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WA Country Health Service &Royal Perth Hospital
A joint venture in improving clinical handover
developing standardised clinical handover
Concepts, Processes and Tools
Project Deliverables
1. Analyse the patient safety risks associated with clinical handover with inter hospital patient transfers.
2. Develop minimum data set for our selected cohort (deteriorating IHPT) both Written & Verbal
3. Develop Toolkit to support implementation
Identify
Situation
Observation
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Agree a Plan
Background
Extent of the problem• 350,000 ED presentations • 110,000 separations• 380,000 in patient bed days• 10,000 patient transfers to another acute care facility within Western Australia (WA). • Over 7,000 of these Via RFDS / St Johns Ambulance/ Fire Emergency services • Complex processes
ReferralArranging patient transportRely too heavily on multiple players having local knowledge of the WA health system and the differing service delineations both within the Perth metropolitan area health servicesWACHS is moving towards a model of central clinical coordination of all inter -hospital patient transfers and part of this project involves the development of clinical handover systemsEmerging picture of serious adverse outcomes from absent incomplte handovers
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Tracing & remedying failures
Transfer of professional responsibility and accountability across multiple systems and providers / agencies/ professional and volunteer groups
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Observation
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Background
Referring Doctor
transfer nurse / volunter ambo
receiving hospital
transit medical/ nursing team
CH
CH
CH
CH
CH
CH
Ambulance paramedic/ nurse escort
CH
Referring nurse
transport provider logistics
transit hospital
CH
CH
CH
CH
CH
Analysis of adverse events and incident
•Clarity of message
•Hierarchy of power influences
•Transfer of accountability
•Team and cross team work
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Collaborative effortIdentify
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Setting the scene…
Royal Perth HospitalIdentify
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WA Country Health ServiceIdentify
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Carnarvon
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Same, same but different
Lake GracePerth
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Trauma teams
RPH
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Burns teams
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Emergency teams
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Psychiatric Emergency team
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Neonatal resus teams
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Multiple transport providers
Project Team
Madeleine Connolly and Jill Porteous absent
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WA Country Health ServiceWA Country Health Service & Royal Perth Hospital& Royal Perth Hospital
Handover is just wordsHandover is just words……iSoBARiSoBAR is an answeris an answer
The Why, the What & The Why, the What & ‘‘How will you know How will you know
when you get therewhen you get there’’??
4 Ps of Marketing4 Ps of Marketing
••ProductProduct
••PricePrice
••Place (distribution)Place (distribution)
••PromotionPromotion
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Background
350,000 ED presentations350,000 ED presentations7,000 transfers via 3 transport providers7,000 transfers via 3 transport providers
ProductProduct
Tracing & remedying failures
Transfer of professional responsibility and accountability across multiple systems and providers / agencies/ professional and volunteer groups
Identify
Situation
Observation
Read Back
Agree a Plan
Background
Referring Doctor
transfer nurse / volunter ambo
receiving hospital
transit medical/ nursing team
CH
CH
CH
CH
CH
CH
Ambulance paramedic/ nurse escort
CH
Referring nurse
transport provider logistics
transit hospital
CH
CH
CH
CH
CH
ProductProduct
Cyclone George
ProductProduct
ProductProduct
ProductProduct
a contour line of constant pressure
•• I I –– IdentifyIdentify
•• S S –– SituationSituation
•• O O –– ObservationObservation
•• B B –– BackgroundBackground
•• A A –– Agree a planAgree a plan
•• R R –– Read backRead back
ProductProduct
ProductProduct
SBAR
• Situation
• Background
• Assessment
• Recommendation
Missing
– Identify
– Read back ProductProduct
ProductProduct
PricePrice-- cost to thecost to the patientpatient
PlaceIdentify
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View from 3 sides of Wyndham hospital
Place
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Kununurra
Place
Mud football , Derby
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Place
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Cable Beach Broome
Place
PromotionPromotion
WA Country Health ServiceWA Country Health Service & Royal Perth Hospital& Royal Perth Hospital
Handover is just wordsHandover is just words……iSoBARiSoBAR is an answeris an answer
Putting it into practicePutting it into practice--Role PlayRole Play
Pitfalls Identify
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Background
Surname URN
Given Names DOB
HospitalAddress Postcode Gender
Date TimeMedicare No. Ambulance fund number DVA colour and number
AB TSI ABTSI Primary language spoken Interpreter required Yes NoContact person/NOK Contact No. NFR status documented Yes NoRelationship Aware of transfer Yes No Organ donor known UnknownReferring hospital contact person: Name Contact number Signature Designation Usual GP/Contact No.Principle diagnosis/problem Other diagnoses/problems
Reason for transfer
AIRWAY BREATHING COLOUR CIRCULATION SKIN PULSE BEHAVIOURALpatent unremarkable unremarkable unremarkable unremarkable Harm to selfcompromised shallow pale warm / hot regular Harm to othersventilated deep flushed cool / cold irregular Requires physical restraint
rapid mottled dry slowslow cyanotic moist / clammy rapid Glascow Coma Scorelaboured strongasymmetrical C-SPINE weak Usual conscious state (if known)
audible wheeze immobilised not palpableAirway management plan
Airway compromise relayed to transport provider Yes (Time) No Outcome;Temp. Pulse Resp rate B.P. SpO2 O2
rate/device Pain Score
Intravenous (IV) access (gauge, site, insertion time/date) IV fluids chartedSecond IV access Fluid balance ChartNo access required Failed IV access Arterial line Central venous line Time last voided
Fasted from Food Fluids Continent IncontinentIntercostal catheter Nasogastric tube Other Indwelling catheter
Past relevant medical history
Current episode medications (refer to Medication Chart for time last given)
Mental Health ActVoluntaryInvoluntaryRisk assessment
Investigations(results if available) Results attached Yes No Drug Allergy(state drug/reaction)
Relevant Social issues
Dietary needs Mobility Forensic Receiving hospital Unit Bariatric ClientReceiving doctor Contact number MicrobiologicalBed arranged with: Confirmed bed Yes No Pressure area riskTransfer form faxed to receiving hospital Yes No Other:
WAC
HS M
EDIC
AL R
ECOR
D TR
IAL I
NTER
HOS
PITA
L TRA
NSFE
R
Government of Western AustraliaWA Country Health Service
ALERTS
Inter Hospital Patient Transfer ADULT/CHILD HANDOVER
Vital signstime:
SIT
UA
TIO
NID
EN
TIFY
ATT
AC
H A
LER
GY
STIC
KEREffect
OB
SE
RV
AT
ION
SB
AC
KG
RO
UN
DA
GREED PLAN
Identify
Situation
Observation
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Agree a Plan
Background
WA Country Health ServiceWA Country Health Service & Royal Perth Hospital& Royal Perth Hospital
Handover is just wordsHandover is just words……iSoBARiSoBAR is an answeris an answer
‘‘How will you know when you get How will you know when you get therethere’’??
Identify Situation Observation Background Agree a Plan Read back
Roll out “ready or not”
• Change ready environment
• Staff encouraged to implement in their context
• The tools and educational support
• Examples - Bed side, patient transfer, allied health referrals………..
• Evaluation of innovation spread
• Variable results
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Background
After the trialThe good • There is less waffle in the communication, and its more succinct
• It prompts us to ask the right questions
• It helps us cope with the high turn over of staff
• We used to have bits of paperwork often go missing, so the isobar form has ensured that a comprehensive summary is passed on
• It has helped to change the culture and increase staff awareness of safety issues associated with verbal handover
• The tools are great
The bad• Focused on the form
• Seen as a medical responsibility especially the A and R
• Looking for a mandate
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Lessons learnt
What worked
• Focusing on a problem that was real and recognized by clinicians
• Clinician lead - not top down
• On the ground engagement and listening
• Marketing expertise
• Diffusion of innovation
• KISS
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Lessons learnt
What didn’t
• Form can become the focus rather than the concept
• Delays in implementation of enabling initiatives (care coordination, RFDS funding arrangements etc)
• Engagement with and of transport providers
• Under scoped we were n’t equipped for the extent of implementation that a change ready environment demanded
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Making it stick –A good proposal for change?• Based on best evidence
• Well presented and attractive
• Concrete messages
• Clear targets
• Different format for different audiences
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Questions?
Diffusion of innovation
Getting ready to changeIdentify
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iSoBAR toolkit
developed
Understand/diagnose YOUR issues in YOUR
context
Plan your SPECIFIC changeConduct a SMALL test
STUDY results and Act on them in next small testkeep testing & expanding target
SOURCE Easy Guide to CPI NSW health
iSoBAR - Getting ready to change
• Context
• Define issues / problem to be resolved - do you need to collect data?
• Describe what you are trying to achieve with whom - Be specific NOT just ‘improve”handover
How will you know the change is an improvement?
• Plan and conduct a SMALL test, how will you STUDY the results before moving on to second test?
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