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

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

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

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 Hazards: that cause danger or risk to patient safety

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.

Handoff reports 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 1. Solet DJ, Norvell JM, Rutan GH, et al., Acad Med, 2005.

Part of the larger care process… Pre transfer care Prepare patient for transfer at sending end Physically transfer patient Stabilize patient at receiving end Handoff Post transfer care Care transitions are part of a larger care process. And verbal handoffs are a critical part of the care transition process.

Care transitions “Set of actions designed to ensure the coordination and 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” Patient ER ICU OR Floor Rehab center Home Home care 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.

Handoffs “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.” Presentation for Standardizing Handoffs for Patient Safety AORN. 2012. Accessed April 8, 2013. Available at: http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=20863

Care transitions intervention

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

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.

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

Good Practices

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

Good practices Prior to patient transfer During patient transfer Hospital Prior to patient transfer During patient transfer At receiving unit prior to verbal handoff During verbal handoff Following verbal handoff At sending unit At receiving unit

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 “Teamwork across unit tool” & “Transitions of care survey” can be used. Jill will present in the near future about using the Teamwork across unit tool

Good practices Prior to patient transfer During patient transfer Hospital Prior to patient transfer During patient transfer At receiving unit prior to verbal handoff During verbal handoff Following verbal handoff At sending unit At receiving unit

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

Good practices Prior to patient transfer During patient transfer Hospital Prior to patient transfer During patient transfer At receiving unit prior to verbal handoff During verbal handoff Following verbal handoff At sending unit At receiving unit

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

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

Good practices Prior to patient transfer During patient transfer Hospital Prior to patient transfer During patient transfer At receiving unit prior to verbal handoff During verbal handoff Following verbal handoff At sending unit At receiving unit

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

Good practices Prior to patient transfer During patient transfer Hospital Prior to patient transfer During patient transfer At receiving unit prior to verbal handoff During verbal handoff Following verbal handoff At sending unit At receiving unit

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 Noise defined as sounds in the environment that prevents clear hearing of what is being said

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 Distractions are things in the environment or other individuals who are not part of the handoff that may draw attention of the individual participating in the handoff away from the verbal handoff Interruptions are a break in what is being said caused by members who are not involved with the handoff or about topics not related to the specific patient

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

Good practices Prior to patient transfer During patient transfer Hospital Prior to patient transfer During patient transfer At receiving unit prior to verbal handoff During verbal handoff Following verbal handoff At sending unit At receiving unit

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

Lets concentrate a little more on the verbal handoffs …

Handoffs Successful transfer of information Provider information Patient information Plan of care Discussion and questions Dedicated time Sufficient length Handoffs Why? When? Where? Who? How? What? 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 Describe the difference between interruptions and distractions 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

Primary objective of handoffs “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.” Meeting the Joint Commission 2008 National Patient Safety Goals, Joint Commission, 2007.

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

Standards of effective communication Brief Clear Complete Timely Verify & validate

Teamwork Teamwork for not only the verbal portion of the handoff but for entire care transition Can use team STEPS model as shown

Toolkit New material Reinforcement Currently implemented 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 

You will need to ACT soon… Assessment of Care Transitions Yes No N/a Pre verbal handoff assessment   Was there at least one nurse present in addition to the primary nurse when the patient arrived at the receiving unit to help stabilize the patient?  Were the monitors and or cables, sent with the patient compatible with the monitors and / or cables at the receiving unit? Was equipment (e.g. monitors) needed for the patient at the receiving unit Available Functional Appropriate / adequate If lines, tubes and cables were transferred to a new monitor, Were all key parameters visible throughout, with less than a 30s disruption? Was a verbal warning provided prior to disconnecting the key line, tube, wire or cable? How long did take to stabilize the patient (from the time the patient first arrived at the receiving unit to the time the verbal handoff started)? min Did a patient related issue increase the overall time stabilize the patient? Was the patient situated, stable and comfortable at the receiving unit prior to the verbal handoff?

Development of a team communication tool 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 Identify needs Identify requirement Needs analysis Design Iterative testing Finalize design

Thank you! Ayse Gurses, Ph.D. Mahiyar Nasarwanji, Ph.D. agurses1@jhmi.edu Mahiyar Nasarwanji, Ph.D. mnasarw1@jhmi.edu