Standardized patient handover in the Emergency Department A qualitativ study among nurses and amulance personnel Master thesis in health- and social science Uneversety of Stavanger. December 2009 Elsa Søyland
Background for chosen topic Exchange of information among ambulance personnel and nurses in the emergency department is critical to the transition from pre and in hospital emissions of the patients. Implementation of a standardized handover protocol for nurses and ambulance personnel in the emergency department June 2007. Precise communications by clinical patient handover are identified as one of the most important elements on the worldwide agenda for increased quality and patient safety.
Simulation- the handover procedure Before the procedure was implemented in the clinic we arranged a 3 hours multi professional simulation course for all the nurses and ambulance personnel in the region. Before the simulation we had a common review of the procedure. Focus: communication and structured patient information The scenarios were related to the whole processfrom the prehospital patient meeting to the patient handover in the Emergency Department Each group 2 scenarios with debriefing- featuring discussion and reflection
EMERGENCY room Context Handover to pre warned trauma-/cardiac arrest team TRIAGE Patient handover from ambulance personnel to triage nurse Triage for walking patients Reception Triage Nurse Illustrasjon 1 T r e a t m e n t u n i t
Patient handover in the Emergency Department Handover is a means of two-way communication between the ED nurse and ambulance service. A standardized procedure will facilitate consistency and continuity of care and enables ED nurses to ascertain the events leading to admission. The handoff is more than just transfer of information- it is also a transfer of professional responsibility (Arora et al., 2008).
Literature Databases: Cinahl, British Nursing Index, Academic Search Elite Keywords: Patient handover, patient handoff, emergency departmet/ - room, nursing, ambulance service, communication, implementation and procedures, patient safety.
Earlier research Transitions of care to one provider to another represent gaps that are considered especially vulnerable to errors (Arora&Johnson, 2006). There is a lack of literature and formal knowledge about patient handover (Bomba&Prakash, 2005). Many studies are related to nurse-to-nurse handovers, and recently some interest in handovers among doctors. Few studies in multi professional information transition and patient handovers (Smith et al. 2008). We need focus on patient handover among pre-hospital and in-hospital care givers (Jenkin, 2007). There is a need for standards and guidelines in relation to both the giver and receivers of ED handovers. This should focus on content and the process to secure patient information. (Jenkin et al. 2007, Owen et al. 2009, Ye et al. 2007, Arora og Johnson, 2006).
Intention To get deeper knowledge in patient handover experiences in an Emergency Department (ED) in a Norwegian hospital. To study emphasized factors which affect the interaction among ambulance personnel and ED nurses during patient handover.
Problem What is the experience of patient handover in the Emergency Department, 2 years after the implementation of a common handover procedure?
Theoretical references Communication related to safe patient handover Relevant articles related to patient handover A model for building a standardized handover procedure.
Method Qualtative method Focus groups - a group interview that stimulates to communication among the participants to generate data and give insight to peoples feelings, attitudes and their understanding of the reality (Morgan, 1998). Multistages - focus groups
Informants The first focus group interview: The second focus group interview: Nurses in the Emergency Department 6 participants 5 women 1 man 6 participants- 3 participated to the first interview- 3 new nurses recruited. 4 women 2 men Ambulance personnel 6 participants 4 women 1 man 4 participants did not participate in the first interview 2 women 2 men Age: 22 years to 58 years 24 years to 55 years Experience: From 1 year to 30 years in the ED From 1 year to 23 years in the ambulance service
Results There are appointed 3 main themes in the study 1) INDIVIDUEL FACTORS SUB THEME: Attitudes Experience and competance Communication 2) ORGANIZATION SUB THEME: Triage Resources avilable Leadership 3) VARIOUS CULTURES TO PROCEDURE COMPLIANCE
Additional result Related to attitudes: The nurses have similar experiences as the ambulance personnel in the handover process in the Emergency Departement. They experience not to be met or heard when they are bringing the patient further in to the chain of treatment. For example when they are going to handover a patient from ED to the ICU, Heart Recovery etc.
Discussion Patient handover in the ED is often the most frustrating part of the whole transport Patient handover can lead to different output, depending on if it is me or a younger colleague who is performing the handover We stay face to face to the ambulance personnel- this is important to recognize and make the best climate for good communication Ambulance personnel: I am the one hand and my colleague the other hand ED nurse: Procedure? No, I have never heard about it!
Conclution: Answers to the research questions? How do ambulance personnel and ED nurses experience patient handover in the clinical daily life? What factors (communication, experience, competence, triage etc) influence good patient handover? Which conditions involves risk related to patient handover? Are there variations between ambulance personnel and ED nurses regarded to experiences related to a standardized patient handover in the emergency department?
Implications for the clinical routines Translate the handover procedure to be more like a checklist - make it more user-friendly. Regularly evaluation of the process. Ask if the procedure is in use and is it functional? This must be fundamental in action plans related to competence and training. More multi professional training to get to know each other better, to exchange knowledge, experiences and cooperate to develop further projects.
Forslag til videre forskning Evalueringsstudie av pasientoverlevering etter intervensjon som feks etter innføring av ny sjekkliste. Evalueringsstudie av pasientoverlevering etter intervensjon som feks etter simuleringstrening med fokus på pasientoverlevering. Observasjonsstudie i akutt mottak, med fokus på pasientoverlevering fra ambulansepersonell til sykepleiere i triage. Case studie relatert til kommunikasjon og pasientoverlevering på tvers av profesjoner og avdelinger
Studiens relevans for brukerperspektivet Brukerperspektivet nedfelt i helselovgivningen: Brukernes rett til informasjon og medvirkning (Pasientrettighetsloven, 1999 3-2) Helsepersonellets plikt til å gi informasjon og bidra til medvirkning (Helsepersonelloven, 1999 10). Dette bygger på prinsipper om innflytelse, tillit, respekt, individuell behandling, tilstrekkelig informasjon. Pasientoverlevering fra ambulansepersonell til sykepleiere i akutt mottak blir definert som en pasientfokusert prosess (Sheehy, 1998). Pasientsikkerhet: opimizing care and avoiding harm (Croscerry et al., 2009)
Datainnsamling Nøkkelspørsmål: 1) Hva er viktigst for deg i prosessen med pasientoverlevering fra ambulansepersonell til sykepleiere i akutt mottak? Hva tror du er viktigst for pasienten? 2) Hvilke erfaringer har du til nyorganiseringen rundt pasientflyt- triage, nye lokaler og implementering av den tverrfaglige overleveringsprosedyren? Kjenner dere alle til dette og har fått god opplæring i overleveringsprosedyren? Hva kjennetegner pasientoverlevering nå, sammenlignet med tidligere? 3) Hvilke erfaringer har dere relatert til kommunikasjon i pasientoverleveringssituasjoner? Hva må til for god kommunikasjon? Hva kjennetegner den tverrfaglige kommunikasjonsprosessen ved pasientoverlevering? 4) Hva tenker du om pasientsikkerhet relatert til pasientoverlevering? Er det noe som kan gå galt? 5) Hva er ditt syn på en/den tverrfaglige pasientoverleveringsprosedyre? Er det behov for en prosedyre? Hvorfor? Forslag til forbedringer?
Validitet/ reliabilitet Validitet- gyldighet Reliabilitet-pålitelighet
Forskningsetiske vurderinger Informert samtykke Konfidensialitet Skriftlig godkjenning fra avdelingsleder i akutt mottak og ambulansesjef i regionen Godkjenning fra NSD
Dataanalyse Menings enhet Inspirert av Graneheim og Lundmans kvalitative innholdsanalyse (Graneheim & Lundman, 2003). Kondensert menings enhet Subtema Tema Jeg velger å tro at jeg får et signal fra innskrivninspersonalet. Ledelsen har bestemt at der ute skal det være sekretærer som møter pasientene og da må jeg jo bare tro at den kvalitetsikringen er god nok Ledelse kvalitetssikrer ved sekretærer Ledelse Organisering Jeg må si at pasientoverleveringen i dag er noe helt annet- også pasientsikkerheten: vi ser joj pasientene når de kommer! Det kan vi ikke akkurat si at vi gjorde før I dag kan vi se pasientene når de kommer- de gjorde vi ikke akkurat før Før og nå Jeg synes at triagen er en veldig dårlig plass å jobbe, når jeg skal få informasjon Triage lite egnet for pasientoverlevering Triage