Daily Dynamic Discharge (DDD) by Patsy Pattie & Carole Morton

“Daily Dynamic Discharge is to improve the timeliness and quality of patient care by planning and synchronising the day’s activities”.
(The Scottish Government, Edinburgh 2016)

The 6 Essential Actions for improving unscheduled care was launched in 2015. The 6 actions were identified as “being fundamental to improving patient care, safety and experience for the unscheduled pathways”. One of these actions is “Patient Rather Than Bed Management”. This approach requires the multi disciplinary team working together to plan and synchronise tasks required to ensure a safe dynamic discharge process, aligning medical and therapeutic care, discharge earlier in the day and transfer back to the GP in time, reducing the length of stay in hospital.

Why do we need it?
The recent day of Care Audit in September 2016 indicated that 30.5% of patients in hospital beds did not require acute hospital care. These patients should have been transferred to another area for continued care or discharged home.
For some health professionals, too many conflicting demands on time often results in optimising work in such a way that may seem logical to the individual, especially if you are covering across wards, but may not be optimal for patient flow. This mis-synchronisation can cause delays and increase the length of stay for patients. Where there is a clear priority of order of tasks for that day, each individual team member plays their part in ensuring the priority tasks for patients is actioned or completed, which works for the patient, thus reducing delays in discharge or transferring the patient.

Who is doing it?
Ward 10 was nominated as the Exemplar ward for DGRI and implementation commenced in early September 2016. Early indications show that time of day discharges are taking place earlier in the day around mid afternoon. Prior to the introduction of DDD 27% of patients had been discharged by 4pm, in the four weeks since implementation the figure has almost doubled to 49%.

When are we doing it?
Each DDD ward huddle usually takes place at 9am each morning. Some wards have incorporated a DDD catch up meeting into their afternoon handover huddle.

What are the benefits?
The DDD approach promotes proactive patient management for today and preparing for tomorrow’s activities i.e. increase accuracy on our discharge position and increase awareness of the need to create capacity at key points throughout the day.
This is aligned to The Royal College of Physicians acute medical care “The right person, in the right setting – first time” (please see link below).
https://cdn.shopify.com/s/files/1/0924/4392/files/acute_medical_care_final_for_web.pdf?1709961806511712341
A recent quote from Vicki Nicoll, SCN ward 10:
“DDD for us has had such a positive impact on the ward as we are finding patients are being seen by all members of the Multi Disciplinary Team (MDT) in a timelier manner.  The patients are being discussed rather than going from one weekly Multi Disciplinary Team meeting to the next.  Interventions are being done more timely from all members.  We have noticed that length of stay has reduced and patients that you would normally presume would be with us for some time seem to be getting home quicker. We recently had a patient who was a complex discharge and I personally thought the patient would have passed away in the ward, but everybody pulled together and we were able to return the patient home.  Sadly, she passed away at home, where she wanted to be with her family”.

“DDD has taken away the thought that nurses should do everything when in fact it is everyone’s job to work together to ensure that the patient is on the right pathway”.

DDD is currently being rolled out to most of the acute wards in DGRI and a test of change commenced on 21st November in Annan Community Hospital. Implementation at the Galloway Community Hospital is planned for mid December.

We all have our part to play in the planning of a safe discharge for our patients, DDD enhances our current processes, promoting an MDT approach with teams working collaboratively and more robustly.

Patsy Pattie works in the Acute Services Improvement Team and Carole Morton is an Assistant General Manager Acute Services for NHS Dumfries and Galloway

Time to do the right thing? by Barbara Tamburrini

During my current secondment to the Emergency Department in DGRI, I recently had the pleasure of reviewing a patient who I will call Jane and who required admission for an acute health issue. Jane was very apprehensive and reluctant to be admitted which is quite understandable. However, on exploring this further to reassure her, I discovered that much of Jane’s apprehension surrounded her experiences during a previous admission to hospital. Jane had been a patient in a very busy general ward and she had required frequent assistance but English was not her first language. Jane was very conscious that her communication and understanding had caused her some challenges and she stated she felt “slow” because of this language barrier.

Jane described in some detail, that she had felt very uncomfortable pressing her buzzer when she required assistance and she explained that she thought the staff on the ward were wonderful and caring but they appeared, in Jane’s words:

“too much, too busy busy, too small time.”

 

Jane’s perception was that by requiring assistance, she was contributing to what she considered to be an already unachievable workload for busy staff. Jane was clear that staff had been efficient and had never expressed displeasure when she requested help but the speed at which staff interacted with her and assisted her, coupled with her self-awareness regarding her language had all made Jane feel “a nuisance”.

 

After spending some time reassuring Jane, I came away from this consultation having been touched considerably by it.

Why?

Because, all too often, I have been one of those nurses on a busy ward, rushing around to get my work done and trying to juggle many different ‘plates’ in the air. It’s so easy to get into this mind set in a healthcare environment which demands so much from staff to deliver optimal services with the limited resources we currently have and a potentially depleted morale.

BUT, and this point is crucial…

Who do we forget about when this work culture is put under the spotlight?

Where does our most important element, our patient, feature in this busy work schedule?

Of course, looking after our patient’s effectively is the reason we are all so busy but is that thinking doing our patients’ an injustice? If we had the chance to ask those who utilise our services and who we interact with during our hectic shift, how they view the busy environmental culture within our wards and departments and what they think and feel about our workload, what would they say? Ask yourself honestly how many of your patients’ or clients have said to you they “don’t want to bother you”? When I think of this, I am certainly left wondering whether I have given my patients the perception that I was too busy for them. Have the patient’s I’ve interacted with during a busy shift been left feeling as though they didn’t want to ‘bother me’ or worse, they didn’t want to be a bother to me? Like most people in the NHS, I came into this profession to care for people in the best way I can but are we achieving this if this is how our patients could be feeling?

A significant quote comes to mind when I consider this…

How have you made someone feel today?

Its certainly a juggling act between making our patients feel listened to and valued and managing the hectic workload. Arguably, that juggling act has been no more challenging than it is in our clinical areas and departments today in the face of financial pressures, tight staffing numbers and a seemingly increasing need for our services.

SO, how on earth do we begin to address this? Ask yourself some very simple questions…

1. The problem is we are too busy but we need to make time for our patient.
2. The solution is to free up time from our current schedule – what do we do consistently and regularly which we could look at?
3. We perform many handovers during a busy shift, what would happen if we made these more efficient?
4. How do we give this a try?

How do we give this a try? When we come up against a question like this but our heads are full of everything else going on in our busy working day, we need a strategy to give us some direction. Think of this strategy as being our ‘work-place problem-solving’ SatNav!

The destination in our ‘SatNav’ is symbolised by the question mark in this diagram and it brings us back to the question in our problem-solving steps – How do we achieve more efficient Handovers?

This diagram leads us to the outcome by asking key questions:

• WHY do we want to achieve more efficient handovers? – To release time to care for our patients.
• WHERE do our handovers occur? – In our care area and in other departments.
• WHEN do these handovers occur? – When we transfer patients and when we change shifts.
• HOW do these handovers occur? – Are they structured, formal enough and does everyone use the same approach?
• WHAT is handed over? – Do we communicate accurate clinical details in the right way to ensure the receivers clearly understand what we want them to?
• WHO are essential participants for our handover to occur? – Which staff groups do we need at which handovers?

The key questions asked in our problem-solving approach provide the foundation for NHSDG’s current Handover Strategy;

WHO?, WHAT?, WHEN?, WHERE? & HOW?

By choosing just one handover process, which occurs at any point in your departmental working day, and answering these simple but crucial questions, you can begin to develop the structure for your departmental handover protocol. A simple protocol document is available either in electronic or paper form, which you can adapt to suit your specific area and handover needs. What’s more, you don’t need to do this alone, assistance is available from myself or Jean Robson as NHSDG handover leads or from members of the Patient Safety & Improvement Team or the NHSDG Handover Group to support and guide you through every stage.

Some tips which will help you to achieve success are:

• Start small and plan well
• Engage all your colleagues in the process
• Build up gradually & extend what you learn
• Expect challenges & address these as they arise
• Use continual evaluation to continually develop & improve
• Never think you’ve finished – its always evolving!

By making this frequently occurring element of our workload much more efficient, we will release considerable time in our day to give back to our patients, relatives and colleagues.

The added ‘Brucey Bonus!’ (and here’s a blast from the past!!) is that a more structured handover will improve the accuracy and safety of clinical communication, which will enhance cohesive, collaborative and consistent multi-disciplinary team working.

The handover group are planning information sessions on 24^th November 2015 to share existing developments from departments working on their handover processes, to learn new ideas relating to improving your handovers and give support in promoting optimal handover practice which is essential, valuable and time-saving.

So, to return to our original thought, look once again at the title of this blog:

‘Time to do the right thing?’

Do you see the question “Is it time to do the right thing?

Or do you see the question “Do we have time to do the right thing?”

The focus of this blog has been the latter. Are we giving time? Are we allowing time in our day to ensure that we do the right thing by our service users and their relatives as well as our peers and colleagues?

I leave you with one final point:

Think of your last work interaction with a patient, relative, colleague or client. During this, did you give them time and have you left them with the perception that you had time for them? If not, what do you need to improve?

Did you make time to read this?

Further information is available from Barbara (btamburrini@nhs.net) Jean Robson (jean.robson@nhs.net) or Amy Sellors, Patient Safety & Improvement Team (asellors@nhs.net).

Barbara Tamburrini, ANP & NHSDG Lead Nurse for Handover at NHS D&G

01387 246246 Ext 32983

 

Hidden eKIS by @kendonaldson

I took a phone call from a patient’s son some months ago. His Dad, Edward, had recently spent 24 hours in our hospital and whilst all members of staff had been kind and helpful he had a few issues he wished to discuss with me. Edward is 83. He had a heart attack 3 weeks ago and has ongoing chest pains. He has Stage 4 Chronic Kidney Disease (about 20% function) and leukaemia. Sadly this last is not amenable to any treatment.

In short Edward has multiple long term conditions and is dying from his leukaemia. He still has a reasonable quality of life and, with his family, has discussed clearly what his wishes for the future are. His GP has entered all of this into his eKIS or Electronic Key Information Summary which can be accessed by all healthcare professionals though the ECS, Electronic care Summary.

So when Edward got sudden onset severe chest pain last week the sequence of events was a surprise to him and his family. Paramedics were called and when they arrived they did an ECG. They then proceeded to fax this to the Golden Jubilee Hospital in Glasgow and discuss his case with the team there. All the time they did this Edward’s son was quietly explaining that this was not necessary, his Dad did not want this level of intervention and that this detail was all available on eKIS. The paramedics had not heard of, and were unsure how to access, eKIS. They apologised for this and took Edward to Dumfries. At least he did not have to go to Glasgow!

On arrival on the Emergency Department the same thing happened. Nobody knew what eKIS was and how to access it. I’m afraid this was replicated in the medical assessment unit. The following day, after Edward had been assessed, he was deemed fit for discharge – a blood transfusion had sorted his anaemia and angina. The first the family knew was when Edward phoned them to tell them. “And” he added “I can now drive!” He was delighted as driving is very important to him.

When Edward’s son arrived, a little surprised and anxious, he discovered that the team, who still had not accessed the eKIS, did not know that Edward had had a heart attack 3 weeks prior and hence couldn’t drive, had not contacted the palliative care team (outlined in eKIS on any admission) and had not really thought through his discharge. “Its not very Holistic” was his understated comment to me. It all got sorted and Edward got home (although a little aggrieved that he couldn’t in fact drive) and neither he nor his family wish to complain but they want to understand why eKIS seems to be a mystery to the Scottish Ambulance Service and most of secondary care.

So what is eKIS? If you click here you will get access to a useful ‘FAQs” about eKIS. You can also read Neil Kellys blog “The KIS of Life”, published on the 14th of February 2014, here. Very simply eKIS is an electronic handover. GPs, in consultation with patients and their families, can enter details about DNACPR, treatment escalation and goals and priorities for the future. The idea is to prevent things like unnecessary trips to Glasgow or, if arriving at the ED in a collapsed state, CTs or endoscopies or trips to theatre. Basically it’s an attempt to communicate a patients wishes to all who care for them. Not much use though if no-one looks at it.

Its important for us all to be aware of eKIS. Not just those of us at the front door. If I review a patient in a clinic or on a ward round and we discuss issues about the future and decisions are made then I should communicate this to the GP and ask for it to be included on their eKIS. I confess I am not very good at this but hope that this story will significantly improve my communication efforts. I must also confess that I did not have a password for ECS when I heard this story but I have remedied that.

It’s almost a daily mantra in my life – “it’s all about communication”. So many small (and not so small!) things go wrong because of poor communication. eKIS is an excellent tool aimed at reducing communication errors. Let’s not be like Peter Pan and keep it hidden, let’s use it.

Postscript: Sadly, since writing this blog, Edward has died. He had a number of admissions to hospital following the one outlined above and had similar problems with communication however died peacefully in the Alexandra Unit.

Ken Donaldson is a Consultant Nephrologist and Associate Medical Director at NHS Dumfries and Galloway

Communication and Handovers – What’s all the talking about? by Barbara Tamburrini

After 2 years and 99 posted blogs, addressing 68 different subject areas, I appear to have inherited the slightly daunting task of writing blog number 100 for dghealth. In that very first blog on 19^th March 2013, Ken Donaldson encouraged us to open our ears, embrace and not be frightened of communication, interaction and feedback between service providers and service users.

Ken’s vision for the future was to achieve “one blog a week from dghealth for a long time to come” and the evidence that this has been met is clearly demonstrated in the widespread engagement, diverse variety of subjects and immense learning that these blogs have generated.

Despite so many differing categories being listed for these blogs, communication is arguably a subject more frequently visited than most and this topic intertwines into every aspect of our professional practice and service delivery. Communication is an area where the effectiveness of its application has a direct impact on the outcome. We have all had situations, both professional and non-professional where ineffective communication has had a negative impact on our experience and when this involves healthcare provision, the effect can be profound.

One essential aspect of clinical communication involves handover and with the publication of NHS Dumfries and Galloway’s new handover strategy, there is an increasingly important focus on this fundamental area of care provision.

NHSDG is leading the way nationally in this area with the formation of a dedicated handover group to support, guide and encourage improvement work relating to handovers.

Furthermore, the senior endorsement of handover as a key area within NHSDG and the addition of this to our 9 point of care priorities has demonstrated that handover improvement work has significant support and advocacy at all levels throughout the organization.

But how do we improve the quality of handovers whilst maintaining our focus and energy on all the other priority areas competing for our professional attention? We work in an environment that can sometimes feel like we’re on a hamster wheel without the money to upgrade to first class travel!

Despite these challenging times, making tangible improvements in our work environment is easier than we might think and this is no less applicable to developing our approaches to handover. Asking 5 simple questions provides the structure required to build a foundation for improvement in handover practice.

 

1. WHO – who should be involved, who are our essential attenders?
2. WHEN – when should our handover take place?
3. WHERE – Where should this handover happen?
4. HOW – How are we going to structure this handover?
5. WHAT – What needs to be handed over?

Developing a local protocol for your department based on these 5 standards allows the identification and development of areas of handover whether they relate to shift handovers or transfers of patient care and the effect can be significant.

The protocol clearly identifies fundamental, locally specific details such as which personnel are essential to making the handover fully effective and the appropriate location and time of the handover being addressed. The manner in which the handover will be undertaken is also outlined and the details that need to be included are prioritized. An appendix can then be added to highlight the structure to be applied to the actual handover procedure and this standardizes the process by ensuring transparency and consistency with the way the handover is undertaken on a continual basis.

Over the last 6 months, the Hospital at Night (H@N) ANP team, based in DGRI, have been developing and enhancing their handover process beginning with the handover from dayshift to nightshift at 2145 hours and evaluation of this work is demonstrating impressive results.

So, how have we achieved this? We initially identified that the handover we wanted to improve was the nighttime meeting at 2145 hours since evidence has indicated that this represented a period of increased significance when care is transferred from dayshift to on-call teams. We then began by formulating a H@N handover protocol based on the 5 handover standards and we identified our target as being 95% compliant as indicated in the NHSDG handover strategy. We then used this local protocol to guide our development of essential elements such as the handover procedure and our improvements measurement.

During this time, we also evaluated our baseline position so we could clearly measure effectiveness and areas for improvement. Once our new handover protocol had been developed and finalized, we set implementation and review dates, publicized the improvement project and undertook team education before implementing and measuring the project.

Although the achievements we have been able to make are clear, we still have challenges in meeting our 95% compliance target in some areas, namely our attendance by essential personnel (WHO) and our punctuality (WHEN). Additionally, this work highlighted that whilst we could measure the handover procedure itself, we had no measurement process for the quality of clinical information handed over and this was felt to be an area of significant concern.

Therefore, the team has developed a quality measuring score for patients handed over using an SBAR-R format which was adapted from an SBAR scoring system implemented within the day surgery unit in DGRI. The aim of this H@N SBAR-R quality score is to measure the quality of clinical communication as well as guiding practice and providing a communication structure. It is also anticipated that this SBAR-R quality measurement can be used to underpin multidisciplinary training and education in relation to clinical communication.

This has definitely been a work in progress and as happens with all improvement work, successes are achieved whilst challenges are also experienced.

Initial and ongoing engagement has been crucial to delivering the improvements demonstrated and this will also be vital in addressing the challenges which still remain. Nonetheless, the handover improvements the H@N team have implemented and achieved, are easily transferrable across any specialty, discipline and clinical area. This presents the opportunity for shared learning and collaboration to assist and encourage areas who may be considering similar improvement work and practice developments across NHSDG.

The H@N ANPs have some challenges ahead to achieve 95% compliance in all 5 standards whilst also implementing quality measurement for handover communication but this is innovative work that we are proud to be sharing. With support from senior management, the improvement team, the handover group and clinical staff, the H@N team is able to progress these developments and participate in an exciting project that NHSDG is leading the way on nationally. It is hoped that data collection will continue to demonstrate the value of this work and its benefit upon delivering safe, reliable, effective, patient-centered care.

After all, isn’t that what we are all here for?

 Barbara Tamburrini is an Advanced Nurse Practitioner for NHS Dumfries & Galloway

 

 

 

 

 

 

12 days……….and so much more by the Patient Safety Team

Sing this to the tune of ‘The 12 Days of Christmas’. Go on you know you want to!!

On the 1^st day of Christmas the safety team said to me A pledge to be harm free.

We are all working towards achieving the aims of the Scottish Patient Safety Programme and you can help us achieve this.

http://www.scottishpatientsafetyprogramme.scot.nhs.uk/about-us

On the 2^nd day of Christmas the safety team said to me 2 improvement advisors, 2 improvement trainees and a couple of Project Officers to support and guide you to make patient care even safer.

For more information on Patient Safety and Improvement team contact us on ext 34138/34154.

On the 3^rd day of Christmas the safety team said to me 3 leaders on a walk round.

There have been 37 leadership walk rounds this year across NHS Dumfries and Galloway. These provide an opportunity for frontline staff to meet with the senior management team and have a structured conversation. This helps to keep leaders in touch with issues for frontline staff that help deliver safe, effective, person centred care and to promote and share areas of good practice.

On the 4th day of Christmas the safety team said to me Get it Right For Every Child with: 4 Early Years work streams.

The early years collaborative aims to make Scotland the best place to grow up. It is the first collaborative of its kind in the world that incorporates health, education and social care. There is a huge amount of work going on across our region to improve the care given to babies, children and families.

Take inspiration from this short video showing how nursery children are becoming involved.    http://vimeo.com/102914044

On the 5^th day of Christmas the safety team said to me (lets improve handovers with…) 5 Handover questions.

November saw our 1^st handover week in NHS D and G. We are the 1^st board to focus our improvement work on handovers. We have recognised handover as a priority and for this reason handover has been added to the 9 point of care priorities for DGRI. We are also leading the way for national improvements. Interested? Them please get in touch and

Ask yourself these 5 questions next time you pass over information and see if you can improve the quality of the handover ….

On the 6^th day of Christmas the safety team said to me sock it to sepsis! Sepsis 6 saves lives; so can you!

The national sepsis awareness day was promoted in DGRI in September. Craig Stobo (from F.E.A.T) came to talk about his very personal account of sepsis. Both he and his pregnant wife contracted Sepsis, Craig survived but very sadly his wife and child did not. Craig also ‘stole shamelessly’ from NHS D and G the idea of the farthest travelled ‘sock it to sepsis’ socks. Here are some of ours. Any guesses as to where we travelled? A real conversation starter as you can imagine!

On the 7^th day of Christmas the safety team said to me 7 improvement programmes.

The patient safety and improvement team support all of these programmes

• We manage the programmes
• provide local learning events
• coach and teach people
• offer support and advice
• link with national teams
• provide monthly reports to drive improvement at ward level
• Provide reports for various management boards.

PHEW! Most importantly we want to remain visible to those providing the care and those working on improvements.

On the 8^th day of Christmas the safety team said to me 8 (hundred) ICU days between.

Well we thought we were onto a winner here with ICU having 888 days between a central line blood stream infection. However they are actually even better with 994 days today! Almost at 1000 days!!!!   What a fantastic achievement. Well done to all involved!!!!

On the 9^th day of Christmas the safety team said to me 9 point of care priorities (plus one).

Surgical site infections                                            Falls                    

Catheter Associated Urinary Tract Infections         Pressure Ulcers

Sepsis                                                                      Safer use of medicines

Heart Failure                                                             Venous thrombo embolism

Deteriorating patient                                                 Handover

Improvement teams have been set up to drive improvement in these areas. If you are interested in any of the above or have some great ideas please contact us and we will put you in contact with the clinical lead.

On the 10^th day of Christmas the safety team said to me 10 safety essentials in routine practice.

These are the areas of work that have been the focus since the start of the Scottish Patient Safety Programme in 2008. The trainee improvement advisors have been visiting all areas in DGRI to validate the data around these essentials and have been supporting teams to plan for the future.

11^th day of Christmas the safety team said to me 11 local learning events.

In 2014 we provided 11 local learning events …WOW!!!!!!  Our team works extremely hard to ensure we inspire, motivate and provide you with the tools to enable you to make improvements for the people you care for.

Feedback has included ‘fantastic event, very well organised’, ‘great to have time out of the ward to focus on improvements’, ‘great day, everyone went away with a game plan and the tools to implement it’.

On the 12^th day of Christmas the safety team said to me 12 months of data.

Measuring helps us to understand whether our changes impact on the goal we have set. As an improvement team our goal was to reduce the number of areas in DGRI not reporting data. The results are shown in the run chart below.

We have demonstrated that by increasing the visibility and accessibility of the team we were able to significantly improve. Well done to all areas. 

We would like to take this opportunity to thank everyone for your hard work and continued support.

 

 

 

Have a very merry Christmas and a happy new year.

From everyone in the Patient Safety and Improvement Team.

Being smart is not enough by Jean Robson

Reflections on Safer Handover Week (24/11/14 – 28/11/14)

Handovers occur many, many times every day; and we know from the evidence that communication failures at handover are responsible for problems in every department in every organisation Worldwide. The Dumfries and Galloway handover group is now established with the aims of:

• supporting improvements in handover at transitions in care as patients pass through our health care services
• supporting improvements in handover at shift changes as our staff pass on responsibilities

The group ran a safer handover week, aiming to raise awareness in all staff of the importance of handover, but also of the strategies which may be employed to ensure effective handover. What did we learn?

Monday 24^th November               

• Passing appropriate information at shift changes and transitions of care is a personal responsibility for everyone.
• Organisations have the responsibility to facilitate this by developing good handover practices
• SBAR-R is a good tool only if used well!

Tuesday 25^th November               

• Using a structured format results in a vastly improved handover. Think:

• WHO should be involved in each handover
• WHAT information should be passed
• WHEN it should happen
• WHERE each handover should happen
• HOW it should happen

Wednesday 26^th November       

• A formal structure (WHO,WHAT, WHEN, WHERE, HOW), advance planning and good quality leadership of handover meetings result in staff having clear prioritised goals for their work, a greater shared understanding of information, AND time savings at handover.
• CORTIX can be a useful tool in evolving and structuring our handovers

Thursday 27^th November             

• Planning care in advance is valued by patients and carers and can result in much more effective and person centred care, and may result in reductions in admissions and lengths of stay
• Ceilings of care are dynamic and need reviewing regularly
• Discussions of ceilings of care can be challenging for staff but we have a responsibility to share decisions
• Survivors of cancer need support in returning to the “New Normal” of life after cancer

Friday 28^th November                   

Friday was the day we aimed to put the learning from the week together and develop some plans. Brian Robson reminded us that,

“It’s all about the people that we aim to serve. Being smart is not enough. We need to work in effective teams where safety culture is supportive, and use available tools.”

 

We heard about some early work on handover problems, and enjoyed spending time considering how we want our handovers to look before addressing barriers. The “yellow hat thinking” got teams off to a good start by dedicating time to planning for the ideal world. There was a real buzz in the room, with teams from a variety of departments working together, and talking to other groups to resolve barriers. It was a fantastic to see primary care teams helping secondary care, theatre teams helping psychiatry, and many others.

The next step

We have a great sense that we are at the beginning of a journey to improving handovers. We know that there will be challenges. Yet, across the board there is a willingness to engage in this work and an enthusiasm for making a difference. The commitment of our executive team was clear from the time they spent supporting the events of the week. Many staff from the shop floor voiced belief that they will be listened to and supported to make changes when they come up with ideas that make care safer at transitions. The handover group are keen to provide support to groups who want to start implementing changes. We would love to hear about the steps you are making to improve your handovers, so contact us to let us know what you are doing!

Jean Robson is a General Practitioner and Director of Medical Education for NHS Dumfries and Galloway

 

 

 

Handover by Barbara Tamburrini

How good do you think your handover technique is? 

Handover is an area of our clinical role which we all encounter regularly during our working day. We transfer patients between clinical environments and transfer clinical responsibilities at shift changes, all of which require handover actions.

As healthcare providers, we understand the importance of good handover communication and recognise the clear benefits of this for our patients and our delivery of optimal and safe clinical care. However, all too often, we are familiar with ineffective handover practice and witness the consequences of this on both the care delivered to patients and the outcomes they experience as a result.

This issue was highlighted to me quite a few years ago when inaccurate information passed on at a night time handover had a direct influence on my ability to provide an effective care response. A patient with hyperkalaemia which had yet to be fully assessed or treated, was handed over to the H@N team using an incorrect patient name. The correct patient could not be located resulting in a delay to the clinical response. During this time, an emergency call went out involving this patient and the error in handover communication became clear.

Sadly, the resuscitation attempt wasn’t successful and subsequent investigations confirmed that the incorrect handover was unlikely to have significantly contributed towards the outcome. The response time between handover and clinical assessment could certainly have been much better and this is what left its mark upon me. This delay could so easily have been avoided and could prove significant in another situation. Many years later, the impact of this episode remains vivid and this has taught me valuable lessons around the accuracy of handover communication which I use to enhance and improve handover practice wherever possible.

How do we do this though?

How do we improve something which is often taken for granted and which every health care facility nationwide finds challenging? Poor handover quality and a lack of standardisation have both been observed throughout UK healthcare facilities over recent years. In fact, it is acknowledged that this has led to medical errors, inappropriate investigations and prolonged in-patient admissions. This means we in NHS D&G are certainly not alone in needing to work on improving our handovers.

But does it make a difference that this is a national challenge? Well, the answer to that is probably No as well as Yes! It doesn’t matter whether we are isolated or whether every single facility in the world has issues with handover communication – we still need to address this and improve our practice.

Having said that, because this is a national and indeed international ‘hot potato’, there are many ideas, strategies and tools already developed and implemented in many hospitals which we can learn from and adapt for local use. So, yes, it does make a difference that this is such a widespread issue.

So the next question is – what can we do to improve our handovers?

The answer is – lots! We have many tools at our disposal which are widely available, of significant value and easily accessed but we often overlook the most basic of these…

We can, of course, use our verbal communication skills much more effectively to handover but this is much less effective when used in isolation. Research suggests only around 2.5% of patient data is retained through verbal-only handover methods. However, this increases to as much as 99% when a printed, structured and regularly updated handover containing all relevant clinical information is utilized. It’s really that simple!

The SBAR-R approach (Situation, Background, Assessment, Recommendations, Review) provides us with a platform to structure clinical communication to ensure it is concise, relevant and accurate and is delivered and received in an effective manner.

This last bit, the review, is crucial since we have all been in the situation where we have delivered what we feel is appropriate information but this may not have been correctly received for whatever reason…

Improving our clinical handovers doesn’t just involve using an SBAR-R approach correctly though. NHS D&G have formed a multidisciplinary handover group to encourage, support and improve handover practice throughout the organisation. The group have set the aim of achieving, by August 2019, 95% of patient handovers between clinical teams and shifts across NHSDG which contain all the relevant information required.

To achieve this, the group want to develop and launch an organisational handover strategy. Additionally, the group will engage with clinical teams to encourage the formulation of protocols and procedures which are standardised across the organisation whilst remaining specific to each clinical area.

The handover group are hosting a ‘Safer Handover Week’ from 24^th to 28^th November involving presentations, educational drop-ins and information sessions to raise awareness of handover practice and its improvement in clinical areas. The week will culminate in a full day event on 28^th November in Easterbrook Hall where the handover strategy will be launched and high profile national speakers will deliver presentations. The day will also involve presentations highlighting local initiatives, a storyboard competition and practical sessions to begin engagement with this improvement process.

Could you benefit from this valuable local event? I would suggest the answer is most definitely YES!

The handover group is looking for all staff, whatever your departmental area to come along to the Safer Handover Week sessions and learn more. We are also looking for multidisciplinary teams of ideally 3 people from each clinical area to attend the Handover Day. Become actively involved in improving handover practice across the organisation and crucially, you will have a direct, positive impact on improving handover practice in your own clinical area.

So, you’ve heard a very real story of the impact of poor handover communication upon our ability to practice effectively and you’ve seen ways in which we can improve this to deliver safer, higher quality care for our patients.

Therefore, my final question to you is more of a challenge. Can you really afford not to attend the Safer Handover Week?

For more information contact: Jean Robson, Director of Medical Education or Rebecca Henderson (x34257 or rebecca.henderson@nhs.net)

Barbara Tamburrini is an Advanced Nurse Practitioner for NHS Dumfries and Galloway