“I’m bringing a patient up,” says Mark Frye, a nurse in the PACU. “Ted Jones, 33 years old. He came in through the ED. We believe he was in a motor vehicle collision. He has an open compound fracture of the left femur with external repair. He remains unresponsive with a head injury of unknown cause.
“Alright, I’ll meet you in the room,” responds Mary Smith, the patient-receiving nurse in the ICU.
Transport brings the patient up to the ICU. Nurse Frye tells Nurse Smith what he knows, based on information from the surgical team, which was based on information from the trauma team.
Nurse Frye turns to leave, and pauses. “Oh – by the way, I got an order for different pain meds but I’m not sure if it’s in the EHR,” he says.
Nurse Smith nods and thanks Nurse Frye as he walks away. She looks at Ted Jones, this unconscious man with no voice. She wonders: What is his story?
She doesn’t have much time to wonder, because she has to get to work re-assessing the patient and placing him on ICU protocols. She changes out his IV tubing. She transitions him to the room ventilator and assesses his bandages to see if there’s any drainage. The cardiac monitor in ICU is not the same type used in the PACU, so she changes out EKG leads. She is doing research from head to toe and documenting all of it. It might be hours before she can go look at the EHR and see that orders have changed.
“I’m bringing a patient up,” says Mark Frye, a nurse in the PACU. “Ted Jones, 33 years old. He came in through the ED. We believe he was in a motor vehicle collision. He has an open compound fracture of the left femur with external repair. He remains unresponsive with a head injury of unknown cause.
“Alright, I’ll meet you in the room,” responds Mary Smith, the patient-receiving nurse in the ICU.
Transport brings the patient up to the ICU. Nurse Frye tells Nurse Smith what he knows, based on information from the surgical team, which was based on information from the trauma team.
Nurse Frye turns to leave, and pauses. “Oh – by the way, I got an order for different pain meds but I’m not sure if it’s in the EHR,” he says.
Nurse Smith nods and thanks Nurse Frye as he walks away. She looks at Ted Jones, this unconscious man with no voice. She wonders: What is his story?
She doesn’t have much time to wonder, because she has to get to work re-assessing the patient and placing him on ICU protocols. She changes out his IV tubing. She transitions him to the room ventilator and assesses his bandages to see if there’s any drainage. The cardiac monitor in ICU is not the same type used in the PACU, so she changes out EKG leads. She is doing research from head to toe and documenting all of it. It might be hours before she can go look at the EHR and see that orders have changed.
She becomes so immersed in her work that she overlooks the changed pain medication order. Caring for the patient is detailed, exacting work that requires her full attention and clinical expertise.
The scenario above provides a glimpse into what makes effective clinical hand-off communication so hard.
What we see is a chain of data and information. Every clinician who works with the patient applies his or her clinical observation and assessment tools, draws conclusions, and adds to the chain.
Within this chain, data points sometimes slip. In the example above, the PACU nurse told the ICU nurse about the change in pain medication. But because the ICU nurse had competing priorities, that information slipped and the order didn’t get entered into the EHR. The lag between when the information was sent verbally and received electronically resulted in an error.
This is how communication begins to break down.
How Big Is the Problem of Ineffective Clinical Communication?
On September 12, 2017 The Joint Commission (TJC) issued a Sentinel Event Alert and accompanying infographic focused on inadequate hand-off communication. In the alert, TJC suggests a set of actions for senders and receivers of hand-off communication. It cites a study released in 2016 which estimated that communication failures in U.S. hospitals and medical practices were responsible at least in part for 30 percent of all malpractice claims, resulting in 1,744 deaths and $1.7 billion in malpractice costs over five years.1
The Experience Innovation Network, part of Vocera, recently uncovered a few statistics pertaining to the challenges of clinical communication. Here is a subset:
- On average, doctors and nurses are interrupted once every two hours to 23 times each hour.2Forty-three percent of the time, those interruptions disrupt direct patient care tasks or interventions. Inefficient communication processes and interrupted processes can have a negative effect on safety.3
- There’s a two times greater likelihood that cross-disciplinary exchanges will result in a communication failure versus intradisciplinary communication. Communication breaks down more often when two or more disciplines are involved.4
- Thirty percent of communications about surgical procedures included a failure. Thirty-six percent of those failures resulted in consequences, such as tension among the care team members (which leads to further communication breakdown) or procedural error.5
What Is a Hand-Off?
TJC’s infographic, 8 Tips for High-Quality Hand-Offs, provides a definition of a hand-off that is worth repeating:
“A hand-off is a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care.”
Technology, Hand-Offs, and Behavior
TJC’s suggestions have bearing on organizational culture, especially the role of leadership, and on the use of technology in hand-offs.
Technology drives behavior because it demands that users interact with it in a specific way. This was the focus of my 2017 CNO report, It’s More Than a Mobile Strategy, It’s a Change to Clinical Practice. When you give nurses and physicians a phone, you’re hard-wiring the behavioral aspects of the way they communicate, and this changes the way they practice.
TJC’s Eight Tips for Quality Hand-Offs
The suggestions in the full-text alert and the infographic vary slightly, but their intent is the same. For simplicity, we’ll reference the infographic’s eight tips in this section. Here is a summary of them:
- Tip 1: Determine the critical information that needs to be communicated.
- Tip 2: Standardize tools and methods used to communicate to receivers. These can be forms, templates, checklists, protocols, and mnemonics such as I-PASS.
- Tip 3: If face-to-face hand-off communication is not possible, communicate by telephone or video conference.
- Tip 4: If information is coming from many sources, combine and communicate it all at one time, rather than separately.
- Tip 5: Make sure the receiver gets the following minimum information:
- Sender contact information
- Allergy list
- Code status
- Medication list
- Dated laboratory tests
- Dated vital signs
- Illness assessment, including severity
- Patient summary, including events leading up to illness or admission, hospital course, ongoing assessment, and plan of care
- To-do action list
- Contingency plans
- Tip 6: When conducting hand-offs or sign-outs, do them face-to-face in a designated location free from non-emergency interruptions, such as a “zone of silence.”
- Tip 7: When conducting a hand-off, include all team members and, if appropriate, the patient and family. This time can be used to consult, discuss, and ask and answer questions.
- Tip 8: Use electronic health records (EHRs) and other technologies (such as apps, patient portals, telehealth) to enhance hand-offs between senders and receivers — don’t rely on them on their own.
Four Steps to Better Hand-Off Communication
Technology that enables better clinical communication and workflow can play a critical role in addressing all aspects of TJC’s guidance. Where TJC offers eight tips, we consolidate them into four steps, or concepts.
1. Incorporate Forms and Checklists
TJC’s tips one, two, and five collectively cover determining the information that needs to be communicated, standardizing on how to communicate it, and managing how care teams send and receive communication.
Technology can help here.
Look for a communication platform that can incorporate templates. Vocera® software can, and has standardized drop down boxes so you don’t have to type out full messages. Patient-specific data captured in the physiologic monitor (such as heart rate, blood pressure, respiratory rate, SpO2, and EKG strip) can be sent to a clinician’s smartphone.
It is possible to configure Vocera software to provide much of the context in TJC’s tip number five with a communication protocol.
2. Connect Directly and Instantly
TJC’s tip three is about communicating verbally via video conference if face-to-face communication is not possible.
Vocera technology shines brilliantly in hand-off communication by enabling care team members to connect directly and instantly, with no need to know names or numbers. The software system routes calls (and texts, alerts, and alarms) by name, role, or group, with automatic escalation paths.
Consider a common scenario in which a patient needs to be transferred to a different floor or department. The existing workflow can take five or more steps:
- The nurse in the transferring unit calls the patient-receiving unit nurse via the unit phone, but receives no answer.
- The transferring nurse tries again, using the call list, switchboard, or page – or gives up and tries again later.
- The patient-receiving nurse may try to return the call, in some cases using a landline to avoid tying up the unit phone.
- The process repeats, often several times.
- The transferring and receiving nurse connect.
Vocera technology can help with this aspect of hand-off communication. We make it easy for the transferring nurse to call the patient-receiving nurse directly and say, for example, “I’m coming down the southeast hall, I’m taking this patient into room 1411. Can you meet me there now?”
Using the Vocera Badge and/or a personal or hospital-provided smartphone, the five-step workflow is “one and done.”
A hand-off could require a conversation between two people, or it could require a group meeting. With Vocera technology, you can call dispersed members of a broadcast group with the single touch of a button.
TJC’s tip six, which is about conducting hand-offs face-to-face in a designated location free from interruptions, at first glance might seem to have little to do with technology. However, a common reason people don’t conduct hand-offs face-to-face is that they’re busy and they can’t find each other. Vocera technology solves that.
Tip seven extends the hand-off meeting to include patients and families. The issues in tips six and seven are similar, and can be addressed the same way.
3. Enhance Hand-Offs with Information in Context
Tips four and eight are closely linked. Tip four is about combining information and communicating it in a consolidated way, and tip eight is about integrating the EHR with other technologies. It’s all about getting more complete information more easily.
Look for a communication platform that can be unified with other clinical and operational systems, including the EHR, and leverage system integration to automate portions of the hand-off template. The Vocera Platform integrates with most systems used in hospitals today – more than 120 in all. This means you have more information; for example, our platform has the ability to provide a record of clinically significant alarms that have taken place during a clinician’s shift. What’s been happening over the last 12 hours is relevant for next 12 hours; we strengthen the integrity of the information trail.
4. Address Organizational and Cultural Aspects
The full text of TJC’s Sentinel Event Alert emphasizes the organizational and cultural aspects of improving hand-off communication. These include:
- Demonstrating leadership’s commitment to successful hand-offs and other aspects of a safety culture
- Managing the environment to provide locations free from interruptions
- Including multidisciplinary team members and the patient and family, as appropriate
- Standardizing training
- Monitoring the success of interventions
- Sustaining and spreading best practices, and making high-quality hand-offs a cultural priority
The Experience Innovation Network, part of Vocera, recently sponsored a Patient Safety & Quality Healthcare (PSQH) webinar called Communication Deconstructed: 7 Elements of Effective Clinical Communication.
The webinar features Marty Scott, MD, MBA, chief transformation officer at Hackensack Meridian Health; and Sue Murphy, RN, BSN, MS, chief experience and innovation officer at University of Chicago Medicine.
The webinar explores the importance of building a shared purpose to guide all clinical communication, and discusses humanized communication tools that help hardwire communication excellence. It sets the stage for our extensive research report coming in October, which will dive deeper into the seven elements of effective clinical communication we identified. View the webinar here.
Bibliography
- CRICO Strategies. Malpractice risk in communication failures; 2015 Annual Benchmarking Report. Boston, Massachusetts: The Risk Management Foundation of the Harvard Medical Institutions, Inc., 2015 (registration required for download).
- Grundgeiger, T., & Sanderson, P. (2009). Interruptions in healthcare: theoretical views. International Journal of Medical Informatics, 78(5), 293-307. http://ai2-s2-pdfs.s3.amazonaws.com/6149/4f5a065fd69269b61578ffe5629918663d63.pdf
- Rivera, A. J., & Karsh, B.-T. (2010). Interruptions and Distractions in Healthcare: Review and Reappraisal. Quality & Safety in Health Care, 19(4), 304–312. http://doi.org/10.1136/qshc.2009.033282
- Hu, Y. Y., Arriaga, A. F., Peyre, S. E., Corso, K. A., Roth, E. M., & Greenberg, C. C. (2012). Deconstructing intraoperative communication failures. Journal of Surgical Research, 177(1), 37-42. https://insights.ovid.com/pubmed?pmid=22591922
- Lingard, L., Espin, S., Whyte, S., Regehr, G., Baker, G. R., Reznick, R., ... & Grober, E. (2004). Communication failures in the operating room: an observational classification of recurrent types and effects. Quality and Safety in Health Care, 13(5), 330-334.
