Envisioning for Handover of Care

Nov 19, 2007 at 9:48 AM
Following on from the posting on Envisioning for Common User Interface, I’d like to use this discussion to solicit feedback in the specific scope area of Handover of Care, which we define as “the development of functionality to support the safe and effective handover of care across all clinical contexts”.

If you have any initial thoughts on design guidance or toolkit controls for Handover of Care that you think would be of greatest value for us to produce, please feel free to add them as a reply to this post.

Best regards,

Tony Rose
NHS CUI Project
Microsoft Ltd.
Dec 1, 2007 at 2:39 AM
Handover on the Wards in a Tertiary Care Teaching Hospital - say, Friday night when you're heading home for the weekend...

You write up a patient list which includes what people used to call a "Bullet" on each patient, a short summary of Course in Hospital, and a list of things to check/watch out for with that patient.

A Bullet is a one or two sentence summary of a patient: "John Public is a 3 year-old boy, previously well, who came in with a five day history of fever to 40, morbilliform rash, nodes and fingertip peeling who's being worked up for Kawasaki Disease" .

House staff will often carry sheets or index cards, and I used to simply copy the bullet from one day's sheet to the next.
You might add, the next day: ' IVIG is likely being started tomorrow. Cardiology's been consulted and his echo is pending. Sed rate is falling; he's on hi-dose ASA and fluids."

Generally it will also include a list of meds and a list of tasks for followup, and med allergies...

The Bullet should be freeform text. Latest abnormal labs would also be useful.

A Med Grid, A Task List, and a Med Allergy List, along with a Bullet, would, underneath a PatientBanner Control, go a long way toward giving house staff a useful tool, IMHO

Geoff Forbes
Developer
Dec 18, 2007 at 10:31 AM
Edited Dec 18, 2007 at 10:32 AM
Geoff,

Thanks for your description of your current handover practice. If this is typical, then it sounds like doctor's shift handover support in North America is quite similar to that in the UK (i.e. paper lists with short summaries per patient). This is encouraging for international applicability of guidance we produce on handover.

An interesting question is what handover support would be like if you had immediate and mobile access to patients' electronic records. We believe that access to the record alone is not enough and some kind of summary representation (along the lines you suggest) is necessary.

A further question is to what degree this per patient summary would need to be specific to shift handover (as opposed to a 'general' patient summary) or differ depending on the clinician's context. For example is there a "nurse's" and "doctor's" summary, or speciality-specific summaries such as including a 'trough level checked?' status column on a renal ward?

Regarding your bullet lists, to what degree do you think that some of this bullet information can be automatically populated from an electronic record? Is the requirement for free-text bullets a consequence of the information in the record not being in an appropriate format, or is the free-text re-writing of this information valuable in itself?

In your experience, are the handover sheets and index cards personal to individual clinicians or are they group objects? For example does one ward have a single sheet that they all maintain?

In our handover work we will have to consider all kinds of handover, in all settings e.g. patient transfer between wards, admission and discharge from hospital, etc. How do you think handover support might be different in some of these other contexts?

James
Apr 24, 2008 at 4:33 AM
Handover or as we like to call it hand off, is pretty clearly defined by JCAHO Patient Safety Goal 2E - the continuity of care during patient hand-off. By including the transactional data or form typically associated with the handoff along with the SBAR method, both the situational detail and summary is provided.

We've built a solution accelerator based on SharePoint and InfoPath, which includes integration to patient data through web services (HL7 ADT), as well as a number of process and performance management dashboard. We'll be adding MSCUI in our next release.

The key is a resuable, standardized, but configurable schema, and a boatload of data views. To meet the JCAHO recommendation we added SBAR communications and a number of ways to close the communications loop. In unit to unit handoffs the dashboard/screen interface works well. In resident signout we believe the variety of views and presentation options we included allow for moderate personalization of the process. Adding in the ability to capture voice recordings, send via fax/email handles a number of inter-facility transfers.

I suspect there are a number of use cases we have'nt encountered yet, but I do believe a single framework can adapt to a significant number of handoffs...
Developer
Apr 25, 2008 at 3:37 PM
Sounds very interesting.

Also have you been able to measure effects of the system, such as on reduction of errors / satisfaction with handover? There's a nice UK study on surgery to intensive care handover that showed measurable benefits of introducing a (non-electronic) protocol into handover.
http://lib.bioinfo.pl/pmid:17474955
http://www.surgery.ox.ac.uk/research/qrstu/Projects/Handover

I'd be keen to know how your users have found the introduction of closed communication loops. In the UK, the more asynchronous handoffs such as hospital discharge to community are often quite unclosed. Information is provided to the reciever (such as a general practioner or community nurse), but there is not an explicit acceptance by the receiver. Have you found that instant transfer of information (by email) has encouraged the receivers to ask for clarification of the handoff?

I'm a fan of Emily Patterson's handover strategies http://csel.eng.ohio-state.edu/patterson/Handovers.html, which the CUI would be considering as part of the work on handover.
Apr 25, 2008 at 5:17 PM
We don’t have enough empirical data to evaluate the overall impact just yet. We do however capture and present metrics around the process (feedback, acknowledgement) and communication techniques (in person verbal, email, etc.). We do see many applications where asynchronous communications is a reality; the metrics and analysis reflect this and provide Quality personnel valuable data to base future improvement of the process. We've also implemented a number of ways to close the loop (acknowledge the hand off). Our next release will include additional technical interfaces which we hope will satisfy a broader number of scenarios. Interfaces like text message, IVR, voice activation as well as mobile apps and gadgets provide a relatively simple means to acknowledge the hand off and close the loop without necessarily having direct online access.

We based our work on a number of sources including Improving Hand-Off Communication, Joint Commission RESOURCES. I believe the CUI should include the Joint Commission suggestion in order to satisfy US obligations. Beginning in 2009 JCAHO will begin to evaluate this area and include their findings in their official report, at the moment is not compulsory.

http://www.jcipatientsafety.org/15427/
http://search.barnesandnoble.com/booksearch/isbninquiry.asp?r=1&ean=9781599400907

Developer
May 9, 2008 at 1:10 PM
Edited May 9, 2008 at 1:10 PM
We'll certainly be considering the JCAHO work for handover. As handover is towards the end of our current roadmap http://www.mscui.net/Roadmap/Schedule.aspx from Feb 09 to Jul 09, hopefully there would be more reports from groups that have implemented and evaluated the JCAHO recommendations.

In your data views for handover, what do you think about more graphical views for multi-patient handovers - such as a representation of patient summaries which are accessible from / overlaid on ward floor plans? Initially this seems quite appealing, but i'm not sure what it adds over a more classic tabular representation.

Disadvantages over tabular might be 1. that could be harder to ensure that you have 'been through' all the patients, 2. that sorting and grouping is not possible, 3. clinicians working accross wards wouldn't have a single aggregated view, 4. the representation might not easily fit on a screen, 5. there probably wouldn't be as much space for text (unless you drilled down), 6. more effort to setup.

Advantages might be that 1. the patient summary has a more of a sense of 'place' within a ward and so MIGHT be more memorable, 2. it's visually appealing, 3. clinicians not familiar with a location might be able to locate patients more quickly, 4. a supplementary indication of which ward is being viewed.