Improving clinical reasoning and communication during handover: An intervention study of the BRIEF-C tool.

BACKGROUND: Existing handover communication tools often lack a clear theoretical foundation, have limited psychometric evidence, and overlook effective communication strategies for enhancing diagnostic reasoning. This oversight becomes critical as communication breakdowns during handovers have been implicated in poor patient care. To address these issues, we developed a structured communication tool: Background, Responsible diagnosis, Included differential diagnosis, Excluded differential diagnosis, Follow-up, and Communication (BRIEF-C). It is informed by cognitive bias theory, shows evidence of reliability and validity of its scores, and includes strategies for actively sending and receiving information in medical handovers. DESIGN: A pre-test post-test intervention study. SETTING: Inpatient internal medicine and orthopaedic surgery units at one tertiary care hospital. INTERVENTION: The BRIEF-C tool was presented to internal medicine and orthopaedic surgery faculty and residents who participated in an in-person educational session, followed by a 2-week period where they practised using it with feedback. MEASUREMENTS: Clinical handovers were audiorecorded over 1 week for the pre- and again for the post-periods, then transcribed for analysis. Two faculty raters from internal medicine and orthopaedic surgery scored the transcripts of handovers using the BRIEF-C framework. The two raters were blinded to the time periods. RESULTS: A principal component analysis identified two subscales on the BRIEF-C: diagnostic clinical reasoning and communication, with high interitem consistency (Cronbach's alpha of 0.82 and 0.99, respectively). One sample t-test indicated significant improvement in diagnostic clinical reasoning (pre-test: M=0.97, SD=0.50; post-test: M=1.31, SD=0.64; t(64)=4.26, p<0.05, medium to large Cohen's d=0.63) and communication (pre-test: M=0.02, SD=0.16; post-test: M=0.48, SD=0.83); t(64)=4.52, p<0.05, large Cohen's d=0.83). CONCLUSION: This study demonstrates evidence supporting the reliability and validity of scores on the BRIEF-C as good indicators of diagnostic clinical reasoning and communication shared during handovers.

Daily handover in surgery: systematic review and a novel taxonomy of interventions and outcomes.

BACKGROUND: Poor-quality handovers lead to adverse outcomes for patients; however, there is a lack of evidence to support safe surgical handovers. This systematic review aims to summarize the interventions available to improve end-of-shift surgical handover. A novel taxonomy of interventions and outcomes and a modified quality assessment tool are also described. METHODS: Ovid MEDLINE®, PubMed, Embase, and Cochrane databases were searched for articles up to April 2023. Comparative studies describing interventions for daily in-hospital surgical handovers between doctors were included. Studies were grouped according to their interventions and outcomes. RESULTS: In total, 6139 citations were retrieved, and 41 studies met the inclusion criteria. The total patient sample sizes in the control and intervention groups were 11 946 and 11 563 patients, respectively. Most studies were pre-/post-intervention cohort studies (92.7%), and most (73.2%) represented level V evidence. The mean quality assessment score was 53.4% (17.1). A taxonomy of handover interventions and outcomes was developed, with interventions including handover tools, process standardization measures, staff education, and the use of mnemonics. More than 25% of studies used a document as the only intervention. Overall, 55 discrete outcomes were assessed in four categories including process (n = 27), staff (n = 14), patient (n = 12) and system-level (n = 2) outcomes. Significant improvements were seen in 51.8%, 78.5%, 58.3% (n = 9761 versus 9312 patients) and 100% of these outcomes, respectively. CONCLUSIONS: Most publications demonstrate that good-quality surgical handover improves outcomes and many interventions appear to be effective; however, studies are methodologically heterogeneous. These novel taxonomies and quality assessment tool will help standardize future studies.

Improving availability and accuracy of the junior doctors' on-call handover through digitalisation.

Clinical handovers from out-of-hours activity are essential for relaying information about events such as new admissions, outstanding or complete investigations, physical health reviews, ward jobs and risk. This information enables the day team to effectively prioritise and follow-up any necessary tasks.Junior doctors at a hospital site in the London Borough of Newham were aware that the existing handover system, constituted of a word document circulated via email, was lacking robustness and that the handover was not sent out reliably on a daily basis.Quality improvement (QI) methods including process mapping, PDSA ('Plan, Do, Study, Act') cycles, driver diagrams and run charts were used to understand the issue, create a more robust process and measure the improvements made, all supported by regular QI project meetings. The change ideas included moving from an informal Microsoft (MS) Word document, which was emailed out, to an Excel spreadsheet stored centrally on MS Teams. Column headers were added for admissions, ward jobs, seclusion reviews, matters relating to mental health law and Accident and Emergency (A&E) assessments, as well as defined columns for outstanding jobs and standard tasks that need to be completed for all admissions. Responsibility for circulating the handover list was given to the incoming day duty doctor if the night doctor was too busy, with admin support to chase the circulation of the handover. Results were studied for the following 18 months.The percentage of handovers being appropriately sent out increased from a median of 80% to 100% during the project period, and the availability of handover data where the data were visible to doctors on MS Teams but had not been sent out also increased from a median of 80% to 100%. The system was deemed safe, effective and easy to use, and has already been replicated at neighbouring hospitals.

Don't interrupt me! development of a handoff education bundle to simulate the real world.

OBJECTIVES: Ineffective nurse-to-nurse handoff communication is associated with information omissions, diagnostic errors, treatment errors, and delays. New nurses report a lack of confidence and ability in handoff communication, which may stem from inadequate training in prelicensure nursing programs. Our objective was to introduce prelicensure nursing students to a standardized, theory-based method for handoff, including behavioral strategies employed by nurses during interrupted handoff. METHODS: A handoff education bundle (HEB) was developed. Kern's six-step curriculum model was utilized to design, implement, and evaluate the handoff curriculum. RESULTS: Student feedback highlighted the importance of integrating multiple, varying distractors during learning cycles and recognition of the impact of distractors on handoff. CONCLUSIONS: Implementing a HEB at the prelicensure nursing level could promote competency in handoff communication for new graduate nurses. IMPLICATIONS FOR INTERNATIONAL AUDIENCE: Handoff is an international patient safety priority, as inadequate communication has been linked to adverse patient events.

[Handoffs in the intensive care unit]. / Übergaben auf der Intensivstation.

BACKGROUND: Effective handoffs in the intensive care unit (ICU) are key to patient safety. PURPOSE: This article aims to raise awareness of the significance of structured and thorough handoffs and highlights possible challenges as well as means for improvement. MATERIALS AND METHODS: Based on the available literature, the evidence regarding handoffs in ICUs is summarized and suggestions for practical implementation are derived. RESULTS: The quality of handoffs has an impact on patient safety. At the same time, communication in the intensive care setting is particularly challenging due to the complexity of cases, a disruptive work environment, and a multitude of inter- and intraprofessional interactions. Hierarchical team structures, deficiencies in feedback and error-management culture, (technical) language barriers in communication, as well as substantial physical and psychological stress may negatively influence the effectiveness of handoffs. Sets of interventions such as the implementation of checklists, mnemonics, and communication workshops contribute to a more structured and thorough handoff process and have the potential to significantly improve patient safety. CONCLUSION: Effective handoffs are the cornerstone of high-quality and safe patient care but face particular challenges in ICUs. Interventional measures such as structuring handoff concepts and periodic communication trainings can help to improve handoffs and thus increase patient safety.

Reaching consensus on the definition of person-centred handover practices in emergency departments: A modified online Delphi.

AIM: To reach consensus on the definition and attributes of 'person-centred handover practices' in emergency departments. BACKGROUND: Handover practices between emergency care practitioners and healthcare professionals in emergency departments are important and should be conducted meticulously. Person-centred handover practices may enhance the delivery of person-centred care in emergency departments. DESIGN: A three-round online Delphi survey. METHODS: Nine experts participated in a three round Delphi survey. The expert panel comprised experts from nine countries. Quantitative data were descriptively analysed, and qualitative data were thematically analysed. A consensus of 80% had to be reached before an attribute and definition could be accepted. RESULTS: Experts reached a consensus of 79% in round one, 95% in round two and 95% in round three. A final set of six attributes were agreed upon and the final concept definition was formulated. CONCLUSION: Person-centred handover practices have not been implemented in emergency departments. Yet, person-centred handover practices may enhance the delivery of person-centred care, which has multiple benefits for patients and healthcare practitioners. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Person-centred care is not generally implemented in emergency departments. Person-centred handover practices can lead to person-centred care. Handover practices in emergency departments are a high-risk activity. Despite numerous calls to standardise and improve handover practices, they remain a problem. Developing a standardised definition could be a first step towards implementing person-centred handover practices in emergency departments. REPORTING METHOD: The study adhered to the relevant EQUATOR reporting guidelines: Guidance on Conducting and Reporting Delphi Studies (CREDES) checklist. IMPACT (ADDRESSING): Improve handover practices and patient care. Improve person-centred care in emergency departments. PATIENT OR PUBLIC CONTRIBUTION: Emergency care practitioners and nurses experienced in handover practices and/or person-centred care, working in clinical and academic fields, participated in the study by sharing their expert knowledge during each of the Delphi rounds.

Nurses engaging with referral letters and discharge summaries: A qualitative study.

AIMS: To investigate the ways that nurses engage with referral letters and discharge summaries, and the qualities of these documents they find valuable for safe and effective practice. DESIGN: This study comprised a qualitative, case-study design within a constructivist paradigm using convenience sampling. METHODS: Interviews were conducted with nurses to investigate their practices relating to referral letters and discharge summaries. Data collection also involved nurses' examination and evaluation of a diverse range of 10 referral letters and discharge summaries from medical records at two Australian hospitals through focus-group sessions. The data were transcribed and analysed inductively. RESULTS: In all, 67 nurses participated in interviews or focus groups. Nurses indicated they used referral letters and discharge summaries to inform their work when caring for patients at different times throughout their hospitalisation. These documents assisted them with verbal handovers, to enable them to educate patients about their condition and treatment and to provide a high standard of care. The qualities of referral letters and discharge summaries that they most valued were language and communication, an awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information. CONCLUSION: Nurses relied on referral letters and discharge summaries to ensure safe and effective patient care. They used these documents to enhance their verbal handovers, contribute to patient care and to educate the patient about their condition and treatment. They identified several qualities of these documents that assisted them in maintaining patient safety including clarity and conciseness of information. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: It is important that referral letters and discharge summaries are written clearly, concisely and comprehensively because nurses use them as key sources of evidence in planning and delivering care, and in communicating with other health professionals in relaying goals of care and implementing treatment plans. IMPACT: Nurses reported that they regularly used referral letters and discharge summaries as valuable sources of evidence throughout their patients' hospitalisation. The qualities of these documents which they most valued were language and communication styles, awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information. This research has important impact on the patient experience in relation to encouraging effective referral letter and discharge summary writing. REPORTING METHOD: We have adhered to the relevant EQUATOR guidelines through the SRQR reporting method. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Improving Direct Admissions to Internal Medicine Services.

BACKGROUND: Direct admissions from clinic or home to the hospital may improve efficiency and reduce emergency room utilization, but nonoptimized processes may increase the risk of harm during the transition of care. Our multidisciplinary team aimed to understand and improve the process of directly admitting patients to inpatient medicine services at a large academic medical center. METHODS: In this single-institution quality improvement initiative, we identified key communication gaps within the direct admission process and implemented a handoff tool in the form of a templated note and order set to bridge those communication gaps. The primary outcome measure was the monthly utilization rate of the handoff note as a surrogate for handoffs and uptake of the intervention. RESULTS: We launched our intervention in April 2022. We achieved sustained use of the SmartText and a peak of 24% of direct admissions utilizing the SmartText in January 2023. Based on feedback during Plan-Do-Study-Act cycles, we added direct admission instructions for outpatient teams to follow in the order set and reduced text in the handoff note. CONCLUSIONS: This study demonstrates the design and implementation of a quality improvement initiative to identify and address communication gaps for direct admissions of adult medicine patients.

Initiative to improve handover notes in a tertiary psychiatric hospital.

Clinical handover is an important process in hospital settings, but it is often carried out inadequately, posing potentially serious consequences for the patients. This project aimed to increase the effectiveness of handover notes when patients were transferred between a general psychiatric ward and other wards in a tertiary psychiatric hospital. Effective handover notes in this project were defined to have the following five components: brief psychiatric history, reason for the patient to be transferred, significant risk issues, reason for psychotropic medication change and active medical issues. Baseline measurement obtained from audits revealed that the completion rate of effective handover notes was only 27.27%, which could potentially compromise patient safety and staff work efficiency. To address this problem, a series of plan-do-study-act (PDSA) cycles was implemented to improve the handover process. The interventions included education to junior doctors, reminders to complete effective handover notes and implementation of a handover template. Following each PDSA cycle, data were gathered to assess whether an effect had been achieved and to identify ways to enhance interventions to maximise impact. After the final PDSA cycle, the percentage of effective handover notes among all transfer cases reached 90.50%. Postintervention feedback from inpatient team indicated that effective communication between different teams was ensured, and staff satisfaction and time savings were improved. This study highlights the importance of employing PDSA cycles to assess and refine interventions and the usefulness of structuring the content of key components of handover notes to obtain measurable improvements.

Involving the Patient and Family in the Transfer of Information at Shift Change in a Pediatric Emergency Department.

BACKGROUND: The transfer of information at the change of shift is a critical point for patient experience during the care process. The aim of this study was to evaluate caregivers' perceptions before and after the implementation of a multidisciplinary bedside handoff in a pediatric emergency department (PED). METHODS: This was a quality improvement pre-post intervention, single-center study. The authors included caregivers of patients allocated in the observation unit of a PED during health care provider shift change. The study was made up of the following phases: (1) preintervention survey distribution, (2) implementation of the bedside handoff, involving all health care professionals (including nurses, nursing assistants, and pediatricians) and caregivers, and (3) postintervention survey distribution. The survey explored the three dimensions of patient experience defined as main study outcomes: information received and communication with professionals, participation, and continuity of care. RESULTS: A total of 102 surveys were collected (51 each in the preintervention and postintervention phases). In the preintervention phase, 94.1% of caregivers would have wished to be actively involved in the change of shift. In the postintervention phase, more caregivers felt that professionals had proper introductions (49.0% vs. 84.3%; p < 0.01), had kept them informed of the plan to be followed (58.8% vs. 84.3%; p = 0.02), and encouraged questions (45.1% vs. 82.4%; p < 0.01). Caregivers of the postintervention phase perceived less disorganization during the change of shift (25.5% vs. 5.9%; p = 0.01) and a greater sense of continuity (64.7% vs. 86.3%; p = 0.02). CONCLUSION: The bedside handoff is a useful strategy to improve patient and family perceptions of communication with professionals, information received, and continuity of care at health care providers shift change. Future lines of research and improvement include ensuring equity in participation in the bedside handoff for all caregivers, monitoring the handoffs to determine how often patients/caregivers participate and correct mistakes in information transfer. and exploring professionals' perceptions.

Improving Outcomes in Patients Sent to the Emergency Department from Outpatient Providers: A Receiver-Driven Handoff Process Improvement.

BACKGROUND: Outpatient providers refer to emergency departments (EDs) due to findings requiring assessment beyond existing capabilities. However, poor communication surrounding these transitions may hinder safety and timeliness of emergency care. Receiver-driven handoff (RDH) is a process that helps ensure that all pertinent information is shared. This quality improvement project aimed to (1) improve knowledge of RDH, (2) increase satisfaction and perceptions surrounding RDH, (3) modify behaviors in relation to RDH, and (4) decrease referred patients leaving without being seen (LWBS). METHODS: The Iowa Model and Implementation Framework guided this evidence-based quality improvement project. A multidisciplinary team developed and implemented a standardized RDH process consisting of screening to determine whether a patient was referred to the ED, review of electronic health record (EHR), and use of EHR documentation. Process measures were collected via questionnaire pre- and postimplementation and were analyzed quantitatively. Outcome measures were trended by a statistical process control p-chart, which was developed to demonstrate changes in the percentage of patients who were referred to the ED from the outpatient setting and LWBS. RESULTS: The average response for the question "How satisfied are you with the handoff of patient information from referring clinic providers to the ED?" increased from 1.51 preintervention to 2.04 postintervention (p = 0.005). Respondents rated the information received during handoff higher postintervention (2.12 vs. 2.52, p = 0.04). Compliance with screening for referral to the ED was 84.0%. The proportion of patients LWBS after referral decreased by 6.2 percentage points (p < 0.001). CONCLUSION: Using RDH in conjunction with a standardized triage screening may improve quality of information shared during this vulnerable transition and may assist in reduction of referred patients LWBS. The RDH process should be adapted into everyday workflow to ensure sustainability and effectiveness.

Development and Evaluation of I-PASS-to-PICU: A Standard Electronic Template to Improve Referral Communication for Interfacility Transfers to the Pediatric ICU.

BACKGROUND: Miscommunication during interfacility handoffs to a higher level of care can harm critically ill children. Adapting evidence-based handoff interventions to interfacility referral communication may prevent adverse events. The objective of this project was to develop and evaluate a standard electronic referral template (I-PASS-to-PICU) to improve communication for interfacility pediatric ICU (PICU) transfers. METHODS: I-PASS-to-PICU was iteratively developed in a single PICU. A core PICU stakeholder group collaboratively designed an electronic health record (EHR)-supported clinical note template by adapting elements from I-PASS, an evidence-based handoff program, to support information exchange between referring clinicians and receiving PICU physicians. I-PASS-to-PICU is a receiver-driven tool used by PICU physicians to guide verbal communication and electronic documentation during PICU transfer calls. The template underwent three cycles of iterative evaluation and redesign informed by individual and group interviews of multidisciplinary PICU staff, usability testing using simulated and actual referral calls, and debriefing with PICU physicians. RESULTS: Individual and group interviews with 21 PICU staff members revealed that relevant, accurate, and concise information was needed for adequate admission preparedness. Time constraints and secondhand information transmission were identified as barriers. Usability testing with six receiving PICU physicians using simulated and actual calls revealed good usability on the validated System Usability Scale (SUS), with a mean score of 77.5 (standard deviation 10.9). Fellows indicated that most fields were relevant and that the template was feasible to use. CONCLUSION: I-PASS-to-PICU was technically feasible, usable, and relevant. The authors plan to further evaluate its effectiveness in improving information exchange during real-time PICU practice.

Development and effectiveness of a metaverse reality-based family-centered handoff education program in nursing students.

PURPOSE: Effective patient handoffs are vital in pediatric populations. This study aimed to develop and identify the impact of a metaverse-based handoff program using ZEPETO on nursing students' handoff competence, handoff self-efficacy, learning realism, and satisfaction. DESIGN AND METHODS: This study used a non-randomized, pre-post nonequivalent group design to develop, implement, and verify a metaverse-based handoff simulation program in a nursing school in South Korea. We assigned 69 senior nursing students from a university to an experimental group or a control group. We developed a metaverse-based, handoff simulation program of family-centered care by building a pediatric intensive care unit (PICU) using ZEPETO. The program included an online lecture, a metaverse rounding discussion, and a metaverse-based handoff simulation of postoperative care for infants with congenital heart disease. We measured handoff competence, handoff self-efficacy, learning realism, and learning satisfaction pre- and post-program. RESULT(S): The experimental group showed significantly higher handoff self-efficacy than the control group (t = 3.17, p = 0.002). No significant differences were found in handoff competency, learning realism, or learning satisfaction between the groups. CONCLUSION(S): This study confirmed that a family-centered care-based handoff metaverse simulation program based on the experiential learning theory enhanced nursing students' handoff self-efficacy. The program equipped students to conduct safe and effective handoffs in real-world clinical settings by providing an immersive learning experience and emphasizing patient-centered communication. PRACTICAL IMPLICATIONS: Based on these results, family-centered, handoff education programs are recommended to be developed that focus on learning realism and learning satisfaction to enhance nursing students' handoff competence.

Eliminating Hands-Off Handoffs: Improvement in Perioperative Handoff Communication With a Multidisciplinary Tool Initiative.

INTRODUCTION: Handoffs between the operating room (OR) and post-anesthesia care unit (PACU) require a high volume and quality of information to be transferred. This study aimed to improve perioperative communication with a handoff tool. METHODS: Perioperative staff at a quaternary care center was surveyed regarding perception of handoff quality, and OR to PACU handoffs were observed for structured criteria. A 25-item tool was implemented, and handoffs were similarly observed. Staff was then again surveyed. A multidisciplinary team led this initiative as a collaboration. RESULTS: After implementation, nursing reported improved perception of time spent (2.63-3.68, p = .02) and amount of information discussed (2.85-3.73, p = .05). Anesthesia also reported improved personal communication (3.69-4.43, p = .004), effectiveness of handoffs (3.43-3.82, p = .02), and amount of information discussed (4.26-4.76, p = .05). After implementation, observed patient information discussed during handoffs increased for both surgical and anesthesia team members. The frequency of complete and near-complete handoffs increased (40%-74%, p < .001). CONCLUSIONS: A structured handoff tool increased the amount of essential information reported during handoffs between the OR and PACU and increased team members' perception of handoffs.

A Discourse Study on Handover Communication Among Care Providers in a Residential Care Home for Persons with Intellectual Disabilities.

Abundant research has focused on handovers among nurses and/or doctors in hospitals; far less is known about handovers among care providers in non-clinical contexts, such as care homes for the elderly or the disabled. Focusing on handovers in a residential care home for persons with intellectual disabilities (RCHID), this study argues that handover communication in non-clinical settings is equally important. Ineffective handovers can lead to the deterioration of the residents' health conditions, chaotic situations and even injuries to both care providers and care recipients. Staff in RCHIDs rely heavily on handover communication to obtain information about the residents' needs and to offer appropriate care services. Combining discourse analysis with interactional sociolinguistics, this study analyzes written and spoken discourses involved in handover communication among care providers in a typical RCHID in Hong Kong to investigate what and how communicative functions were achieved through the participants' language use. The data were collected by convenience sampling, including handwritten notes and handover recordings of twelve sessions. Then a group interview of seven care providers was conducted to obtain supplementary data. Findings suggest that handover communication includes informational and interpersonal functions. While information delivery is the main purpose, care providers also establish relationships with one another through small talk about care home residents. The results suggest potential drawbacks of the handovers, including illegible notes, inconsistent information collection, and low interactivity. This study proposes a model that elucidates the correlation between discourse, handover communication and healthcare services, and suggests strategies to enhance such communication.

A Review of Verbal and Written Patient Handoffs Applicable to the U.S. Military's Expeditionary Care System.

INTRODUCTION: Long considered a danger point in patient care, handoffs and patient care transitions contribute to medical errors and adverse events. Without standardization of patient handoffs, communication breakdowns arise and critical patient information is lost. Minimal training and informal learning have led to a lack of understanding the process involved in this vital aspect of patient care. In 2017, the U.S. Army commissioned a report to study the process of patient handoffs and identify training gaps. Our report summarizes that process and makes recommendations for implementation. MATERIALS AND METHODS: Scoping literature review of 139 articles published between 1999 and 2017 using PubMed, CINAHL, Cochrane, and Medline databases. Verbal tools for handoffs were evaluated against 12 criteria including patient ID, history, current situation, contingency planning, ability to ask questions, ownership, and read back. Written tools were evaluated against a matrix of 126 casualty/treatment attributes. RESULTS: Among verbal communication protocols, the highest scoring handoff mnemonics were HAND ME AN ISOBAR, IPASS the BATON, and I-SBARQ. Among written handoff tools, the highest scoring documents were the Special Operations Forces (SOF) Mechanism, Injuries, Signs, and Treatment (MIST) Casualty Treatment Card and the Department of Defense (DD) Form 1380 Tactical Combat Casualty Care (TCCC) Card. Four critical process elements for patient handoffs and transfers were identified: (1) interactive communications, (2) limited interruptions, (3) a process for verification, and (4) an opportunity to review any relevant historical data. CONCLUSIONS: The findings in this review highlight the need for standardized tools and techniques for patient handoffs in the U.S. Military's expeditionary care system. Future research is needed to trial verbal and nonverbal handoffs under field conditions to gather observational data to assess effectiveness. The results of our gap analyses may provide researchers insight for determining which handoffs to study. If standardized handoffs are utilized, training programs should incorporate the four critical elements into their curricula.