Purpose: To increase provider satisfaction with patient handoff in the Neonatal Intensive Care Unit (NICU) through implementation of an electronic handoff tool as well as examine the relationship between implementation of the tool and patient safety.
Methods: An electronic tool was implemented during patient handoff. Surveys were analyzed before and after implementation from Registered Nurses (RNs) who were receiving report. Additionally, patient occurrence reports were analyzed during this time to assess for any correlation with patient safety.
Findings: Results indicated that electronic patient handoff tools have the potential to increase provider satisfaction. Time spent receiving report, type of shift worked, and nurse to patient ratio can affect provider satisfaction. Occurrence reports were unaffected by implementation of the electronic handoff tool.
Conclusions: This project shows the potential impact that electronic handoff tools have on increasing provider satisfaction. Continual research to determine best practices in regards to patient safety is needed as the use of electronic handoff tools increases.
Keywords: shift report; handoff, electronic communication, computerized shift report, and patient safety.
Background and Significance
Communication has consistently been proven to be a high-risk process as it relates to the concept of patient care. Ineffective communication and documentation can lead to ineffective delivery of care and have a negative impact on patient safety (Freitag & Carroll, 2011). Patient handoffs can often be complicated by interruptions, distractions, and time constraints (Streitenberger, Breen-Reid, & Harris, 2006). With the advancement of healthcare tools and treatment options, the safe and efficient transfer of care has decreased over the years. Additionally, lack of detailed knowledge about patients and poor communication regarding plans of care consistently add to the problem with inefficient patient handoffs (Van Eaton, Horvath, Lober, & Pellegrini, 2004).
An addition was made to the Joint Commission’s National Patient Safety Goals, which state that health care systems must improve the effectiveness of communication among caregivers (Joint Commission Resources, 2007). Handoff has been defined by the Joint Commission as a means of providing accurate information about a patient's care, treatment, and services, current condition, and any recent or anticipated changes. In a recent review, more than 80 % of sentinel events stem from issues related to poor communication, continuity of care and care planning.
No best practices have been identified in the concept of the patient report, but standardizing the report and situational briefing techniques such as Situation Background Assessment Recommendation (SBAR) are recommended by the World Health Organization (World Health Organization, 2007). Standardization of patient handoff has been shown to increase communication of crucial information regarding patient care to include previous hospital events and treatment goals for the future (Collins, 2012). The Joint Commission also recognizes standardization as a way to ensure high quality of care and optimize patient safety during handoffs (Arora & Johnson, 2006).
The NICU or intensive care unit of any type can prove to be dynamic and fast paced. Additionally, this population proves to be even more challenging for giving and receiving patient reports because the patients cannot advocate for themselves. The patient’s individual handoff requires extensive amounts of information exchange due to complexities of illnesses and frequent interventions (Jagsi, Kitch, Weinstein, Campbell, Hutter, & Weissman, 2005). Many NICUs have transitioned to electronic documentation, making paper report tools time consuming and sources of error for transcribing information. Barriers to implementing electronic standardized tools include staff resistance to change and the requirement for tailoring such tools to each specialized unit to increase efficacy.
Review of Literature
Articles from the years of 2007-2013 were retrieved in the literature review. These articles were retrieved using MUSC Library database and included searches in Medline, CINAHL, and Pub Med. Additionally, references from articles retrieved from these databases were also utilized. Search terms included “handoff”, “handover”, “communication”, “patient safety”, and “medical errors”.
Although currently there are no best practices for improving handoff communication, incorporating situational briefing techniques such as the SBAR (situation, background, assessment, and recommendation) process, as a standard communication framework may be of assistance (World Health Organization, 2007). One reason that ineffective communication is such a problem is that staff members may not realize how important the process of handoff communication is to the well-being of their patients (Freitag & Carroll, 2011). By educating staff on the importance of accurate documentation and effective communication regarding patient handoff, accuracy and completeness of information relayed can be increased with the potential for positively impacting patient quality of care (Ahmann, 2004).
A systematic review completed by Collins (2011) examined content overlap, artifacts in handoff and the future of electronic health records (EHR) in patient handoffs. The review demonstrated that challenges of creating standardized documentation tools are related to the many types and varieties of patient handoffs. However, when electronic documentation was used successfully, daily workflows were enhanced, and communication between healthcare providers and patient’s quality of care was increased (Collins, 2011).
Reviews aimed at studying implementation strategies have identified that education should focus on barriers related to individual caregivers and tailored to different groups of stakeholders (Ploeg, Davies, Edwards, Gifford, & Miller, 2007). Also identified is that factors associated with the highest success rate of practice change include educational interventions, multifaceted interventions and reminder systems (Grimshaw, et al., 2004). The most commonly reported barriers to implementation include time restraint, workload, lack of access to resources, and staff resistance to change (Ploeg, et al, 2007).
The purpose of this project was to increase provider satisfaction of handoff communication in a Level III NICU. This includes increasing accuracy and efficiency in patient handoff. The current practice includes completing shift report using a paper tool. This was modified by implementing the use of a standardized, electronic handoff tool called the “Mpage”. Incomplete documentation on a paper tool increases the possibility of incomplete or over-education of imperative information or procedures that could compromise patient quality of care (Collins, 2011). With an electronic tool, physician orders and other patient variables are automatically populated over, cutting down the opportunity for errors in transfer of information to paper forms.
Provider satisfaction around handoffs has not been shown to have a direct effect on patient safety. However, low scores are unacceptable because satisfaction with communication has a positive association with job performance (Streitenberger, Breen-Reid, & Harris, 2006). Therefore, improving handoff communication has the potential to improve patient safety by increasing provider performance. Benefits other than improving provider communication include increasing awareness of the importance of effective handoff communication and serving as a way to educate staff on the essential components of quality handoff communication.
In the hospital setting, the primary function of the handoff is to communicate patient information to facilitate continuity in the plan of care. Also included in patient handoff is general information about unit activities, staffing, and other organizational factors that may have an impact on care delivery. Other functions of the handoff include education, team building, social interaction, and networking (Streitenberger, Breen-Reid, & Harris, 2006).
One of the most effective ways to reduce error is to standardize and simplify processes to minimize risks associated with human functions. A standardized electronic handoff tool is one way to organize content of information, reduce variability between practitioners, and ensure that critical information is communicated during the handoff process. One study even showed that standardization of the handoff instrument results in improvements in caregiver perceptions regarding accuracy and completeness (Bakken, 2004).
This project was focused on improving provider satisfaction with patient handoff at shift change in a Level III NICU, leading to a clinical outcome of improving patient safety. Evaluation of such an intervention is just as important to success of implementation as the intervention itself (Marcellus, Harrison, & Mackinnon, 2012). Therefore, the Plan-Do-Study-Act Model was utilized in this project to implement and evaluate a standardized electronic patient handoff tool aimed at increasing caregiver satisfaction with patient handoff. This allowed the effect that provider satisfaction had on patient safety to be analyzed. Any planned intervention in the NICU involves a multitude of healthcare providers. The PDSA cycle has been shown to be effective in implementation and evaluation of a process that involves multiple caregivers (Marcellus, Harrison, & Mackinnon, 2012).
Through the use of an electronic survey, RNs responsible for patient handoff communication reported their satisfaction with the patient handoff that was received from the outgoing shift. Additional questions were aimed at determining ease of use, time in minutes spent on patient handoff, accurateness and thoroughness of patient information, number of patient’s cared for, if the electronic tool was used, and type of shift worked. After these responses were noted, an educational PowerPoint aimed at increasing awareness and understanding of the electronic tool was sent to staff for review. This occurred for the duration of three weeks before the education of staff and then again beginning one month after the implementation of the standardized electronic document, for measurement at three and six weeks.
The sample population surveyed with the questionnaire was the same pre-intervention and post-intervention. On this unit, nurses responsible for direct care are RNs and all are females. The population surveyed with the pre-intervention questionnaire included the RNs responsible for the direct care and completion of the current forms. There are generally two shift changes a day with all nurses working a 12 hour shift from 7am to 7pm and then 7pm to 7am. There are circumstances when a patient is transferred to the step-down unit that is also a part of the NICU. This can happen at times other than 7am and 7pm in which there may be more than two patient handoffs a day. Admissions from other areas of the hospital were not be included in this project, as these other areas do not currently use the same paper patient handoff form so pre and post comparisons would not be possible.
Previous research on increasing electronic documentation has led to the discovery of some potential roadblocks to successful implementation. In specialized units, such as NICUs, standalone tools specific to these units must be customized to fully utilize the benefits of electronic documentation (Palma, Sharek & Longhurst, 2011).
This project’s intervention included multiple parts with the ultimate goal of increasing provider satisfaction with patient handoff in order to increase patient safety. After gaining IRB exemption, an electronic survey was administered to RNs responsible for patient handoff. The goal of this survey was to assess provider satisfaction with the current paper handoff form. The survey was given a three-week time frame for completion. After barriers were identified through the survey, an educational PowerPoint to address these barriers and stress the importance of handoff communication was created and distributed via work email to the same staff members. The PowerPoint included a description and screenshot of the electronic form, and instructions on when to complete the survey after intervention had begun. A helpful tips sheet was also placed in the charge nurse notebook and NICU resource books at each bedside station. The survey was then re-administered post-implementation and data were collected at the three and six-week post implementation mark.
Individual, organizational and environmental factors are all critical to address in successful practice change (Ploeg, et al, 2007). The PowerPoint addressed individual barriers that could influence practice. Environmental factors were addressed by placing educational flyers in the nursing lounge and most viewed areas throughout the unit. Organizational support was attained through leadership with the current staff educator and nurse manager. Constant communication with leaders was maintained throughout the implementation and review process. Handoff-related occurrence reports were also monitored during the same time frame the surveys were analyzed.
The instrument measured was the provider satisfaction survey sent before and after the implementation of the electronic form. Likert-style questions were used to collect baseline data and to later measure the effectiveness of the new process. Survey questions targeted the Joint Commission's guidelines for handoff communication and were previously utilized by Manser, (2010) for the same purpose. Although this survey is intended to assess the quality of handoff communication and provider satisfaction, it is not validated. Additional questions added to the survey assessed time spent receiving report, shift worked, number of patient’s report received and if the electronic tool was utilized during the report.
The pre- implementation survey results guided implementation of an educational slideshow that highlighted tips and the importance of patient handoff accuracy as it relates to quality of care. The slideshow also addressed the implementation of the electronic form to be used during patient handoff. The survey and slideshow were both distributed electronically via staff email.
The primary measure was provider satisfaction, reported as overall handoff score, (OHS). Secondary outcomes included the use of components outlined by the Joint Commission's guidelines for safe handoff. Data was collected using a Likert-style survey as well as numeric answers for “time spent in minutes receiving report” and overall handoff scores (0-10 with 10 being the best possible score). Compilation was done using Microsoft Excel software. Surveys pre-intervention and post-intervention results were an indicator used to determine if the education was beneficial and if the electronic forms increased provider satisfaction. Additionally, occurrence reports completed by unit staff during the same time period pre and post intervention were analyzed to determine if the “occurrence” or “near miss” was related to patient hand off.
Collection of data measuring staff’s satisfaction of the paper form took place through an electronic survey administered via staff email. This data was then analyzed by the NICU staff educator and the project coordinator in order to create an effective online educational Power Point aimed at increasing provider understanding on the importance of patient handoff and the electronic form. Data from the surveys were analyzed before and after the implementation. The oncoming RN completed the survey for each shift worked during this time frame. The overall results were then analyzed with occurrence reports during the same time frames. Occurrence reports were included and recorded as an instance if they were found to be handoff related occurrences or near misses.
No identifying names or personal characteristics were recorded or utilized in this project. Demographic information from the staff survey included usual shift worked, time in minutes receiving report and understanding on importance of accurate patient handoff. Data collection on occurrence reports occurred on site with the permission of unit management. The Intranet used was password protected, confidential and only accessible onsite. As employees of the hospital system, the NICU staff educator and the project coordinator had access to this system. Data collected from the surveys were compiled and analyzed via Microsoft Excel. The surveys held no identifiable information, were completed onsite and electronically. Each computer throughout the entire unit had access to the Internet so lack of accessibility was not a barrier to completion of surveys. The link to the survey was sent to each employee’s email account and was also placed in the Charge Nurse notebook for quick reference.
Increased provider satisfaction with patient handoff as well as decreased handoff-related occurrence reports were both expected outcomes of this intervention. Additionally, understanding of staff on the electronic form and importance of the accuracy in patient handoff was anticipated. It was expected that with need-based education to increase provider knowledge related to patient handoff, the overall quality of care for the patient and family would be increased as evidenced by increased provider satisfaction.
The sample population was all female and all were RNs with at least an associate’s degree in nursing. The pre-intervention sample had 41 responses and was balanced with 48% from day shift (7am-7pm) and 52% from night shift (7pm-7am). The post-intervention six-week sample had 53 responses that were comprised of 47.2% day shift and 52.8% night shift responses. The post intervention six-week sample had 55 responses and was again quite even with 46.6 % day shift and 53.4 % night shift. Table 1.1 shows in detail the results broken down by question asked. This information indicates that type of shift alone did not influence the outcomes of our intervention.
Table 1.1. Survey Question Results Broken Down By Question Asked.
Occurrence reports were analyzed and marked as “handoff-related” if they could have been avoided with improved communication during the handoff process. During the pre-intervention period, there was one known instance. Additionally, at three weeks post-intervention, there were two known instances. At the six-week mark, there was only 1 known instance for the time period measured. See Figures 1.1 and 1.2 for a comparison of OHS compared to occurrence reports.
Figure 1.1 Overall Handoff Score Compared to Handoff Related Incident Reports Pre-Intervention, 3 Weeks Post Intervention and 6 Weeks Post Intervention.
Figure 1.2. Percentage of Handoff Related Occurrences.
As expected, initially there was an increase in handoff related occurrence reports due to the newness of the electronic tool and the effort put forth by the staff to achieve a 73% usage rate of the electronic tool during the same time frame. However, 6 weeks post-intervention the decrease in handoff related occurrence reports fell back to one which was promising since there was a 75% usage rate of the electronic tool.
OHS prior to intervention was considerably high taking into account the culture of the NICU. As indicated previously, often there is little time for patient handoff and many times, the conditions of the patient are so complex that there are multiple topics that need to be addressed during the handoff. Pre-intervention, OHS was reported at an average of 8.95. Post-intervention, at six weeks the average was 9.1 followed by 9.0 at 6 weeks. The increase in OHS during these time frames is promising and although there was a slight decrease from the three to six week marks, the final OHS was still higher than pre-intervention, which suggests some success from the intervention.
Unit census during these times and nurse to patient ratio could also have significant impact on perceived quality of OHS. Pre-intervention and three weeks post-intervention, the highest average nurse to patient ratio was 1:3. However, six weeks post-intervention, the highest average nurse to patient ratio was 1:2. This decrease in nurse to patient ratio could have also had an impact on the 75% usage rate as well as the OHS.
Another factor addressed is the time in minutes spent receiving report in relation to the OHS. Pre-intervention, the average time in minutes spent receiving report was 12.1. At three weeks post-intervention, the average jumped to 15. Finally, at six weeks, the average decreased back to 12, which corresponded well to the initial average pre-intervention. This is significant in that a brand new electronic tool was used on average 75% of the time during this timeframe. In addition to the implementation of the electronic tool, the decreased nurse to patient ratio from the three- to six-week post-intervention mark could have affected this time in minutes as well. See Table 1.1 for a full analysis of data compiled from the staff surveys.
Table 1.1. Survey Question Results Broken Down By Question Asked.
This project had several limitations. This was a practice improvement project that used a convenience sample, since the survey was not mandatory. Participation in the survey was dependent upon each oncoming RN. There was equal involvement between night shift and day shift but complete participation in the surveys was not achieved. Additionally, NICUs across the country differ in culture, nurse to patient ratios, as well as bed spaces. Finally, the OHS that was used in this project has previously been utilized, but it is not validated.
This project shows the potential impact that electronic hand off tools can have in increasing provider satisfaction. The lack of increase in handoff-related occurrence reports with the implementation of the electronic tool is promising. Continual research to determine best practices in regards to patient safety is needed as the use of electronic hand off tools increases. Also, due to the complexity of NICU environments all over the world, further research in NICU specific demographics is needed.
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Rachel Dyches BSN, RN Rachel is attending Medical University of South Carolina to earn her MSN/DNP combined, focused on Family Practice Nurse/Nursing