Improving Standardized Handoffs In Emergency Departments: A Quality Improvement Proposal

You need to reflect on your clinical experience to date and identify an issue of interest to research such as, wound care, nursing care procedures etc. You are then required to develop a quality improvement proposal on this topic of interest. The content of the proposal will include: the background and significance of the project; statement of the problem; significance or importance of the problem; the premise of the project /or clinical question; assumptions and definitions; review of related literature; outline of the project procedure; use of appropriate improvement approach etc.

Introduction

Background

Each day in health facilities, the responsibility of caring for the patients is transferred from one or a team of care providers to another. This exercise arises in a busy and interruptive setting which typically describes a hospital. This process is known as “handover,” “handoff” or “end-of-shift-report.” It is primarily done through communication and therefore, for this project’s purpose, the terminology “handoff” shall be used. Information, responsibility, and authority are the three fundamental things that are transferred for the continuation of care or management as planned (Farhan, Brown, Vincent, & Woloshynowych, 2011).

Various hospital sections such as the emergency department have the problem of overcrowding and overburdening, and they mostly handle critical cases that require utmost attention. It means that the handoff process has to be thorough to avoid any unlikely situations such as delays in treatment, substandard interventions, and patients leaving without being attended to, and worse off, unnecessary deaths. Frequently, handoffs have been conducted in various ways, and they depend on the roles of the caregiver, traditions, circumstances and hierarchies (Fernando, Adshead, Dev, & Fernando, 2013). The utilization of a standardized handoff guideline has been identified as the most efficient way of ensuring the patient is safely managed.

An information system of managing clinical details known as Electronic Medical Record (EMR) is dedicated to the manipulation, collection, availing and storage of patient information that can help in the delivery of care (Han, 2014). Some of these systems are automatic and handle information such as doctor’s prescriptions, nursing care notes, results from the laboratory and others.

Since there lacks a proper process of standardizing handoffs, the potential of EMR is not maximized. Whereas handoffs occur at all hospital departments, this project focuses on those that occur between the emergency department and the nursing staff of the inpatient unit.

Significance

The handoff process was set for some adjustments as a goal under the National Patient Safety program. The patients’ information transfer is a critical issue in that any interruption of communication among health care providers has contributed to the events referred to as “Sentinel”. The Joint Commission (TJC) defines a “sentinel event” as an unexpected happening that may cause serious psychological or physical impairments, and even death to one or more patients, also, it is not attributed to the patient’s illness as a natural course. For instance, injury due to the constant replacement of a given medication with another ("The National Patient Safety Foundation and the AAPM", 2013).

Significance

Relating to sentinel events, it has been established that between 64%-74% of the occurrences are related to a breakdown in communication (Weyand, Kang, Junck, & Heiner, 2014). Poorly communicated handoffs have been identified as the cause of poor patient satisfaction, delayed prescription and treatment, and increased admission of patients with minor problems. The most reported issues include leaving out essential information and its misinterpretation. Plans have been established to maximize the use of EMR for standardization of handoffs. It is unlikely that most of the information is shared verbally than it is recorded in EMR. Also, some factors such as work culture, tradition, and context complicate the application of EMR in health care facilities ("The National Patient Safety Foundation and the AAPM", 2013).

As much as a structured process of communication has been in place to guide nursing practice, there is no evidence suggesting best practice in handoffs. Researchers have not carried out a quality study about the topic. Patterns of communication between doctors and nurses had the highest interruption rates at 30%. This finding on nurses’ and physicians’ communication also confirms that details about the patients’ alternating condition and needs are deficient and thus creates a series of errors in manageable cases. The intention of handoffs is ensuring that there is continuity of care, identify and communicate a patient response to interventions and address any changes in the condition of the patient. Lingard (2014) emphasizes that the epicenter of quality outcomes in teamwork is communication (Goldszmidt, Dornan, & Lingard, 2014).

Care of patients is a complex activity where different health workers collaborate in a bid to restore full functionality. A healthcare environment has a lot of mixed issues ranging from interruptions, chaos, sadness and others. It is imperative to comprehend the uniqueness of the context of handoffs process during admission from the emergency department.

It was established that vulnerabilities in information technology, communication, the environment, allocation of duties and flow of patients influence the emergency department handoffs. This project is meant to provide an opportunity for nurses from all cadres to understand handoff as a nursing procedure and engage them in formulating the best way possible for quality improvement. An opportunity to improve care is critical to advancing the nursing profession (Duncan, Montalvo, & Dunton, 2011).

Problem Statement.

The details presented by a nurse on duty to another or other care providers during a change of shifts is crucial for the management of the patient. A significant number of patients may pass on because of inadequate provision of handoff information. Success in the general outcome of treatment and care in emergency department pivots on the concept of “standardized handoffs”. Precious time may be wasted on the uninformed particulars such as availability of laboratory results. For instance, missing out on the main issues like communicating the cause of the patient’s problem as blunt trauma may lead to a lot of time wastage instead of an immediate intervention through surgery and intensive care therapy.

Nursing Implications

A study carried out on 264 physicians of the emergency department identified that 31% of the respondents reported at least one adverse event attributed to handoffs. A similar study noted that 74% of the handoffs are conducted in a common area within the department. 90% of them reported that there is no policy regarding the process. 50% indicated that the physicians receive patient information verbally from the nurses and their colleagues. They say it gets rampant when they familiarize with each other (Flanigan, Heilman, Johnson, & Yarris, 2015). A review of the literature indicates that there is a significant mortality and morbidity caused when health workers delay initiating best practice interventions because of weak inter-shift transfer reports. Concerning this project, a fair amount of research has been undertaken overseas. There is the limited literature on research about this subject particularly in the field of nursing in Australia (Bish, Kenny, & Nay, 2013).

Significance Of The Problem

The proposal is essential for nurses and other health workers because it would provide guidelines on some of the significant means of improving handoffs and ultimately the outcomes of health interventions. They would gain knowledge and expertise in health promotion and quick response in an emergency department as the remedies touch on the emergency response which integrates inter-shift transfers. Furthermore, patients and families would be enlightened on their rights in an emergency department so that quality is always expected. Professional development would also be fostered especially the professions of nursing and medicine as the project incorporates local and international policies on healthcare.

Premise Of The Project

 The deliberate ignorance of using handoff guidelines by nurses and other healthcare providers is wrong and has to be punitive. Furthermore, most of the hospitals do not lay the best strategies in helping patients and encouraging their staff to uphold best practice in all departments, specifically the emergency section. Also, there are inadequate nursing profession-based research studies on the subject hence promoting the rampant problems in the handoff process. The best way of improving adherence to the guidelines is the use of EMR and triggering consciousness in every healthcare professional to optimize ethical principles such as “do no harm” and respect for humanity (Halstead, 2012).

Assumptions And Definition Of Terms

Assumptions.

The assumptions identified about the relevance of this proposal include;

All the emergency departments have a clear policy on the handoff process. It is because the project identifies gaps in the policies and proposes how quality can be improved.

Problem Statement

All hospitals have an emergency department and in-patient sections so that there is at least an initial management of cases before they are referred; this is because the project focuses on handoffs between an emergency department and the inpatient section.

The hospitals have the capability of installing EMR systems. It is a recommendation in this project to help improve handoff and promote good patient outcomes.

The nursing literature on the topic is sufficient to make credible recommendations on the subject.

All hospitals have sufficient staff who are involved in the handoff process.

Completeness of the available records is guaranteed. Based on these records, recommendations and conclusions shall be projected for future nursing practice and studies.

Emergency department: the section of a hospital that receives and admits patients who need immediate care like in trauma. In some hospitals, it is the first point where clinicians see all patients.

Inpatient Department: A section in a hospital where patients are admitted for further management and monitoring after receiving primary care in the emergency department.

Handoff: The process of transferring responsibility, care and accountability of a patient from one staff to another.

Management: Treatment or care of a patient.

Patient outcome: The response of a patient to treatment with the inclusion of possible complications in the first 48 hours of management.

Sentinel events: An event that is unanticipated in care and it is not related to the natural cause and course of the health problem.

Review Of Related Literature.

Little, Risenberg and Leitzsch (2012) finished a review of the literature in a systematic way by majoring on nursing handoffs in the United States and the utilization of mnemonics. One of the mostly raised mnemonics was Situation, Background, Assessment, and Recommendation (SBAR) (Riesenberg, Leitzsch, & Little, 2012). Authors expressed concerns about the lack of evidence on its validation. They recommended further studies that would prove how useful mnemonics are for handoff process (Sloper, Edmonds, Bailey, Lewis, & Charlton, 2015).

Additionally, Leitzsch and colleagues did a nursing literature review relating to handoffs and established that among the more than 90 articles studied, there were only twenty that involved nursing. Based on other reviews, it was found that quality nursing research on handoffs was limited (Burns, Grove, & Gray, 2011). Even though the topic of some of the recognized nursing studies was handoffs format, the outcomes and content accuracy was not integrated. Impediments and organizers to handovers in Nursing were identified, but there was no prove of best practice (Riesenberg, Leitzsch, & Little, 2012).

Significance of the Problem

Outline Of Project Procedure

There are steps developed by the Institute for Healthcare Improvement (IHI) which help conduct a quality improvement project. First, the organization establishes the main issue to be improved and develops goals that are measurable and time-specific (Sivaram & Tan, 2011). Secondly, develop measures which prove the strategy works. Additionally, the changes needed for improvement are then examined using Plan-Do-Study-Act (PDSA) model. PDSA has to begin with smaller sections before it is spread throughout the entire organization. Finally, the changes are implemented entirely to realize the improvement (Byrne, Xu, & Carr, 2014). 

Use of an appropriate improvement approach.

Firstly, the strategy will identify process owners and early adopters. A team of few members who are ardent about this proposal has to be ascertained, and they will begin the first PDSA stage by utilizing the SBAR approach for handoffs (Eberhardt, 2014). The first cycle of PDSA has to involve; plan, where a tactic of lowering destructions is developed, there is the use of SBAR and question time established (Byrne, Xu, & Carr, 2014). Draft a concise statement of what is to be achieved. It has to be smaller and focused for the purpose of improvement. Again, you can establish a target that you are hoping to achieve. Additionally, the steps to be implemented are established for the cycle. Also, the population to work with and the timeline for the study are determined. Predictions can be made on what may happen and for which reasons.

 Do, where adopters test the process. It involves execution of the plan and a keen scrutiny is employed to ensure finer details are captured. Afterwards, draft the findings during the observation for instance, it may be the reaction of patients, nurses, doctors and other workers to be interviewed. Ask self if things went as planned or if there is need for modification. The study, where satisfaction is evaluated. It involves going through the results. Identify a new thing that was learnt and establish whether the goal was met. Communicate how well the approach worked after you have achieved the goal. Observations may be unexpected therefore it has to be documented for that matter. The entire process involves analysis.  

Finally Act, where the changes are implemented after satisfaction. It is realized through identifying the conclusion from the cycle. Standardization of handovers in an active emergency department is crucial in that the needs are prioritized hence safety. The next step is for them to identify the residents who can convince others that the approach improves patient outcome during shift change. The adopters may want to train the broad groups who will later adopt their own PDSA utilization measures. Furthermore, it involves developing a plan for the subsequent study if modifications are to be made. In a nutshell, plan includes; set objectives, who are to be involved? What do they do? When and where? Do involves; pilot beginning, carrying out the plan, observation and making data. Study; data analysis, compare results with target, and establish changes. Act; implement changes or redo the cycle.

There may be some barriers that impede this process like the inability to follow instructions. Therefore, clinicians have to be cooperative in sharing any necessary information. Furthermore, opinion leaders may want to sustain the status quo in fear of the unknown. They may hinder the process, and so early adopters have to work an extra mile in ensuring full adherence (Apolinarski, 2012). The use of EMR has to be fostered in most of the hospitals when there are cases of neglect and malpractice, patient prioritization is not affected, and therefore, the outcome of care is always upheld.

References

Apolinarski, A. (2012). Proposal for a leader nurse role implementation at Palomar Pomerado Health.

Bish, M., Kenny, A., & Nay, R. (2013). Using participatory action research to foster nurse leadership in Australian rural hospitals. Nursing & Health Sciences, 15(3), 286-291. https://dx.doi.org/10.1111/nhs.12030

Burns, N., Grove, S., & Gray, J. (2011). Understanding nursing research. Maryland Heights, MO: Elsevier/Saunders.

Byrne, J., Xu, G., & Carr, S. (2014). DEVELOPING AN INTERVENTION TO PREVENT ACUTE KIDNEY INJURY: USING THE PLAN, DO, STUDY, ACT (PDSA) SERVICE IMPROVEMENT APPROACH. Journal Of Renal Care, 41(1), 3-8. https://dx.doi.org/10.1111/jorc.12090

Duncan, J., Montalvo, I., & Dunton, N. (2011). NDNQI case studies in nursing quality improvement. Silver Spring, Md.: American Nurses Association.

Eberhardt, S. (2014). Improve handoff communication with SBAR. Nursing, 44(11), 17-20. https://dx.doi.org/10.1097/01.nurse.0000454965.49138.79

Farhan, M., Brown, R., Vincent, C., & Woloshynowych, M. (2011). The ABC of handover: impact on shift handover in the emergency department. Emergency Medicine Journal, 29(12), 947-953. https://dx.doi.org/10.1136/emermed-2011-200201

Fernando, K., Adshead, N., Dev, S., & Fernando, A. (2013). Emergency department multi-professional handover. The Clinical Teacher, 10(4), 219-223. https://dx.doi.org/10.1111/tct.12018

Flanigan, M., Heilman, J., Johnson, T., & Yarris, L. (2015). Teaching and Assessing ED Handoffs: A Qualitative Study Exploring Resident, Attending, and Nurse Perceptions. Western Journal Of Emergency Medicine, 16(6), 823-829. https://dx.doi.org/10.5811/westjem.2015.8.27278

Goldszmidt, M., Dornan, T., & Lingard, L. (2014). Progressive, collaborative refinement on teams: implications for communication practices. Med Educ, 48(3), 301-314. https://dx.doi.org/10.1111/medu.12376

Halstead, J. (2012). Embracing Ethical Principles for Education in Nursing. Nursing Education Perspectives, 33(1), 5-5. https://dx.doi.org/10.5480/1536-5026-33.1.5

Han, Q. (2014). Design and Application of Electronic Medical Record Template. Chinese Medical Record English Edition, 2(2), 41-46. https://dx.doi.org/10.3109/23256176.2014.902173

Riesenberg, L., Leitzsch, J., & Little, B. (2012). Systematic Review of Handoff Mnemonics Literature.American Journal Of Medical Quality, 24(3), 196-204. https://dx.doi.org/10.1177/1062860609332512