toccafondi et al ahfe 2012

Handover process in multidisciplinary health care: information transfer and common ground construction

Giulio Toccafondi, Riccardo Tartaglia, Stefano Guidi, Sara Albolino

Background

Handover can be defined as “The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis”

(Wong M. et al 2008 )

In health care systems patients’ transictions between diferrent care settings are increasing in frequency. Usually more than one medical team is taking care of a patient . The transfer of patient may pose threats to patient safety.

Poor communication during the exchange of medical information contributes tohandover incidents and inefficacy of care processes

http://www.jointcommission.org/Sentinel_Event_Statistics/

According to the Joint Commission the lack of effective communication is among the main root causes for the majority of sentinel events that occurred from 2009 to 2011 in the United States

http://www.jointcommission.org/Sentinel_Event_Statistics/

Handover as Communication

The 31% of the residents indicated something had happened while they were on call that the handover had not prepared them for; and thatthe only variable influencing doctors’ perception of preparedness for their night on-call was the quality of the handover.

The handover of medical information is a communication activity which plays an important role in orienting care.

In order to make sense of patient handovers and improve them, we need to analyze the relationships between the content conveyed and the social context in which the communication occurs.

(Borowitz SM et al. 2008)

Common ground: pertinent knowledge, beliefs and assumptions that are shared among the involved parties, and support interdependent actions in some joint activity

(Clark & Brennan, 1991)

Handover as CooperationPatient handover, like all human communication, is a relational activity involving at least two actors sharing a common ground

Study Setting

Handoffs at internal

shift changes

General Intensive Care Unit ICU (10 beds)

General Surgery ward (12 beds)

Setting 2 - SECONDARY REFERRAL CENTER TERRRITORIAL HOSPITAL

Emergency Intensive Care Unit ICU (10 beds)

High Dependency Unit HDU (8 beds)

Setting 1 - TERTIARY REFERRAL CENTER TEACHING HOSPITAL

Handover

SENDER UNIT - High Acuity RECEIVING UNIT- Low Acuity


shift changes

Data on 22 transictions of care collected by 1 hospital physician and 1 nurse in each unit

High Acuity Low Acuity

Study Objective• Focus - critical handover scenario: transfer from high acuity care to low acuity care

• Objective - observe the media and work patterns enabling handover process in order to assess the level of concordance between critical care units on handover content items


shift changes

Handover


shift changes

Handover Content Items

Diagnosis and present state of the patient

Recent changes in the conditions or treatment.

Anticipation in changes of conditions or treatment

What to monitor along shifts (physicians and nurses)

Warning signs

Handover Probe

Care continuity

Anticipatory guidance

Presence of content item in discharge form Relavance and

reperebility

Type of media

Clinical information acquired by health care providers of the sender units based on their recent experience with the patient

Minimal set of information about the patient health status

Handover Probes outcomes

Collection of data on in ‘blind copy’ in two units of each setting on the transitions of care.

•Presence of handover content item in discharge form•Perceived relavance of content item•Reperebility of content item in extended patient record

High Acuity Low Acuity






Warning signs






Warning signs

Level of concurrence

Quantity and Relevance of content items

The sender unit reported the presence of a significantly higher amount of information in the DF than the recipient unit (p<0.01). The difference was only relative to the amount of information about the anticipatory guidance. (p<.0001)

The sender unit also reported the presence of a significantly higher amount of relevant information in the DF than the recipient unit (p<0.05).

Accessibility of content itemsTha average accessibility of content in the medical documentation reported by recipient unit was lower than that reported by the sender unit (p<.01).

Poor agreement between the units about the presence in DF and the relevance of items relative to predictable changes and warning signs.

Agreement among unitsP<.01

P<.05

Results in contextThe outcomes of the probes were discussed in focus groups with the health practitioners in order to contextualize the data, and understand the characteristics of the common conceptual ground.

Focus groups revealed that:

•anticipatory guidance is communicated implicitly;•the medical staff is more involved in the pre-handover than the nursing staff;•verbal and face-to-face interactions are mainly used to transmit information about anticipatory guidance

ConclusionsOur study highlighted that the handover process is shaped more by the information needs of the sender units than by those of the recipients.

The handover practices used in the settings seems to be lacking in important information connected to the anticipatory guides.

The limited participation of the nursing staff to a common conceptual ground reduces the reliability and possibility of correct interpretation of patient handovers and may contribute to adverse events.

Further research should address the interaction among sender and receiving units and the common ground construction. Focusing only on tools and media, in fact, does not allow to understand all the possible breakouts in handover processes.

Agreement among units

Poor agreement between the units about the presence in Df and the relevance of items relative to predictable changes and warning signs.

toccafondi et al ahfe 2012

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