductive content analysis. The frequency of content discussed at handover that fell within the a priori categories of the ISBAR schema (Identify-Situation-Background-Assessment-Recommendation) was calculated. Results: Forty nursing team leader handovers were recorded resulting in 277 patient handovers and a median of 7 (IQR 2) patients discussed at each handover. The majority of nurses discussed the Identity (99%), Situation (96%) and Background(88%)of the patient, however Assessment (69%) content was varied and patient Recommendations (60%) were discussed less frequently. A diverse range of additional information was discussed that did not fit into the ISBAR schema. Conclusions: Despite universal acknowledgement of the importance of nursing team leader handover, there are no previous studies assessing its content. Study findings indicate that nursing team leader handovers contain diverse and inconsistent content, which could lead to inadequate handovers that compromise patient safety. Further work is required to develop structured handover processes for nursing team leader handovers

Handover patterns: an observational study of critical care physicians

Abstract Background Handover (or 'handoff') is the exchange of information between health professionals that accompanies the transfer of patient care. This process can result in adverse events. Handover 'best practices', with emphasis on standardization, have been widely promoted. However, these recommendations are based mostly on expert opinion and research on medical trainees. By examining handover communication of experienced physicians, we aim to inform future research, education and quality improvement. Thus, our objective is to describe handover communication patterns used by attending critical care physicians in an academic centre and to compare them with currently popular, standardized schemes for handover communication. Methods Prospective, observational study using video recording in an academic intensive care unit in Ontario, Canada. Forty individual patient handovers were randomly selected out of 10 end-of-week handover sessions of attending physicians. Two coders independently reviewed handover transcripts documenting elements of three communication schemes: SBAR (Situation, Background, Assessment, Recommendations); SOAP (Subjective, Objective, Assessment, Plan); and a standard medical admission note. Frequency and extent of questions asked by incoming physicians were measured as well. Analysis consisted of descriptive statistics. Results Mean (± standard deviation) duration of patient-specific handovers was 2 min 58 sec (± 57 sec). The majority of handovers' content consisted of recent and current patient status. The remainder included physicians' interpretations and advice. Questions posed by the incoming physicians accounted for 5.8% (± 3.9%) of the handovers' content. Elements of all three standardized communication schemes appeared repeatedly throughout the handover dialogs with no consistent pattern. For example, blocks of SOAP's Assessment appeared 5.2 (± 3.0) times in patient handovers; they followed Objective blocks in only 45.9% of the opportunities and preceded Plan in just 21.8%. Certain communication elements were occasionally absent. For example, SBAR's Recommendation and admission note information about the patient's Past Medical History were absent from 22 (55.0%) and 20 (50.0%), respectively, of patient handovers. Conclusions Clinical handover practice of faculty-level critical care physicians did not conform to any of the three predefined structuring schemes. Further research is needed to examine whether alternative approaches to handover communication can be identified and to identify features of high-quality handover communication.http://deepblue.lib.umich.edu/bitstream/2027.42/112680/1/12913_2011_Article_1919.pd

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

The Development and Testing of a Measurement System to Assess Intensive Care Unit Team Performance

Teamwork is essential for ensuring the quality and safety of healthcare delivery in the intensive care unit (ICU). Complex procedures are conducted with a diverse team of clinicians with unique roles and responsibilities. Information about care plans and goals must also be developed, communicated, and coordinated across multiple disciplines and transferred effectively between shifts and personnel. The intricacies of routine care are compounded during emergency events, which require ICU teams to adapt to rapidly changing patient conditions while facing intense time pressure and conditional stress. Realities such as these emphasize the need for teamwork skills in the ICU. The measurement of teamwork serves a number of different purposes, including routine assessment, directing feedback, and evaluating the impact of improvement initiatives. Yet no behavioral marker system exists in critical care for quantifying teamwork across multiple task types. This study contributes to the state of science and practice in critical care by taking a (1) theory-driven, (2) context-driven, and (3) psychometrically-driven approach to the development of a teamwork measure. The development of the marker system for the current study considered the state of science and practice surrounding teamwork in critical care, the application of behavioral marker systems across the healthcare community, and interviews with front line clinicians. The ICU behavioral marker system covers four core teamwork dimensions especially relevant to critical care teams: Communication, Leadership, Backup and Supportive Behavior, and Team Decision Making, with each dimension subsuming other relevant subdimensions. This study provided an initial assessment of the reliability and validity of the marker system by focusing on a subset of teamwork competencies relevant to subset of team tasks. Two raters scored the performance of 50 teams along six subdimensions during rounds (n=25) and handoffs (n=25). In addition to calculating traditional forms of reliability evidence [intraclass correlations (ICCs) and percent agreement], this study modeled the systematic variance in ratings associated with raters, instances of teamwork, subdimensions, and tasks by applying generalizability (G) theory. G theory was also employed to provide evidence that the marker system adequately distinguishes teamwork competencies targeted for measurement. The marker system differentiated teamwork subdimensions when the data for rounds and handoffs were combined and when the data were examined separately by task (G coefficient greater than 0.80). Additionally, variance associated with instances of teamwork, subdimensions, and their interaction constituted the greatest proportion of variance in scores while variance associated with rater and task effects were minimal. That said, there remained a large percentage of residual error across analyses. Single measures ICCs were fair to good when the data for rounds and handoffs were combined depending on the competency assessed (0.52 to 0.74). The ICCs ranged from fair to good when only examining handoffs (0.47 to 0.69) and fair to excellent when only considering rounds (0.53 to 0.79). Average measures ICCs were always greater than single measures for each analysis, ranging from good to excellent (overall: 0.69 to 0.85, handoffs: 0.64 to 0.81, rounds: 0.70 to 0.89). In general, the percent of overall agreement was substandard, ranging from 0.44 to 0.80 across each task analysis. The percentage of scores within a single point, however, was nearly perfect, ranging from 0.80 to 1.00 for rounds and handoffs, handoffs, and rounds. The confluence of evidence supported the expectation that the marker system differentiates among teamwork subdmensions. Yet different reliability indices suggested varying levels of confidence in rater consistency depending on the teamwork competency that was measured. Because this study applied a psychometric approach, areas for future development and testing to redress these issues were identified. There also is a need to assess the viability of this tool in other research contexts to evaluate its generalizability in places with different norms and organizational policies as well as for different tasks that emphasize different teamwork skills. Further, it is important to increase the number of users able to make assessments through low-cost, easily accessible rater training and guidance materials. Particular emphasis should be given to areas where rater reliability was less than ideal. This would allow future researchers to evaluate team performance, provide developmental feedback, and determine the impact of future teamwork improvement initiatives