Development of a Nursing Handoff Tool: A Web-Based Application to ...

Development of a Nursing Handoff Tool: A Web-Based Application to Enhance Patient Safety Denise Goldsmith, RN, MS, MPH1, Marc Boomhower, RN, BS1, Diane R. Lancaster, RN, PhD1, Mary Antonelli, RN, MPH1, Mary Anne Murphy Kenyon, RN, MPH, MS1, Angela Benoit2, Frank Chang2, Patricia C. Dykes, RN, DNSc2,3 1

2

Brigham and Women’s Hospital, Boston, MA; Partners Healthcare System, Boston, MA; 3Department of General Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

Abstract Dynamic and complex clinical environments present many challenges for effective communication among health care providers. The omission of accurate, timely, easily accessible vital information by health care providers significantly increases risk of patient harm and can have devastating consequences for patient care. An effective nursing handoff supports the standardized transfer of accurate, timely, critical patient information, as well as continuity of care and treatment, resulting in enhanced patient safety. The Brigham and Women’s/Faulkner Hospital Healthcare Information Technology Innovation Program (HIP) is supporting the development of a web based nursing handoff tool (NHT). The goal of this project is to develop a “proof of concept” handoff application to be evaluated by nurses on the inpatient intermediate care units. The handoff tool would enable nurses to use existing knowledge of evidence-based handoff methodology in their everyday practice to improve patient care and safety. In this paper, we discuss the results of nursing focus groups designed to identify the current state of handoff practice as well as the functional and data element requirements of a web based Nursing Handoff Tool (NHT). Introduction In 2006, the Joint Commission introduced a National Patient Safety Goal that requires hospitals to implement a standardized approach to hand-off communications.1 Failures in communication between healthcare personnel are known threats to patient safety. These failures account for over 60% of root causes of sentinel events reported to The Joint complex clinical Commission. 2 Dynamic, environments that can be found at the Brigham and Women’s Hospital (BWH) in Boston present many challenges for effective communication among health

care providers. The omission of accurate, timely, easily accessible, vital information by health care providers significantly increases risk of patient harm and can have devastating consequences for patient care. The transfer of essential patient information between nurses at change of shift or when patients are moved from unit to unit, or for meal breaks is known as a “handoff”. An effective handoff supports the standardized transfer of accurate, timely, critical patient information, as well as continuity of care and treatment, resulting in enhanced patient safety. Ineffective handoffs contribute to gaps in communication and increased risk to patient safety. A major limitation of the existing nursing handoff process at BWH is its lack of standardization. Additionally, while a minimum dataset of information is currently standardized by nursing department policy, the remaining majority of information included in a handoff is not. This situation dramatically increases the chances of handoff errors and thus risk to patient safety which could result in unreported decline in patient condition, lack of communication of critical test results, and missed treatments. In a given year at BWH, the number of handoffs that occur among nurses alone for transfer of care, is approximately 2 million, and as such, illustrates the high potential to miss the communication of a critical piece of information at each transition point. This multiplicity of handoffs has been shown to potentially result in a progressive loss of information known as “funneling,” a situation where certain information is missed, forgotten or otherwise not accurately conveyed. 3 At Brigham and Women’s Hospital, Computerized Provider Order Entry has been in place since the 1990s 4 and barcode based electronic medication administration records (eMAR) have been in place since 2005.5 BWH is currently undertaking a large

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inpatient electronic documentation initiative known as Acute Care Documentation (ACD). While this project will have as an outcome a set of standardized nursing documentation tools including flowsheets and notes, it does not, at this time, include a standardized mechanism for nursing handoff. The Brigham and Women’s/Faulkner Healthcare Information Technology Innovation Program (HIP) is supporting the development of a web based nursing handoff tool. The goal of this project is to develop a “proof of concept” handoff application to be evaluated by nurses on inpatient intermediate care units. The handoff tool will enable nurses to use existing knowledge of evidence-based handoff methodology in their everyday practice to improve patient care and safety. The two nursing workflows that will be impacted, first in the pilot units, and then subsequently across BWH intermediate care units are: 1) routine change of shift nursing handoff and 2) the practice of placing a patient in the temporary care of a nursing colleague. The handoff tool will be accessed through the Clinical Workstation and therefore will be easily accessible within the current workflow of the nurse. Background Multiple reports in the literature have called for systems that allow ease of access to accurate information to improve hand-offs. 6 , 7 , 8 , 9 A standardized method to guide the transfer of critical information has been recommended. 10 , 11 , 12 , 13 , 14 , 15 Pothier et al,16 examined three different methods for transferring information during five consecutive simulated handoffs of twelve patients. The method demonstrating the greatest amount of information retention involved a verbal report and use of a preprinted form containing essential clinical data, followed by the verbal report and note taking method, and lastly, only verbal report. The amount of data retained for each of the three handoff methods varied considerably. This study demonstrated the need to standardize handoff data and tools and eliminate reliance on verbal-only reports, in order to optimize communication among clinicians and safety for patients. Methods The Spiral method for software design and development was used to identify requirements and to build the NHT. The development was conducted using an iterative approach over a series of four phases: (1) Requirements gathering, (2) Design, (3) Build, and (4) Test. Development continued until the final product was considered ready for release.

The research team conducted focus groups with approximately 60 unique clinical nurses to document the current state of nursing shift to shift handoff and to identify and define critical data elements and design/workflow requirements for the handoff tool. After obtaining approval from the Partners HealthCare Institutional Review Board (IRB) nurses were recruited for participation through focus group interviews. Nursing leadership at the participating hospital identified potentially “good informants,” professional providers who could articulate their experiences and who participate in nursing practice committees at BWH. 17 Potential participants were contacted via email and invited to participate. Once verbal consent was obtained, participants were scheduled for a focus group interview, and asked to be thinking about patient handoff practices on their care units. Using a semi-structured interview guide, interviews were conducted to explore the current state with regard to patient handoff including best practices and areas where improvement is needed. Data collection included tape recorded focus group interviews to learn about current handoff practices from the perspective of nurses working on acute inpatient care units. We followed basic content analysis methods 18 to interpret descriptive data obtained from individual and focus group interviews. The tape-recorded focus group discussions were held in a private conference room at the hospital. A discussion guide was used, but the approach was individualized to guide participants to help us understand what they do and perceptions of barriers and facilitators to effective handoff practices. Notes were taken to guide specific follow-up questions. Probes, such as “Tell me some more about…, Help me understand…,” were used. Research team members took notes during the discussion and kept reflective notes during the qualitative phase. The group interviews were transcribed, reviewed/corrected for transcription accuracy and removal/masking of any identifying characteristics of patients or team members for coding and support of analysis. The research team participated in identifying themes and achieving consensus for the analysis. We then used a process of debriefing among researchers, engagement with the raw data and codes, and employed field and reflective notes to assure reliability and validity. The Qualitative analysis of focus group content was completed and key themes were identified and translated into handoff tool requirements.

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Once the initial set of requirements was established, the development team worked with appropriate IS groups to secure relevant information to autopopulate NHT. For example, web services were used to get information for the following data: Patient demographic data, labs, medications, and allergies. The application was subjected to usability testing, underwent iterative changes and then when deemed ready by the development team was made available for pilot testing in the live environment. The application was accessible only to nurses who cared for patients on the experimental unit.

Barriers to use of Handoff Tool (cont’d) Facilitators to use of Handoff Tool

Inability to capture individual patient issues with a standardized tool Current verbal report allows for questions/clarifications, Interruptions A link between handoff tool and MD Orders, Plan of Care, Test & Procedures Results Current taped report is less focused, can’t remember follow-up questions, may be out dated

Results Current Nursing Handoff Practice

Functional Requirements for NHT

From the focus group interviews the research team identified six key themes related to current handoff practice. Within each of the themes there was significant variability in the current state of nursing handoff practice. Table 1 outlines the key themes identified from qualitative analysis of focus group content.

In addition to key themes related to current handoff practice, the functional requirements found in Table 2 were identified by the focus groups as crucial to the success of an electronic sign-out solution.

Table 1: Current State Theme Handoff Method

Use of Handoff Guidelines

Handoff Workflow

Handoff Errors

Barriers to use of Handoff Tool

Content Variability Taped Verbal Computer print out Combinations of above Local standardized form BWH Nursing policy TJC elements MD Sign-out sheet Daily MD Goal sheet Receive on all/own patients Receive before/after assignment Receive at bedside Receive outside room Receive in conference room Person to person/Person to Group Omissions Forgotten information Miscommunication of information Discrepancies of information Time for data entry Computer literacy Maintaining currency/reliability of data Documentation redundancy of handoff data Information overload De-emphasizes face to face dialogue

Table 2: Functional Requirements for NHT

















Leverage existing workflow and systems Pull forward key information from existing systems to pre-populate fields Avoid redundancy, avoid information overload Flexible/tailored to target population Include plan/tasks/follow-up for next shift Support layout preferences Access to all clinicians Reports persist for defined period Display last updated date and time Printing capability Multiuser capability Individual patient/Multi-patient views Links to resources Static header with required data elements Fast, efficient Downtime Plan

Critical Data Elements for NHT The critical data elements, found in Table 3, were identified as crucial to the success of an electronic nursing sign-out solution. The first six items on the list clearly cross all disciplines with regards to relevance. The rest are likely to be most relevant to the clinical nurse providing care. These data mostly represent content related to nursing actions, knowledge, and reasoned judgments, combined with care decisions.

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Table 3: Critical Data Elements for NHT







Current Date, Date of Admission Full name, Room #, DOB, Age, Gender, MRN, Language Code Status, Allergies, Precautions Medical Diagnosis, PMHx, Procedure/Surgical Pending tests H.O. coverage (with pager #) (PEPL)

















Safety Concerns Restraints Risk for Falls Mental Status Skin Integrity Wound Care Dietary Needs/Restrictions Activity Restrictions Elimination Issues Pain Med (last dose) Tubes/Drains Care IV Fluid Status Telemetry Status Oxygen Requirements

so a standard set of data from these sources will automatically populate the corresponding fields on the NHT. Additionally a core set of standard data elements was designed into the tool so that handoff data is standard across all patient care units. To maintain current information in the NHT, nurses are required to update the NHT at shift change, and update critical information throughout their shift as needed. Compliance with the use of the NHT would be a mandatory practice change for all intermediate care unit nurses. This practice change is supported, and will be reinforced by nursing leadership. Success Criteria: As part of our pilot study we will measure the success of the project using the following criteria: 1. 2.

Discussion In this paper, we discuss the results of nursing focus groups designed to identify the current state of handoff practice, the functional and data element requirements of a web based Nursing Handoff Tool (NHT). Through this work we validated handoffs in care are important to nurses and current systems are sub-optimal in terms of patient safety and efficiency. Like sign-out systems for ordering clinicians, handoff systems for nurses must be integrated with existing systems to support work-flow and eliminate redundant data entry. In the cases of nurses, this requires integration with CPOE orders, nurses Plan of Care (POC), and information regarding orders for, and results of tests and procedures. A major limitation of the existing BWH nursing handoff process is its lack of standardization. Shift to shift handoff methodologies can vary from verbal, taped, or written reports as well as combinations of all three. Additionally, while a minimum dataset of information is currently standardized by BWH nursing department policy, the large majority of information included in a handoff is not. This situation increases the chance of handoff errors and thus risk to patient safety. It is anticipated that the newly developed web based handoff tool will interface with existing web services

3.

Extent to which the NHT meets data capture requirements identified in focus groups. Application usability. • Nurse survey to rate usefulness, ease of use, feasibility and user interface. • Nurse satisfaction with the extent NHT meets data capture requirements • Nurse satisfaction with workflow integration Extent of usage • Measure the % compliance with usage for shift to shift and meal break handoffs • Measure the frequency with which the tool is updated during a 24 hr time period.

Conclusion The single biggest problem in communication is the illusion that it has taken place. Such is the case with our current handoff system. We expect that the handoff tool, developed as part of this work, will serve to reduce; 1) inaccuracy of data transfer, 2) missing critical information, 3) funneling, 4) data transcription error, and 5) time to prepare and give handoff report. Future study of this tool will help to determine if we have achieved any or all of these objectives.

Acknowledgements The authors would like to acknowledge the BWH clinical nursing staff who participated in the focus groups for their time and expertise; and to the Brigham and Women’s/Faulkner Hospital Healthcare Information Technology Innovation Program (HIP), for their financial support of this work.

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