A study of registrars’ handover at the Alfred hospital

1. A study of registrars’ handover at the Alfred hospital Leila Alem, Michele Joseph, Stefanie Kethers, Cathie Steele ,Ross Wilkinson CSIRO ICT, Bayside Health

2. Registrar’s Handover • Failures in the care of patient are often attributed to information failure • Information discontinuity may be increased by handovers • Good clinical outcomes require handovers to be effective and efficient , they are the vital point of continuity of care • little research on medical handovers !

3. Focus of the Study: Weekend Handovers at PGMU • Our Hospital Setting • Metropolitan hospital with 335 beds • General medical ward (PGMU) • Two wards (A ) & (B ) + rapid assessment unit (R) • Admitting registrar & ward registrar • Two handovers per day : 8 am and 9 pm • Weekend handovers : less staff • 8 am – 9 pm : 1 ward registrar • 2pm- 9pm : 1 admitting registrar • 9pm – 8 am : 1 ward registrar

4. A two stages study • Preliminary study : Aug 04 – Dec 04 • Understand handovers: Function, information space, context • Formulate a research question • Main study: Jan 05- May 05 • Design intervention : information tool for use during handover • 2 weeks Observation before intervention= W1 & W2 • 2 weeks Observation after intervention = W3 & W4 • Evaluate effect of intervention

5. Handovers are complex • Handovers are multi function • Transfer of information • Transfer of responsibility • Learning : case review + reflection • Communication of situation awareness • Existing information tools not adequate for handovers • Patient records are not used : too much info? • Patient lists are used: not enough info

6. Our research Hypothesis • An information tool that gives just about the right amount of info at the patient level and a tool that gives a sense of who has been discussed in previous handover could lead to improved continuity of discussion • Our intervention = • patient information sheet that provides minimum about the patient • + • A snap shot of handover discussions over previous shifts

7. Intervention part one = Patient info sheet

8. Intervention part 2= summary of handover discussion • Friday 9m: P1 (admission), P2(med call), • Sat 8 am: P1( admission ), • Sat 9m : P3(admission), P4 ( med call), • Sun 9am P5(worried) • Sun 9pm • Mond 8am

9. The study: assess effect of intervention • Wk 1 + Wk 2: Handover Observations without any intervention • Wk3 + Wk4: handover Observations with intervention e.g. handovers using patient info sheet per patient + summary of handover discussions

10. Observations data • When : date and time of handover • Who : the two registrars involved in the handover • Who gets a mention : patient name and ID • Why they are mentioned : new admission, worried about , call from nurse

11. Study Protocol • Patient information prepared by Alfred staff on Friday afternoon • At start of handover: presentation of info folder • Registrars were encouraged to create a new patient information sheet per admissions, and update existing ones during shift • During handover : update of the handover summary discussion by observers • Hand updated info folder to incoming reg after handover as they start their ward work

12. Results 1: Continuity of discussion w2 w1 w3 w4

13. Measures: Continuity/Cumulative Weeks 1-2 Weeks 3-4

14. Revisiting our research hypothesis • Our intervention has increased the continuity of patient discussion • W4 has a substantial change of pattern in term of continuity of discussion

15. Conclusions • this study indicates that a change in the information environment in the form of a simple information tool can have an effect on the continuity of handover discussions • the study indicative only! • Future work: • Refine information tools • Build info tool into working environment & test usage • Test quality outcomes.

16. Some reflections • From electronic handover to awareness support tool • Very light weight ICT intervention to fit the practice • Mixed evaluation methods : ethnographic to articulate the research question and measure of the effect of the intervention to answer the question and demonstrate benefits

17. Thank You!