Clinical medical handover between doctors, also known as signout or handoff, forms a critical part of the patient care process. The quality of the passage of information between medical staff is paramount, as there is significant potential risk in patient care when one medical team who is familiar with the patient is handing over to one that is not [1].
In Australian hospitals, Junior Medical Staff (JMS), comprising interns, residents, registrars and fellows, provide the majority of on-site inpatient medical cover across any 24-h period. The number of JMS has increased with the introduction of safe working hour restrictions, with many working shifts that overlap [2]. Consequently, the number of episodes of clinical handover where the sharing of patient information between providers involved in a single patient’s care has also increased. Together with time pressures and increasing clinical and administrative loads amongst other training requirements, quality clinical handover is increasingly important yet more challenging to achieve.
Previous studies of JMS handover have shown significant variability in style, structure, quality and content [3], [4]. Horwitz et al. have also identified cross-specialty gaps between JMS on various units, including poorly written documentation, lack of training and evaluation and an absence of standard handover policies [5]. This increases the risk for poor clinical communication and a subsequent well-established increased risk of patient care related adverse events [6].
Existing literature, including studies from Australasia, demonstrates that computer based handover systems assist in maintaining accurate patient care [7], [8], [9], [10]. Starmer et al. have shown a significant reduction in both medical errors and preventable adverse events after the introduction of a JMS handover package with three components − standardized handover training, a verbal mnemonic and redesign of the handover workflow structure amongst the junior medical staff team [11]. When the additional step of an unintegrated computerized handover was introduced, a resultant decrease in the omission of key handover data was also observed.
Thus, in an effort to standardize and improve both the standard and efficacy of clinical handover across Australia, the above processes have been adopted as a national quality assurance and improvement benchmark as part of the National Safety and Quality Health Service (NSQHS) Standards, developed by the Australian Commission on Safety and Quality in Health Care (ACSQHC) [12]. Similar efforts have been previously employed worldwide to tackle this problem [13].
The Royal Children’s Hospital Melbourne (RCH) campus-wide introduction of an Electronic Medical Record (EMR) in April 2016, together with an EMR-integrated medical handover tool, provided an excellent opportunity to consider potential effects on current clinical handover practice amongst the JMS cohort.
This study evaluates the impact such a tool had on the adoption and usage of the EMR-handover tool, as well as impacts on quality (accuracy and redundancy) of handover data, JMS workflow (time management and communication) and JMS satisfaction.
A cohort study was conducted at The Royal Children’s Hospital Melbourne (RCH); a 315-bed pediatric quaternary referral and academic hospital in Melbourne, Australia.
All JMS who were eligible were invited to complete pre and post-intervention electronic surveys. Eligibility criteria included all JMS who were:
Working at RCH across a range of specialties in which a formalized handover currently takes place and used the standardized EMR-integrated handover tool
Working at RCH at ALL time points of
46 out of 51 eligible JMS responded to all three surveys, with a response rate of 90.2%. The majority were female (71.2%), with a spread of resident seniority and specialty.
There was a significant uptake of the electronic handover tool after go-live, with 87.0% and 67.4% of JMS using the tool at 1 and 3 months post implementation respectively (Table 1). There was minimal change in concurrent use of verbal handovers for information transfer (76.1% pre vs 82.6% at 1 month and 78.3% at 3 months).
Our standardized and integrated electronic handover tool was designed to be a functional component of a systematic EMR rollout. Coupled with comprehensive end-user training, its introduction addressed key challenges across all medical specialties such as lack of training, standardization and poor written documentation [5]. To the authors’ knowledge, this is the first Australasian study examining an electronic handover tool or initiative integrated with a fully electronic EMR system, which
A limitation of this study is the reliance on JMS perception rather than direct measurement of workflow effects such as impact on quality or communication. This is unfortunately difficult to measure given the multifactorial nature of the handover process, and the potential confounding influence of other non-EMR related effects. Nonetheless, given handover is part of their daily routine, JMS have excellent estimation and judgment for their handover process and its related effectiveness.
A newly introduced integrated EMR electronic handover tool had a high uptake amongst JMS, and resulted in improvement in perceived handover efficiency, a reduction in redundant data entry and improved JMS handover satisfaction.
Nil to declare.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. SUMMARY TABLE What was already known on the topic: Effective clinical medical handover ensures quality and safety of patient care Significant variability in style, content and structure of clinical handovers currently exist Electronic tools have been shown to assist in efficiency and accuracy of JMS handover What this study added to our knowledge: An integrated electronic
Nil to declare.
