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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Background

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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Situation

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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

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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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Background

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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