Whether a patient is being transferred from the Emergency Department to a medical floor or from the Operating Room to the Surgical Intensive Care Unit, patient handovers are key. The clinical information provided in handovers contributes to continuity of care, patient safety, and a reduction in clinical errors.
However, multiple regulatory groups and professional organizations have identified significant shortcomings in handovers. The lack of standardized processes, structure, and documentation, as well as the failure to confirm the patient’s information contribute to the problem.
As an Internal Medicine resident at Ohio State University (OSU) Wexner Medical Center, Iahn Gonsenhauser, MD, set out to improve the multidisciplinary patient handover process as part of his research project for the ABMS Visiting Scholars Program. Launched last year, the one-year, part-time program facilitates research projects designed to improve patient care. The program also exposes the scholars to the fields of professional assessment and education, health policy, and quality improvement (QI).
The self-directed learning module developed by Dr. Gonsenhauser and his team allows providers to assess their performance and identify opportunities for improvement in their handover practices and general communications. Providers can run reports on their own performance and compare it to their peers, as well. The module offers a standardized structure for the individual patient summary using the pneumonic—O-H-I-O—as follows:
Overview – Name/location/code status
History – Status (New/Hand-Back/Discharge) (Sick/Not) (Stable/Improving/Declining) plus one line summary or principal diagnosis
Interval History – Pertinent recent changes/events
Ongoing – Action Summary – Things to do/expect overnight
Other tools include a series of checklists focusing on the handover’s structure, opportunity for feedback, and content. “Using these tools requires limited resources and takes very little time,” said Dr. Gonsenhauser, who is now an Assistant Professor Clinical in the Department of Internal Medicine, Division of Hospital Medicine. “In fifteen to thirty minutes, providers can improve the quality and safety of inpatient transitions of care using this simple toolset.”
For the Visiting Scholars research project, the efficiency, effectiveness, and sufficiency of handovers used among the Internal Medicine residents, General Surgery residents, and hospitalists were measured. An intervention group and control group were established and data was collected pre- and post-intervention for approximately 600 handovers used between October 2014 and June 2015 across OSU Wexner Medical Center, which is composed of five hospitals and a network of community-based offices and care centers.
The post-intervention handovers were rated much more reliable and complete than the pre-intervention handovers, noted Dr. Gonsenhauser, who was recently appointed Associate Chief Quality Officer. The most significant improvement was related to information added to the handovers. “Providers recognized that the additional information gave a better understanding of the patient’s status and trajectory,” he said. They had a better sense of whether the patient was improving and headed home, or whether the patient needed to be actively managed and was going to be hospitalized because of potentially getting worse.
The preliminary data also showed handovers that were very long prior to the intervention were shorter after the intervention. Conversely, short pre-intervention handovers were longer post-intervention. “We wanted them to meet in the middle because longer handovers typically included unnecessary information while shorter ones typically lacked necessary details,” Dr. Gonsenhauser said. Obtaining such consistency was an improvement because of how much variability existed among providers, disciplines, and services. “The behavior that surrounds handovers has to be one of the most widely varied processes in health care,” he noted.
And while Dr. Gonsenhauser’s Visiting Scholars project is complete, the QI effort it has inspired is far from over. The Department of Family Medicine, Surgical Services, Orthopedic Surgery, and Urology have all adopted the principles used in the module. Nursing staff in areas that have already implemented the module with their physicians are using the improved handovers. Other procedural areas, such as Interventional Radiology and Nuclear Medicine, are looking to standardize the module’s use among their nurses. More residency programs continue to incorporate it. Departments with the module already in place continue to collect data on a monthly basis as a continuous practice improvement initiative. Many departments started collecting handover data in the beginning of 2015 for new house staff. Additionally, the module will be the focus of a QI initiative for the ABMS Multi-Specialty Portfolio Approval Program, of which OSU Wexner Medical Center recently became a sponsor.
“It’s often difficult to recognize the point of completion for projects that address cultural change when the behavior you’re trying to spread becomes more ubiquitous,” he said. “It’s hard to say that’s enough since we continue to find new places to implement the module.”