To standardize and improve patient handoffs, some children’s hospitals are testing new interventions that other organizations can replicate to help curb miscommunication and ensure patient safety.
By Tina Logsdon, M.S.
A collaborative through the Children’s Hospital Association demonstrated a reduction in handoff-related care failures among 23 children’s hospitals that involved handoffs in different patient care settings and among various types of providers. This large-scale study from 2010-11 will be published in an upcoming issue of Pediatrics. This work demonstrated improvement when hospitals committed to implementing a suite of best practices for patient handoffs and adapted those resources to fit their particular patient populations or handoff situations. Here’s more about hospitals’ experiences testing and adopting strategies for improving handoffs.
Starmer and a team at Boston Children’s began a study in July 2009 involving 84 residents. The team developed and tested a bundle of interventions to ensure the hospital’s residents were thoroughly and accurately briefed on each patient’s medical history, status and treatment plan in a standardized way. The bundle is built upon the I-PASS mnemonic (right) to help residents remember key information to pass on.
After implementing I-PASS, the team moved the needle: medical errors fell by 40 percent—from 32 percent of admissions at baseline to 19 percent of admissions three months following implementation. But that wasn’t all. Doctors spent more time with patients, logging an average of 225 minutes per 24-hour period, versus just 122 minutes before the handoff program. Computer time decreased from 408 to 370 minutes per 24 hours. Handoffs were twice as likely to occur in a private or quiet location, and handoff documents contained significantly more information. “We feared committing to a new way of doing things could interfere with care providers’ work, but we found the opposite to be true,” Starmer says. “Users became more productive and could focus more energy on the job.”
The pilot led to a multi-center study of the bundle from January 2010 to May 2013. Nine hospitals in the U.S. and Canada served as data collection sites for the study. Each site had six months to implement I-PASS before embarking on an additional six months of post-intervention data collection. “I-PASS has brought together medical educators, hospitalists and health services researchers from across North America to develop a robust handoff bundle that can be broadly disseminated, without impacting previously existing workflows,” says I-PASS principal investigator Christopher P. Landrigan, M.D., MPH, research and fellowship director of the inpatient pediatrics service at Boston Children’s.
The study, led by Starmer and Nancy Spector, M.D., associate residency program director at St. Christopher’s Hospital for Children in Philadelphia, included more than 50 faculty members from across North America with expertise in health services research, faculty development, medical simulation, curriculum development and change management. The Pediatric Research in Inpatient Settings (PRIS) Network and the Initiative for Innovation in Pediatrics Education (IIPE) contributed to the management and oversight of the I-PASS study. Some content in the I-PASS handoff curriculum includes materials adapted from TeamSTEPPS, a teamwork curriculum developed by the Agency for Healthcare Research and Quality and the Department of Defense Patient Safety Program. The finalized I-PASS curriculum is now available to hospitals at ipasshandoffstudy.com.
Families play a pivotal role in safety, advocating for their children and monitoring their child's progress through acute illness. Provider communication with families happens in various ways and frequently occurs only once a day, often during rounds. As the day progresses, clinical updates, consultant recommendations and diagnostic test results do not always reach families in a coordinated way. Without current information, families are less able to effectively advocate for and support their children.
The team at Boston Children’s decided to empower families of hospitalized children to play a more active, informed role by using an interactive, structured family tool that mirrors the I-PASS system. When the parent is going to leave the child’s bedside for a significant period of time, he or she lets a staff member know. And then the parent receives an update on the child’s situation upon returning. The medical team distributes this information every day with a family-friendly version of the I-PASS mnemonic:
Illness severity: How sick the child is compared to the previous day
Patient summary: Updates about the child from that time period
Action items: The care plan for the next 12 hours
Situational awareness: What to watch out for in the next 12 hours
Synthesis: A space for families to write down questions for providers
The team is now integrating this into the EMR. Improving communication with families may not only improve family engagement, but it may also improve patient safety, providing an extra safeguard against miscommunications and mistakes.
The I-5 model
Before joining the Association’s collaborative in 2010, a team at Children’s National Medical Center in Washington, D.C., was exploring opportunities to improve patient handoffs since early 2000. The hospital achieved varying levels of success with each initiative, including using TeamSTEPPS. Not quite finding what they were looking for, team members reviewed current literature and an assessment of organizational safety events. The group decided to focus on building shared mental models—a common understanding—when transitioning patient care. “The tool teams used had to comply with organization-wide standards for handoffs, and it must be used by everyone in a specific unit,” says May Britt Sten, RN-BC, director, performance improvement. Based on their findings and experience, the team developed phrases to cue staff members to critically think about patient care, later named I-5:
I know what is wrong with the patient.
I know what to do for the patient.
I know what to worry about for this patient.
I know what to escalate.
I see what you see.
As part of the I-5 tool development, the team recognized much of the handoff process information could easily be accessed from the EMR, such as the date of birth, PO status, medications and relevant diagnoses. They designated the provider who accepts care for the patient responsible for integrating medical record data with other information to develop the shared mental model of the patient’s care. The idea is that staff members spend communication time focused on thoughts, plans and perceptions about what needs to happen with the patient.
Nurses from the cardiac intensive care unit (CVICU) and the inpatient surgical care unit piloted the I-5 model as they transferred responsibility of care for patients who had open heart surgeries. The tool helped experienced staff members mentor new ones in critical thinking. “We realized the way we talk to each other impacts care,” says Catherine Williams, RN, NE-BC. “In one circumstance, a physician explained how he wanted a tube repositioned, but it was not clear to the provider who was accepting responsibility for patient care. Using I-5, they caught a potential care failure before it occurred.”
The team showed it could improve handoffs through standards rather than through standardized tools. Compliance with the process and I-5 model increased staff satisfaction and decreased care failures. The hospital has now spread the model to other types of handoffs as well as to bedside report, family-centered rounds and discharge.
Staff members at All Children’s Hospital in St. Petersburg, Fla., wanted to assess how well they were executing patient handoffs for cardiac patients transferring from the cardiovascular operating room to the CVICU. To assess this, the team took a video of a routine patient handoff. When they reviewed the recording, they thought about doing a retake because there was so much background noise they could barely hear people talking. But then the team realized the video was providing the information they needed: The handoff experience was occurring in a loud environment. Disjointed activity was occurring around the providers. Nurses were transferring equipment and organizing IV lines. There was a lack of organization. It was clear that the hospital was facing challenges with handoffs.
As the group researched how to improve handoffs, some of the physicians happened to watch a Formula One car race where a Ferrari pit crew was deftly transferring equipment from one environment to the other. Watching the crew perform like a well-oiled machine, they drew a correlation to what their staff members do in the CVICU. So, they applied Formula One pit crew principles, which address personal strengths, essential roles and appropriate task assignment.
The team defined staff roles that addressed the handoff process for postoperative cardiovascular patients. Changes included completing the line setup in the cardiovascular operating room before transferring the patient to the CVICU, developing a patient transport report form, and ensuring arrival activities are conducted in a quiet environment with one person speaking at a time. Three months into the project, reports of interruptions and distractions during handoffs spiked. “This was a result of educating our staff on how handoffs should be handled," says Susan Collins, MBA, RN, administrative director. "Expectations had increased—nurses were more critical about handoff procedures.” But in the end, handoff-related care failures decreased, while staff satisfaction increased.
Staff members at Lucile Packard Children’s Hospital Stanford (LPCH) in Palo Alto, Calif., pored over their three-year culture of safety survey results and were not happy with what they saw. According to the data, handoffs and transitions were their weakest area. Other safety domains showed improvement over time, but handoffs were stagnant. To address this, the hospital created a team that included nurses, physicians, residentphysicians, quality management staff, data analysts and even patients’ family members. They were charged with developing a new approach—beginning with handoffs from the operating room to the intensive care units—using best practices from the Association's collaborative.
A “one message, one time” patient transition model was developed to allow essential providers to hear the same information at the same time after the patient’s arrival in the ICU—with no interruptions. This approach, which used the I-PASS method, also helped staff answer family questions more consistently. The model was embedded in the organization’s EMR system. Having information technology experts at the table through the development of the tool allowed the team to make adjustments along the way and made this effort much more manageable.
Everyone was engaged to make handoff improvements in real time. Interns monitored handoffs in the PICU during the day shift for two months to provide coaching and document progressive improvement. Bedside nurses eventually took ownership of the audit process, fostering consistent processes. In one instance, a surgeon started the handoff process immediately upon arrival in the ICU, but the nurse spoke up because he was not ready. The surgeon paused until the nurse could choreograph the handoff properly.
Six months into the project, the organization demonstrated a reduction in care failures, and staff members recognized they had been missing several opportunities for good communication. The culture of safety data showed progress—even at the mid-point within the collaborative. And handoffs were happening in almost half the time. The hospital has since taken this model and disseminated it to multiple units.
Changing the culture
Like so many other hospitals, Children’s Medical Center Dallas has been working on patient handoff communications and processes for several years, particularly with care transitions between the emergency department (ED) and the inpatient floors. “We were battling practices that were ingrained into the culture, which created throughput issues as well as handoff-related care failures,” says Joshua Bourgeois, RN.
The EMR contained information including computerized charting, medication barcode scan data and all orders. The team realized it could improve the handoff process by creating a report with only the essential information for a safe handoff, supplemented by an electronic “sticky note” describing why the patient came to the ED, why he or she was being admitted, and any important psychosocial issues. The team piloted an electronic handoff process between the ED and two inpatient floors. A page notified the inpatient nurse of an admission, triggering a review of applicable data in the system within 15 minutes. The nurse clicked “accept” in the EMR to indicate the care team was ready to receive the patient. The receiving team member could request a conversation for more information. Early results showed improvement in handoffs, but staff satisfaction with the electronic handoff tool was poor—about 20 percent.
When the hospital began participating in the Association’s collaborative, the team looked at the process again. “We wanted to spread the standardized nursing handoff process to other areas of the organization and across our campuses,” Bourgeois says. Based on the pilot experience, the group knew it wanted to continue using technology, but it needed to improve the tools. The initial work group was expanded to include representatives from acute care, critical care, perioperative care and clinical informatics with the goal of standardizing the handoff process for permanent transfers of care.
The team reviewed progress monthly, brainstormed about the basic components of a handoff, and reviewed EMR modifications. “While the technology was important, we didn’t want to eliminate the verbal aspects of the handoff,” Bourgeois says. “We wanted nurses giving and receiving responsibility for the patient’s care to be looking at the most current information in the EMR and discussing the situation.” Once they completed the major changes, they piloted the revised tool and process at a smaller legacy campus. After implementation, staff at both campus locations saw a dramatic reduction in handoff-related care failures and staff satisfaction rose to about 80 percent.
Children’s hospitals are tackling these projects because they know patient safety requires effective communications. And patients are safer when teams use processes and checklists to ensure consistency in handoffs.
Tina Logsdon, M.S., is director of collaboratives at the Children’s Hospital Association. Alisa Khan, M.D., also contributed to this article and is a research fellow at Boston Children’s Hospital.
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