Essay: Improving Emergency Department Efficiency w/ Clinical Audit and Mnemonic Checklist



Improving the efficiency of patient handover in trauma center of Emergency Department by implementing a standardized approach

Ali Shahrami a, Masoomeh Nazemi-Rafi a,*, Hamidreza Hatamabadi a, Afshin Amini a

a Department of Emergency Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 1617763141

* Corresponding author. Tel.:+989134936949.

E-mail addresses: alizarife@yahoo.com (A. Shahrami), m_nazemi_r@yahoo.com (M. Nazemi-Rafi), hhatamabadi@yahoo.com (H. Hatamabadi), a.amini@sbmu.ac.ir (A. Amini).

Abstract

Purpose: The discontinuity of information during inter-shift handover leads to malpractice, adverse outcome and legal claims. To overcome these problems, we performed a clinical audit of patient handover records at the trauma center. Then, we created new procedure by using educational program and mnemonic checklist.

Materials and methods: The study was included the following steps: 1. pre- interventional period (pre-proforma) during 26 inter-shift handovers 2. educational program and evaluating mnemonic checklist performance in a re-audit of 26 inter-shift handover data (post proforma).

Results: From total of 248 pre-interventional patients, 49 patients were not handed over while in post interventional period, it was 16 from 255. The result revealed clearly that the highest percent of handing over of checklist items related to post proforma with accompanying checklist (94%), followed by the post proforma without checklist (25%) and pre-proforma (8%) respectively. furthermore, handover duration per patient and taking part of first-year residents increased significantly in pre-proforma compared with post proforma.

Conclusions: Implementation of a simple checklist of ten items (WHO MISSED IP?) and educational program of residents improved quality of handover. Also, the study showed that involving of junior resident is an important factor for improving the handovers.

Keywords: audit, handover, patient safety, emergency department

Introduction

With regard to susceptibility high error incidence, the emergency department (ED) is a critical area within the healthcare domain (Cheung, Kelly et al. 2010).  In this area, most trauma patients are critically at risk, not only because of severity of injuries, but also due to risk of high communication errors (Zakrison, Rosenbloom et al. 2015). Weak communication is known as a main factor attributing to 24% of missed diagnosis claims in ED (Kachalia, Gandhi et al. 2007; Cheung, Kelly et al. 2010). Fifty-nine percent of surgical and medical residents reported that at least one of their patients had been hurt by inadequate handovers (Kitch, Cooper et al. 2008). Patient handover between residents is noticed as a vulnerable point in the patient's care (Devlin, Kozij et al. 2014). However, there is a little knowledge on how to rectify communication shortcoming (Calleja, Aitken et al. 2011). It is necessary to recall that some studies have offered recommended strategies, but there is no agreement which one is the most effective (Patterson and Wears 2010). This issue can be attributed to health care's complexity and diversity, that so implementation of single protocol is not possible (Johnson and Barach 2009). Despite that existing handover protocols have been evaluated and improved between health care staffs in other hospital sectors (Malekzadeh, Mazluom et al. 2013; Evans, Murray et al. 2010), there is poorly structured and predetermined format in emergency resident-resident handover (Arora, Johnson et al. 2005; Jenkin, Abelson-Mitchell et al. 2007). By considering these facts, identifying strategies for improving handover communication would play an important role in reduction of avoidable errors (Vioque, Kim et al. 2014). The aim of this paper is to design a clinical handover checklist for resident to resident handovers in ED and to assess the performance of pre-prepared checklist handover against verbal handover with note-taking style in the information maintenance.

METHODS

The research was conducted in the ED of Imam Hossain teaching hospital with an annual patient census of approximately 25,000. In the ED, trauma patients were handed over verbally with taking notes. All handovers were between second-year residents without presence of first-year residents. The morning and night handover sessions were from 8-8:30am and 8-8:30pm with a little shift overlap between morning and night team.

The mnemonic checklist was designed based on information in the medical literatures and under the guidance of senior emergency medicine (EM) faculty physicians to address quality and safety of patient care. The penultimate checklist was tested in handover sessions to convince that all essential information and detail were included in a handover. Ten item mnemonic checklist (WHO MISSED IP?) used in the intervention. It reminds residents to concentrate on information with brevity for particular items on handover time as Who (patient ID as patient's name, sex and preinjury health status), Mechanism of trauma, Injury (suspected or sustained), Sign & Symptom (containing observations and monitoring), Evaluation (paraclinic), Diagnosis, Intervention (therapy and consulting), Plan for patient management and "?" giving an opportunity to question.

The observation of 26 pre and 26 post interventional handover sessions were prospectively evaluated. The pre intervention survey occurred between 31 March and 9 May 2016 and the post intervention period was between 16 May and 24 June. There were 26 handover sessions (13 day and 13 night shift), during each of pre-intervention and post-intervention. The participants for pre- and post-intervention phase included thirteen second-year residents. All participants were not aware that shift handover process were being evaluated.

Before beginning intervention course, the same thirteen second-year residents were informed about the use of mnemonic checklist with ten items as well as the assistance of first-year residents. The presenting of checklist items was performed by the investigator at weekly conference. Although there were supposed to implement checklist, but due to high workload, post-intervention handover divided into two subgroups: verbal handover with accompanying checklist and verbal handover without checklist.

Along the handover process in pre and post-interventional phase, incoming third-year residents recorded any omission or wrong presentation of information with regarding to checklist and the patient’s file, respectively. Also, Information on the patient's numbers, participants characteristics and duration of handovers were prospectively recorded by incoming third-year residents.

Statistical methods

The data collection was conducted by investigator (NM). Data were imported into Excel spread sheet. Statistical analyses were performed using SPSS 22.0 software. The data were analyzed using

Wilcoxon rank-sum test for continuous variables and chi-square test or Fisher’s exact test for categorical variables.

Results

During 52 shift handover sessions, from total of 503 admitted trauma patient, 175 and 328 patients were in the morning and night handover sessions, respectively. The handover of 248 and 255 patient were observed in pre and post intervention period, respectively. Also, 77% of pre and 74% of post intervention patients had a direct trauma to vital organs. Our findings show that 19.7% of pre-intervention patients (2.8 % in morning and 16.9 % in night sessions) were not handed over (Fig 1). Wilcoxon test showed that there was a significant difference between percent of patient handover and time of handover sessions (p=.000), So that higher percent of patient handover was seen in morning sessions. After educational program, all patients were handed over except for 9% of patients of the night handover sessions (Fig 1). The educational program had significant effect on percent of patient handover (p= .000; Wilcoxon test) and taking part of first-year residents (p= .000).  

Despite of significant increasing involvement of first-year residents in handover (78%), in night handover sessions only 34% of patients were with accompanying checklist. While this amount was increased to 94% in morning handover sessions. The accompanying checklist significantly increased the percent of patient handover (p= .000; Wilcoxon test).

Average duration of handover spent per patient was increased significantly from a pre-intervention with 73±14 seconds to a post-intervention with 96±18 seconds. There was a significant increase in handover duration of morning handover sessions compared to night sessions, in both groups of pre and post intervention. The education affected significantly on handover duration (p=0.0001; t-test). The analysis demonstrated that, educational program and taking part of first-year residents had a significant effects on handover duration of post intervention. However, handover duration showed no significant difference between two post interventional groups (Wilcoxon test).

The rate of omission or wrong information in post intervention was significantly lower than  pre-intervention (all at p=0.0001) for the Patient ID and preinjury health status (20.6 vs 58.3%), mechanism of trauma (4 vs 22.6%), injury (35.1 vs 68.3%), sign & symptom (19 vs 57%), paraclinic (17 vs 34%), therapeutic intervention (10.4 vs 37.6 %), plan (10.8 vs 21.6 %). But there was no significant difference for the effect of intervention (education) on diagnosis and consulting (Table 1). Results revealed a moderate to strong association of educational program (post proforma) with handover of items as injury (phi=0.407) and sign & symptom of patients (phi=0.393). Also, there was a moderate association with patient identification (phi=0.384) and therapy intervention (phi=0.365). The association of the educational program with handover of trauma mechanism (phi=0.277), paraclinic (phi=0.201) and plan management items (phi=0.147) was weak to moderate.

In post intervention with accompanying checklist, the errors and omissions in trauma mechanism, diagnosis and consulting data was reduced to zero (p=0.0001) (Table 2). Additionally, there was a very strong association of checklist accompanying with handover of injury data (phi=0.546). While this association with trauma mechanism (phi=0.230), diagnosis (phi=0.23) and consulting (phi=0.281) data was weak to moderate. The association in the rest items was moderate to strong. The educational program significantly decreased rate of errors and omissions in the night handover sessions as compared with pre-intervention, except for paraclinic, diagnosis and consulting data (Table 3). Whereas, education had significant effect on the incidence of errors except for diagnosis data (Table 4). In overall, the effect of checklist accompanying on the incidence of errors in the morning and night handover sessions was shown at Table 5,6.

In pre-intervention period, the minimum, maximum and mean number of items handed over per patient was 2, 10 and 5.97 (with σ =1.74) respectively. The more than 8 items were found only in 8% of patients of this group. However, educational program resulted in which the minimum and mean number of handed over items reached to 3 and 8.54 (with σ = 1.76), respectively, so that 64% of patients had ≥ 9 score. There was a significant difference between educational program and handover score (p=0.0001; Wilcoxon test). The accompanying checklist resulted in increasing the minimum and mean number of handed over items to 7 and 9.7 (with σ = 0.659) respectively. So, about the 95% patients had ≥ 9 handed over items. It is interesting to be noted that these amounts with verbal checklist was 3 and 7.1 (with σ = 1.63) respectively, so that 26% of patients perceived equal or higher score of 9 (Fig 2). Our results revealed a significant effect of accompanying checklist on handover score (p=0.000; Wilcoxon test).

The mean score of the handed over data in night handover session (6.30 with σ =1.86) of pre-intervention was significantly higher than morning handover session (5.54 with σ =1.46, p=0.002; Wilcoxon test). While in post intervention, morning handover sessions had significantly higher mean score (9.63 with σ =0.891) as compared to night handover sessions (7.96 with σ =1.83, p=0.0001). Even so, accompanying checklist increased the mean score to 9.73 (with σ =1.83) and 9.69 (with σ =0.540) in the morning and night handover sessions, respectively.

DISCUSSION

Each hospital/department needs to have own policy of patient handover which could identify key people and substantial gap in transfer information as lack of structure and dedicated time to complete handover (Association 2006). We have presented a description of trauma Patient handover from one resident to another across emergency department. In this paper, the potentially dangerous handover condition was highlighted and to be assigned to environmental, team, task and resident factors (Pronovost, Holzmueller et al. 2006). From one side, every second in ED must be considered as a golden time which should to be efficiently used (Cheung, Kelly et al. 2010). From other side, the handover process is time consuming (Solet, Norvell et al. 2005). So, the amount of needed time for patient handover would directly effect on the content of handover (Solet, Norvell et al. 2004). In previously reported data on handover duration, Solet et al. (2005) have reported variability in amount of time by types of medical wards (intensive care unit vs general medicine ward) (Solet, Norvell et al. 2005). Handover in our ED was informal, disorganized and error prone (Bomba and Prakash 2005). The competitive essence of ED for time and imbalance between conciseness and completeness led to inadequate handover. At the same time, the lack of educational programs of residents in the field of handover was added to issue (Solet, Norvell et al. 2005). Also, fatigue, poor memory and cognitive bias as resident factors and lack of standard approach to handover as a task factor adversely influenced to handover (Cheung, Kelly et al. 2010).

This paper was consistent with already published data in emphasizing the dependency of verbal handover to personal qualities (Bhabra, Mackeith et al. 2007). The primary aim of each handover is the perfect transfer of patient data (Patterson, Roth et al. 2004). Thus, with regard to our results, the educational program (Wong, Yee et al. 2008) and mnemonic checklist had achieved this goal by providing valuable data (Mullan, Macias et al., 2015; Salzwedel, Mai et al, 2016). We note that increasing effect of checklist on transfer of our patient data was agreement with reports of other authors (Møller, Madsen et al. 2013; Sujan and Spurgeon 2015). Furthermore, in New Zealand, McCann et al (2007) demonstrated that about 60% of doctors were confronted by medical errors which associated with miscommunication during handover. They stated that 31% of doctors believed 'on-call'/handover sheet to be effective in improving patient handover. Also, Salzwedel, Mai et al (2016) found that implementation of a standardized checklist would lead higher quality in patient handover from OR to ICU. To improve quality of care, our study proposed following solutions as emphasis on the handover of all patients even if patient had temporarily left the ED (Cheung, Kelly et al. 2010). Also, for reducing of shift change errors, handover need to encourage the receiving residents to question and to clarify their understanding of information given (Patterson and Woods, 2001; Cheung, Kelly et al., 2010). In order to accessing this subject, the latest item of mnemonic checklist had chance to lighten the obscure points of handover. A key finding of our study was that the 87% increasing of number of admitted patients on the night handover sessions.  This issue was a challenge to care and continuity of patient information (Association 2006). Also, due to having less trend to writing in high workload time (Sujan and Spurgeon 2015), 34% of patients were handed over with checklist in the night compared to the morning sessions (94%). One of the key questions about the night handover sessions issue was how to improve quantity and quality of patient handover. We identified that busy tertiary education hospitals such as ours require a shift crossover (Association 2006) to complete handover process.

Our study determined that instruction of checklist components as well as increasing of first-year residents' involvement resulted in increasing average patient handover duration of 96 seconds compared to adult ED settings of 73 to 92 seconds per patient (Mullan, Macias et al., 2015). This could be attributed to three facts: (i) there is a trend to abbreviate the verbal handover because of the high workload, so we have faced an inadequate communication and forgotten information (Sujan and Spurgeon 2015); (ii) junior resident, who took history, was likely to be more familiar with patient’s background information; (iii) since the handover process is a part of medical practice, first-year residents' involvement is crucial (Association 2006).

This paper demonstrated that educational program and accompanying checklist declined communication errors. The main limitation of this study was that the handover sessions were not sighted by the investigator and only reported data from senior residents were used as a basis of survey. It was possible that recording handover would affect the residents' practice and thus lead to bias in the assessment.

Conclusion

Suitable handover is not found by chance. It needs dedicated adequate time, education, cooperation and alertness of all those who have involved in it. We demonstrated that the handover of trauma patients in the ED faced many pitfalls. Thus it is better that the handover style to be specifically designed based on local handovers in specific units and patient specific.  Although, all styles need a planned format and architecture to insure that all doctors are updated with patients’ information.

Acknowledgments

We would like to appreciate all physicians of the emergency medicine department, Imam Hossein hospital, Shahid Beheshti University of medical sciences, Tehran.

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