Haphazard handover: A medical weekend handover improvement project

Quality Improvement Poster Download

Background & Problem

Handover is an internationally recognised vulnerability in patient care with reviews by NPSA1, NCEPOD2 and RCP3. Medical weekend handovers at GRH and CGH comprised of unstructured handwritten or highlighted ward lists filed for on-call weekend teams. This system was identified as a significant risk for preventable patient harm:

• Illegible handwriting and irreplaceable paper sheets that were easily lost could both lead to serious incidents.
• Unstructured format and incomplete information led to inefficiencies and hampered the ability to identify unwell patients and prioritise jobs.

Aim

For medical weekend handovers, trust wide, to contain 90% of patient handover information defined by the RCP Acute Care toolkit3 by August 2017.

Method

Focus groups amongst junior doctors and a questionnaire explored change ideas.

PDSA cycles:

• Standardised handover proforma developed and introduced on a single ward in CGH.
• Amendments to proforma before trust wide roll-out. Proforma available on intranet and can be typed in.
• Handover guidelines issued to new incoming junior doctors.

Prospective data was collected from weekend handovers and collated against RCP standards throughout. Questionnaire repeated post interventions.

Results

Outcome measure:

Improvement in patient handover information from 78% to 85% at GRH. Pre-existing proformas at CGH resulted in no significant increase and need further data collection is needed.

Process measure:

Uptake of typed proformas correlated with increased handover information: Typed proformas contained on average 90% of RCP required information compared to 82% for non proformas.

Balancing measure:

Safety and satisfaction scores by junior doctors increased by 15% and 20% respectively.

Implications

Despite the widespread scrutiny, current literature has yet to determine an outcome measure which translates whether handover improvements result in patient care improvements. Our results, after the introduction of a standardised handover proforma are promising, however the greatest challenge has been changing behaviours. We aim to build on these improvements with verbal Friday handover meetings, which are currently being trailed at CGH, and transition to an electronic handover system.

1. National Patient Safety Agency (2004) Seven steps to patient safety. London: National Patient Safety Agency. http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/?entryid45=59787
2. National Confidential Enquiry into Patient Outcome and Death (2007) Emergency Admissions: A jouney in the right direction?. London. National Confidential Enquiry into Patient Outcome and Death. http://www.ncepod.org.uk/2007report1/Downloads/EA_report.pdf
3. Royal College of Physicians (2011) Acute care toolkit 1: handover. London: Royal College of Physicians. https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-1-handover