Improving JMO clinical handover at all shift changes - ARCHI

34 Pages·2011·1.2 MB·English

Improving JMO
clinical handover at
all shift changes
Implementation Toolkit
NSW DEPARTMENT OF HEALTH
73 Miller Street
NORTH SYDNEY NSW 2060
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www.health.nsw.gov.au
Produced by:
Workforce Development and Innovation
NSW Department of Health
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This work is copyright. It may be reproduced in whole or in part for study
training purposes subject to the inclusion of an acknowledgement of the
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for purposes other than those indicated above requires written permission
from the NSW Department of Health.
© NSW Department of Health 2010
SHPN (HSPI) 100536
Further copies of this document can be downloaded
from http://www.archi.net.au/e-library/safety/clinical/nsw-handover
December 2010
Foreword
The Acute Care Taskforce is working to promote safe clinical
handover in the NSW health system, with a special focus on
clinical handover at all shift changes (weekdays and weekends)
for Junior Medical Officers (JMO).
Dr Tim Smyth
Deputy Director-General, Health System Quality,
Changing medical work hours has benefited the work–life
Performance and Innovation
balance of medical officers, but leads to increased transfers
of patient care between clinicians.
JMOs are the least experienced members of the medical
workforce, and frequently move between wards, facilities
and Health Services. Inexperience and variable or absent
processes relating to clinical handover have been shown
to present significant risks for patient care.

Ms Vicki Manning
Ensuring that handover happens with consistency and quality, Acute Care Taskforce
at all shift changes, will provide clarity of responsibility and Co-Chair
accountability for all clinicians. Improving clinical handover by
providing strong senior leadership and supervision of handover
will enhance patient care, JMO learning, staff communication
and confidence.
Safe clinical handover is essential to patient care.

Professor Jeremy Wilson
Acute Care Taskforce
Co-Chair

Professor Steven Boyages
Chief Executive, Clinical Education and Training Institute

Dr Hamish Dunn
Chair, Junior Medical Officer Forum (CETI)
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Contents
At a glance ..........................................................................................................................................................................3
Why we must change ........................................................................................................................................................5
Key elements for implementation ....................................................................................................................................6
1. A communication framework to facilitate clinical handover at JMO shift change (ISBAR) ............................................6
2. Senior leadership: deciding who and what to hand over at shift change ......................................................................7
3. Shift to Shift handover: key principles for locally appropriate implementation ..............................................................9
3.1 Handover Happens ..............................................................................................................................................10
3.2 Handover Leadership ...........................................................................................................................................10
3.3 Handover Set-up ..................................................................................................................................................11
3.4 Handover Process.................................................................................................................................................12
Appendices ........................................................................................................................................................................13
A. A clear case for change (QSA data, literature, JMO perspectives) ...............................................................................13
B. Wider issues that require consideration (wider implementation for other junior doctors, rostering) ............................14
C. Points to consider for implementation across 24 hours ..............................................................................................16
D. Clinical information to consider when handing over a patient....................................................................................17
E. Implementation framework to assist facilities with JMO clinical handover ...................................................................20
F. Implementation support (templates, tools and links to guide implementation of JMO clinical handover at facilities) .......22
G. Prevocational training networks in NSW ....................................................................................................................26
Useful references ..............................................................................................................................................................27
Acknowledgements ..........................................................................................................................................................28
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At a glance
Between the Flags (PD2010_026) and Safe Clinical Handover (PD2009_060) are two important mandates in
the NSW health system that place a strong focus on effective and early clinical communication of changes to
patient condition.
This document aims to assist facilities to implement locally appropriate clinical handover processes at all Junior Medical
Officer (JMO) shift changes, improving the consistency and quality of clinical communication for better patient outcomes.
Both junior and senior medical officers, with metropolitan and rural representation, have collaborated in the writing of this
document to ensure that it meets their needs.
Clinical handover definition
– Detail on senior leadership at handover commences
page 7.
Clinical handover has a nationally and internationally
recognised definition. 3 Shift to shift handover: key principles for locally
appropriate implementation.
‘…transfer of professional responsibility and
JMO clinical handover processes must be appropriate
accountability for some or all aspects of care
to local needs and appropriate to the specific shift
for a patient, or group of patients, to another
person or professional group on a temporary change (day, evening or night and on weekends).
or permanent basis.’ 1,3,10.
All facilities have the flexibility to determine locally
appropriate processes, but need to ensure that those
In your facility, does JMO clinical
processes (day, evening and night) meet a set of key
handover: principles.
– Detail on the key principles commences page 9.
• happen at all shift changes?
• have a consistent process? But wait… who is a JMO?
• promote quality clinical communication?
• improve patient care outcomes? For the purpose of this document, a JMO is defined as a
medical officer who is a part of the prevocational training
program of the NSW Clinical Education and Training
Three key elements have been defined
Institute (CETI, formerly IMET):
to help improve JMO clinical handover
• Australian medical school postgraduates,
1
A communication framework for JMOs (ISBAR). Year 1 and Year 2 and
A communication framework using a minimum data • Australian Medical Council graduates,
set to guide clinical handover can ensure consistent Year 1 and Year 2.
and complete, yet concise, handover interactions.
– Detail on the ISBAR communication framework There is a broader intention to
commences page 6. the program.
2
Senior leadership: who and what should be All facilities are encouraged to consider how the key
handed over? elements of the JMO shift handover project can be
All JMOs require leadership and supervision from transferred or tailored to other ‘junior’ doctors and other
more senior clinicians (eg Registrars, Consultants) to scenarios of handover (eg handover between medical
determine which patients and what information have teams or transfer between facilities or the community).
the greatest priority for handover.
NSW HealtH Improving JMO clinical handover – IMpleMeNtatION tOOlkIt    3
What is my responsibility? How to use this document
There must be no point during a patient’s journey
where there is ambiguity about who has responsibility 1. At a Glance – get a basic
and accountability for that patient’s clinical care. understanding (pp 3-4)
Transfer of responsibility and accountability for patient 2. Understand why we must
change (pp 5)
care is important at several levels:
3 Junior Medical Officers have a professional 3. Get more detail on ISBAR, senior
Continue leadership and key principles that
responsibility to prepare for and engage in effective guide implementation (pp 6-12)
to monitor
clinical handover
and
3 Registrars (or similar) have a professional responsibility improve 4. Access implementation
to lead and supervise JMOs in clinical handover clinical supporting tools and templates
3 Consultants/VMOs/Staff Specialists have a professional handover and further back ground
information (Appendices)
processes.
responsibility to oversee the clinical handover process
and education for JMOs
5. Review, redesign and implement
3 Administrators have a professional responsibility to processes for clinical handover
develop overlapping rosters that facilitate clinical at all JMO shift changes.
handover at all JMO shift changes.
6. Don’t forget to monitor,
evaluate and revise your
JMO perspective
processes after implementation
The JMO perspective has contributed to all aspects of
this document.
Clinical handover at JMO shift changes needs to NOTE: Improvements in clinical handover are evolutionary.
improve because…
Different teams will have different requirements,
“Handoverfromweekdaytoweekendandback opportunities and challenges when improving
againisabigproblem.Bytheendoftheweekend clinical handover.
themessagesaboutsickpatientshavebeenlost”
Facilities are encouraged to continually review and
incrementally challenge their handover processes,
“Itismuchsaferandmoreeffectivewheneven
in line with the overall objectives.
minimalsupervisionofhandoveroccurs”
“Morninghandovermeetingsinourdepartment
haveprovidedsomeofthebestlearningexperiences.
Theconsultantsreallyparticipateandsharetheir
thinkingprocesseswiththejuniordoctors”.
Detailed ‘Case for Change’ information can be found
at Appendix A.
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Why we must change
Why we must change Root Cause Analysis case study
Improving clinical handover processes for JMOs at shift The following summary highlights the critical importance
change is imperative because: of effective clinical handover.
• The research literature and Root Cause Analysis This incident also highlights the importance of
evidence identify poor clinical handover as a significant immediate escalation of deteriorating patients and the
contributing factor to many adverse patient events essential requirement of senior supervision for Junior
• Quality Systems Assessment data shows that there are Medical Officers.
many times when clinical handover does not occur
• JMOs are highly mobile between wards, facilities and A 56 year old man was admitted for a significant elective
Health Services in the NSW public health system abdominal/thoracic procedure. He became febrile on the
• Processes for clinical handover can be highly variable fourth post-operative day, and required review by the
• JMOs are the least experienced in the medical team, after-hours JMO.
have high work loads and are frequently fatigued
through working shifts across 24 hours of the day On the following day he began to experience respiratory
• JMOs want greater consistency and supervision in symptoms and was again reviewed by the after-hours
clinical handover procedures. JMO who sought assistance from the intensive care unit.
Detailed ‘Case for Change’ information can be found at The patient’s condition further deteriorated and he
Appendix A. developed multi-organ failure caused by overwhelming
sepsis and died.
The Root Cause Analysis found that:
• The treating medical team had not received any
information about febrile night episodes and,
therefore, did not initiate further investigations or
antibiotic treatment
• The handover process from night staff should require
that all Clinical Review patients are notified to the
Registrar and the morning nursing team leader
• All patients who were reviewed overnight should
be included in the morning handover and
morning rounds.
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Key elements for implementation
1. A communication framework What, and how much, clinical
to facilitate clinical handover information should I hand over?
at JMO shift change (ISBAR)
Appendix D has a summary to provide guidance on the
clinical information that should be considered when
The ISBAR framework represents a standardised approach handing over specific patient types:
to communication which can be used in any situation.
ISBAR is based on ‘SBAR’ a system which was developed • Medical
by the US Navy for use in nuclear submarines. • Surgical
• Paediatric
ISBAR stands for Introduction, Situation, Background, • Psychiatry
Assessment and Recommendation.7 • Obstetrics and Gynaecology
• Emergency Department.
A communication framework increases the consistency
in the delivery of information. As yet, there is no evidence Sufficient clinical information must be handed over to
proving that one mnemonic is the gold standard. ISBAR is ensure transfer of responsibility and accountability for
recommended because: patient care.
• It is well recognised in the current Safe Clinical Patients who are less stable or have changing
Handover implementation plans of a number of management plans may require a detailed handover,
Health Services while others who are relatively stable and with fewer
• It aligns with Between the Flags and DETECT training outstanding tests or actions can be summarised
• It is portable, memorable and easy to use more quickly.
• It helps you to organise what you’re going to say
• It is a generic communication framework that is Senior clinician supervision at clinical handover is
applicable to both clinical and non-clinical settings important to help JMOs decide which patients, how much
• Consistency of practice will benefit Junior Medical and which clinical information needs to be handed over.
Officers who often move between facilities and (See page 11 for further assistance.)
Health Services.
See Appendix D for more detail on the clinical information
you should be considering at handover.
ISBAR templates are available to download:
http://www.archi.net.au/e-library/safety/clinical/
nsw-handover
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Key elements for implementation
Hand over relevant clinical information 2. Senior leadership:
in the ISBAR framework…
deciding who and what to
hand over at shift change
I IdentIfIcatIon
At the end of handover, the JMO receiving handover
Identify yourself, the patient and who you should have a clear understanding of:
are talking to.
• sick, deteriorating and unstable patients
“I am (name and role), from (ward/facility) and
• outstanding actions, procedures, tests or results
I’m calling regarding (multiple patient identifiers,
to be reviewed
such as; name, age, gender, Ward/bed, Medical
Record Number)” • other important factors that will impact work on
the following shift.
S SItuatIon
JMOs are at the beginning of their careers and are
developing their clinical experience and knowledge base.
State the patient’s diagnosis/reason for
The leadership and supervision by senior clinicians is
admission and the current problem.
essential to help JMOs provide effective clinical handover.
“The situation is that I have a patient (age/
gender), who is (diagnosis/deteriorating/stable).
My concerns are (clear and succinct concerns). The Senior clinicians are defined as:
current presenting symptoms are (clear, current • Registrars
and relevant symptoms and observations).” • Career Medical Officers
• Consultants
B Background • Staff Specialists
• Visiting Medical Officers
• Senior Nurses.
What is the clinical background or context?
By way of background (Give pertinent information
which may include: Date of admission / presenting Senior clinicians have experience that can help JMOs
symptoms / medication / previous recent vital signs deliver the most important key messages for effective
/ test results / status changes)
transfer of patient care in a complete yet concise manner.
A aSSeSSment
The leadership roles required from senior clinicians include:
• oversee and implement handover processes
What do you think the problem(s) is? • attend and lead handover at JMO shift changes
(Don’t forget to have the current vital signs • understand the signs and symptoms of deterioration
and a key problem list ready!) • recognise clinical risks and convey these concepts
“My assessment on the basis of the above is that
to JMOs
the patient is….. they are at risk of….. and
• prioritise which patients and what information is
in need of….”
handed over
• Involve JMOs in clear prioritisation of patients and
R recommendatIon allocation of tasks.
What are you asking the person to do? Some examples of how senior leadership for JMO
“My recommendation is that this patient needs handover can be demonstrated include:
(what test/action) by (who) within (timeframe)”
Repeat to confirm what you have heard.
Eg “I understand that I am to…. and you will…”
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• Senior Medical Officers involving and guiding JMOs • Any patients you are worried about –
in clinical decision-making before and during clinical do not discount your clinical acumen.
handover
Do not discount your clinical acumen:
• Senior Medical Officers attending and leading
handover to manage clinical issues early and reduce
call outs Deciding who should be handed over cannot be limited
• Using handover as a teaching opportunity to a strict categorisation.
• Senior nurses facilitating the process of handover.
If for any reason you are concerned by any part of a
It is recognised that not all facilities have patient’s clinical situation or their management plan, this
registrars rostered on all shifts with JMOs. concern should be handed over to the oncoming shift.
In such facilities the role of the Registrar in
handover could be filled by:
Senior leadership at handover is an important part of
• Career Medical Officers
clarifying and managing patient care concerns.
• Consultants
• Staff Specialists
• Visiting Medical Officers Do not wait for shift handover:
• Senior Nurses (for facilitation of the handover
process, rather than clinical supervision). Escalation of concerns for any part of a patient’s clinical
situation or management plan must not be held back until
It is feasible that there may be occasions when senior shift handover (See PD2010_026).
clinicians are unable to attend and lead clinical handover.
According to the escalation protocols of DETECT and
In such instances, JMOs should have access to senior Between the Flags,6 JMOs should escalate concerns about
leadership in preparing their patient lists for shift handover. patients to senior clinicians immediately, rather than
waiting for shift handover.
Prior to handover, senior clinician leadership can include:
• JMOs consulting with senior medical staff, including What else is important to hand over?
Consultants, Staff Specialists and Visiting Medical Officers
• Registrars and JMOs should discuss which patients and Handover of other information about environmental
what information to handover at shift change features may benefit the oncoming shift and should be
• JMOs undertaking a face to face or telephone paper led by registrars, including:
round with registrars prior to handover. • critical care bed availability
• ward patient flow or bed pressure points
Which patients should be handed over?
• staff levels or availability
• relevant contact persons if required
• Sick or deteriorating patients (eg, PACE/MET calls or • any specific patient or equipment risks that are likely
patients with unstable or deteriorating observations) to affect JMO or staff safety.
• Patients with significant changes in condition or
management plan during the previous shift NOTE: The ‘Concept Testing’ final report for the JMO
• Important outstanding actions, including: clinical handover project contains clear key messages from
– tests or procedures that need to be done both junior and senior clinicians about the importance of
– test results that need review senior leadership in clinical handover for junior clinicians.
– transfer of care planning (this includes inter-ward The report is available for download: http://www.archi.
or inter-hospital care and also discharge to GP care) net.au/e-library/safety/clinical/nsw-handover
• New patients
8    NSW HealtH Improving JMO clinical handover – IMpleMeNtatION tOOlkIt