Abstract and Introduction
Abstract
Objective: To describe the characteristics and barriers in the handover process in a medical intensive care unit.
Design: A cross-sectional descriptive study using a checklist to observe nurses and doctors during handover of patients in and out of the intensive care unit.
Setting: The study was conducted at a 1000-bed tertiary hospital in Singapore. The unit admits all patients under university medicine clusters, except those needing cardiology services.
Participants: Handover between 90 pairs (180 participants)—50 nurse-to-nurse (100 nurses) and 40 doctor-to-doctor (80 doctors)—were passively observed in real time during morning and evening shifts over weekdays.
Main Outcome Measures: The number and types of distractions and their relationship to the time spent during handover, the information included during handover, and the number of working shifts.
Results: The results showed that there were 1.26 (±1.75) distractions per handover. In 45 (50%) handovers, no distraction occurred. The human factor was the most common distracting factor during handovers, whereas short message service and monitor alarms were not identified as distracting factors. The information included least often was 'do not resuscitate' (DNR). Nurses spent significantly longer during handovers than doctors.
Conclusion: The findings provide information for improving the handover process during the transfer of patients in and out of the intensive care unit. Distractions during handovers are common and are associated with longer durations. Nurses and doctors rarely address DNR status during handover of ICU patients in this study.
Introduction
Identifying high-risk situations for patient safety helps healthcare providers focus on enhancing quality of care. One high-risk area for patient safety is patient handover, which is a process of transferring patients' clinical data to another person or professional group and can occur at the staff break time, during shift changes, and when patients are transferred in and out of the units and departments within and outside hospitals. Breakdown of communication is the leading cause of medical errors and sentinel events. Many previous studies have shown that ineffective communication during handovers has led to medical errors. Li et al. also found that a poor handover process was a significant contributor to medical error in intensive care units. Since the Joint Commission released a National Patient Safety Goal aimed at improving communication, health care organizations have urged improved communication during patient handover. It is imperative that handover processes are improved to prevent medical errors and improve patient safety and quality of care.
The Australian Commission on Safety and Quality in Health Care has evaluated the handover process after implementing the handover guidelines. They found that distractions during handover were related to ineffective communication and additional time spent on handovers. Regular distractions such as telephone alerts, approaching of patients' relatives and medical staff interrupting increase the length of handovers and result in important information not being passed on effectively. A study by Currie also reported that the longer handover time has led to lower attention spans of both reporting and receiving staff during handovers. During transfer of patients, information regarding tests undertaken and treatment or care received is transferred between healthcare providers to formulate a plan for continued care. To ensure patient safety, the barriers to and the nature of the handover in each context must be identified and evaluated to enhance the quality of the handover process.
Many studies have investigated the success factors and outcomes of effective handover and are mainly interview based. The results of those studies have shown that effective handover improves communication and patient satisfaction. Because direct observation of the handover process is labour intensive, only a few studies have addressed specific factors or situations that occur, such as people interrupting each other, distractions, inadequate time allowed, limited communication methods, and failures to communicate or understand the significance of data or events. The focus of those studies carried out was on shift-change reports and patient transfer in the general ward. Data in the critical care setting are sparse.
Patient transfer in and out of ICUs is more complex due to their condition and the need for intensive monitoring. Patient transfer has been recognized as an area facing more communication problems due to cultural differences, work-load challenges and differences in clinical specialties. Hence, effective handover of ICU patients is even more complex than handover during shift changes or at the bedside on the general wards. In our medical ICU (MICU), senior staff have observed the handover process and found that taking calls and interrupting the conversation during handovers led to instances where important patient information was missed, which later jeopardized patient safety. According to the literature and our observations, concern over safe handover has been brought to the attention of the hospital administrators and healthcare providers. As a result, a quality improvement (QI) team at the MICU was formed to describe the handover process and initiate a strategy to enhance the process in ICUs (PDSA cycle). The QI project adopted two methods: it used the post-handover survey of the healthcare professional involved and a structured direct observational method. The survey method was used to identify the differences in practices and perceptions of handovers between nurses and residents in the critical care setting, thereby improving the process by mutual learning. The results of the survey have already been published. For this paper, we reported the results of the structured observational method, which aimed to identify the types of distractions and factors relating to distractions (duration, time and people involved) during handovers of patients being transferred in and out of MICU, to enhance patient safety and quality of care.
The specific objectives of this initiative were as follows:
To identify the types of distractions, documentation, tools and information that were included during handovers of patients being transferred in and out of the MICU.
To differentiate the time spent and the number of distractions between nurse-to-nurse and doctor-to-doctor handovers of patients transferred in and out of the MICU.
To differentiate the time spent and number of distractions between day shifts and evening shifts during handovers of patients transferred in and out of the MICU.
To identify the relationships between time spent and the number of distractions during handovers of patients transferred in and out of the MICU.