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| Patient safety is a top priority in every hospital, and rightly so. But even though clinicians strive to deliver quality care, errors and accidents happen. Improving processes is one step in the right direction to better patient care; and a good start is patient handoffs. When inaccurate patient data is passed between departments, patient care and safety can be compromised. Sometimes the consequences are negligible, but other times, they arise in the form of medication errors and/or wrong-site surgery. Preventing them can be as easy as checking a box. |
It matters little whether a patient is entering a hospital on referral, moving within the building for tests or procedures, or leaving the facility for home or another medical setting. When it comes to patient safety during a handoff, medical professionals agree that communication is vital. What to communicate, and how, is less clear.
The range of information that is communicated during a handoff, and particularly the format in which it is communicated, varies from one hospital system to the next and among medical facilities within the same system. Adopting and executing a standardized approach is one of the Joint Commission’s 2008 goals for improving patient safety. Miscommunication or lack of communication during handoffs can result in medication errors, unnecessary tests, wrong-site surgeries, equipment contamination and patient deaths.
“People have been struggling with this and to define the best way to handle it,” says Lori Ellingson, R.N., nursing division director of the surgical and oncology inpatient unit and outpatient oncology unit at Oregon Health & Science University (OHSU) in Portland. Ellingson recently gave a talk on the hospital’s handoff tool during a knowledge transfer meeting hosted by the University HealthSystem Consortium, Oak Brook, Ill.
Representatives of 20 academic centers who attended the session were either in the process of formalizing a handoff system or planning to implement one. However, none of them had a tool similar to the one used at OHSU.
“It seems like any transition for patients is a challenge,” she says. Hospitals have what they need to treat patients, but they must share pertinent information to make sure they are treating patients safely. To this end, OHSU has created a transfer communication form and imbedded a “trip ticket” into it to help improve communication. More than one transfer is reportable on a single form, eliminating the need for multiple papers.
Trip tickets are boxed-in areas on the hospital’s transfer of care form where the transport time, destination and any restrictions are entered. Checkmarks entered next to a list of items on trip tickets mean yes; leaving an item blank means no. These items include patient is aware of transport, patient is OK to transport, identification has been verified and oxygen is required. Hospital policy requires that patient charts include a transfer form and travel with patients. “The form has normal assessments imbedded in it, and you check off what’s normal and make an indication if it’s abnormal,” she says. It covers physical as well as psycho-social issues identified by staff as necessary to care for patients safely.
Getting to this point took a number of years and started with staff identifying lapses in getting all necessary information, Ellingson says. Like many hospitals, OHSU relied on verbal reports or nothing at all during hand-offs. When people were under pressure or extremely busy, they sometimes forgot to pass along essential information.
Taking the lead in championing changes to resolve these communication issues was Barbara Jennings-Garant, R.N., nurse manager for solid organ transplant. She also is responsible for the contracted dialysis unit, Ellingson says. Dialysis is an area where a handoff form is essential because inpatients come from other medical units and are in the care of dialysis nurses for three to five hours at a time.
Gathering input from nurses about what a handoff document should address was easily supported because the hospital’s nursing division operates under a shared governance model, Ellingson says.
“We (hospital staff) finally came up with a product that we’re proud of,” she says. “This form faxed ahead of time helps to ensure we have the needed equipment and staff, that we’re making the right bed assignments, that confused patients are placed closer to the desk or in a private room and that isolated patients are placed in the right room.”
The form is formatted using the SBAR framework, she says. SBAR is a mnemonic for types of information needed during a handoff: situation-background-assessment-recommendation. Each SBAR category contains background information about patients that focuses on safety, just-in-time assessments and other information people will need as a patient transitions to either a different level of care or to a diagnostic area for a procedure, Ellingson says. Items in each category depend on what a hospital deems necessary information to care for patients safely. The SBAR framework sets expectations for what will be communicated and how. It was developed in the naval nuclear submarine industry to relay critical information in a concise format and later adapted for health care by the Human Factors Group at Kaiser-Permanente in Northern California, says Lauren Toomey, senior program analyst, U.S. Department of Defense (DoD) HealthCare Team Coordination Program (HCTCP) in Virginia.
“Numerous facilities are adopting SBAR in some form or fashion, either in small departments or throughout their organizations,” John Courtney, senior health care analyst with the HCTCP says.
The DoD Patient Safety Program offers a health communications toolkit that includes information on SBAR and two other handoff tools: “I pass the baton,” a mnemonic for introduction, patient, assessment, situation, safety concerns, background, actions, timing, ownership, next; and the six Ps of handoffs, which are patient, plan, purpose, problems, precautions, physician assigned to coordinate (captain of the ship), developed by Gary Yates and Shannon Sayles of Sentara Health Care in Virginia.
Each of the three handoff tools is similar. The first letter of each word in SBAR and “I pass the baton” stands for a category of information that needs to be communicated about a patient.
Programs for safety
Following a 1999 Institute of Medicine (IOM) study that found medical errors caused up to 98,000 deaths annually, the institute recommended that health care organizations create team training programs for critical care staff to develop better teamwork and coordination to prevent patient harm. Acting on the recommendation, the DoD partnered with the U.S. Department of Health & Human Services’ Agency for Healthcare Research Quality in Maryland to develop and make publicly available free of charge the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program, which includes communications and teamwork materials, strategies and training curricula for successfully integrating teamwork principles into health care systems, says Toomey, co-author of the program’s instructor guide. Medical facilities for all three branches of the U.S. military have been using the program since early 2005.
“By conducting things such as a brief at the start of a shift and the start of a case, where everyone on the team knows the plan, that is a very critical element in providing good care,” Toomey says. The DoD also has partnered with the Association of periOperative Registered Nurses (AORN), Denver, and granted it permission to customize patient safety program communication handoff toolkit materials for use in perioperative environments. The adapted toolkit can be downloaded for free on the AORN Web site (www.aorn.org) and has received about 5,000 unique hits to date, according to AORN’s information technology division. The toolkit contains sample patient handoff tools that include examples of forms drafted by various hospitals using SBAR, I pass the baton, the six Ps and several other mnemonics, as well as recommendations, policy guidance, talking points and other resources.
An executive summary of the toolkit notes that of more than 3,000 sentinel events analyzed between 1995 and 2004, the Joint Commission identified that 65 percent of them were caused by communication problems. This percentage in-creased in 2005 to 70 percent.
“Effective communication is necessary to ensure continuity in the treatment, planning and services provided to a patient during the perioperative experience, says Sharon Giarrizzo-Wilson, R.N., who worked on the customized handoff tool-kit. “Without a standardized process to streamline information exchanges between the health care team, critical patient data may be lost in transmission and result in patient harm.”
A hand in improvement
Handoffs at Arlington (Texas) Memorial Hospital are a work in progress that is heading toward the systemwide implementation of a standardized form that follows the SBAR format, says Pablo Bracho, clinical manager. The hospital is one of three separate hospital systems that merged into one under Texas Health Resources. Each system had its own way of performing handoffs. “(A standardized form) is going systemwide so we can go through the same process and everybody knows that they are asking the same questions and receiving answers to the same questions,” Bracho says.
Regardless of the system hospitals adopt, staff engagement is the key to creating a system geared to the individual needs of a hospital system and to accomplishing a smooth transition, Ellingson says. Innovative people who accept the change will bring along the others, she says. Gaining the acceptance of innovators is facilitated by allowing them input about what they need to take care of patients safely and creating a tool that addresses their needs.
Transitions in care is one of this year’s hot topics, says Cheri Lattimer, R.N., executive director of the Case Management Society of America and project director for the National Transitions of Care Coalition (NTOCC), both based in Little Rock, Ark., which comprises 28 associations and organizations addressing critical transition issues. The IOM estimates that 1.5 million medication errors occur annually in the United States at a cost of $3.5 billion, she says, and an estimated 60 percent of medication errors occur during transitions.
“Communication is a significant issue,” Lattimer says. Not having adequate tools to communicate clearly is the primary reason that it is an issue. NTOCC advisory task force members have been studying the full continuum of health care services and patient assessment workups to develop a range of tools and materials to help bring consistency to what medical information is shared and where and how it is shared, Lattimer says.
A massive campaign is planned, possibly in June, to roll out the materials, including forms for patients to keep track of their own medication use. The materials will be available free on the NTOCC’s Web site (www.ntocc.org).
“What we think needs to happen is, don’t create the tool in the silo like we do everything else,” Lattimer says.
Another document coming from the group will help patients ask the right questions. Implementation guidelines for using the materials in various medical settings are being developed. “There’s a significant amount of opportunity for us to really come together, as we have discovered in the coalition. This isn’t about worrying whose business we are treading on, but instead, bringing patients to this patient-centered model and saying, for patient safety, for better quality of care and collaboration, we must improve communication, bring tools forth that will help us do that in a consistent format and align the incentives appropriately,” Lattimer says.
Johns Hopkins Hospital, Baltimore, reviews event reports to determine where weaknesses lie and to bring items that need attention to the forefront, says Lori Paine, patient transition and safety coordinator. “Patient handoff is one of those areas where there’s been some type of breakdown in communication,” she says. The hospital sees 10 to 15 of these events weekly. “Sometimes it’s not an egregious error that resulted in patient harm, but it’s just a system problem that can continually cause delays.” For instance, sometimes an operation is finished, but staff is unable to figure out where to send a patient.
“The patient is sitting in there eating up OR time while we’re trying to figure out by the devices that she has in use whether she should go to this ICU or that recovery room,” Paine says.
After the Joint Commission issued its most recent handoff requirements, the hospital added to its continuity of care policy some guidance for information transfers within disciplines. However, it offered little guidance for communicating across disciplines. “We remain challenged by the fact that some of these events, what’s at the root of them is a breakdown in communications,” she says.
The nursing department has developed a policy to standardize these communications when transferring patients. More substantively, it has adopted a transportation tag for level one and two transports that don’t require a critical care team to go along. The tag is handwritten and attached to a patient’s wristband. “It’s the CliffsNotes of what someone taking care of this patient temporarily off the unit needs to know about him,” Paine says. Attaching the tag to identification bracelets also reinforces that staff should look at the wristbands, she says. While staff reviews are mixed about patients wearing something that resembles a luggage tag, Paine says, “I think if we explain the importance to a patient, nobody will complain.”
The success of a handoff system depends on its acceptance and consistency of use, Ellingson says. Some departments have adopted the change faster than others at OHSU. “It can take up to a year in reality for it to really become part of people’s way of doing their work. Not that it’s a negative change—I think basically it’s viewed by the staff as positive because they really do appreciate the information and they really do appreciate safe patient handoff.” It just takes time for it to become second nature, she says.
Nancy Torner is a freelance writer based in Roseville, MINN.
This article first appeared in the March 2008 issue of Materials Management in Health Care.
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