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Standardizing handoff communication

Author(s): Jo Freel, MSN, RN, and Brandon Fleharty, MHA, MSN, RN-BC, PMP, CPHIMS

An electronic tool helps ensure care continuity and reduces miscommunication.

Takeaways:

  • 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.)

About handoffs

Standardizing handoff communication About handoffs

For several years, The Joint Commission and the Agency for Healthcare Research and Quality’s hospital survey on patient safety culture have cited care transitions as an area of concern. In addition to adverse events, ineffective handoff communication also has contributed to prolonged lengths of stay, avoidable readmissions, delayed or inappropriate treatment, increased costs, inefficiencies related to rework, and care omissions. Consequently, both agencies have emphasized improving and standardizing handoff communication.

Handoff is a real-time process that involves the transfer of essential patient data from one caregiver to another. This occurs several times throughout a patient’s hospital stay, so successful communication between nurses is essential to providing relevant information related to the patient’s care and condition and ensuring care continuity. Information shared during the handoff process typically includes

  • diagnosis
  • pertinent medical history
  • hemodynamic status
  • completed or pending procedures
  • care plan
  • any other pertinent information necessary for continuity.

Most communication errors occur during this information transfer, especially during shift-to-shift handoff. When handoff is compromised, the patient is placed at an increased risk for an adverse event. According to Wheeler, approximately 70% of serious medical errors are the result of ineffective handoff communication.

Handoffs completed at the patient’s bedside—which allow for direct patient visualization and communication between caregivers—improve the process. In addition, handoffs conducted at the bedside encourage the patient and family to participate in the care plan.

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.

Team-based assessment

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.

ISHAPED tool

The ISHAPED tool contains information pertinent to patient-centered handoffs. Each section of the tool should include specifics. Examples are included below.

Introduce: Allergies, code status, contact information, advance directives, provider teams, ancillary consults

Story: Hospital problem, treatment plan, admission screening information, learning assessment

History: Links to the emergency department summary, link to history and physicals in the notes, medical and surgical history, blood administration history for the past 72 hours

Assessment: Vital signs, activities of daily living, diet orders, pain management, assessments, current medications, intake and output summary, lab results, radiology results from the past 24 hours

Plan: Care plan goals, orders to be acknowledged and completed, current infusions, as-needed medications, nursing orders, patient-initiated and patient-advocate goal documentation

Error prevention: High-alert warnings, patient-specific medication information

Dialogue: Shift report given, how patient and family were involved

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.

Implementation

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.

Measuring success

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.              AN

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.

References

Friesen MA, Herbst A, Turner JW, Speroni KG, Robinson J. Developing a patient-centered ISHAPED handoff with patient/family and parent advisory councils. J Nurs Care Qual. 2013;28(3):208-16. doi:10.1097/NCQ.0b013e31828b8c9c

Jewell JA. Standardization of inpatient handoff communication. Pediatrics. 2016;138(5):e20162681. doi:10.1542/peds.2016-2681

Kear TM. Patient handoffs: What they are and how they contribute to patient safety. Nephrol Nurs J.2016;43(4):339-42.

Mardis T, Mardis M, Davis J, et al. Bedside shift-to-shift handoffs: A systematic review of the literature. J Nurs Care Qual. 2016;31(1):54-60. doi:10.1097/NCQ.0000000000000142

Nasarwanji MF, Bardir A, Gurses AP. Standardizing handoff communication: Content analysis of 27 handoff mnemonics. J Nurs Care Qual. 2016;31(3):238-44. doi:10.1097/NCQ.0000000000000174

Schuster KM, Jenq GY, Thung SF, et al. Electronic handoff instruments: A truly multidisciplinary tool? J Am Med Inform Assoc. 2014;21(e2):e352-7. doi:10.1136/amiajnl-2013-002361

Smeulers M, Lucas C, Vermeulen H. Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. Cochrane Database Syst Rev. 2014;6:CD009979. doi: 10.1002/14651858.CD009979.pub2

Wheeler KK. Effective handoff communication. Nursing Critical Care. 2015;10(6):13-5. DOI-10.1097/01.CCN.0000472849.85679.c4

Zou X-J, Zhang Y-P. Rates of nursing errors and handoffs-related errors in a medical unit following implementation of a standardized nursing handoff form. J Nurs Care Qual. 2016;31(1):61-7. doi: 10.1097/NCQ.0000000000000133.

1 COMMENT

  1. Seems a little burdensome to an already “over-charting” workday. If using EPIC, an oncoming nurse should be able to extract the needed information from the “current active orders” section the nurses notes, and “results” (labs, radiology reports, etc). RN’s can give a written report in the notes section and a verbal at the bedside…why have us chart an additional report in another section?
    Even if “ONLY” clicking buttons to transfer information into one section of the chart, it still seems like a time-consuming process multiplied by the number of patients one is assigned. So what if it saves a few clicks—takes more time to prepare each hand-off.

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