Examining current practice is an essential element for the development of an action plan to achieve higher practice levels and improved patient care.1 In our intensive care unit [ICU], clinical handover of patients to be transferred to the wards was identified as presenting a complex scenario that might present an opportunity to improve practice.
Effective clinical patient handover is a critical element in protecting patients from harm and providing quality care. When a previously critically ill patient is transferred from the ICU to a general ward there is the potential for ineffective communication that can have a profound impact on the patient’s continuity of care leading to patient harm.2, 3 Defective patient handover transfers constitute one of the major reasons for hospital incident reports.4, 5
A commonly used mnemonic ISBAR (Identity, Situation, Background, Assessment, Recommendation) handover tool is advocated at the site but in practice, rarely used for ICU handovers. Although the ISBAR tool is designed to help staff formulate information this in practice lacks clarity and specificity.6 Understanding clinicians’ perceptions, barriers or reasons that deter clinicians from using the ISBAR method, despite it being hospital policy, will inform future initiatives to improve handover.7
Objective: To examine current patient handover from ICU to a general ward from the perspective of ICU and ward nurses.
Methods:
As part of a larger study that observed handover and conducted chart audits, qualitative semi-structured interviews of ICU and ward nurses were conducted post-handover to assess the nurses’ perceptions of handover effectiveness.
Site and sample: The study site was an Australian Magnet accredited tertiary-referral hospital with a 28 bed ICU. On improvement, ICU patients are then transferred to the ward that specializes in the patient’s major clinical need. Purposive sampling of patient handover opportunities was sought with multi-trauma patients as they universally present the greatest complexities with multiple systems affected. Patients and their respective ICU and ward nurses were invited to participate.
Data collection: Interviews were face-to-face and audio-taped. Semi-structured questions and prompts were used to elicit participants’ perceptions of the patient handover experience. Interviews sought feedback on barriers to handover/discharge process, and outcomes of handover (implications of handover deficits and errors). Field notes were made and used to assist with data analysis validation.
Data analysis: Data were analysed using inductive thematic analysis and involved looking for units of information with similar content, symbols or meaning to identify emerging themes.8 HREC approval was received (HREC/17/QPAH/600).
Results:
Ten patients and their respective ICU and ward nurses were recruited with 20 interviews taking place between 16/11/2017 - 17/01/2018. Two major themes were identified and included: practices of handover and processes of handover. Each theme has sub-themes [see Table 1]. These reflected that ICU to ward patient handover was complex and there were areas identified for improvement.
Table 1: Themes and sub-themes
|
Themes |
Sub-themes |
|
Practices of handover |
1. Improvement strategies identified 2. Interruptions are detrimental 3. Handover quality 4. Frequency of involvement in ICU handover |
|
Processes of handover |
1. Workload impacts process and quality 2. Handover is related to complexity and patient acuity |
Discussion: We sought to examine current patient handover from ICU to a general ward from the perspective of ICU and ward nurses. It was important that both ICU and ward nurses provided data to understand the broad issues underpinning patient handover which is a two-way-process.9 The participating nurses identified a number of ways handover was effective and could also be improved. These were grouped in the themes of the practices of handover and processes of handover.
The complexity of ICU patient care, where multiple teams of health care professionals provide ongoing care, was a key element in our findings. ICU patients always present complex care scenarios but developing processes to support accurate handover of this information is required. The success and sustainability of future interventions depends on nurses’ ownership of the situation, commitment to its improvement and staff empowerment.10
When misinformation is conveyed [as occurred in this study], continuity of care and patient safety is jeopardized. The opportunity for error, omission and reduced quality of ongoing care is manifestly present.3 Providing a concise, accurate, complete handover of patient care information in a way the ward nurse can use, is essential, yet complex.11 Clinical frameworks and standardized tools designed with clinician involvement for a specific context is advocated and has successfully been developed in other specialty areas.6
Conclusion:
Clinical handover of ICU patients being transferred to the ward presents complex situations that constitute critical safety points of hospitalization. ICU and ward nurses’ perspectives identified that both the practices and processes of handover were key elements where improvements can be made. A patient-centered, purpose-specific, standardized, handover tool developed by a multi-disciplinary team is advocated.