Reducing Risk by Moving Clinical Handover to the Bedside

Sydney South West Area Health Service

Abstract

A systematic process was needed and developed to assist staff with the process of information transfer and clinical risk reduction within the Emergency Department (ED). Clinical reviews identified the clinical handover process either contributed to or failed to screen for risk or potential for error in some episodes of patient care. The clinical handover was moved to the bedside with an opportunity for patient input and staff viewing of the patient and the relevant monitoring equipment and infusion devices.

Confirmation of the clinical plan occurs with the patient clinical record with a systematic process that covers the presentation, observations, medications, treatments, plan and documentation.  What developed was a structure that enabled staff to deliver effective handover and early problem or risk identification.

Aim

Develop a reliable, safe and systematic process for clinical handover. The process should to be easy to use, transportable, identify potential issues or problems and measureable.

Nature of the Problem

There was a repetitive feature to some of the clinical incidents occurring in the ED. Missed, duplicated, incorrect medication; lack of recognition of a sick or deteriorating patient; and a lack of reference to results was a basis for error. Complaints from staff also identified time was lost correcting problems from the previous shift; clarifying if interventions / treatments were actually carried out as indicated in handover; and finding information e.g. the patient clinical record, medication and observation charts was also time consuming and provided no clinical value.

Extent of the Problem

The problem existed across all shifts throughout the department and hospital. Meetings were conducted with senior clinicians and management. Repetitive features across the units included lack of recognition of the deteriorating patient with a subsequent action and the process of clinical handover. Random clinical audits and reviews based upon clinical incidents were undertaken to identify how the problem occurred and why staff were not recognising deterioration or identifying important information at the time of handover.  The audits were conducted across the hospital and looked at the patient’s clinical presentation, admission and journey through the hospital.

Common themes were developed out of the audit results and related to interpretation of observations, clinical action, and handover of the information. Collectively the senior nurses with collaboration of medical staff developed an education and clinical handover process that would be consistently utilised throughout the ED and wards of the hospital.

Strategic Importance

The work promotes a better experience for the patient; prevents clinical error by eliminating or identifying risk; is sustainable without added cost; and provides a safe framework for motivated and skilled staff to deliver high quality service in a safe environment. Opportunities for learning and teaching are provided. A safe, reproducible and systematic process for handover is essential to ensure care is provided in the right setting. The design of a handover process must ensure that the patient is central to the process. All patients, monitors and devices are sighted, with the opportunity of patients to contribute to the discussion that occurs about them.

Planning and Implementing Solutions

The changes that needed to occur related to the development of a systematic process for handover and critical education. A two day critical education process was established. The implementation of the Present VITAL process together with a bedside handover would be established within the ED and supported by education, policy, audit and evaluation.

The senior clinicians and managers were involved collectively with the design & delivery of the education and each unit would manage the implementation of a handover process using the VITAL process as taught in the education sessions.  Clinical Handover in the ED encompassed the following features. All staff were educated about the importance of handover and the reasons for change. The clinical record would be amalgamated into one and used in handover (previously there were two separate files – nursing / observations and the medical clinical record). No other additional information is required. No other written notes are necessary or recorded separately by staff.
 

To strengthen the importance and reliability, each patient folder in the ED has the following notice placed on the front cover of the patient file.

Outcomes & Evaluation

The implementation provided several opportunities:

Audit of 161 episodes of handover. Audit period February to June 2008.
When problems arose during handover themes were developing: (n=55)

It was necessary to establish a plan for dealing with the identified problems.
Immediate – Correction before moving on. E.g. a medication given but not signed for.
Delayed - Could wait until the end of handover. Eg: Observations or documentation regarding treatment.
Hand over - Could be safely handed over to the oncoming shift for action.

Since the changes made to handover, there has been a reduction in clinical incidents reported. Improving clinical handover may have been one of the factors helping to reduce the occurrence of clinical incidents.

Sustaining Change

The process has been established into the department. All staff are orientated to the procedure and feedback is provided to staff regarding the problem themes identified during handover audits. Notices on the front covers of the patients clinical record are a constant visual reminder of the process.  The process is identified in the departmental policy manual. The senior members of the ED team are responsible for ensuring this is an opportunity for risk identification, safety and learning.

Future Scope

The process involves prospective problem identification and is applicable to any clinical unit in any hospital. To demonstrate this, the ED has engaged a transfer practice whereby the ward is to first have a telephone handover utilising the Present VITAL elements. The information is displayed at telephone points in the ED and at telephone points on the wards. The ward staff have a systematic questioning process (VITAL) for accepting patients without escort, and the ward team leader will document and ask pertinent questions. The ward staff have been empowered to identify the relevant clinical information necessary where there is no physical handover and subsequently, the ED is satisfied that sufficient clinical information is being given to the next team of care providers.

Acknowledgement

Thank you and recognition to the Clinical Nurse Consultants, Directors of Nursing, Nursing Unit Managers, ED nursing staff and supporting Medical staff of Campbelltown Hospital who assisted with the establishment of the critical education and training programme. Thank you to the reviewers.

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