Handover can be defined as the transfer of professional responsibility of patient care between clinicians (British Medical Association, 2014). It has received a lot of attention as failure to communicate vital patient information is frequent (Arora, 2005), with some research indicating that such failures have contributed to 43% of surgical adverse events. Other studies have shown that patients admitted “out of hours” (OOH) have increased mortality rates, drawing further attention to OOH handover (Aylin et al., 2010). However, research on improving handover to date is poor. Historically, approaches to improving healthcare processes either taka a bottom-up (to secure frontline engagement) or top-down approach, both of which present significant issues. Within this study, we attempted to improve the OOH handover, whilst placing an emphasis on coordinating both frontline and managerial staff in their improvement efforts.
This study took place in a 236 bed district general hospital as a before-after study over a 9-month period. Existing handover processes were analysed through a series observations and informal staff interviews. OOH handover and care processes were mapped and a staff focus group explored and identified four key issues to be addressed:
1)A lack of multidisciplinary input resulting in exclusion of some patient cohorts/staff not receiving key information
2)A narrow focused handover with no clear criteria for identifying deteriorating patients resulting in omissions
3)An uncomfortable, chaotic venue with many distractions
4)A lack of standardised processes resulting in a lack of clear management plans/pending tasks for the night
Through facilitation between frontline staff and management five changes were made:
1)Development of a Standard Operating Procedure for information handover
2)Development of a Standard Operating Procedure for identifying deteriorating patients for handover
3)Establishment of new venue
4)Creation of a new coordinator role to coordinate handover and oversee pending tasks
5)Creation of a single hospital-wide multidisciplinary OOH handover
Observational data collected pre- and post-intervention for evaluation included; meeting participation, meeting efficiency, patients discussed and information transfer.
Improvements were observed in the start time efficiency of handover meetings (36% to 75%, p=.002). Multidisciplinary participation improved, with percentage of full team attendance per handover increasing from 0% to 62.5%, p<.001. The number of deteriorating ward patients handed over also increased significantly (p=.009). There were improvements in terms of clear communication of patient management plans (p=.002) and tasks which needed to be completed (p<.001). No improvements were found in terms of diagnosis, patient history or comorbidities. The new changes had been maintained 113 days post-intervention, suggesting some sustainability which is often difficult to achieve in healthcare improvement work. Ensuring facilitation between management and frontline staff resulted in a practical solution, supported by frontline staff, that was in line with organisational aims.