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Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
Toccafondi et al AHFE 2012
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Toccafondi et al AHFE 2012

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  • Healthcare are c omplex systems. M icorsystems are groups of clinicians and staff owrking together with a shared clinical purpose to provide care for a population of patients. It is very important to have continuity of care at the interface between different health microsystems.
  • B orowitz. P rospective study on handover during night on-call in a pediatric high acuity care ward. 158 of 196 (81%) potential surveys were collected. Quality assessed on a survey on a five-point Likert scale from 1 = inadequate to answer call questions to 5 = adequate to answer call questions.
  • C onsidering the handover process as a form of communication, aimed at orienting care and maintaining the continuity of care, means that it can be analysed as a relationshipp between to at least two actors, which are involved in a confersation and which share a commond ground. C ommond ground is essential for effective and meaningful communication. It requires several skills: A bility to share, inform and request A bility to jointly share attention and intentions with other C ommon cultural knowlegde
  • C areggi, torregalli, pontedera, orbetello. Ma pontedera ha sbagliato a compilare le schede, mentre orbetello è troppo piccolo e non si confronta bene con altri due ospedali grandi e paragonabili
  • A ustralian commission OZIE guide showed that handover da ICU a low acuity care is critical. C ontent item presi da piattaforma elearning australian commission
  • F ollow up revealed that the difference was only relative to the item “things to monitor in the next hours” p<.05
  • Predictable changes: 40% (ci: 19%-62%) agreement on Presence. 47% (25%-70%) agreement on Relevance Warning signals: 50% (28%-72%) agreement on Presence. 20% (4%-52%) agreement on Relevance.
  • P articipants: 4 physicians (2 high acuity unit – 2 low acuity) and 5 nurses (2 HC – 3 LC/HDU) in one setting 2 physicians (1ICU- 1 surgery ward) and 3 nurses (1ICU, 2 ward) in the other one 1. What type of medical information do you currently receive from the high acuity care unit? 2. What type of medical information do you currently give to the low acuity care unit? 3. What type of information would you like to receive from the high acuity unit? 4. What type of information would you like to give to the low acuity unit? 5. Which are the strong point and weak point of the handover practice as it is currently organized?
  • Predictable changes: 40% (ci: 19%-62%) agreement on Presence. 47% (25%-70%) agreement on Relevance Warning signals: 50% (28%-72%) agreement on Presence. 20% (4%-52%) agreement on Relevance.
  • Transcript

    • 1. Handover process in multidisciplinary health care:information transfer and common groundconstructionGiulio Toccafondi, Riccardo Tartaglia, Stefano Guidi, Sara Albolino
    • 2. BackgroundHandover can be defined as “The transfer of professional responsibility andaccountability for some or all aspects of care for a patient, or group of patients, toanother person or professional group on a temporary or permanent basis” (Wong M. et al 2008 )In health care systems patients’ transictions between diferrent care settings areincreasing in frequency. Usually more than one medical team is taking care of apatient . The transfer of patient may pose threats to patient safety.Poor communication during the exchange of medical information contributes tohandover incidents and inefficacy of care processes
    • 3. According to the Joint Commission the lack of effective communication isamong the main root causes for the majority of sentinel events that occurredfrom 2009 to 2011 in the United States http://www.jointcommission.org/Sentinel_Event_Statistics/
    • 4. Handover as CommunicationThe handover of medical information is a communication activitywhich plays an important role in orienting care.The 31% of the residents indicated something had happened while they wereon call that the handover had not prepared them for; and thatthe only variable influencing doctors’ perception of preparedness for theirnight on-call was the quality of the handover. (Borowitz SM et al. 2008)In order to make sense of patient handovers and improve them, we need toanalyze the relationships between the content conveyed and the social contextin which the communication occurs.
    • 5. Handover as CooperationPatient handover, like all human communication, is a relational activity involving at leasttwo actors sharing a common ground Common ground: pertinent knowledge, beliefs and assumptions that are shared among the involved parties, and support interdependent actions in some joint activity (Clark & Brennan, 1991)
    • 6. Study Setting Setting 1 - TERTIARY REFERRAL CENTER TEACHING HOSPITAL Emergency Intensive Care High Dependency Unit Unit ICU (10 beds) HDU (8 beds) Setting 2 - SECONDARY REFERRAL CENTER TERRRITORIAL HOSPITAL General Intensive Care Unit General Surgery ward ICU (10 beds) (12 beds)SENDER UNIT - High Acuity RECEIVING UNIT- Low Acuity Data on 22 transictions of care collected by 1 hospital physician and 1 nurse in each unit Handoffs at Handoffs at internal shift Handover internal shift changes changes
    • 7. Study Objective• Focus - critical handover scenario: transfer from high acuity care to low acuity care• Objective - observe the media and work patterns enabling handover process in order to assess the level of concordance between critical care units on handover content itemsHigh Acuity Low Acuity Handover Content Items Diagnosis and present state of the patient Recent changes in the conditions or treatment. Anticipation in changes of conditions or treatment Handoffs at Handoffs at internal shift What to monitor along shifts (physicians and nurses) internal shift changes changes Warning signs Handover
    • 8. Handover Probe Type of media Care continuity Minimal set of information about the patient health status Anticipatory guidanceClinical information acquiredby health care providers ofthe sender units based ontheir recent experience withthe patient Presence of content item in discharge form Relavance and reperebility
    • 9. Handover Probes outcomes Collection of data on in ‘blind copy’ in two units of each setting on the transitions of care. •Presence of handover content item in discharge form •Perceived relavance of content item •Reperebility of content item in extended patient record High Acuity Low Acuity Handover Content Items Handover Content ItemsDiagnosis and present state of the Diagnosis and present state of thepatient patientRecent changes in the conditions or Recent changes in the conditions or Level oftreatment. treatment. concurrenceAnticipation in changes of conditions or Anticipation in changes of conditions ortreatment treatmentWhat to monitor along shifts (physicians What to monitor along shifts (physiciansand nurses) and nurses)Warning signs Warning signs
    • 10. Quantity and Relevance of content itemsThe sender unit reported the presenceof a significantly higher amount ofinformation in the DF than the recipientunit (p<0.01).The difference was only relative to theamount of information about theanticipatory guidance. (p<.0001)The sender unit also reported thepresence of a significantly higheramount of relevant information in theDF than the recipient unit (p<0.05).
    • 11. Accessibility of content itemsTha average accessibility of content in the medical documentation reported byrecipient unit was lower than that reported by the sender unit (p<.01).
    • 12. Agreement among units P<.01 P<.05Poor agreement between the units about the presence in DF and the relevance ofitems relative to predictable changes and warning signs.
    • 13. Results in contextThe outcomes of the probes were discussed in focus groups with the healthpractitioners in order to contextualize the data, and understand thecharacteristics of the common conceptual ground.Focus groups revealed that:•anticipatory guidance iscommunicated implicitly;•the medical staff is moreinvolved in the pre-handoverthan the nursing staff;•verbal and face-to-faceinteractions are mainly used totransmit information aboutanticipatory guidance
    • 14. ConclusionsOur study highlighted that the handover process is shaped more by the informationneeds of the sender units than by those of the recipients.The limited participation of the nursing staff to a common conceptual groundreduces the reliability and possibility of correct interpretation of patienthandovers and may contribute to adverse events.The handover practices used in the settings seems to be lacking in importantinformation connected to the anticipatory guides.Further research should address the interaction among sender and receivingunits and the common ground construction. Focusing only on tools and media,in fact, does not allow to understand all the possible breakouts in handoverprocesses.
    • 15. Agreement among units Present in DF RelevantContent item Senders Recipients p-value * Senders Recipients p-value *Diagnosisand present 100% 100% – 96% 91% 1state of the patientRecent changesin the 96% 76% 0.375 96% 67% 0.063conditionsor treatmentAnticipation of changesin 91% 38% 0.006 86% 55% 0.109condition or treatmentWhat to monitor along 96% 71% 0.125 82% 76% 1shifts(physicians/ nurse)Warningsigns 50% 10% 0.02 67% 33% 0.344Poor agreement between the units about the presence in Df and the relevance ofitems relative to predictable changes and warning signs.

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