Healthcare Consulting Services with a Focus on Patient Safety Solutions and Quality Improvement Across the Health Care Continuum. Your Patient Safety Resource Solution.

Patient Safety Tip of the Week 

June 30, 2009           

iSoBAR: Australian Clinical Handoffs/Handovers

Most academic healthcare systems have been welcoming their new incoming residents and fellows in that past 2 weeks. Fortunately, most programs are now incorporating patient safety training into their orientation programs for those new members of the healthcare team. And many have begun to incorporate specific sessions on the importance of handoffs and introduced them to the structured formats that we have been using at our individual organizations.

So it is timely that the June 1, 2009 issue of the Medical Journal of Australia contains an entire supplement dedicated to clinical handoffs. It covers handoffs from offices, from long-term care units to emergency rooms, using TeamSTEPPS training to improve communication in a mental health unit, use of video recordings of handoffs in emergency departments to improve communication, use of whiteboards, use of a standardized communication tool for maternity settings, a framework for communication in a post-anesthetic care situation, plus your more common in-hospital and inter-hospital handoffs.

They have articles on two modifications of the well-known SBAR format. One is the SHARED (situation, history, assessment, risk, expectation, documentation) format. The second is the iSoBAR (identify–situation–observations–background–agreed plan–read back) format, which they have used as a clinical handover checklist.

If you don’t have subscription access to the Medical Journal of Australia (it is not included in most of our academic electronic journal collections but you can purchase 1-week online access to it for about $25), you can still read about the iSoBAR program at the Australian Commission on Safety and Quality in Health Care website and download for free some really great materials about the tools developed and how to use them.

Communication problems underlie at least 75% of sentinel events and can be found as an important contributing factor in almost every root cause analysis (RCA) that we do. It is well-recognized that handoffs are a high-risk activity from a patient safety perspective. Development of structured handoff formats has been an important milestone in patient safety. The SBAR (Situation-Background-Assessment-Recommendation) format was originally developed in the Kaiser-Permanente health system and has been widely adopted as a handoff tool.

Perhaps the biggest problem with handoffs is that they all too often tend to be one-way in practice. On the other hand, good handoffs are clearly two-way communication sessions. They should be conducted in an environment that is conducive to interaction and not subject to interruptions. The most important things are allowing adequate time for the “recipient” to ask questions and seek clarification and for both parties to clearly understand and agree on what needs to be done. Therefore, a regional and national collaborative in Australia modified certain elements of the SBAR format to better recognize these needs (Porteous et al 2009). Involving teams with clinicians, nurses and others, they analyzed data from multiple sources and developed both standardized operating protocols (SOP’s) and minimum datasets (MDS’s) that could be integrated into checklists and/or forms to be used for handoffs and transfers of care. However, one concept they emphasized was that, even though they ultimately want a structured and standardized format, flexibility and the ability to adapt the process to meet needs at the local level were essential. That flexibility plus engagement of clinicians to apply the concept within the context of their local healthcare environment is important in influencing both ownership and adoption of the processes and tools. So they both added to and made some subtle, but important, changes to the SBAR format. The additions are the “i” for “identify” (identify yourself and the patient) and the “o” for “observations” (factual information about the patient’s condition, diagnostic studies, etc.). But it is the changes that are the most important features. The “a” has been changed from assessment to “agreed plan” and the “r” has been changed from recommendation to “read back”. The latter is important to clarify for all parties a shared understanding of the plans and who is responsible for what. The resulting acronym iSoBAR thus stands for:

            i            Identify

            S            Situation

            o            Observations

            B            Background

            A            Agreed Plan, Accountability

            R            Read Back

While one of the tools first developed using iSoBAR was an inter-hospital transfer form, the concept and checklist can be readily adapted to multiple other types of handoff, including the typical change-of-shift handoffs that nurses and physicians do daily in hospitals. One group (Yee et al 2009) refined the process even more. Their team conducted extensive interview and observation sessions, and analysis of not only verbal and written handoff content but also factors such as body language and frequency of interruptions. Through an interative process they arrived at a new SOP and MDS with the catchy acronym “HAND ME AN iSoBAR”. The “iSoBAR” part is unchanged from above but the additions are helpful in operationalizing and preparing for your handoffs.

The HAND part stands for:

            H            Hey, it’s handover time!

            A            Allocate staff for continuity of care

            N            Nominate participants, time and venue

            D            Document on written sheets and patient notes

This ensures that all the pertinent parties are available for an effective handoff and that sufficient arrangements have been made for others to provide patient care so that minimal interruptions occur during the handoff.

The ME part stands for:

            M            Make sure all participants have arrived

            E            Elect a leader

This means ensuring protected time for all parties, that sessions will be prompt, and that one person ensures the agenda items are covered in a timely fashion.

The AN part stands for:

            A            Alerts, attention, and safety

            N            Notice

This part is really about prioritizing and anticipating. The alert and attention part is to make clear to everyone the items that need to be addressed first (eg. patients who are deteriorating, test results that need to be checked soon, etc.) and other items that may be important for patient safety and safety of staff and others. The “notice” part deals with anticipating all potential patient movements so that arrangements can be made for changes in workflow.

In hospital pilot projects, the Yee group was able to adapt the “HAND ME AN ISOBAR” approach to shift-to-shift handoffs for both medical and nursing staffs on general medicine, general surgery, and emergency medicine. The concept has been well accepted in those settings. They are now in the process of testing the concept in multiple other clinical settings and collecting data about the effects on clinical outcomes.

They stress the importance of a culture change in recognizing the importance of the clinical handoff and making it a priority.

Those of you who are regular readers of our columns know we are proponents of using videotapes with feedback to help improve communications in multiple venues (see the discussions on the sterile cockpit in our Patient Safety Tips of the Week for October 2, 2007 “Taking Off From the Wrong Runway” and May 26, 2009 “Learning from Tragedies. Part II”). One of the articles in the MJA supplement (Iedema et al 2009) used such videotaping in improving the handoff process. They used a “video-reflexive” tool called HELiCS (Handover-Enabling Learning in Communication for Safety) to redesign handoff processes in emergency department and ICU settings. They began with discussing handover processes, observing some actual handovers, and then watching videotapes of themselves during actual handoffs. This led to the clinicians improving both their intra- and inter-disciplinary communications and redesigning multiple facets of their handoffs. Videotapes are powerful tools for promoting change. Just like we use “story telling” and “personalization” as powerful tools to effect change in multiple aspects of patient safety, use of videotapes personalizes whatever process is being reviewed and makes one both aware of his/her interactions and remember them.

There are multiple other great lessons in this MJA supplement. They are well worth your time. Also, take some time to play with the downloadable educational toolkit on iSoBar from the Australian Commission on Safety and Quality in Health Care website.

Kudos to our Australian colleagues who have taken the lead in developing, validating and piloting a number of tools to improve the handoff process. It should be emphasized that measuring the impact of implementing these tools is not yet complete but it is expected that publication of that data will be forthcoming in the near future.

References:

Clinical handover: critical communications

Med J Aust 2009; 190 (11 supplement): S108-S160

http://www.mja.com.au/public/issues/190_11_010609/contents_suppl_010609.html

Western Australia Country Health Service and Royal Perth Hospital. iSoBAR for Inter-hospital Patient Transfers. Austrailian Commission on Safety and Quality in Health Care website.

http://www.health.gov.au/internet/safety/publishing.nsf/content/PriorityProgram-05_IHPT

Porteous JM, Stewart-Wynne EG, Connolly M, Crommelin PF. iSoBAR — a concept and handover checklist: the National Clinical Handover Initiative . Med J Aust 2009; 190 (11): S152-S156.

http://www.mja.com.au/public/issues/190_11_010609/con11210_fm.html

Inter-Hospital Patient Transfer Form (from the WACHS Clinical Handover Initiative)

http://www.health.gov.au/internet/safety/publishing.nsf/content/com-pubs_CH-IHPT/$File/IHPT-Form.pdf

Yee KC, Wong MC, Turner P. “HAND ME AN ISOBAR”: a pilot study of an evidence-based approach to improving shift-to-shift clinical handover. Med J Aust 2009; 190 (11): S121-S124.

http://www.mja.com.au/public/issues/190_11_010609/yee11187_fm.html

Iedema R, Merrick ET, Kerridge R, Herkes R, Lee B, Anscombe M, Rajbhandari D, Lucey M, White L. Handover — Enabling Learning in Communication for Safety (HELiCS): a report on achievements at two hospital sites. Med J Aust 2009; 190 (11): S133-S136.

http://www.mja.com.au/public/issues/190_11_010609/ied11188_fm.html

See also some of our prior columns on handoffs:

February 26, 2008 “Nightmares….The Hospital at Night”

September 30, 2008 “Hot Topic: Handoffs”

December 2008 “Another Good Paper on Handoffs”

Print “iSoBAR: Australian Clinical Handoffs/Handovers”

Click here to leave a comment on this tip.

To get "Patient Safety Tip of the Week " emailed to you, click here and enter "subscribe" in the subject field.

If you don't see the search term you expected to see here, its probably because that tip already went to our Tip of the Week Archive. We do a new tip every week. Click here to search the entire site or you can Go to Tip of the Week Archive a patient safety resource solution loaded with tips, tools, and techniques you can use in your patient safety and quality improvement initiatives. Or it may have moved to our What's New Archive.

Click here to see the consulting services and patient safety solutions that we provide.

What's New in the Patient Safety World?

Some of our most popular columns, CMS's Final Rule on Non-Payment for "Never Events" and Joint Commission 2009 National Patient Safety Goals  have already moved to the What’s New Archive. To see them, either click on the links above or go to the What’s New Archive.

July 2009

Editorial on Medicare Nonpayment for Falls

NPSA Review of Patient Safety for Children and Young People

Failure to Inform Patients of Clinically Significant Outpatient Test Results

Unintended Consequences of a DVT Prevention Strategy

Editorial on Medicare Nonpayment for Falls

In the June 4, 2009 issue of the New England Journal of Medicine, Sharon Inouye and colleagues authored an editorial about the Medicare policy of nonpayment for falls and its potential for unintended consequences. They make the argument that there really is not a good evidence base for interventions that prevent falls or prevent injuries from falls. They do note that their own multimodality intervention for delirium prevention, the Hospital Elder Life Program or HELP (see our October 21, 2008 Patient Safety Tip of the Week “Preventing Delirium”) has also been successful in reducing falls, though that data has not been published.

Their major concern is that hospitals may inappropriately intervene by using restraints in an ill-advised attempt to reduce falls (use of restraints, in fact, increases the likelihood of injury from falls). That may have the unintended consequence of reducing patient mobility. They even point out that the new Medicare policy has spurred an industry manufacturing devices intended to circumvent guidelines against traditional restraints.

We share their concerns about such unintended consequences. However, the CMS policy has caused hospitals to renew their focus on fall prevention. Most of the interventions in the HELP program (such as scheduled toileting, avoidance of restraints, avoiding psychoactive medications in the elderly, etc.) just make common sense and should be encouraged even without a more definitive evidence base, particularly since the cost of such implementation is relatively inexpensive.

References:

Inouye SK, Brown CJ, Tinetti ME. Medicare Nonpayment, Hospital Falls, and Unintended Consequences. NEJM 2009; 360:2390-2393

http://content.nejm.org/cgi/content/extract/360/23/2390

Print “July 2009 Editorial on Medicare Nonpayment for Falls”

NPSA Review of Patient Safety for Children and Young People

The National Patient Safety Agency in the UK has published its report “Review of patient safety for children and young people”. This summarizes learnings from data reported in the NPSA’s Reporting and Learning System (RLS). Of almost a million incidents now in that system, 2% relate to neonates and 5% to children. They acknowledge that reporting of incidents from primary care areas has been suboptimal so most of the incidents in the database come from hospitals.

The most commonly reported safety incident involving children or neonates related to “medication incidents”. In fact, the age group 0-4 had the second highest incidence of medication errors, surpassed only by the over 75 age group. Incorrect dose or strength was a big problem, including multiple examples of erroneous calculations and problems with decimal points (leading to 10-fold dosing errors). Note that a recent study in Austrailia also pointed out deficiencies in drug dose calculation skills, particularly of housestaff and less experienced physicians.

The report also highlights problems with recognition of severity of illness and continued problems with communication as issues of concern. Interestingly, the third most common type of incident was “slips, trips and falls”. Actually that should not be so surprising since in the age group of concern, slips trips and falls are very common amongst those healthy children who are not hospitalized. It does, however, emphasize the need to consider fall risk in our assessments of children as well as adults during hospitalization.

References:

NPSA (UK). Review of patient safety for children and young people. 2009

http://www.npsa.nhs.uk/nrls/improvingpatientsafety/children-and-young-people/

Simpson CM, Keijzers GB, Lind JF. A survey of drug-dose calculation skills of Australian tertiary hospital doctors. Med J Aust 2009; 190 (3): 117-120

http://www.mja.com.au/public/issues/190_03_020209/sim10260_fm.html

Print “July 2009 NPSA Review of Patient Safety for Children and Young People”

Failure to Inform Patients of Clinically Significant Outpatient Test Results

One of our continuing hot buttons is results of significant clinical findings slipping through the cracks. We discussed these extensively in our May 1, 2007 Patient Safety Tip of the Week “The Missed Cancer” and our February 12, 2008 Patient Safety Tip of the Week “More on Tracking Test Results”.

A new paper sheds some light on the frequency with which such failures to inform patients about clinically significant tests occur. Casalino et al reviewed charts from both community and academic primary care practices to find documentation of followup of abnormal results of 11 common blood tests and 3 common preventive tests. They found apparent failure to inform patients of such abnormal test results 7.1% of the time. Perhaps the most interesting finding is that those practices using a combination of paper and electronic records (so called “partial EMR”) had higher failure rates than those having either a full EMR or full paper-based systems. They found that very few practices had explicit rules or systems for managing test results and usually relied on the individual physician to devise his/her own system. Unfortunately, some were still telling patients to rely on the old “no news is good news” concept, which obviously is very flawed and unsafe.

This entire issue remains problematic and better systems are needed to ensure such abnormal test results do not slip through the cracks. Further research is needed to develop the evidence base for best practices in this regard.

References:

Casalino LP, Dunham D, Chin MH et al. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results. Arch Intern Med. 2009;169(12):1123-1129.

http://archinte.ama-assn.org/cgi/content/full/169/12/1123

Print “July 2009 Failure to Inform Patients of Clinically Significant Outpatient Test Results

Unintended Consequences of a DVT Prevention Strategy

Often we implement quality improvement or patient safety strategies without considering all the possible unintended consequences (or we simply do not know what unintended consequences to look for!). For years, graduated compression stockings have been used as a strategy to prevent DVT in patients with stroke. Though in the US we have felt that the evidence for use of these (as opposed to pneumatic compression stockings) in stroke patients was scant, they have been used extensively in other countries. And, while we were skeptical about their effectiveness, most of us took an attitude that “it can’t hurt”. Well, now a new study published in Lancet (CLOTS trial 1) shows that not only do thigh-high graduated stockings not prevent DVT in stroke patients, they actually cause harm. Skin breaks, ulcers, blisters, and skin necrosis were significantly more common in patients allocated to GCS than in those allocated to avoid their use.

The same group is now looking at both the efficacy and safety of pneumatic compression stockings in stroke patients (in the CLOTS-3 trial).

Whereas there is evidence to support use of graduated compression stockings in surgical patients, there will now undoubtedly also be studies now looking at the overall efficacy and unintended consequences of graduated compression stockings in other conditions.

Reference:

The CLOTS Trials Collaboration. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. The Lancet 2009; 373:1958 - 1965, 6 June 2009

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60941-7/abstract

Print “July 2009 Unintended Consequences of a DVT Prevention Strategy”

Print “July 2009 What's New in the Patient Safety World (full column)”

Print “July 2009 Editorial on Medicare Nonpayment for Falls”

Print “July 2009 NPSA Review of Patient Safety for Children and Young People”

Print “July 2009 Failure to Inform Patients of Clinically Significant Outpatient Test Results”

Print “July 2009 Unintended Consequences of a DVT Prevention Strategy”

Go to the "Whats New Archive"

To get "What's New in the Patient Safety World" emailed to you, click here and enter "subscribe" in the subject field.