Improving handover from intensive care to ward medical teams with simple changes to paperwork.
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ABSTRACT:
SUBMITTER: Messing J
PROVIDER: S-EPMC4645919 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:PurposeTo systematically review and evaluate the effectiveness of interventions in order to improve the safety and efficiency of patient handover between intensive care unit (ICU) and general ward healthcare professionals at ICU discharge.MethodsPubMed, CINAHL, PsycINFO, EMBASE, Web of Science, and the Cochrane Library were searched for intervention studies with the aim to improve clinical handover between ICU and general ward healthcare professionals that had been published up to and including June 2013. The methods for article inclusion and data analysis were pre-specified and aligned with recommendations outlined in the PRISMA guideline. Two reviewers independently extracted data (study purpose, setting, population, method of sampling, sample size, intervention characteristics, outcome, and implementation activities) and assessed the quality of the included studies.ResultsFrom the 6,591 citations initially extracted from the six databases, we included 11 studies in this review. Of these, six (55 %) reported statistically significant effects. Effective interventions included liaison nurses to improve communication and coordination of care and forms to facilitate timely, complete and accurate handover information. Effective interventions resulted in improved continuity of care (e.g., reduced discharge delay) and in reduced adverse events. Inconsistent effects were observed for use of care, namely, reduction of length of stay versus increase of readmissions to higher care. No statistically significant effects were found in the reduction of mortality. The overall methodological quality of the 11 studies reviewed was relatively low, with an average score of 4.5 out of 11 points.ConclusionsThis review shows that liaison nurses and handover forms are promising interventions to improve the quality of patient handover between the ICU and general ward. More robust evidence is needed on the effectiveness of interventions aiming to improve ICU handover and supportive implementation strategies.
| S-EPMC4392116 | biostudies-literature
Project description:Patients who have stepped down from intensive care tread a precarious clinical course, and the handover of care between clinical teams at this point should be treated as a high risk event. Poor handover can leave patients vulnerable to suboptimal care and preventable harm. Properly structured written discharge summaries have been shown to improve information transfer and quality of care. The National Institute for Health and Care Excellence (NICE) has published guidelines entitled "Acute illness in adults in hospital: recognising and responding to deterioration," which states that patients transferred from intensive care should have a formal structured handover supported by a written plan, and it provides minimum criteria for what information should be included. A retrospective audit was carried out (n=28) to identify if discharge summaries were compliant with these standards. Discharge summaries consistently lacked essential criteria, including psychosocial needs (29%), nutritional needs (50%), therapy needs (29%), ceilings of care (39%), and communication needs (18%). Less than a third of verbal handovers between the nursing and medical teams were documented. After consultation, a new summary template was developed and embedded into practice. The new design prompted trainees to ensure they completed adequate information in all domains of care. Additional sections were added to improve recording of when, and to whom, clinical handover took place, which led to improved clinical governance. The overall quality of discharge summaries was improved, with increased compliance in 11 out of 13 domains. Feedback from staff about the new discharge summaries was positive. This project is easily transferable, and has the potential to improve patient safety and quality of care.
| S-EPMC4693087 | biostudies-literature
Project description:The European Working Time Directive means safe patient hand over is imperative. It is the responsibility of every doctor and an issue of patient safety and clinical governance [1]. The aims of this project were to improve the quality of patient handover between combined assessment unit (CAU) and surgical ward FY1 doctors. The Royal College of Surgeons England (RCSEng) guidelines on surgical patient handover [1] were used as the standard. Data was collected throughout November 2013. A handover tool was then introduced and attached to the front of patient notes when a patient was transferred from CAU to the surgical ward. The doctor handing over the patient and the ward doctor receiving the handover signed this document. Policy was also changed so that handover should take place once the patient had received senior review on the CAU and was deemed appropriate for transfer to the surgical ward. Data from the handover tool was collated and checked against the list of surgical admission for February 2014. The number of patients handed over improved from 15 % to 45%. The quality of patient handover also improved. 0 patient handovers in November 2013 included all of the information recommended by the RCSEng guidelines. 100% of the patient handovers in February 2014 contained all the recommended information. Introduction of a handover tool and formalisation of timing of patient handover helped to improve quality and number of patients being handed over. Further work needs to be done to improve safe handover of surgical patients, particularly out of hours.
| S-EPMC4645925 | biostudies-literature
Project description:Despite thromboprophylaxis, patients with coronavirus disease 2019 (COVID-19) exhibit hypercoagulability and higher venous thromboembolic risk, although its real incidence is still unknown. The aim of this study was to evaluate the incidence of venous thromboembolism (VTE) in patients with COVID-19 admitted to both intensive care units (ICUs) and medical wards (MWs). Consecutive patients admitted for COVID-19 to the MW and the ICU at Padua University Hospital, all receiving thromboprophylaxis, underwent systematic ultrasonography of the internal jugular, and the upper and lower limbs veins every 7 days (± 1 day) after the admission; and, if negative, once-weekly until discharge or death. In case of suspected pulmonary embolism, a multidetector computed tomographic angiography was performed. The primary outcome was the proportion of any deep-vein thrombosis (DVT) and symptomatic pulmonary embolism in both groups. An extended blood coagulative test was performed as well. From March 4 to April 30, 2020, a total of 85 patients were investigated, 44 (52%) in MWs and 41 (48%) in the ICU. Despite thromboprophylaxis, VTE occurred in 12 patients in the MWs (27.3%) and 31 patients in the ICU (75.6%) with an odds ratio of 9.3 (95% confidence interval (CI) 3.5-24.5; P < 0.001). Multiple-site DVT occurred in 55.6% of patients (95% CI 39.6-70.5). Increased D-dimer levels significantly correlated with VTE (P = 0.001) and death (P = 0.015). Summarizing, patients with COVID-19 admitted to the MW or ICU showed a high frequency of venous thromboembolism, despite standard-dose or high-dose thromboprophylaxis. Whether thrombosis, particularly asymptomatic events, may play a role in the morbidity and mortality of patients with COVID-19 remain to be clarified.
| S-EPMC7567296 | biostudies-literature
Project description:Background: In-hospital transfers such as from the intensive care unit (ICU) to the general internal medicine (GIM) ward place patients at risk of adverse events. A structured handover tool may improve transitions from the ICU to the GIM ward. Objective: To develop, implement, and evaluate a customized user-designed transfer tool to improve transitions from the ICU to the GIM ward. Methods: This was a pre-post intervention study at a tertiary academic hospital. We developed and implemented a user-designed, structured, handwritten ICU-to-GIM transfer tool. The tool included active medical issues, functional status, medications and medication changes, consulting services, code status, and emergency contact information. Transfer tool users included GIM physicians, ICU physicians, and critical care rapid response team nurses. An implementation audit and mixed qualitative and quantitative analysis of pre-post survey responses was used to evaluate clinician satisfaction and the perceived quality of patient transfers. Results: The pre-post survey response rate was 51.8% (99/191). Respondents included GIM residents (58.5%), ICU rapid response team physicians and nurses (24.2%), and GIM attending physicians (17.2%). Less than half of clinicians (48.8%) reported that the preintervention transfer process was adequate. Clinicians who used the transfer tool reported that the transfer process was improved (93.3% vs. 48.8%, P = 0.03). Clinician-reported understanding of medication changes in the ICU increased (69.2% vs. 29.1%, P = 0.004), as did their ability to plan for a safe hospital discharge (69.2% vs. 31.0%, P = 0.01). However, only 64.2% of audited transfers used the tool. Frequently omitted sections included home medications (missing in 83.4% of audits), new medications (33.3%), and secondary diagnosis (33.3%). Thematic analysis of free-text responses identified areas for improvement including clarifying the course of ICU events and enhancing tool usability. Conclusion: A user-designed, structured, handwritten transfer tool may improve the perceived quality of patient transfers from the ICU to the GIM wards.
| S-EPMC8043311 | biostudies-literature
Project description:Transferring patients from the intensive care unit (ICU) to a general ward is commonly associated with error and adverse events, and is one of the most challenging and high-risk transitions of care. Patients discharged from ICUs often require sustained intensive multi-disciplinary team input, part of which can be provided by nurse or clinician-led outreach teams. Unfortunately, due to a lack of resources many institutions do not have such programmes. We work in one such hospital with no ICU outreach service for recently discharged patients. We noted that a disproportionate number of patients recently discharged from the ICU needed acute medical reviews by on-call evening and overnight junior doctors. Furthermore we noted that many of these patients had not been reviewed by their medical team after having arrived onto the general ward from the ICU. We aimed to foster a fundamental culture change within junior doctors to review patients within six hours of arrival onto a ward from the ICU. We introduced simple and low-cost interventions that included educational sessions for junior doctors and ward-based nurses, as well as posters that acted as visual reminders in relevant departments. Overall, the number of patients discharged from the ICU to general wards that were reviewed within six hours improved from 22% to 70% in the space of six months. In the same period, the number of patients requiring an acute medical review by the evening or overnight on-call junior doctor dropped from 14% to 0%. Whilst our project is not necessarily appropriate for many larger institutions that already have outreach teams in place, it is certainly applicable to other similar sized smaller hospitals. We hope that others who face the same inherent barriers are inspired to implement similar projects, to bring about positive change, and ultimately improve the safety of their patients.
| S-EPMC4693071 | biostudies-literature
Project description:The GMC states that, 'You must be satisfied that, when you are off duty, suitable arrangements have been made for your patients' medical care…including effective hand-over procedures' [1]. The medical weekend handover system at this tertiary referral centre involved multiple pieces of paper with no clear list of tasks, and no way to identify critically unwell patients. Patients could be missed from the ward round or could be difficult to identify under pressure. The authors felt this process could pose a threat to patient safety so decided to improve it. A questionnaire was distributed to all 11 medical SHOs with 100% response rate. Results showed that 72% thought the process was unstructured, 81% did not think the process was always safe, and 100% thought it could be improved. After discussions with senior medical management and with the approval of the trust audit committee, a new weekend handover proforma was designed, taking into consideration the results and comments from the questionnaire. The new proforma is accessible through a shared drive, which can be accessed by all medical SHOs in the hospital. Each team is able to copy their patients onto the combined ward-based list. There are columns for specific weekend jobs and registrar/SHO reviews. Any potentially unwell patients are highlighted in bold and discussed with the on-call SHO on Friday. All medical SHOs were given a post-implementation questionnaire after the new handover process had been in place for two months. Results of this showed that 100% of SHOs felt an improvement had been made, with 100% stating that the new system was more structured (64% always, 36% most of the time). The SHO's perception of patient safety increased from 81% generally unsafe, to 100% generally safe. The new handover has been well received and supported by the current SHO cohort. Improvements in the structure of handover have been made with perceived improvements in patient safety. Due to the success of the system, the handover proforma is being implemented in the trust's sister hospital.
| S-EPMC4652704 | biostudies-literature
Project description:In recent years medical handover has been identified as an increasingly important area for hospitals to improve upon, in light of the changes in shift patterns for doctors. Significant changes to weekday handover had recently been successfully introduced at Broomfield hospital. Weekend handover remained a concern, with an electronic and paper system being used simultaneously. Our objectives were to introduce a new electronic handover system for weekend handover at Broomfield Hospital and improve the organisation of the weekend handover meeting to promote patient safety. Doctors involved in weekend handover were surveyed using a questionnaire, to establish insufficiencies in the weekend handover process; where both the electronic ExtraMed system and paper were being used inconsistently. A new weekend handover system was introduced together with a new user-friendly electronic handover database, addressing the identified difficulties in the current system. These changes met the medical handover guidelines set by the Royal College of Physicians. Three months after the launch of the new system, doctors were re-surveyed using a modified questionnaire to assess the impact our changes had made. Before changes were implemented only 12% of doctors surveyed used the electronic system for weekend. Eighty-nine percent found sorting through jobs time consuming and 67% were handed jobs to them meant for a different grade of doctor. Only 41% were aware who to hand weekend discharges to. Subjective assessment of safety was 3.18 out of 5. The electronic system was felt to be time consuming and complicated. After execution of the new weekend handover process, 100% of doctors reported using the electronic system for weekend handover. Only 47% of doctors felt sorting through jobs was time consuming and 89% of doctors were aware who to handover weekend discharges to. Subjective assessment of the safety of weekend handover improved to 3.84 out of 5. Informal interviews on the ward revealed a high degree of satisfaction with the new weekend handover system. In conclusion we found that a structured, well organised weekend handover meeting together with an effective electronic handover system improves the quality of medical weekend handover.
| S-EPMC4693034 | biostudies-literature
Project description:Clinical handover is a process of transferring a patient's clinical information from one team to another. Poor quality of handover of critically ill patients associates with misunderstanding, delay in treatment, and adverse outcomes. Therefore, a high quality and standardized information flow process and documentation are definitely crucial. We have developed a web-based platform for generating printed ICU consultation reply and data collection. Baseline measurement was performed by randomly identified 50 case records among 220 ICU consultations in March 2015, before the implementation of the system. We found that there were only 16% of cases had printed ICU consultation reply, 42% had documented patient's premorbid activity of daily living, 30% had recorded patient's mobility, 74% had written down patient's past medical history, 72% had clearly stated the ICU admission decision, 18% had provided the reasons for rejecting ICU admission, and 32% had remarked the mechanism for contacting ICU senior to review the admission. After implementation of the ICU consultation reply platform, the percentage of using printed consultation reply has increased to more than 90%, documentation of patient's morbidity and mobility have raised to over 80% and patient's past medical history has been recorded in over 95% of cases. Standardised ICU admission decision tree has been designed to assist ICU doctor to clearly state the ICU admission decision and the reasons behind. Appeal mechanism for doctors in general ward to contact ICU seniors for case discussion is included in every consultation reply. In short, ICU consultation platform improves the quality of ICU consultation reply and enhances communication among ICU doctors and general ward staff. It also serves as a big data pool for audit cycles which in turns direct ICU consultation service improvement.
| S-EPMC4856893 | biostudies-other
Project description: Not available
| S-EPMC7328182 | biostudies-literature