An electronic tool helps ensure care continuity and reduces miscommunication.
- Using a standardized electronic handoff tool improves nurse-to-nurse communication.
- It ensures care continuity and reduces adverse events.
Although adverse events can occur anytime during hospitalization, handoff communication is often the cause of avoidable adverse events. Miscommunication, care continuity disruption, critical data omission, medication errors, and serious adverse outcomes during handoffs create a vulnerable gap in care. (See About handoffs.)
Nebraska Medicine, an academic medical center in Omaha, recognized the variability in its handoff process across units and disciplines. Although the organization used the SBAR (Situation, Background, Assessment, Recommendation) tool for handoffs and encouraged patient and family participation in the process, an opportunity for improvement and reduced variability existed. The organization noted that any lack of standardization placed patients at increased risk for medical errors and serious adverse events.
Because the greatest number of handoff opportunities occur during shift-to-shift transitions, Nebraska Medicine chose to focus its initial efforts on improving the process at this level. Using The Joint Commission, Agency for Healthcare Research and Quality, and National Quality Forum recommendations for standardized and systematic communication, Nebraska Medicine aimed to design a project centered on creating a standardized shift-to-shift handoff tool and process for all inpatient nurses. Ideally, handoff would be a streamlined process between the outgoing and oncoming nurses at the patient’s bedside with limited interruptions, individualized care plan communication, and patient and family inclusion. Active communication between nurses is essential to ensure a comprehensive handoff.
Nebraska Medicine created a project team to produce a standardized handoff tool and process. The team consisted of leadership from nursing professional practice and development, enterprise applications (electronic health record [EHR] analysts), clinical effectiveness, and clinical decision support. The team started by working to understand the negative issues related to the current handoff process. The inpatient oncology and hematology specialty care unit expressed an interest in working to improve its handoff process, so the project team engaged unit leadership and staff to help during the initial phase of the project, identifying gaps in information and processes.
As the project progressed, the hospital’s shared governance practice council was brought in because it would ultimately be responsible for the handoff process. A sub-committee of the practice council was created to work with the project team to research existing handoff tools and build a tool to better meet the organization’s needs. The team reviewed the current SBAR handoff tool, listing its pros and cons, and then investigated other tools. The project team looked for tool content that would meet the needs of Nebraska Medicine and use various aspects of the EHR to provide ease of content identification. They wanted a tool that could document dialogue between the outgoing and oncoming nurse, identify patient-specific quality and safety issues that might influence outcome improvement, and allow the receiving nurse to ask questions and clarify content (active communication).
After careful deliberation, the project team recommended the ISHAPED (Introduce, Story, History, Assessment, Plan, Error Prevention, and Dialogue) patient-centered bedside report tool to the shared governance practice council. (See ISHAPED tool.) The INOVA Health System created the ISHAPED tool in 2010 to standardize patient-centered bedside handoff with face-to-face communication between caregivers. The tool was created in a paper format, but the project team at Nebraska Medicine preferred an electronic tool that could be updated in real-time and considered the “source of truth” (meaning that everyone would be using the same tool to gather data needed for handoff). They proposed using the foundation of the ISHAPED tool but incorporating it into the EHR. The shared governance practice council approved the proposal, and the practice council sub-committee began work with the project team to build the electronic ISHAPED handoff tool.
Usability and design
The ISHAPED electronic handoff tool was designed to guide nurses through pertinent patient information gathered from other parts of the EHR, such as patient demographics, medical history, nursing documentation, patient-specific risk assessments, and orders. Nurses would still be expected to use standard tools for managing labs, orders, or imaging results as designated by the organization. As appropriate, the ISHAPED tool pulls patient information into the designated ISHAPED section or hyperlinks to the area in the EHR. Displaying only pertinent items reduces the time needed for staff to process and communicate information. ISHAPED is designed to serve as an information repository rather than a documentation tool. As a result, the corresponding handoff process requires that all other nursing documentation in the EHR must be completed before the handoff report.
As patients transfer between care areas, the ISHAPED tool displays information specific to the patient’s current location. This design feature allows nurses participating in handoff communication to review the most crucial information related to the patient’s transfer. Visualizing the same information during handoff communication creates an environment for nurses to have meaningful conversations about patient needs at various levels of care. As the handoff tool was implemented, new care area designs were integrated into the existing framework for seamless application across the organization.
The shared governance practice council and subcommittee served as ISHAPED champions throughout the organization. Training and education were developed using an e-learning module to introduce staff to the ISHAPED tool and set expectations for its use. An interactive feedback form embedded within the tool encouraged staff to provide real-time recommendations for improvement and to determine whether suggested enhancements are functionally possible within the EHR system.
The handoff tool was rolled out for use in both shift-to-shift and unit-to-unit transfers (for example, emergency department [ED] to an inpatient unit, inpatient unit to a procedural area, ambulatory clinic to the ED). Several areas—including obstetrics, neonatal intensive care unit, ED, and the infusion center—required customized builds because of unique patient populations.
Success was measured using three outcomes. First, the team reviewed the overall effectiveness of the tool, including use, nursing overtime data, number of adverse events related to handoff communication, and quality data. The results indicated that the tool effectively improved each factor. The second outcome measure was engagement. The team reviewed patient and family satisfaction from the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Nursing engagement was evaluated using a Survey Monkey assessment tool. Third, efficiency of the ISHAPED tool was measured by reviewing the overall design, conducting a Survey Monkey assessment, and evaluating the number of clicks nurses made within the tool. Initial usability studies to evaluate overall efficiency found that the tool decreased the number of clicks necessary to find pertinent information. Patients, families, and many nurses were satisfied with the ISHAPED tool; however, some nurses indicated resistance to adopting it.
Recommendations for practice
Handoff communication remains a high-risk activity. Translating processes from other safety methods, such as medication administration, to the handoff communication process will lead to more effective and safer handoff practices. Handoff should be completed separately from other nursing actions and
include the patient and family to decrease medical errors and enhance communication between the healthcare team and the patient. Active participation by patients and family members promotes an environment that improves patient safety and quality by allowing patients and families to clarify and correct potential inaccuracies.
Healthcare safety transparency is a public concern. The rollout of the ISHAPED tool at Nebraska Medicine has demonstrated a decrease in adverse events related to communication errors and an improved culture of awareness of the benefits of a standardized electronic handoff tool.
Access references at myamericannurse.com/?p=72775.
The authors work at Nebraska Medicine in Omaha. Jo Freel is a nursing practice specialist in the department of nursing professional practice and development. Brandon Fleharty is an application manager for enterprise clinical applications.
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