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Methods: Initially a three-month plan, do, study, act, (PDSA) rapid cycle improvement project was conducted on a cardiac interventional floor at an urban academic medical center (Klee et al., 2012). Unit champions were involved in creating a training video and in supporting Registered Nurse (RN) peers during implementation (Cairns et al., 2013). All RN staff received video training and attended staff meetings where evidence from current literature was reviewed. Implementation involved utilizing I-PASS, a standardized verbal handoff format (Starmer et al., 2014) with a written tool, and SAFETY, an innovative bedside handoff acronym created at this hospital to organize bedside handoff into a consistent structure with a checklist. S-Stand at the bedside, A- assess for safety (specific items on a checklist) F- falls risk or other safety concern?, E- explain the plan of care to the patient in a way they can understand, T- try to involve the patient/family in the plan, Y-time for questions. Compliance was assessed using a standardized audit tool. Nurses were surveyed for their perceptions of the new processes six months post-implementation (Friesen et al., 2013). Selected questions from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) were evaluated.
Post-pilot implementation hospital-wide of the process involved significant senior leadership support, and the addition of an electronic handoff tool to support the hardwiring of the structured handoff process (Staggers et al., 2012) I-PASS with SAFETY. Front-line nurse champions were instrumental in the development of the electronic handoff tool along with nurse informatacists, and nurse educators.
Results: RN staff and patients reported many qualitative benefits that represented a significant positive change in the unit culture. Auditing showed high levels of compliance with the standardized process for handoff. Based on unit level HCAHPS data, there was a 50% increase in the question “Staff Do Everything to Help with Pain”, a 16.7% increase in the “Nurses listen carefully to you” question, an 8.3% increase in the “Nurses explain things in a way you understand” question, and an 8.3% increase in patients’ “Rating the hospital a 9 or 10” during the 3 month pilot period. The fall rate, although variable, decreased 51% from 6.11 per 1,000 patient days pre-pilot to 2.97 per 1,000 patient days over a 6 month period.
Hospital wide data showed improvement in both the nurse communication domain and rate the hospital scores on HCAHPS data. Patient safety was impacted positively by hospital wide implementation. The hospital-wide falls rate declined over 2015 and sustained a > 25% decrease. Preventable adverse events are also being evaluated and reporting of these events is encouraged to support a culture of safety (Cairns et al., 2013). Case studies are provided regularly to staff to reinforce the value of bedside handoff. Patient comments about bedside handoff are also shared with staff to support sustainment efforts.
Conclusion:The success of the pilot led to hospital-wide implementation of the standardized approach of integrating IPASS and SAFETY for nursing bedside handoff and verbal report. While pilot data showed global improvements on the unit, researchers concluded that it is important to focus post-implementation on sustainability and hardwiring of those processes that would further improve patient experience and satisfaction on the unit.
Keywords: I-PASS, bedside handoff, nursing communication, HCAHPS, quality improvement, patient safety
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