Context This project aimed to improve handover for paediatric medical specialties, paediatric surgery and general paediatrics at a regional tertiary paediatric centre. As well as doctors of varying grade and specialty, others involved include the nursing outreach team and bed manager.
Problem Handover occurs three times a day and with 50–80 complex patients it needs to be an efficient process ensuring patient safety and communication of essential appropriate information. Issues around the quality and safety of handover were highlighted from clinicians within the department, trainee feedback and the GMC survey.
Assessment of problem and analysis of its causes Baseline measurements were obtained over 16 consecutive handovers. Measures included: start time, length of handover, number of bleep interruptions, time of specialty handover, and missed patients.
Problems identified included:
Late specialty handovers resulting in delays to commencing shifts
Frequent non-urgent bleeps interrupting flow and causing distraction
Patients not handed over in order meaning patients ‘missed’
Multiple late ‘corridor handovers’
These findings were presented to different stakeholders to address concerns, identify good practice and suggest areas for improvement. Suggestions included; introduction of a handover checklist, reminders on ward phones of protected handover times, and the introduction of a traffic light system to classify patients into an acuity category.
Intervention Utilising small tests of change (PDSA cycles) we implemented sequential changes. For example a handover checklist was introduced at the start of each handover. Simple additions such as shutting the door gave clear non-verbal clues to people who were late. Stratifying patients according to traffic light acuity red (un-stable) amber (potentially unstable) and green (stable and on pathway) helped keep handovers focused.
Strategy for change These changes were introduced and measured over an additional 16 handovers with continual feedback from junior doctors and outreach nurses. The consultant body was kept informed by the project lead.
Measurement of improvement Measurements were undertaken over specific periods rather than continually. The project began in the quieter summer months with lower total patient numbers and the 3rd data collection is from November during busier times on the unit.
Effects of changes Several small changes have considerably improved the handover process. Verbal feedback has been really positive. Some of the initial changes have now been incorporated into the trust-wide computer system and are now used routinely in adult practice.
We are continuing to measure variables and make changes. Uptake of some of the changes is variable (see results, Table 1), however as we reinforce successful changes and introduce handover education into induction, we hope to make adjustments standard procedure.
Next steps are to develop a standardised structure for handover of patients according to acuity category. This will be linked to need for review and outreach involvement.
Lessons learnt Getting buy-in from the consultant body and key stakeholders has been paramount. The senior lead empowering the juniors who are present on a daily basis to continue change when faced with those less willing to engage in a new process has been essential to success.
Using regular feedback has enabled us to review improvements. We have been able to re-adjust changes on a short time scale, enabling us to reflect on the impact of our adjustments on the safety of handover.
Message for others Simple rapid small changes have significantly improved the efficiency and safety of handover. Front line junior staff, empowered by more senior clinicians, have introduced these changes. Engaging the whole team is critical to sustained success. Change is a continual dynamic process and monitoring effects of interventions helps identify where further work is needed.
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