National Handover Conference

 This blog goes through some of more memorable moments from the National Handover Conference, 30/6/11, at 76 Portland Place. 

MAIN LEARNING POINTS:

1. Those involved in handover should be aware of definitions surrounding handing over: Briefing, Vertical/Horizonatal, Complete/Selected
2. Handovers should be designed with the aim of mitigating the main risks posed to the patients
3. An IT system which compliments handover and reduces duplicated effort is an essential part of handover
4. New systems should be developed using a consensus based approach and constantly feedback to achieve the best results
5. Checklists and Acronyms are an essential part of briefing and handover, althought arguably they are best produced locally

Definitions

Briefing vs Handover
Ken Catchpole differentiated between a briefing and handover. A briefing can be designed to alleviate risk by, for example, introducing all members and identfying elements of that day that were different. Clare Rees picked this up in with Think FIRST. She uses the FIRST mneumonic at the beginning of her handover to identify potential and be aware of previous critical incidents.

(F)ind out at the start of your shift
Have there been any I()ncidents or near misses in the last shift
What are the (R)isks or potenital reisks in this shift
Who are the (S)ick or potentially sick patients
How is the (T)eam going to tackle these

Although she did not specifically refer to this as a briefing, but it is implicit in its timing “at the start of handover” that this is what it is. My experience of a briefing like this in Medicine is limited. The WHO Surgical Checklist is an excellent briefing tool, although the best experience I have of a briefing is the A+E nursing twice daily briefing. An incoming led checklist, which covers the main areas of risk in the department.

Both Dr Steve Adler and Dr Alkak Choudhury defined handover as either Vertical or Horizontal. Horizontal handover occurs between shifts and is a handover of responsibility (with or without information). Vertical handover can occur within and between shifts and is the transfer of a task. There can be a combined Vertical and Horizontal Handover - e.g. Take U+E from Miss X. Furthermore, Dr Choudhury chose to define a handover as either Complete or Selected. Some situations e.g. ITU require Complete handover where all patients cases are handed over, while during a general medical handover between on-call shifts (e.g. Sat Day - Sat Night) cannot encompass all patients and are therefore selected. Dr Choudhury also chose to define the shift gap, as the handover of a task which neccessarily bridges a gap in shifts, e.g. Weekday ward team requests to check U+E on Sunday Day - a request potentially bridging 4 shifts.

Evaluating a handover

Both Ken Catchpole and Dr Steve Adler spoke of the challenges of evaluating handover.

Ken Catchpole’s background in Human Factors research lead him to look systematically at the influences of human performance: Organisation, Tasks, Technology and Environment, with people as the central point for all these factors (Canayon et al Qual Saf Health Care 2006). In his example of handing over a patient from the Anaesthetic team to the ITU team at GOSH, he was able to “walk through” the handover in detail, showing that the surgical team arrived at different times to the anaethetists, while the nursing team were spending time configuring the IV lines while taking the handover. These systems led to waste and potential risk. He referred to the role of the “process map” in analysing the handover, however i was left slightly unclear as to how it this produced his main findings.

Steve Adler entry point, perhaps less systematic although more patient centred, was the view that handover was all about how communication affected the patient experience. His team chose to focus on Handovers within the Neurology team. They mapped what handovers took place during a patients admission and created a time stream.

Both Ken Catchpole and Steve Alder focussed on the mitigation of risk in designing their handover system. KC provided “Failure Mode Effect Analysis” as tool to assess risk: Essentially each task identified in the handover is analysed to give an “Error mode”, essentially what could go wrong. These “worst case scenarios” are then given a score out of 10 for and a multiplication of the three gives the final result:

Occurence - likleyhood of happening (0 = not likely)
Severity - how to bad it would be (0 = no effect)
Detection - how likely to detect straightaway (0 = straightaway)

SA decided to focus on the prevention of three main risks. These were arrived seemingly by a more vague process of deciding what steps added value to the patient:
 

P
A         Getting the correct diagnosis

T          Getting the correct acute treatment
I           Getting correct ongoing treatment
E          Managing complications of treatment
N         Returning to functional stability
T

The three main identified risks in these steps wer:

1.     Losing patients off the list - happening even prior to diagnosis!

2.     Not receiving the treatment

3.     Not anticipating complications of treatment

The core data set, therefore expected to be handed over for each patients, was based on these value-adding steps and included

Presenting complaint

Diagnosis

Tests

Treatment

Complications

Patient/Relative Issues?

Whats keeping them in

Although the method through which SA came to his value adding steps, from the patients persepective, is not entirely clear, there is no doubt that this is a valuable viewpoint, and that using these to identify risk is a good starting point. However, I was left unclear how each of these were to be mitigated, and most specifically how they were to avoid patients being lost. For ensuring the prompt treatment and identifying complications, it seemed that purely by handing over in a systematic way, these were achieved. He noted that aspirin compliance in stroke had increased from 53% to 90%. The other data he used to support the success of his intervention is the percentage of core data sets which were present at handover (see figure 2). More interestingly, perhaps, is HOW they came to have such good outcomes, which I will come on to in the implementation section. Although not measured SA’s team felt that ward and board rounds were accomplished quicker following the introduction of the new system.

Tools for Buidling an Excellent Handover

Technology: The case for an integrated system

The most fascinating approach of the day to handover came from Aklak Choudhury, from Barking, Havering Redbrige. He described their experience of creating and implementing a computer system for handove, over the past 18 months. The headline success is that BHR have gone from one of the poorest trusts for Handover, as rated by their trainees in the PMETB survey, to the highest in London. 

Following the talk I can only think it is a matter of time before it becomes completely essential to have a computerised handover system which, for the essential elimination of duplicated efforts, acts as a ward list system as well.

He describes a system which allows for real-time logs of handover tasks, which allow for the transfer of handover tasks between shifts (including bridging between shifts). It is functional from the moment of admission and can pull patient data from the CRS system. As such it functions as the immediate “take list”, as well as ward and handover lists. There is a traffic light system for outstanding, being completed and completed tasks. As I have previously noted, it acts as a ward nursing list, consultant list and team list, as well as the “take list”. Finally it provides an auditable trail of handover tasks.

There is no doubt that the presentation has a bias. Dr Choudhury, and BHR, are now marketing this as a product with “Ascribe” Healthcare. However, there is little doubt that either this, or a similar competitor is an essential part of a good handover process. From discussion with colleagues, it appears that Salisbury also work a similar computer system, which has its own strengths and weaknesses.

This system comes in at between £25, 00 - £40,000 with £2,000 a year administration cost. Whether this is the total cost, I am not sure. And whether it is as popular with trainees as it first appears remains to be seen. One of the key strengths of the system is that it is clinically designed and led. This, apparently, means is it easy to use and training occurs on the job. However, I am unsure whether it would be as readily picked up on in a new trust as it has in the trust it was designed in. Despite these limitations, this is clearly the future, and this system and others like it (such as the medical handover designed by one of our trainees and Salisbury) needs to be investigated. 

The Checklist and the Acronym

The conference presented examples of a checklist, by SA, and an acronym, by CR. It is fairly clear that there is a place for both in modern medicine, as when used effectively they mitigate risk. SA found that by handing over a core data set in a systematic way, using an aide memoir, the percentage of that data set handed over increased. CR’s FIRST checklist functioned as a useful briefing tool. 

Our experiences so far at handovers in BLT show that checklists are an excellent method for ward briefings (e.g. A+E nursing handover, Cambridge handover). I think one of the key elements appearing is that checklists must be situationally relevant. As medical team the diagnosis, treatment and complications are the most relevant. As a ward nursing team, with elderly patients for example, those at falls risk or infection risk are most important. What is most important therefore is that a checklist or an acronym exists, not what its structure is. And in fact, a locally generated list or acronym probably is most effective as they feel ownership of it and it includes the locally generated risks.

Buidling in risk management and resilience in the system

I have covered already most of the points relating to this. CR produced a checklist which raises the importance of knowing about critical incidents and broadly assessing the risks and how to respond to these. SA describes creating a system aimed at reducing the three main risks identified, and KC describes using an FMEA analysis to identify risk. SA and KC’s approach is perhaps the more comprehensive of the three, as it pre-empts what the main risks to your patients may be. Either way there can be little doubt that handovers should be designed with both common pitfalls and variable risks in mind.

One interesting approach, highlighted by KC, to encouraging interaction and reducing risk is to make junior members of the team handover. This way if any mistakes are made then the more senior member will clarify or interrupt and it encourages trainees to become involved in handover, instead of being passengers.

The unwellness of a patient is something that all handovers should be able to impart. There is potential in these situations to think of a different format of handover, specific to this type of patients?

Implementing a new model: Predicting some of the challenges

Two significant difficulties were described by SA in implementing the new safer system in Plymouth. Firstly, many doctors including consultants, were resistive to change. It wasn’t entirely clear how they bridged this gap, or what exactly the grievances were. However he did mention the standardization vs autonomy argument, the only response to this was to reinforce that idea that this was not an infringement of clinicians autonomy. Secondly, how to encourage ownership and prevent fatigue from the changes? For this they created a weekly email, with audits of percentage’s of the core data sets handed over, and where successes and failure were occurring.