Handover in resus: Quality improvement for patient safety
Background:
It is widely accepted that handover of patients carries significant potential risk.1 The handover of critically ill patients in the resuscitation room from the pre-hospital to Emergency Department (ED) team is fraught with potential for communication error.2 Anecdotally this process within the ED at the Queen Elizabeth University Hospital (QEUH ) was felt to be suboptimal in relation to its lack of standardisation and structure, raising significant patient safety concerns.
The use of a structured handover tool, IMIST (Identification, Mechanism / Medical complaint, Injuries / Information regarding medical complaint, Signs / Symptoms, Treatment / Trends) has been shown to reduce variation, improve information volume, and reduce interruption, duration and repetition at the handover3.
Aim:
This quality improvement project’s overall aim was to improve patient safety at the handover in the resuscitation room. This was carried out through the introduction of a standardized and structured approach was introduced to the face-to-face handover in the resuscitation room. The project involved the SAS crews as well as the clinical team in the ED, receiving the patient.
Methods:
6 key performance indicators (KPI’s) were drawn up through reviewing current literature and discussion with clinical team. Compliance with these standards was assessed for 50 handovers between Scottish Ambulance Service (SAS) crews and the receiving clinical team in resus. Previous work with the SAS had led to the introduction of IMIST as a standardised handover tool between SAS crews and the ED. The compliance of SAS crews with this method of handover was also assessed.
Following this a number of interventions were implemented using the model for improvement and Plan- Do- Study- Act (PDSA) cycle, involving both paramedics and hospital clinicians. Interventions included: discussing findings at clinical governance meeting, information posters displayed within resus, face to face ‘hot’ debrief with paramedic teams following the handover, increasing distribution of pocket- aide memoirs for SAS crews, skills & drills sessions and simulation training.
Results:
On analysis of pre-intervention data, it was noted that compliance with KPI’s is currently 58% and the most common KPI’s missed are: no interruptions from clinician during paramedic handover and clarification sought on next of kin. Compliance with IMIST handovers by SAS staff was only 10% and the mean time of handover was 170 seconds (30-752.)
As the staggered changes are implemented, a run chart of results will demonstrate increased compliance with preset standards, an increase in clinician and paramedic satisfaction as well as a decrease in total time of handover.
Conclusion:
It is well recognised that communication errors account for a significant number of adverse clinical events. The handover of critically ill patients from the pre-hospital to the receiving hospital team carries additional potential hazard due to the time critical nature of the handover and multiple human factors involved in dealing with stressful clinical events.
Through the implementation of sustainable interventions involving both ED and ambulance staff, communication at handover is improving. This will ultimately benefit the safety of time critical and vulnerable patients
