US medical service: Ineffective handovers were associated with increased risk of preventable adverse events (Petersen, 1994). US teaching hospital trainees: 15% mistakes were associated with poor handover (Jagsi et al, 2005). UK obstetric anaesthetic handovers: Anaesthetists (4%) reported critical incidents that resulted from poor handover (Sabir et al., 2006). ICU to ward nursing handover: Ward nurses say they did not receive enough information to provide direct patient care; ICU nurses failed provide the information ward nurses needed, which implicated risk associated with discharge from ICU (Whittaker and Ball, 2000) . ICU safety: lack of communication were associated with preventable adverse events (Pronovost et al., 2002).
Participants including doctors, nurses, and ward clerks. Participants: 85 participants recruited. Observation of discharge process: 17 days over a 8 week period, with 8-14 hours/day were spent in the field; 28 ICU discharges were tracked. Semi-structured interviews: 56 interviews were undertaken (audio-taped). Contact summaries. Field notes. Examining/collecting written policies and other documents to determine critical information flows. Demographic data sheet to describe the participants. Hospital database: ICU statistics on admissions, discharges, delayed discharges, ICU occupancy rate, and patient discharge destination
These are the examples of problem areas identified in the discharge process.
the issues of loss of information during handover, and the distrusting relationships and conflicts among teams and departments due to lack of communication. : the collaborative teamwork strategies some departments used to optimise the discharge process.
Observations and interviews suggested that there was lack of standard protocol and structure in clinical handovers, including the medical morning handover, ICU to ward nursing phone handover and face to face handover. There was variations in the amount of information transferred, information loss, the misunderstanding of the purpose of the handover, and interruptions to the handover. There has been a growing recognition of the need to underpin handover with key principles in recent research literature. It was suggested that leaders’ understanding and participation, making handover a priority, ensuring relevant parties present at the handover, handing over at an appropriate time and a place that is free of distractions and interruptions, standardising handover process, and regularly evaluation of the handover process and quality were the key principles (Australian Commission on Safety and Quality in Health Care, 2010; Australian Resource Centre for Healthcare Innovations (ARCHI), 2009). The findings of this research suggested that the current clinical handover process did not follow some of the principles including giving face to face handover priority, handing over at a place that is free of distractions and interruptions, and standardising handover content as suggested by literature. The lack of interdisciplinary communication between doctors and nurses in ICU and on the wards prevent the potential errors from being identified early and may result in
Valentin et al., found that LOS was a predictor of sentinal events in ICU.
Researcher as instrument: become insensitive to some issues; also as participant, interference with the practice.
Tools use Such as computer programs for bed management.
Overall, patients had an average delay time of 3.2 hours (4.6 prior and 1.0 after the intervention). The second phase of the research was carried out by other team members, therefore it is not the focus of this talk. But the assessment of the discharge process informed the research.
The Implication of Teamwork and Communication on ICU Patient ...
The Implication of Teamwork and
Communication on ICU Patient Discharge
Frances Lin (PhD Candidate)
Professor Wendy Chaboyer
Professor Marianne Wallis
School of Nursing & Midwifery
Research Centre for Clinical and Community Practice Innovation
Griffith University, Gold Coast, Australia
Better teamwork was found to be associated with less mistakes,
decreased LOS, reduced cost, and increased patient safety (Jain et
al., 2006; Nemeth, et al., 2006; Pronovost et al., 2003;Salas & Cannon-Bowers, 2000; Sims,
Salas & Burke, 2004).
Sub-optimal communication among team members was found to
be associated with increased adverse events (Pronovost et al., 2002).
Poor communication between doctors and nurses was
associated with preventable adverse events (Donchin et al., 1995).
Poor clinical handover was associated with increased mistakes
(Jagsi et al, 2005), preventable adverse events (Petersen, 1994) and critical
incidents (Sabir et al., 2006).
The Impact of Teamwork and
Communication on Patient Safety
A literature review of organisational, individual and teamwork factors
contributing to THE ICU discharge process (Lin, Chaboyer, & Wallis, 2009)
Flow and performance
Personality and social
Use/not use protocols
Aim of The Study
To describe ICU patient discharge process in an Australian
metropolitan hospital in order to make recommendations for
clinical practice improvement.
This research was the first phase of a larger action research
project - Enhancing Intensive Care Unit discharges through
multidisciplinary approaches. Phase 2 and 3 of the larger study
focused on implementing and evaluating an improved ICU patient
1. What is the ICU patient discharge process?
2. What are the factors contributing to the ICU patient discharge process?
3. How are discharge decisions made in the ICU patient discharge process and
who are the main decision-makers?
4. What roles, responsibilities does each member play in the discharge
process and how do the team members interact?
5. What are the vulnerabilities in this process that may present risks to patient
Theoretical underpinnings: Distributed Cognition (Hutchins, 1999) and
Activity Theory (Engestrom, 1987).
Cognitive ethnography: using ethnographic data collection
techniques (Williams, 2006).
Setting: A large Australian metropolitan tertiary public teaching
hospital with a level 3 ICU was selected.
Participant recruitment: ICU and ward.
Ethics approval was obtained and all participants gave written
Rules Division of Labour
The ICU discharge process is a cognitive process which involves
The elements of Distributed Cognition:
Cognitive process is distributed among members of the group.
Team members interact with each other in a meaningful context.
Team members interact with artefacts (tools, discharge decision-
One on one semi-structured interviews.
Examining/collecting existing documents.
Demographic data sheet.
Preliminary data analysis during data collection:
Contact summaries and case summaries.
Transcribing data: checking transcripts against audio tape files.
Coding, recoding, and recoding.
Looking for patterns and themes.
Figure - Activity Theory in ICU patient discharge process adopted from Engestrom (1987)
Division of Labour
Computer programs for bed management
Conflicting objectives across
ICU and ward doctors, nurses, ward clerks, etc
Findings – Description of The ICU Discharge
Themes & Subthemes (on teamwork and communication)
Communicating ineffectively among teams and departments
Barriers of ICU to ward nursing handover.
Communicating ineffectively between departments.
Communicating insufficiently between medical and nursing teams
Working collaboratively to optimise the discharge process
Working beyond team and departmental boundaries for optimised
Pushing the discharge process forward.
Nurses safe-guarding the discharge process to improve
communication among teams.
Supporting inexperienced team members.
Sub-optimal communication may contribute to adverse events, and
ICU to ward nursing handovers – followed a strong routine but
need standardised protocol and structure as suggested by the
Australian Commission on Safety and Quality in Health Care (2010)
and Australian Resource Centre for Healthcare Innovations (2009).
Tools’ design and use issues - such as computer programs were
not used effectively to communicate vital information timely. The
use of some tools was found to optimise coordinated patient care
(Maloney, Wolfe, Gesteland, Hales, & Nkoy, 2007; Nicholls & Young, 2007).
The poor communication may have contributed to discharge
The lack of interdisciplinary communication between doctors and
nurses in ICU and on the wards may have patient safety
implications (Alvarez & Coiera, 2006; Donchin et al. 1995; Nadzam, 2009; The Joint
Collaborative teamwork optimised the discharge process
Collaborative teamwork shortened ICU discharge delays, which
improved the efficient use of hospital resources and may optimise
patient outcome (Valentin et al., 2006).
Supporting other team members (ICU nurses supporting junior
doctors, ICU liaison nurse supporting ward nurses) are essential
for better teamwork (Flin et al., 2008), which may contribute to better
patient outcomes (Ball, Kirkby, & Williams, 2003; Chaboyer et al., 2005; Priestley et
Researcher as instrument.
Participants change of behaviour due to the observer’s presence.
Conclusion and Recommendations
Improve clinical communication
Standardise clinical handover structure and protocol.
Leadership involvement in improving interdisciplinary communication.
Reinforce tools’ use in clinical communication using organisational
Redesign tools related to handover.
Encourage collaborative teamwork
Adopt collaborative teamwork initiatives across the hospital.
Contributions of The Research Findings
Interventions informed by the research findings were
implemented. Examples of the interventions:
ICU to ward nursing handover process was redesigned, emphasis
was given to the face to face handover.
Tools modified and implemented to facilitate communications.
ICU provide predicted discharge date to the wards in order to help
the wards to plan patient care.
Outcome: shortened discharge delays (4.6 hours prior, and 1.0
post intervention), but no change to mortality.
(Chaboyer, et al., 2010, Submitted for publication)
Queensland Health Clinical Practice Improvement Centre (CPIC)
The research group for the larger project
Australian Commission on Safety and Quality in Health Care. (2010). The OSSIE guide to
clinical handover improvement. Sydney: ACSQHC.
Australian Resource Centre for Healthcare Innovations (ARCHI). (2009). Standard key
principles for clinical handover. Retrieved from http://www.archi.net.au/e-
Alvarez, G., & Coiera, E. (2006). Interdisciplinary communication: an uncharted source of
medical error? Journal of Critical Care, 21, 236-242.
Ball, C., Kirkby, M., & Williams, S. (2003). Effect of the critical care outreach team on patient
survival to discharge from hospital and readmission to critical care: non-randomised
population based study. British Medical Journal, 327, 1014-1017.
Chaboyer, W., Gillespie, B., Foster, M., & Kendall, M. (2005). The impact of an ICU liaison
nurse: a case study of ward nurses’ perceptions. Journal of Clinical Nursing 14, 766-775.
Donchin, Y., Gopher, D., Olin, M., Badihi, Y., Biesky, M., Sprung, C., et al. (1995). A look into
the nature and causes of human errors in the intensive care unit. Critical Care Medicine,
Engestrom, Y. (1987). Learning by expanding: An activity-theoretical approach to
developmental research. Helsinki: Orienta-Konsultit.
Flin, R., O'Connor, P., & Crichton, M. (2008). Safety at the sharpe end: a guide to non-
technical skills. Burlington, USA: Ashgate Publishing Company.
Hutchins, E. (1999). Cognition in the wild. Cambridge: MIT Press.
Jagsi, R., Kitch, B. T., Weinstein, D. F., Campbell, E. G., Hutter, M., & Weissman, J. S.
(2005). Residents report on adverse events and their causes. Archives of Internal Medicine,
Jain, M., Miller, L., Belt, D., King, D., & Berwick, D. M. (2006). Decline in ICU adverse events,
nosocomial infections and cost through a quality improvement initiative focusing on teamwork
and culture change. Quality & Safety Health Care, 15, 235-239.
Lin, F., Chaboyer, W., & Wallis, M. (2009). A Literature Review of organisational, individual
and teamwork factors contributing to the ICU discharge process. Australian Critical Care, 22,
Maloney, C. G., Wolfe, D., Gesteland, P. H., Hales, J. W., & Nkoy, F. L. (2007). A tool for
improving patient discharge process and hospital communicatio practices: the aatient tracker
Paper presented at the AMIA 2007 Symposium Prodeedings, Chicago.
Nadzam, D. M. (2009). Nurses’ role in communication and patient safety. Journal of Nursing
Care Quality, 24 (3), 184-188.
Nemeth, C. P., O’Connor, M., Klock, P. A., & Cook, R. I. (2006). Discovering healthcare
cognition: The use of cognitive artifacts to reveal cognitive work. Organization Studie, 27,
Nicholls, A. G., & Young, F. R. (2007). Innovative hospital bed management using spatial
technology. Spatial Science Queensland, 2, 26-30.
Priestley, G., Watson, W., Rashidian, A., Mozley, C., Russell, D., Wilson, J., et al. (2004).
Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a
general hospital. Intensive Care Medicine, 30, 1398-1404.
Peterson, G. L. (1994). Communicating in organizations: a casebook. Scottsdale, Arizona:
Gorsuch Scarisbrick Publishers.
Pronovost, P., Wu, A. W., Dorman, T., & Morlock, L. (2002). Building safety into ICU care.
Journal of Critical Care, 17(2), 78-85.
Pronovost, P., Berenholtz, S. M., Ngo, K., McDowell, M., Holzmueller, C., Haraden, C., et al.
(2003). Developing and pilot testing quality indicators in the intensive care unit. Journal of
Critical Care, 18(3), 145-155.
Sabir, N., Yentis, S. M., & Holdcroft, A. (2006). A national survey of obstetric anaesthetic
handovers. Anaesthesia, 61(4), 376-380.
Salas, E., & Cannon-Bowers, J. A. (2000). The science of training: a decade of progress.
Annual Review of Psychology, 52, 471-499.
Sims, D. E., Salas, E., & Burke, S. C. (2004). Is there a "big five" in teamwork? Paper
presented at the 19th annual meeting of the Society for Industrial and Organisational
The Joint Commission. ( 2007). Improving handoff communication. Joint Commission
Williams, R. F. (2006). Using cognitive ethnography to study instruction. Paper presented at
the 7th international conference on Learning Sciences, Bloomington, Indiana.
Valentin, A., Capuzzo, M., Guidet, B., Moreno, R. P., Dolanski, L., Bauer, P., et al. (2006).
Patient safety in intensive care: results from the multinational Sentinel Events Evaluation
(SEE) study. Intensive Care Medicine, 32, 1591-1598.
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