ORIGINAL ARTICLE
Structured Handover in General Surgery: An Audit of Current Practice Huw Geraint Jones, MBBCh MRCS, Bethany Watt, MBBCh, Lauren Lewis, MBBCh, and Shiban Chaku, MBBCh Introduction: Verbal handover alone compromises patient safety, and supporting written documents significantly increases retention of information, with printed handover sheets being the best at avoiding data loss. The Royal College of Surgeons (RCS) has produced guidelines on safe handover practice, in which a minimum dataset is recommended for inclusion when handing over patients to incoming surgical teams, and studies have indicated better adherence to these guidelines when preprinted handover proformas are used. Methods: All surgical handover sessions were attended for a one-week period, and copies of handover sheets were taken. These were analyzed against RCS guidelines on the essential dataset for safe handover practice. A standardized handover sheet, developed in accordance with these guidelines and designed to encourage impartation of this minimum dataset, was then circulated among members of the surgical department and made readily available on wards. After a 6-week period, a postintervention audit was conducted using the same methods. Results: Striking differences were seen in the quality of information handed over preintervention and postintervention. The documentation of patient location increased significantly (56%–87%, P < 0.0001; 95% CI, 0.460–0.151), as did the documentation of important outstanding clinical tasks (45%–89%, P = 0.004; 95% CI, 0.439–0.089). Documentation of blood results increased (P < 0.0001; 95% CI, 0.523–0.226), and the proportion of patients for whom the occurrence of a senior review was documented increased from 28% (18) to 85% (45) (P < 0.0001; 95% CI, 0.717–0.419) Conclusions: The use of a structured, computer-generated handover proforma significantly improved compliance with RCS guidelines within the surgical department of our hospital, and we recommend its continued use among on-call surgical teams. Key Words: handover, safety, surgery, proforma, standardization, audit (J Patient Saf 2015;00: 00–00)
I
n 2004, the European working time directive was implemented among junior physicians, reducing the number of hours worked by trainees. With this came the introduction of shift systems and a loss of continuity of care, with patients being looked after by more than one team of physicians over the course of any given day. Consequently, handover of clinical information between such teams has become more frequent, and the need for robust handover mechanisms more important (British Medical Association [BMA]). Handover may be defined as “the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis” (BMA). Accurate handover is integral to the safety of patients, allowing health-care professionals to communicate outstanding tasks and From the Department of Vascular Surgery, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, North Wales. Correspondence: Huw Geraint Jones, MBBCh MRCS, Department of Vascular Surgery, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, North Wales, LL57 2PW (e‐mail: [email protected]). The authors disclose no conflict of interest. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf • Volume 00, Number 00, Month 2015
avoiding vital aspects of patient care being missed. Omitted patient information in handover can lead to suboptimal care,1 and poor communication between physicians can have devastating consequences for patients.2 It is apparent that written information to support verbal handover significantly increases retention of information, with printed handover sheets best avoiding data loss.3 The Royal College of Surgeons (RCS) has produced guidelines on safe handover practice,4 in which a minimum dataset is recommended for inclusion when handing over patients to incoming surgical teams, and studies have indicated better adherence to these guidelines when preprinted handover proformas are used.5,6 However, handover practice among surgical teams varies widely, and sadly, a large proportion of hospitals do not use such proformas.7–9 We found our district general hospital to be one such place in which preprinted handover sheets were not used. The aim of this audit was to objectively assess adherence to RCS guidelines and to investigate and reform our own practice. This is the first report in the literature on general surgical handover practice and the possible impact of introducing structured handover.
METHODS Within our surgical department, handover occurs twice daily. During these sessions, patients admitted throughout the previous shift are handed over to the incoming team of surgical physicians, usually with the aid of a “handover sheet” passed between teams and containing information to prompt discussion and aid in keeping track of new admissions. However, before this study, no standardized handover template was readily available or widely used within the department, and the composition of information sheets varied widely between individual surgical physicians. All surgical handover sessions were attended for a 1-week period, and copies of handover sheets were taken. These were analyzed against RCS guidelines on the essential dataset for safe handover practice. A standardized handover sheet (Fig. 1), developed in accordance with these guidelines and designed to encourage impartation of this minimum dataset, was then circulated among members of the surgical department and made readily available on wards. After a 6-week period, a postintervention audit was conducted using the same methods. Data analysis was carried out using SPSS statistical software version 20.0. Data were entered and coded numerically. Analysis was done using frequency, percentages, and comparison of means using independent samples t test with equal variances not assumed. P < 0.05 was considered statistically significant with 95% confidence intervals (not containing 0).
RESULTS During the preintervention audit, 64 patients were handed over during a 1-week period. Patient details were written on plain sheets of paper in all handover sessions, but a wide variety of formats were used. After the introduction of a standardized proforma, 53 patients were handed over during a 1-week postintervention audit period, during which there was 86.8% compliance with the proforma. Although not formerly assessed, www.journalpatientsafety.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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J Patient Saf • Volume 00, Number 00, Month 2015
Jones et al
FIGURE 1. Standardized proforma.
staff attitudes were generally positive toward the newly introduced proforma, and a number commented on the greater ease with which they were able to follow information written on handover sheets. The proforma aimed to encourage the use of computergenerated patient identifier labels to improve the handover of patient demographics as defined by the inclusion of date of birth and hospital number, in addition to patient name. Before its introduction, labels were used for 52% (33) of patients, compared with 73.6% (39) afterward. There was improvement in the handover of patient demographics, although this unfortunately did not reach statistical significance. Striking differences were seen in the quality of information handed over preintervention and postintervention (Table 1). There was a large increase in the proportion of patients for whom a location was documented, with ward and bed documented in 56% of cases preintervention and 87% of cases postintervention (P < 0.0001;
2
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95% CI, 0.460–0.151). The results of significant or pending investigations were statistically significantly better recorded, and outstanding tasks were documented in 89% (47) of cases after the introduction of the proforma, compared with only 45% (30) in the initial audit period (P = 0.004; 95% CI, 0.439–0.089). In addition, documentation of blood results significantly improved with the use of the proforma (P < 0.0001; 95% CI, 0.523–0.226). Most notably, however, the proportion of patients for whom the occurrence of a senior review was documented increased from 28% (18) to 85% (45) (P < 0.0001; 95% CI, 0.717–0.419) (Figs. 2 and 3). There was no difference in the duration of the handover before (25 minutes) or after the intervention (27 minutes).
DISCUSSION Improvements in all aspects of handover were shown with the introduction of a standardized handover proforma. Although it © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2015
Structured Handover in General Surgery
TABLE 1. Data Captured Pre- and Postinteverntion Sample Pre-Proforma Demographics: Name Patient label DOB Hospital no. Age
Location: Admission date Ward/bed History and diagnosis: PC Working Dx Investigation: Blood test Imaging Further management: Outstanding tasks Senior review
Sample Post-Proforma
P
95% Confidence Interval
64 33 59 50 60
100.00% 51.60% 92.20% 78.10% 93.80%
53 39 52 50 52
100.00%
16 36
25.00% 56.30%
30 46
56.60% 86.80%
Structured Handover in General Surgery: An Audit of Current Practice Huw Geraint Jones, MBBCh MRCS, Bethany Watt, MBBCh, Lauren Lewis, MBBCh, and Shiban Chaku, MBBCh Introduction: Verbal handover alone compromises patient safety, and supporting written documents significantly increases retention of information, with printed handover sheets being the best at avoiding data loss. The Royal College of Surgeons (RCS) has produced guidelines on safe handover practice, in which a minimum dataset is recommended for inclusion when handing over patients to incoming surgical teams, and studies have indicated better adherence to these guidelines when preprinted handover proformas are used. Methods: All surgical handover sessions were attended for a one-week period, and copies of handover sheets were taken. These were analyzed against RCS guidelines on the essential dataset for safe handover practice. A standardized handover sheet, developed in accordance with these guidelines and designed to encourage impartation of this minimum dataset, was then circulated among members of the surgical department and made readily available on wards. After a 6-week period, a postintervention audit was conducted using the same methods. Results: Striking differences were seen in the quality of information handed over preintervention and postintervention. The documentation of patient location increased significantly (56%–87%, P < 0.0001; 95% CI, 0.460–0.151), as did the documentation of important outstanding clinical tasks (45%–89%, P = 0.004; 95% CI, 0.439–0.089). Documentation of blood results increased (P < 0.0001; 95% CI, 0.523–0.226), and the proportion of patients for whom the occurrence of a senior review was documented increased from 28% (18) to 85% (45) (P < 0.0001; 95% CI, 0.717–0.419) Conclusions: The use of a structured, computer-generated handover proforma significantly improved compliance with RCS guidelines within the surgical department of our hospital, and we recommend its continued use among on-call surgical teams. Key Words: handover, safety, surgery, proforma, standardization, audit (J Patient Saf 2015;00: 00–00)
I
n 2004, the European working time directive was implemented among junior physicians, reducing the number of hours worked by trainees. With this came the introduction of shift systems and a loss of continuity of care, with patients being looked after by more than one team of physicians over the course of any given day. Consequently, handover of clinical information between such teams has become more frequent, and the need for robust handover mechanisms more important (British Medical Association [BMA]). Handover may be defined as “the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis” (BMA). Accurate handover is integral to the safety of patients, allowing health-care professionals to communicate outstanding tasks and From the Department of Vascular Surgery, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, North Wales. Correspondence: Huw Geraint Jones, MBBCh MRCS, Department of Vascular Surgery, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, North Wales, LL57 2PW (e‐mail: [email protected]). The authors disclose no conflict of interest. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf • Volume 00, Number 00, Month 2015
avoiding vital aspects of patient care being missed. Omitted patient information in handover can lead to suboptimal care,1 and poor communication between physicians can have devastating consequences for patients.2 It is apparent that written information to support verbal handover significantly increases retention of information, with printed handover sheets best avoiding data loss.3 The Royal College of Surgeons (RCS) has produced guidelines on safe handover practice,4 in which a minimum dataset is recommended for inclusion when handing over patients to incoming surgical teams, and studies have indicated better adherence to these guidelines when preprinted handover proformas are used.5,6 However, handover practice among surgical teams varies widely, and sadly, a large proportion of hospitals do not use such proformas.7–9 We found our district general hospital to be one such place in which preprinted handover sheets were not used. The aim of this audit was to objectively assess adherence to RCS guidelines and to investigate and reform our own practice. This is the first report in the literature on general surgical handover practice and the possible impact of introducing structured handover.
METHODS Within our surgical department, handover occurs twice daily. During these sessions, patients admitted throughout the previous shift are handed over to the incoming team of surgical physicians, usually with the aid of a “handover sheet” passed between teams and containing information to prompt discussion and aid in keeping track of new admissions. However, before this study, no standardized handover template was readily available or widely used within the department, and the composition of information sheets varied widely between individual surgical physicians. All surgical handover sessions were attended for a 1-week period, and copies of handover sheets were taken. These were analyzed against RCS guidelines on the essential dataset for safe handover practice. A standardized handover sheet (Fig. 1), developed in accordance with these guidelines and designed to encourage impartation of this minimum dataset, was then circulated among members of the surgical department and made readily available on wards. After a 6-week period, a postintervention audit was conducted using the same methods. Data analysis was carried out using SPSS statistical software version 20.0. Data were entered and coded numerically. Analysis was done using frequency, percentages, and comparison of means using independent samples t test with equal variances not assumed. P < 0.05 was considered statistically significant with 95% confidence intervals (not containing 0).
RESULTS During the preintervention audit, 64 patients were handed over during a 1-week period. Patient details were written on plain sheets of paper in all handover sessions, but a wide variety of formats were used. After the introduction of a standardized proforma, 53 patients were handed over during a 1-week postintervention audit period, during which there was 86.8% compliance with the proforma. Although not formerly assessed, www.journalpatientsafety.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
J Patient Saf • Volume 00, Number 00, Month 2015
Jones et al
FIGURE 1. Standardized proforma.
staff attitudes were generally positive toward the newly introduced proforma, and a number commented on the greater ease with which they were able to follow information written on handover sheets. The proforma aimed to encourage the use of computergenerated patient identifier labels to improve the handover of patient demographics as defined by the inclusion of date of birth and hospital number, in addition to patient name. Before its introduction, labels were used for 52% (33) of patients, compared with 73.6% (39) afterward. There was improvement in the handover of patient demographics, although this unfortunately did not reach statistical significance. Striking differences were seen in the quality of information handed over preintervention and postintervention (Table 1). There was a large increase in the proportion of patients for whom a location was documented, with ward and bed documented in 56% of cases preintervention and 87% of cases postintervention (P < 0.0001;
2
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95% CI, 0.460–0.151). The results of significant or pending investigations were statistically significantly better recorded, and outstanding tasks were documented in 89% (47) of cases after the introduction of the proforma, compared with only 45% (30) in the initial audit period (P = 0.004; 95% CI, 0.439–0.089). In addition, documentation of blood results significantly improved with the use of the proforma (P < 0.0001; 95% CI, 0.523–0.226). Most notably, however, the proportion of patients for whom the occurrence of a senior review was documented increased from 28% (18) to 85% (45) (P < 0.0001; 95% CI, 0.717–0.419) (Figs. 2 and 3). There was no difference in the duration of the handover before (25 minutes) or after the intervention (27 minutes).
DISCUSSION Improvements in all aspects of handover were shown with the introduction of a standardized handover proforma. Although it © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2015
Structured Handover in General Surgery
TABLE 1. Data Captured Pre- and Postinteverntion Sample Pre-Proforma Demographics: Name Patient label DOB Hospital no. Age
Location: Admission date Ward/bed History and diagnosis: PC Working Dx Investigation: Blood test Imaging Further management: Outstanding tasks Senior review
Sample Post-Proforma
P
95% Confidence Interval
64 33 59 50 60
100.00% 51.60% 92.20% 78.10% 93.80%
53 39 52 50 52
100.00%
16 36
25.00% 56.30%
30 46
56.60% 86.80%
