Patients in a hospital must necessarily pass from the care of one clinician to another. During these “handovers,” critical information about the patient also needs to be passed along. But errors can and do creep in. One study found that medication needs were omitted during 69% of handovers, and 22% of the time at least one clinically significant health problem was not mentioned.
A study in JAMA last December looked specifically at resident and intern rotations. When these doctors-in-training moved to their next specialization, and handed over patients to the next team, these patients were almost twice as likely to die, the study found.
Drawing a straight causality is problematic—patients who are sicker stay in the hospital longer and are therefore more likely to experience such a resident handover (which typically happens every four weeks). But it spurred a closer look at the importance of training young doctors to communicate.
“Most medical students and residents still receive little or no formal education in structured, standardized handover and communication techniques,” says David Shahian, vice president of quality and safety at Massachusetts General Hospital. Using the I-PASS model developed at Boston Children’s Hospital, Shahian and his colleagues have launched one of the country’s largest efforts to overhaul the way a hospital hands over patients—not only for residents but for the entire staff of 6,000 doctors, nurses and therapists.
Use Digital Records…
Cincinnati Children’s Hospital Medical Center made handover documentation a part of the digital records that track a patient’s care. That increased the success of handover information between the pediatric intensive care unit and the general medical floor from 58% to 94%.
…And Verbal Reminders
The hospital also taught residents about the importance of verbal handovers when moving patients from the pediatric ICU. That training increased the use of such handovers from 76% to nearly 100% within five months.
Implement I-PASS
The Cincinnati effort used I-PASS, an approach to handovers developed by Boston Children’s Hospital. I-PASS incorporates summaries and action plans, and requires the person taking over a patient’s care to repeat the instructions they’ve heard. (This is the system Shahian is implementing at MGH.) The system has decreased overall medical errors at Boston Children’s Hospital by 23%.
Implement TST®
The Joint Commission Center for Transforming Healthcare developed an electronic application in 2012: the Hand-off Communications Targeted Solutions Tool®. Using it, one hospital brought the time needed to move patients from the emergency department to an inpatient unit down by 33%.
Speak Bedside
A bedside shift report—in which nurses going on and off shift share information while with the patient—increases nurse satisfaction, gives patients the opportunity to ask questions and correct erroneous information, and decreases report time (in one study, from 45 minutes to 29 minutes).
