Improving Transitions of Care, Handoffs and Coordination Across Units

1. Improving Transitions of Care, Handoffs and Coordination Across Units Dr. Ayse Gurses & Dr. MahiyarNasarwanji Armstrong Institute for Patient Safety and Quality

2. Objective To highlight the importance of smooth care transitions and handoffs To provide a list of good practices during transitions of care

3. Overview • Background • Define • Care transitions • Handoffs • Good practices • For each stage of the transition • Handoffs • Other pieces of the intervention package

4. Significance of Care Transitions • 46% to 56% of all medication errors during transitions (Pippins et al 2008, Barnsteiner 2005) • Hazards (Horwitz 2009) • Inadequate support for situation awareness • Inaccurate / inadequate information transfer • Unstructured / non-standardized handoff • Responsibility / Role ambiguity • High workload

5. Communication Breakdowns are frequently the root cause of…undesirable outcomes Improving Handoff Communications: Meeting National Patient Safety Goal 2E, Joint Comm Perspectives on Patient Safety, 2006.

6. Handoff reports 1. Solet DJ, Norvell JM, Rutan GH, et al., Acad Med, 2005. • Patients are particularly vulnerable during handoffs • Incorrectly communicated information • Information not communicated at all • Appropriate measures for evaluating effectiveness of handoffs still need to be established and validated1

7. Part of the larger care process…

8. Care transitions American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557. “Set of actions designed to ensure the coordinationand continuity of health care as patients transfer (move) between different locations or different levels of care. Care transitions encompass both the sending and the receiving aspects of the transfer”

9. Handoffs Presentation for Standardizing Handoffs for Patient Safety AORN. 2012. Accessed April 8, 2013. Available at: http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=20863 “The transfer of information(along with authority and responsibility)during transitions in care across the continuum for the purpose of ensuring the continuity and safety of the patient’s care.”

10. Care transitions intervention

11. Evidence • CSTS project (site visits) • Observations • Interviews • Tool analysis (handoff report checklists) • Literature • Wisdom of crowds (Clinical expertise and experiences)

12. Systems Engineering Initiative for Patient Safety (SEIPS) Model Carayon, P., Hundt, A.S., Karsh, B.-T., Gurses, A.P., Alvarado, C.J., Smith, M. and Brennan, P.F. “Work System Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i50-i58, 2006.

13. How do we implement it? • Leverage your CUSP teams • Covered in the face to face meeting • Identify executive leadership  • Identify units involved  • Identify team  • Identify current practice and expectations Today • Assessment of current system • Training program • Develop and roll out handoff tool • Periodic assessment • Continual improvement

14. Good Practices

15. Focus • Concentrates on transfers from • OR  ICU • ICU  Floor • List of good practices are generic • Some many not apply to specific transition

16. Good practices Hospital At sending unit At receiving unit

17. At the hospital level • Handoff policy • That all staff are aware of • Or staff know where to locate • Adequate and appropriate training on care transitions and handoffs • Coordination and teamwork between units should be regularly evaluated and improved • Designated champions at various locations • Can be contacted for questions • Can collect feedback • Equipment should be functional and ready to use • Consider compatibility of devices across units when making purchasing decisions

18. Good practices Hospital At sending unit At receiving unit

19. Prior to patient transfer • Inform receiving unit of • Patient’s time of arrival • Patient related information (telephone handoff) • Specific equipment needs • Inform sending unit of patient’s destination • All cables, lines and wires should be • Clearly labeled • Organized and secured • Patient should be stable and ready for transfer

20. Good practices Hospital At sending unit At receiving unit

21. During patient transfer • Equipment should permit stable movement of the patient • Bed / wheelchairs used for transport should have adequate and appropriate locations to place and secure all equipment required for transfer • At least one individual should be aware of the exact destination at the sending unit

22. During transfer of patient • Remove all barriers • Provide an assigned or limited access elevator for transfers • Path of travel should be a barrier free zone • No equipment in the corridors • No movement past family waiting areas

23. Good practices Hospital At sending unit At receiving unit

24. At receiving unit prior to verbal handoff • At least one nurse in addition to the primary nurse should be present to receive the patient (dependent on patients condition) • The cables and monitors in from the sending unit should be compatible with those in the receiving unit • When transferring cables and lines • Cables and lines should be transferred sequentially • Warning should be provided prior to disconnecting • No more than a 30s disruption • Patient should be stable and comfortable

25. Good practices Hospital At sending unit At receiving unit

26. Verbal handoff (1 of 3) • At least the primary nurse and/or the provider from the receiving unit (e.g., intensivist) should be present • The environment should • Be free of noise • Provide adequate space for all the key players • Not interfere with other clinical workflow • Adequate time should be provided to complete the handoff

27. Verbal handoff (2 of 3) • There should be an identified leader that initiates and directs the verbal handoff • The primary nurse or provider should be asked and explicitly acknowledge readiness for the handoff • There should be no distractions and interruptions other than for • Clarifications • Questions • To take care of critical patient related issues in the unit • Nurses and providers should be able to pause the handoff • Everyone should feel comfortable asking questions

28. Verbal handoff (3 of 3) • A standardized handoff checklist or tool • Should be consistently used • Kept as a temporary record • Primary nurse and provider should make notes of what is being discussed • The primary nurse or practitioner at the receiving unit should explicitly acknowledge assumption of care • Principles of good teamwork should be followed • Empowerment • No role or responsibility ambiguity • Appropriate conflict resolution • Clear, complete, brief and timely communication

29. Good practices Hospital At sending unit At receiving unit

30. Following verbal handoff • The nurses and physicians at the receiving units • Should be aware of the short-term and long-term goals for the patient • Know who to contact after the handoff for questions and concerns • How to contact them • Should verify critical information communicated during the handoff • Should be a mechanism to provide immediate informal feedback

31. Lets concentrate a little more on the verbal handoffs …

32. Successful transfer of information • Provider information • Patient information • Plan of care • Discussion and questions • Dedicated time • Sufficient length • Clear leadership • Good communication • Team involvement • Avoid interruptions • Discussion and questions • With the aid of checklists, tools and technology • Close to work area • Large enough space • Free from distractions • Access to required information and technology • Key personnel / players • Active involvement of senior physicians Adapted from: AMA Clinical Handover Guide - Safe Handover: Safe Patients: https://ama.com.au/ama-clinical-handover-guide-safe-handover-safe-patients

33. Primary objective of handoffs Meeting the Joint Commission 2008 National Patient Safety Goals, Joint Commission, 2007. “The primary objective of a “hand off ” is to provide accurate information about a [patient’s] care, treatment, and services, current condition and any recent or anticipated changes.”

34. What information? • Customized to hospital and setting • Use pre-existing format and Mnemonics • Some guidelines • Introduction of all care providers and their roles • Identifiable patient information • Past medical history/ comorbidities of the patient • Current situation / state of patient • Current assessment and diagnosis • Plan of care • Anticipated problems and contingency plans • Read-back and / or synthesis by receiver • Questions • A genuine invitation to call for additional clarifications

35. Standards of effective communication

36. Teamwork

37. Toolkit • New material • Assessment of Care Transitions (ACT) Upcoming • Participatory user centered design approach Upcoming to tool / checklist development • Reinforcement • Teamwork across unit tool Upcoming • Barrier identification and mitigation tool • Currently implemented • Transitions of care survey  • Part of HSPOS  • Relational Coordination 

38. You will need to ACT soon… Assessment of Care Transitions

39. Participatory user centered design approach to tool / checklist development • Development of a team communication tool • Information needs from all players considered • Standardized form • Shared and used by all team members

40. Thank you! Ayse Gurses, Ph.D. agurses1@jhmi.edu MahiyarNasarwanji, Ph.D. mnasarw1@jhmi.edu