Handovers: a measurement and interventional framework

1. Handovers: a measurement and interventional framework Eleanor Robertson MB ChB, BMSc (hons), MRCS Clinical Research Fellow QRSTU, University of Oxford

2. Healthcare mindset ‘If I were there, that would have never happened.’ ‘if only they had tried harder…’ Blame culture is still prevalent within healthcare ‘of course, the outcome was inevitable…’ ‘which way?!’ Dekker, ‘the field guide to understanding human error.’

3. Swiss cheese model Wrong site surgery example Surgeon previously met patient Consent form Surgical Mark Out patient clinic letter Awake patient Pre-operative checklist WHO checklist http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html

4. In healthcare • Are we too dependant upon people making last minute saves? • Rewards • The benefits and rewards of upstream actions are difficult to pinpoint • Extra effort often goes unnoticed • The system is hungry

5. Definition of handover ‘‘The transfer of professional responsibilityand accountability for some or all aspects of the care of a patient, or group of patients, to another person or professionalgroup on a temporary or permanent basis.’’* ‘this is Mr Jones, he was found cold and unresponsive at 08.10 by his neighbour….’ ‘can you watch him for a minute while I’m on my break?’ ‘can you check room 5’s trop t at 10pm?’ ‘This young man has had a right knee arthroscopy. Same as usual. OK?’ ‘Hi there Dr Ransom, this is Dr Robertson from St Cross Hospital, we were wondering if you would be able to admit Mrs Smith to the cottage hospital for recuperation?’ *National Patient Safety Agency. Safe handover: safe patients. Guidance on clinical handover for clinicians and managers. London: BMA, 2004

6. Handover education • Only taught as communication skill • Historically given low priority • Once qualified • Apprentice learning model • Learn through doing http://caracaschronicles.com/2010/05/18/dropping-the-exchange-market-baton/

7. European Working Time Directive • Handovers have always existed • Cruciality of handover brought in to sharp focus http://www.bma.org.uk/images/safehandover_tcm41-20983.pdf

8. What does ‘right’ look like? http://www.gmc-uk.org/static/documents/content/GMP_0910.pdf http://www.rcplondon.ac.uk/sites/default/files/acute-medicine-toolkit-may-2011.pdf http://www.rcseng.ac.uk/service_delivery/working-time-directive/docs/Safe%20handovers.pdf

9. Do mnemonics hold the answer? Cost Implications  The pilot has been cost neutral and a national rollout would involve poster printing only. Is genuinechange this easily obtained?

10. Central themes • Handover is still unreliable • Point of weakness in clinical care • Approaches try to tackle the moment or handover meeting • However, handover is nestled within a wider context

11. Governmental policy Culture NHS NHS Trust Ward People & Tasks Training Money

12. Comparison • The art of clinical medicine is turning a symptom in to a diagnosis • Can we apply the same mentality to patient safety? • What clues from a handover equate to symptoms of underlying ‘disease’?

13. Occupational history & biopsy Microbiology assessment International virology comparison COUGH Targeted therapy Patch testing Biopsy Salbutamol lung function testing Drug history, stop the medicine http://blogs.pitch.com/wayward/arturo%20the%20grain%20of%20pollen.php http://pbjpaulito.posterous.com/?tag=birdflu http://brccbio205sp11.blogspot.com/2011/06/drug-resistant-tuberculosis.html

14. Handover is Complex! There is little evidence as to the actual reliabilityof clinical handovers. This is exacerbated by the fact that no universally agreed definitions or methods of studying handover exist. • Layering of task with information • Sensory information • Written augments • Varying quality • This fragile moment rests upon organisational infrastructure • Distractions, location, shifts, discipline stress, targets • Patient factors • Urgency of work is in constant flux http://www.health.org.uk/public/cms/75/76/313/587/How%20safe%20are%20clinical%20systems%20full%20length%20publication.pdf?realName=1DVi2p.pdf

15. ‘Investigations’ and ‘treatment’ • Video-reflective approach • New handover protocol • Mnemonics • Memory aids and prompts • High risk industry translational research • ‘non-technical skills’ assessment • Airlines, crew resource management, F1 what & how what & how what & how Carayon P et al. QualSaf Health Care 2006;15:i50-i58

16. Royal college of surgeons http://www.rcseng.ac.uk/service_delivery/working-time-directive/docs/Safe%20handovers.pdf

17. Royal college of anaesthetists handover audit standards http://www.rcoa.ac.uk/docs/ARB-RecoveryHandover.pdf

18. Discussion • The handover process is difficult to pin down • Are there new elements for us to observe in the handover process? • How can we target interventions for systemic change? • How do we rate quality in handover?

19. Task for us • Use the SEIPS model • Attach….. • Symptoms • Investigations • Treatment …..to appropriate section on model • Discussion

20. Many thanks…. Any comments or further chat….. …..eleanor.robertson@nds.ox.ac.uk