Nurses help lead efforts on safe patient handoffs and transfers
Note: This is the first of two articles in a series looking at nurses’ contributions in addressing patient safety.
The number of patient handoffs that take place every day in healthcare settings across the country is immense. Making sure that every handoff, from admission to discharge, is accomplished perfectly may seem like an insurmountable task. Yet nurses are among those who continue to strive to develop protocols and tools to ensure that every patient handoff and transfer is a safe one.
Routine, but not
“While it sounds simple, a high-quality handoff is complex,” noted The Joint Commission in a September 12, 2017, Sentinel Event Alert. The commission described communication issues as a common problem in handoffs. Specifically, “expectations can be out of balance” between the person providing the clinical information and the receiving caregiver. And inadequate information or miscommunication around handoffs contributes to sentinel and other adverse events.
The commission initially addressed handoff communication in a National Patient Safety Goal in 2006, and 4 years later made it a standard. Yet the problem of inadequate handoff communication persists, prompting the commission to issue the alert along with strategies to ensure successful patient care transfers.
“Effective patient handoffs are an important aspect of patient safety, and we can be doing a better job,” said Justin Winger, PhD, RN, who served as chair of a 2017 committee reviewing the Emergency Nurses Association’s (ENA’s) position statement on patient transfers and handoffs. ENA is an organizational affiliate of the American Nurses Association (ANA).
Most nurses pay very close attention when administering medications because the potential for making a serious error has been ingrained in them since school, Winger said. Traditionally, however, nurses— and others—haven’t placed patient handoffs in the same category of concern, so reporting off to the next care provider is done almost by rote.
Winger said effective patient handoffs are a particularly salient issue in emergency departments (EDs) because they occur so often and between different levels of providers, including emergency medical technicians and nurses.
One ED’s solution
“In the past, handoff reports to inpatient nurses were very inconsistent,” said Amy Scott, MSN, RN, CPN, quality improvement program coordinator, emergency department, Children’s Mercy Kansas City. “Nurses in the ED told nurses on inpatient units what they felt was important. And if patients weren’t critically sick, a tech accompanied them to their new room. As a result, nursing staff on the inpatient units often said that they didn’t feel as if they had enough knowledge about the patient and what had been done in the ED. “Nurses in the ED also were playing a lot of phone tag to see if beds on the units were available, which took time away from patient care.”
To bolster patient safety, Scott and a team of nurses worked to develop and implement a standardized patient handoff tool and process, which included RNto- RN, face-to-face reporting at the patient bedside for ED-to-inpatient transfers. (The team included nurses from the ED and inpatient units, where RN-to- RN bedside reporting was initiated the previous year.) The goal was to have the new process up and running by March 2017. Training materials and videos also were created to help staff learn the process.
The first critical component is called PITCH, which stands for pre-inpatient telephone call handoff. The RN from the ED calls the appropriate inpatient unit to speak to an RN, which doesn’t have to be the one taking the patient, so they can prepare the room. Basic patient information also is provided, such as name, age, diagnosis, language needs, if the patient must be on oxygen or in isolation, and social concerns. At that point, the communicating RNs determine a time for the patient transfer, whether the patient will be brought to the unit or picked up at the ED, and the mode of transportation, such as wheelchair, wagon, or bed.
When the patient is transitioning from the ED to the inpatient setting, the face-to-face, RN-to-RN report is given at the patient bedside either in the ED or on the inpatient unit.
“Nurses go through a standardized process when giving their reports, and provide patient information in a set sequence,” said Scott, a Missouri Nurses Association member. The report starts with an introduction of the patient and family members to the inpatient nurse and verification of the patient’s name and any allergies. It also covers diagnosis, previous medical history, vital signs, pain score, and the ED nurse’s focused assessment of the relevant patient system. The ED nurse then logs into the computer, reviews the orders and the medication administration record, and looks for outstanding consults. Together, the nurses check the I.V. site and rates, and any wounds. The family then is asked if information was left out and if they have questions.
“The inpatient unit nurses feel they get much better reports now,” Scott said. “It’s not only more information, but the necessary information that allows us to give the best care to our patients.”
Nurses and families both have responded positively to the standardized patient handoffs, according to Scott. They had 90% compliance 120 days after the tool and process were implemented. Additionally, the collaborative approach helps nurses from the ED and inpatient units better understand each other’s clinical approaches and assessments in meeting patients’ needs.
Scott and the team members, however, continue to meet to address some of the “pain points,” such as patient handoffs around shift change and having enough transport equipment.
This safety initiative was shared during a poster session at the 2018 ANA Quality and Innovation Conference.
Easy as 1, 2, 3
Making sure patient flow actually flows—and with seamless provision of care—can be a persistent problem. However, through an innovative project, Heather Runnels, MSN, RN, CRRN, and an interdisciplinary team discovered a solution that’s aimed at making patient admissions and inpatient and ED transfers more efficient and safer for patients, physicians, and nurses.
The project was initiated after community physicians expressed difficulty directly admitting patients into Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, according to Runnels, senior director of nursing for patient care services. As Runnels and her team began systematically examining their facility’s current process of managing patient admissions and transfers, they realized it was cumbersome and inefficient, leading to delays in care and impacting patient outcomes.
“We wanted an ‘easy’ button,” said Runnels about finding an enhanced way that clinicians and patients experience the admitting and transfer process. Their solution was to develop a centralized patient referral center, which would serve as the portal for all patient flow, and a new process. Physicians were provided with education on the new, three-step model for direct admissions, which started with a call to the patient referral center. Nurses and other key staff also learned the process and model.
After calling the referral center, a clinical access nurse completes the initial patient intake process, such as addressing physician admitting orders and lab work, and then hands off the patient to a receiving nurse on the newly created express admission unit. There, fully seasoned nurses perform a head-totoe admission assessment and begin implementing the plan of care, such as administering medications, among other interventions, according to Runnels, a Louisiana State Nurses Association member.
The express admission unit is located in a former intensive care unit with an open, bullpen design, which allows nurses to easily watch patients for any status changes that may necessitate transferring them sooner or to a higher level of care. The average length of stay on the unit is about 1 hour, Runnels said.
When a bed on the appropriate unit is available, the express admission nurse provides a detailed report to the receiving, inpatient unit nurse, who no longer has to take on the extra work of handling a comprehensive patient admission on top of an existing patient- load.
“We want to make sure all nurses have the information they need and are on the same page,” Runnels said.
Hand-off reports are given in a standard manner across the hospital, using BSAP (background, situation, assessment, plan), according to Runnels. The patient’s history is given, current acute medical problems are discussed, and the patient’s vital signs, intake and output, and review of systems assessment performed by the nurse are relayed along with the initial plan of care.
Since the referral center and new process began in April 2017, Runnels said patient safety has improved. (A poster presentation on this effort was shared widely at the ANA conference.)
“Patients feel safer because they don’t feel like they are lost in the cracks,” Runnels said. “And the biggest takeaway has been improved communication, including during patient handoffs. Response has been nothing but positive from nurses receiving patients on their units since this process has been put into place.”
Winger said that implementing a standardized communication approach during handoffs—including those aided by mnemonics like I-PASS (illness severity, patient summary, action list, situation awareness and contingency planning, synthesis by receiver) and SBAR (situation, background, assessment, recommendation)—is vital. That point is emphasized in the ENA position statement, which also notes that caregivers involved in patient handoffs have different levels of knowledge, skills, and clinical judgment.
“Nurses should work with their facilities to pick a format that allows for all the pertinent patient information to be conveyed accurately,” Winger said. “If vital information is lost, patient safety is an issue.”
— Susan Trossman is a writer-editor at ANA.
The Joint Commission Sentinel Event Alert:
Emergency Nurses Association position statement:
ena.org/docs/default-source/resource-library/ practice-resources/position-statements/patient handofftransfer.pdf?sfvrsn=e2c42cb6_10
January 2019 Frontline FINAL
I am writing in support of the article written by Susan Trossman, RN “Consistent, quality communication.” The author advocates for proper use of handoff between nurses and other healthcare providers as a method to increase patient safety and enhance quality improvement. The author also identifies a significant decrease in sentinel events as the result of the implementation and proper use of handoff reporting. As a nursing student, I have been implementing and practicing handoff reporting using the SBAR mnemonic thus far, but I didn’t realize just how important this communication approach is until now. According to a report published by the Institute of Medicine (1999), “To Err is Human,” 66% of healthcare errors are related to poor working relationships and communication amongst healthcare professionals. With this incredibly high percentage in mind, it is our duty as nurses to increase our awareness of the issues that compromise the quality and safety of patient outcomes.
The author also introduced the idea of a three-step admission model which includes a referral center, an express admission unit and lastly, admitting the patient to the appropriate inpatient unit. Within the first two units, nurses perform their specific duties. The idea of the express admission unit within the model is absolutely brilliant! Because the nurses on this unit focus mainly on the initial head-to-toe assessment and the formulation of an individualized plan of care, they have the opportunity to become experts in this vital aspect of patient care. After completing the assessment and care plan, these express admission nurses then develop a detailed report to handoff to the receiving nurse on the inpatient unit, subsequently lowering his/her workload considerably. According to The National Center for Biotechnology Information (NCBI), often the initial history and physical exam lead to the identification of life or limb-threatening conditions that can be stabilized promptly, ensuring better patient outcomes. NCBI also states that in the fast-paced, resource-challenged healthcare environment today, a thorough assessment can pose a challenge for the healthcare provider but is essential to safe, quality care. By establishing units, much like those in the three-step model, issues which compromise patient safety can be greatly reduced. I strongly believe that if this system was implemented in hospitals across America, it would greatly improve and shape the future of healthcare.
Sonia Piekarczyk, RN
SUNY Downstate College of Nursing