Improving hand off communication: New solutions for nurses Jennifer Newcombe, DNP, MSN, CNS-BC, CPNP-PC/AC Pediatric Cardiothoracic Surgery Improving hand off communication: New solutions for nurses

Introduction Hand offs occur in many different forms varying among institutions, specific units and even individual nurses. Patients in the inpatient care setting have become increasingly more complex requiring higher levels of care, more complex interventions, and coordination of multiple specialties to manage their disease process. Nurses use written or verbal formats to exchange information. Information can be exchanged at the bedside or a central nursing station

Introduction 44,000-98,000 patients die each year due to medical error that effective communication could play a key role in preventing (IOM, 1999). Nursing hand off occurs 2-3 times per day for each patient. Hand off styles vary and are often based on nurse’s own personal style (Kerr, 2011). Ineffective communication is commonly acknowledge as a contributing factor to medical errors

Background 14 bed cardiothoracic intensive care unit Staff 48 Full Time 6 Part Time 3 Per diem Time to complete report was 25 minutes 87% of staff were using LLEAP overview 25% All of the time 21% Most of the time 42% Some of the time 27% Experienced a delay during report Incremental overtime was between 60-90 hours a pay period ($6,000-8,000) Median overtime 74.1 hrs

Shared Governance Team Raeann Sandquest, RN Sean Cavence, RN Juan Morales, RN Amanda Joy, RN Angelica Bennett, RN Maureen Hokama, RN Jennifer Newcombe, NP Decrease staff overtime in order to fund CNS postion

PICO Question In the CTICU does a structured nurse hand off as compared to the current process decrease staff incremental overtime?

Objective and Aims RNs to initiate hospital course tab upon admission in LLEAP RN would be responsible for updating hospital course each shift Hand off would be done in the SBAR format Decrease interruptions during report Decrease staff incremental overtime by 3% RNs were writing down the patients hospital course with each shift report. Very time consuming

Project Design PDSA is a validated process improvement model in healthcare

Project Methodology Information technology Consistency of information LLEAP hospital course section Consistency of information SBAR Limiting interruptions Report in progress sign Peer to peer accountability 5 minute wrap up S- Patient name, age B-Past Medical History, significant clinical events A-Significant vital signs, labs, assessment by system R-Recommendations for next shift

Issues of Implementation Unit census varies with diagnosis and complexity ICU to discharge Unit start time changed from 6:30 A.M/P.M to 7:00 A.M./P.M Report in progress sign not consistently placed by RN circulator Circulator not present for every shift

Issues of Implementation Hospital course was not always initated on day of admission Hospital course with unnecessary information Not updated appropriately (Q shift) Nov Some not updated appropriately Some admissions not started. Update Q 12hrs Made team question what information is pertinent to include in hospital course?

Overcoming barriers Unit shift huddles Routinely presented data at staff meetings Education board in report area In God we trust Everything else we need to see the data

Data Analysis There was a significant difference between how long it took to complete the report before any changes were made and how long it took after the latest changes were made (p=<.001).

More nurses are completing the report on time than not Data Analysis More nurses are completing the report on time than not

Data Analysis Those who completed the report on time completed the report in a significantly shorter amount of time than those who did not (p<.001)

Data Analysis

Data Analysis

Data Analysis Interruptions remains a significant reason for why reports are not completed on time (p<.001). The number of people who were interrupted did not significantly change.

Data Analysis Those who were interrupted took significantly longer to complete their report than those who were not interrupted (p<.001). Those who were interrupted were 4 times more likely to not complete their report on time.

Data Analysis

Conclusion RNs who used LLEAP hospital course completed report on time. RNs who were interrupted took significantly longer to complete their report than those who were not interrupted (p<.001). Those who were interrupted were 4 times more likely to not complete their report on time.

Questions

References IOM (1999). To error is human: Building a safer health system. Retrieved April 23, 2018 from www.nationalacademies.org/hmd/~/media/Files/Report Files/1999. Kerr, D., Lui, S., McKinlay, L., Fuller, C. (2011). Examination of current handover practice: Evidence to support changing the ritual. International Journal of Nursing Practice, 17, 342-350.