The clinical handover process is an integral component of patient care. communication between clinicians regarding a patient's condition, treatment plan and care is directly related to the quality of health outcomes and systems success. Poor communication has been implicated as the leading cause of medication errors, delays in treatment, perinatal deaths and injuries, patient falls and wrong site surgeries. A study by the Joint commission on Accreditation of Healthcare organisations in the united States found that communication errors were the root cause of almost 70 percent of all sentinel events, with 75 percent of patients involved dying.
Effective communication is a complex concept requiring skill, insight, cognition and understanding. Although used frequently in day-to-day care, it remains a skill that must be learned, practiced and refined by all clinicians. Healthcare providers need to learn how to communicate in a clear, concise and appropriate manner within hurried, noisy and frantic healthcare environments.
Variations and inconsistencies in handover practices together with an apparent lack of best practice guidelines contribute to increased risk for patients and interruptions to the continuum of care. With this in mind, the PACT project was designed to develop, implement and evaluate for improvements in clinical communication.
The project took place during 2008 in a regional, private hospital in south-eastern Australia. The 103 bed hospital provides acute inpatient and outpatient medical, surgical and mental health services to a predominantly rural catchment area within a radius of 150 km.
• There were particular challenges in this setting:
• No resident medical officers on site;
• Nurses have to communicate directly with specialists;
• Poor mobile telephone coverage, and
• High proportion of part time, on call and junior nursing staff.
The PACT Project
The key objective of this project was to improve communication and increase patient safety by the development, implementation and evaluation of formalized tools and education processes for clinical handover. This initiative was entitled 'The PACT Project', to convey the essential elements of effective clinical handover.
P - Patient Assessment. Nurses must have the skills to conduct an effective patient assessment, particularly for patients whose condition is deteriorating.
A - Assertive Communication. Assessment findings must be communicated clearly and completely to other clinicians to ensure patient safety
C - Continuum of Care. Patient safety must be maintained by the timely, accurate and complete transfer of responsibility for patient care from nurse to nurse and shift to shift.
T - Teamwork with Trust. All health care providers regardless of their position and experience have the right to speak up and express their concerns or opinions about a patient in a trusting and respectful team environment.
A project team (the authors) was established to guide the development, implementation and evaluation phases of the initiative. A critical reference group (PACT champions) of seven experienced nurses from the wards met regularly with the project team. They promoted the project to ward staff and reported views and opinions of nurses on the floor back to the team.
The project team kept staff informed of progress through monthly PACT newsletters, posters and notice boards located in wards and the staff dining room. All project materials were coloured bright pink to provide a visual reminder of the PACT message.
Questionnaires were designed by the project team to determine opinions of nurses and specialist doctors about the effectiveness of clinical handover and information exchange between nurses and other healthcare providers. In total, 49 nurses (response rate 54 percent) and 16 specialists (response rate 73%) responded. The results supported the belief that improvements in clinical handover were needed at the hospital. Key figures were:
• 94% identified that different nurses give handover in different ways;
• 82% stated that a standardised way of giving handover was needed;
• 85% believed that improvement was needed in the way nurses communicate with each other;
• 86% agreed that improvement was needed in the way that nurses communicate with specialists, and
• 60% wanted to deliver handover more effectively.
All nursing staff attended one-hour workshops on assertive communication and patient assessment, primarily focused upon early recognition of the deteriorating patient. Workshops were mandatory and staff were paid to attend. Presentations were interactive and covered both theory and the lived experiences of staff, highlighting from their own practice examples of good and poor communications.
Two communication tools developed by the project team became the cornerstones of the project. The first was a handover prompt card which provided a template for standardising shift to shift handover. The prompt card was designed to provide a structured, standardised format for handover by establishing a sequence for information transfer, making it easier for staff to identify if information was omitted. The bright pink handover prompt cards attached to staff identity badges, ensuring they were always available.
The second tool was a communication template or script, to be followed when nurses contacted specialists by telephone about deteriorating patients who required review. This template used a hybrid of the bullet point communication style favored by doctors and the descriptive narrative preferred by nurses. The format helped nurses to structure their communication to facilitate listening and comprehension. It prompted staff to assess the patient, gather pertinent information and be prepared for questions the doctor may ask. There is space to record doctor's orders and any follow up required. Once completed, this form becomes part of the medical record.
For Staff The tools were evaluated using action research (four competed cycles) and amended as a result of staff feedback and evaluation. Staff identified the value of the tools for ensuring accurate, consistent handovers and keeping staff on task when delivering handover, especially if they were tired at the end of a long shift.
A post implementation survey of nurses showed that:
• 68% stated that they now always get the information they need at handover;
• 72% agreed that handover is more structured now than before the project;
• 68% of nurses believed shift to shift handover has improved, and
• 80% felt more confident when communicating with doctors.
In a focus group conducted by the external project team members (EP & EC) PACT champions identified the following benefits:
Handovers more comprehensive and omissions easily identified;
• Increased confidence among junior staff, recent graduates and students;
• Assessment workshops and communication tools led to earlier intervention for deteriorating patients;
• Improved written documentation;
• Less stress for staff in giving handover and when contacting doctors, and
• Nurses now able to identify and act on emerging clinical trends.
Anecdotal evidence supports these findings. Nursing Unit Managers and nurses identified improvements in the quality and structure of handovers given by staff. Handovers were generally more comprehensive and detailed, and structured to include information relevant to each patient. Nurses reported their confidence had increased when giving handover and they strongly supported the use of the template when telephoning doctors about deteriorating patients. Although the template could not remove all anxiety when calling a doctor at 3 am, staff felt more comfortable with a format to follow which kept them focused and prepared.
For Patient SafetyThere have been a number of patient care benefits from the project. Analysis of the communication templates used by nurses when calling doctors allowed the identification of emerging clinical trends. To date the major reasons for calls include:
• Uncontrolled nausea and vomiting;
• Uncontrolled pain, and
• Observations outside normal limits.
One outcome has been the introduction of an antiemetic protocol. Since its implementation there have been no telephone calls to doctors regarding uncontrolled nausea and vomiting. Staff identify and respond to deteriorating patients much sooner than previously, leading to more timely care and interventions. Collection of statistical data including Medical Emergency Team (MET) calls and transfers to the high dependency unit is continuing, to evaluate the long term impact of the PACT project.
A key focus for hospital managers today is to ensure optimal treatment, patient safety and early identification of issues that might lead to delays in discharge. Timely discharge and high patient satisfaction are especially important in the private (for profit) sector. The PACT project has shown one way to achieve these outcomes.
Another key issue is recruitment and retention of nurses, with stress cited as a major cause of staff morbidity, absenteeism and departure. The PACT project has shown one way to reduce stress among nurses by increasing their skills and confidence.
Future initiatives for this project include expanding and adapting the tools to the specialty areas of the hospital including Post Anaesthetic Care Unit, Oncology and Mental Health Units. There are also plans to extend the use of the PACT project to other hospitals across Australia.
The ongoing challenge for the project is to maintain staff enthusiasm for and compliance with the structured programme. This can be achieved through embedding it in hospital policy, including it in orientation programmess for new staff and having mandatory annual updates for all staff.
Acknowledgements This project was supported by funding from the Australian Commission on Safety and Quality in Health Care.