Patient Safety Tip of the Week
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
In September we talked about the hazards of handoffs (September 30, 2008 Patient Safety Tip of the Week Hot Topic: Handoffs) and our September 16, 2008 Patient Safety Tip of the Week “More on Radiology as a High Risk Area” spoke about many of the hazards of transporting patients to the diagnostic imaging suite. One way to facilitate such handoffs would be to include information on various risks in a structured communication tool for transports like the “ticket to ride” we described in our April 8, 2008 column “Oxygen as a Medication”. Some excellent tools have been developed to improve the handoff processes that take place during such transports.
One of the most
interesting papers we’ve seen on ICU transports (Esmail 2006)
focuses on development of a standardized decision/communication tool. Though
the paper does not report any outcome data, it provides some incredible
insights into issues associated with development of such tools. It describes
the efforts of a Canadian collaborative project to improve ICU transport safety
that arose after 2 incidents of cardiopulmonary arrest that occurred in ICU
patients that had been transported to diagnostic imaging areas. It goes through
all the steps involved in development of a decision “scorecard” to determine
the stability of the patient for such transport and the resources necessary if
such transport does take place. They used multiple PDSA cycles to test and
revise the tool. Their multidisciplinary performance improvement team began by
flowcharting all the steps involved in transporting an ICU patient to
diagnostic imaging and back to the ICU. They found 29 steps in all (those steps
are all included in a figure in the paper). They scanned the literature to find
other guidelines and tools for such transports and utilized these to develop
their own tool.
One of the most
important lessons from this collaborative was the involvement of a human
factors expert and their focus on how humans interact with reading and filling
out forms. They collected about 80 forms through their iterative processes and
found that many of the forms were too complex and not user-friendly. As a
result they progressively simplified the form and sought to include only “show
stoppers” as their clear decision points. Originally using the traffic signal
metaphor, they had green-yellow-red columns for various levels of safety for
transport. But in the final analysis, they moved to a geen-red or go/no-go type
format. (Red means that the ICU physician must determine whether the potential
benefits of the transport outweigh the risks and, if so, the physician should
accompany the patient during the transport). But they note that effective forms
accommodate two-way flow of information: instruction to the person filling out
the form and collection of information from that person. They cite research
that shows form fillers read less than 50% of relevant information such as
instructions. And they make the very important distinction between “directed
forms” and simple “checklists” Directed forms require a yes/no type of response
for each item, forcing a decsion and forcing the form filler to read carefully
before coming to that decision. They caution that checklists, on the other
hand, often lead to the form filler scanning the list for relevant items and
often skipping critical information they might perceive to be irrelevant.
(Important: note that most of the Peter Pronovost-type checklists you’ve heard
us advocate really fit the “directed forms” format defined in this paper).
Particularly
enlightening is their discussion of instructions for form use. They note that
instructions are often placed on a face sheet or introductory page and, if they
are even read, are often forgotten by the time the form filler gets to the area
of the form they apply to. So a good form includes the instructions visually at
the point where they are relevant.
The second lesson was
their insight that the tool needed to be designed so that a “novice” staff
member could use it.
A third lesson had to do
with some of the resistance to the form that was encountered at one
participating site. That particular site had its diagnostic imaging area
located adjacent to the ICU and staff there did not perceive the same pressing
needs for such a transport decision tool. We strongly agree with the conclusion
of the authors that such proximity likely gives rise to a false sense of
security and that adverse events are a danger related to even short transports.
A new paper on use of
the “ticket to ride” type checklist as a handoff tool (Pesanka
2008) also just appeared in the Journal
of Nursing Quality. Analysis of events occurring during off-unit transports had
identified a number of issues, so Pesanka and colleagues at UPMC put together a
team to develop a standardized handoff communication tool to be utilized during
in-hospital transports. The form they developed utilizes an SBAR format and
includes most of the key elements you need to consider during patient
transports, with appropriate checkboxes and places for sign-off (initials) by
everyone involved in the transport (sending team, transport team, receiving
team) at all destinations. Importantly, the UPMC Ticket to Ride includes the
patient himself as a key stakeholder and participant in the transport. The tool
also does a good job of addressing the issue of adequacy of oxygen therapy
during transports and stays off the unit (remember our original discussion of
the ticket to ride concept arose because of the frequent problem with oxygen
during such trips). Though the tool was originally intended for use during
transports to diagnostic imaging, it is now being rolled out as a tool for all
sorts of transports system-wide in the UPMC system.
Summarizing from the two
papers, there are several keys to developing a “ticket to ride” form:
- Keep it simple
- Put instructions visually where they are needed
- Use a structure (such as SBAR)
- Verify each of the key elements at each handoff
- Consider how even the least experienced staff
member would use it
- Involve the patient in the process
- Tie outcomes collection to the tool
The Esmail paper and the
Pesanka paper provide good examples that you might use for ICU transport
decisions and actual transports, respectively. However, rather than just
adopting such tools we strongly encourage you to read the articles for the
wealth of information they contain about the development of such tools. You
will use many of the lessons learned for development of a variety of tools in
your organization.
References:
Is Your Patient Ready for Transport? Developing an ICU
Patient Transport Decision Scorecard.
http://www.longwoods.com/view.php?aid=18376&cat=452
Pesanka DA, Greenhouse PK, Rack LL, Delucia GA, Perret RW,
Scholle CC, Johnson MS, Janov CL. Ticket to Ride: Reducing Handoff Risk During
Hospital Patient Transport. J Nurs Care Qual. 2008 Aug 26. [Epub ahead of
print]
http://www.patientsafetysolutions.com
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