Handover of Care - Literature review Example

Handover of care Healthcare has been increasing in quality in leaps and bounds throughout the years. Doctors are also adapting to new practices everyday and one change has been the introduction of shifts to curb the amount of time a doctor spends in the hospital. The European Working Time Directive has meant that the number of hours that a doctor works is broken up into shifts (Ferran et al, 2008). This has led to an increased importance in the handover of care between medical personnel at the end of a shift onto the personnel working the next shift. The handover of care can essentially be described as the transfer of information regarding a patient’s medical condition to another doctor, nurse or other medical personnel, either verbally or through written records. Whilst healthcare practices have steadily been improving, it still holds true that the handover of care is seen as a weak link in this profession. In many hospitals, in-patients see a substantial number of medical workers and it is essential that information handover occurs in a manner in which there is a continuity of care. In a study carried out in New Zealand, it was seen that the average patient requires the care of up to six doctors and a surgical patient sees ten doctors (Ferran et al, 2008 from Whitt et al, 2007). This number is likely to be valid for many countries in the Western world and so highlights the importance of effective communication between medical personnel so that the quality of care is maintained throughout with no human errors. In this paper, an attempt will be made to examine the results of five major studies that were done to assess the quality of handover of care. The first study that will be considered is by Currie, 2000 and looks at the handover to nurses. The second study looked at in this review is by Ferran et al, 2008 and looks at trauma patient handover. Two other studies will be looked at which deal with handover in the intensive care unit and were carried out by Catchpole et al, 2007 and by Smith et al, 2009. The final study is a case study by Kassean and Jagoo, 2005 and looks at nursing handover from a traditional to a bedside manner. These studies are not specific to any one country and instead range from the UK to Mauritius. It seems fair to say that the handover of care is an important aspect in any hospital and this is what will be examined. The methodology used to assess the handover of care will be given a brief description of followed by a summary of the results to gauge whether the quality of handover of care between medical personnel is at par with what it should be. The first study that will be looked at is one that examined the handover of care to nurses in one hospital in Birmingham (Currie, 2000). A pilot study was first carried out to examine whether the design of the study would hold up and no major changes were reported. The study looked at the time for handovers and this was timed from the moment a particular patient was introduced to the time that it took finish talking about the patient. The content of information that was passed on was evaluated by the use of a checklist and was carried out immediately following the handover. In order to prevent bias, the staff who had agreed to participate in this audit were not informed of which handovers were being evaluated. Results from this study by Currie, 2000 indicated that the average length of time for a handover was 20 minutes. It was also noticed that only 20% of handovers appeared to take place in the room in which the patient was. Only 60% of the nurses appeared to use written documentation about the patient’s medical condition to facilitate the handover and instead chose to rely on verbal handovers. From examining past research done on this topic, results from the study by Currie, 2000 seem to indicate that while the average time spent on handovers (20 minutes) is acceptable. More time than this might lead to an information overload on the nurse. However, what was found to be lacking was a patient’s involvement in their care a majority of handovers did not take place at a patient’s bedside. Currie, 2000 (from Sherlock, 1995) has stated that it is beneficial to patients to conduct handovers at bedside as this facilitates the feeling of a ‘partnership’ between the medical personnel and the patient and also gives the patient a chance to ask any questions that they may have (Currie,2000). Another study by Ferran et al, 2008 examined the handover of medical information pertaining to trauma patients between shifts in one hospital in the Orthopaedic Unit. Trauma patients are especially in need of quality handover systems as this will otherwise the trauma lists being prepared. The study was done over the period of a week and the data used for patient handover was collected and analysed. The data in this case referred to handwritten points on a plain sheet of paper regarding the patient’s condition that were used as an aid in verbal handover. Following one week of analysing this data, a standard form was presented to the staff at the hospital to be used instead of using the plain sheets of paper that were normally used. The quality of handover was assessed using this standardised form and junior doctors were asked for their opinions and input regarding this form. A new form was then designed utilising the opinions of the doctors and this was tested for another week. For each patient, a point score was used to evaluate how much of the data was handed over. The loss of one point could for example be as the result of a blood test result not being included in the data being handed over. The study by Ferran et al, 2008 indicated that there was a significant increase in the quality of handover data following the use of a standardised form. The figures jumped from 73% to 98% with the introduction of the standardised form. However, a criticism of this study is that the researchers were not present during the actual handover and missed the verbal interaction that took place between the medical staff. Another study carried out by Catchpole et al, 2007 took a very different approach to the handover of patients from surgery to the intensive care unit. They investigated what the effect of a ‘pit stop’ like the ones used in Formula 1 racing. This pit stop method was developed based on the idea that multi-professionals come together to aid in a complex task. The primary aim of this study was to combine ideas to allow for the development of a simple, reliable handover protocol that would benefit the patients in the crucial time that follows a complex surgery. Some of the ideas taken from Formula I racing included the fact that everyone has a set task, the presence of checklists, briefing of all individuals concerned, awareness of the situation at hand, maintaining discipline and composure at all times, high quality training and review amongst others. Using all these ideas, protocols were developed and implemented. Results from this study indicated that the mean number of handover errors fell from 5.42 per handover to 3.15%. This study, though small, indicated that the introduction of new protocols to ensure patient handover occurred safely was encouraging. The steps that were implemented were simple and easy to understand, was fairly easy to train people in and could be established in less than 30 minutes. The use of the methods described in this study encouraged teamwork which as mentioned in the study by Currie, 2000 is an essential component of ensuring patient safety in handovers. It must be noted thought that while this system was modelled on Formula 1 racing pit stops, it must be said that in healthcare, medical personnel often rotate into different units very often and hence it may be difficult to keep the flow going if too many people rotate at the same time. If this was a system that was implemented in many hospitals, it would most certainly be possible. A further study that will be reviewed in this paper is one by Smith et al, 2009.this study examined the quality of patient handover in intensive care units (ICU) in north western England. This study employed a method whereby they conducted phone interviews with doctors who were on call at the ICUs. The questions consisted asked related to handovers that had been done during that particular day as well as the quality of handovers in general. Some questions were free answer ones while others only needed either a positive or negative response. The main reasons for the interruptions of handovers stemmed from a nursing staff having a question or from a referral to the ICU. The doctors indicated that they felt the quality of handover information that they received was sufficient to ensure continuity of care for the patients. Results from this study by Smith et al, 2009 showed that all the hospitals contacted had methods in place to try and optimise the data transferred during handovers. However, there appeared to be interruptions in many handovers that took place. Only 31% appeared to be free from interruptions. Ideally, a handover should be free from outside interruptions that disrupt the flow of information being passed on. Handovers were frequently carried out with no multidisciplinary representative present and considering the number of specialists that a patient sees during their time in the ICU, it seems logical to say that the presence of one such representative would be beneficial. Also, this study found that handovers were more likely to be interrupted if they occurred at bedside (78%) as opposed to if they were carried out in another room. This seems contradictory to what said by Currie, 2000 as it was suggested that bedside handovers would make the patient feel more involved and enable them to ask any questions they may have. It was mentioned that up to 60% of data can be lost during strictly verbal handovers (Smith et al, 2009 from Bhabra et al, 2007) and yet 20% of ICUs still operate solely using a verbal handover system. Both the studies by Smith et al, 2009 and Ferran et al, 2008 (discussed earlier) point to the fact that the use of standardised forms, either computer generated or otherwise minimises the risk of data being lost during handovers. While the study by Smith et al, 2009 documented the interruptions that occurred during a handover, it did not look at the effects of these interruptions and the authors have suggested this would be an interesting area of research. The final study being looked at in this review is one that investigated the handovers to nurses and investigated some of the inadequacies of the tradition system that was in use (Kassean and Jagoo, 2005). The gynaecological ward in which this study was carried out had handovers that were carried out away from the patient’s bedside. Handover instructions were given verbally from one nurse to the next, at the end of a shift. One thing that was striking about the method in place was the lack of attention to individual patient conditions. The information about the patient’s medical conditions were only recorded in ward diaries, nurses notes or patient files. The information needed for the study was obtained from written information on the white board that was up in the office. Due to this method of reporting on patient’s conditions, much of the data was outdated and irrelevant and quite possibly compromised the quality of care that a patient would receive. In addition, it was observed that when nurses were questioned by the doctors in the ward, they would often blame other nurses for the inaccurate information. Without question, it was the case that the root problem of the issues on this ward all stemmed from a lack of proper organisation for the handover of patient information. A protocol was developed over a period of time to address this situation and recommended solutions such as handovers occurring at bedside, inclusion of patient’s opinions in their care, better management of confidentiality issues and many others. While there was some resistance to implementation of all of the protocols suggested, most of this was overcome by encouraging open communication. Following implementation of these recommendations, patients were interviewed and asked about their experiences. An astounding number of patients reported that the quality of care had improved greatly. For many of the questions asked, 95-100% appeared to be completely satisfied and these new protocols also fostered an atmosphere that was much more pleasant amongst the nurses. In conclusion, it can be said that the handover of patient data is an extremely important aspect of healthcare in a hospital. Unfortunately, the methods in which handovers are carried out in many cases are not up to the standard at which they should be. It seems disgraceful that good quality healthcare is being compromised as a result of accurate data about patients not being passed between the different medical personnel. Several studies have looked into the problems relating to healthcare and have suggested a number of solutions to address the problem. While some sources do state to the contrary, one change that most researchers agree on is that handovers should occur at patient’s bedsides. This appears to minimise loss of data as well as instil a level of trust in the patient as they have a say in their care and get to address any concerns, questions or comments they may have. In addition, studies have also indicated that a large amount of data is lost during verbal transfers and hence written handovers need to occur too. Standardised forms that contain all the relevant information about a patient seem like a good option and it has been recommended that computerised forms are probably the most favoured option to date. Ideally, a handover should happen in less than 20 minutes and should consist of written and verbal data being presented on the patients care. In many wards like the ICU, it seems logical that multidisciplinary doctors who are treating the patient should all be present to offer insight and relevant information. Furthermore, recommendations also suggest that handovers should be carried out with no interruptions as this may compromise further care. One study used the novel approach of designing a system based on Formula 1 pit stop analogy to model the different work stations of the medical profession. Errors were seen to be reduced in this case as medical personnel were clearly aware of what was going on and knew what their task was. However, while this pilot study was successful, it may encounter problems if it was tested in the real world as so many doctors and nurses rotate around hospitals and there would be a constant stream of people who would need to get familiarised with the protocol under use. Finally, it can be summed up that handover is an essential component of healthcare that appears to need re-organisation and re-structuring in the years to come. Improvement of this area would benefit patients and make work easier for the medical teams that are in charge of their care and it seems that the implementation of some very simple protocols could result in a big increase in quality of handovers. Works Cited Bannard-Smith, J., Booth, CMA, Saha, B. and Washington, S. (2009), "Quality of patient handover on intensive care units in northwest England", JICS, 10(3), pp.186-188. Catchpole, K.R., De Leval, M.R, McEwan, A., Pigott, N., Elliott, J., McQuillan, A., Macdonald, C., and Goldman, A.J (2007), "Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality", Pediatric Anesthesia, 17(1), pp.470-478. Currie, J. (2000), "Audit of nursing handover", Nursing Times, 96(42), pp.44. Ferran, N.A, Metcalfe, A.J., ODoherty, D (2008),"Standardised proformas improve patient handover:Audit of trauma handover practice",Patient Safety in Surgery, 2(24). Kassean, H.K. and Jagoo, Z.B. (2005), "Managing change in the nursing handover from traditional to bedside handover - a case study from Mauritius", BMC Nursing, 4(1). Read More