Improving after-hours multidisciplinary clinical handover processes to improve patient outcomes

By Dave Piggott

A recent review examining the outcomes of 26 hospitals saw that the mortality rate of patients admitted on weekends is as much as 10% higher than for patients admitted on weekdays.

It’s an alarming statistic for most hospitals – especially considering that two thirds of the week is deemed after-hours. Deficiencies in after-hours care have been well recognised, and ineffective clinical communication can be a major contributor in this. As a result, many hospitals are actively looking for ways to improve how clinical staff handover patients to the after-hours team.

One such hospital is the Royal Brisbane and Women’s Hospital, the largest provider of healthcare services in Queensland. The RBWH employs more than 7,450 multidisciplinary staff, and more than 90,000 people are admitted every year.

Clinical handover processes at Royal Brisbane and Women's Hospital

Staff from Royal Brisbane and Women’s Hospital identified a few troubling weaknesses in their own after-hours clinical handover processes and began to advocate for change.

Anthony Nesbit, Nursing Director, and Mary Fenn, Assistant Nursing Director, from the Patient Flow Unit at RBWH identified a few troubling weaknesses in their own after-hours clinical handover processes and began to advocate for change.

Their team was often troubled by:

  • Insufficient communication between daytime and after-hours staff. For example, doctors and nurses were frequently unaware of incoming patients through inter-ward or inter-hospital transfers, or were left to care for patients they knew very little about;
  • The absence of a standardised clinical handover process, which meant that critical information about patients could be overlooked in the ad-hoc briefs given to after-hours staff. This also meant that the hospital was at risk of non-compliance with the National Standards for Clinical Handover;
  • An inability to identify and prioritise patients of concern. This lack of visibility prevented doctors from prioritising rounds and reviews based on clinical need and had the potential to be detrimental to overall patient welfare.
  • A tendency to rely on effective responses to after-hours medical emergencies (MERTs) rather than prevention. While plenty of processes exist around stabilising after-hours MERTs, clinical staff felt that more could be done to reduce their occurrences by improving the quality of daytime to after-hours clinical handover.

Before RBWH could begin to solve these problems, Mary and Anthony first had to understand what they needed to fully address the issue at hand.

So they reached out to their multidisciplinary team at RBWH for their input. Together, they determined that any solution they implemented needed to:

  • Strengthen communication between daytime and after-hours staff by providing a planned and collaborative environment for handovers;
  • Provide a single, comprehensive framework for a standardised communication process;
  • Provide a single source of truth to capture and access all patient status information;
  • Allow clinical staff to easily identify and prioritise patients of concern;
  • Be easy to use to ensure a higher level of compliance by all staff;
  • Be customisable to RBWH’s specific requirements; and
  • Support the hospital’s ability to comply with the National Standards for Clinical Handover and Safety.

The first step they took towards implementing a multidisciplinary after-hours clinical handover process was a compulsory nightly meeting for doctors and nurses to handover patients and discuss any concerns. The feedback indicated that while the meetings helped build fundamental inter-disciplinary relationships, they lacked structure and were of limited value. It was clear that the process required a more formal approach to produce the results RBWH wanted to see.

RBWH was already using Health IQ’s Patient Flow Manager (PFM) to achieve increased visibility for bed management and capacity planning. However, Anthony and Mary also saw the opportunity to build on PFM’s existing functionality to design and implement a new Medical Handover tool directly into Patient Flow Manager.

Working in collaboration with the hospital’s staff, we were able to provide RBWH’s multidisciplinary team with:

  • A single platform for implementing a standardised communication process between daytime and after-hours staff;
  • A formal medical handover template built specifically to meet RBWH’s needs to capture all critical information;
  • Real-time visibility over patients’ status for multidisciplinary staff;
  • The ability to track, identify, and prioritise patients based on special circumstances, i.e. ‘patients of concern’; and
  • The ability to hold staff accountable to their responsibilities and performance,
  • All on a platform that staff were already familiar with.

The PFM Medical Handover tool was well-received at the nightly meetings. “It’s changing the culture,” says Mary, “The teams are getting a lot more value out of the nightly handover meeting.”

“It’s still early days, but we’ve seen doctors become really passionate about this,” says Anthony, “No other tool we’ve tried has lasted this long and been this well-received.”

After kicking off the after-hours multidisciplinary handover process using PFM, there has been a demonstrated reduction in the number of reported MERTs that occur after-hours.

Results of the improved clinical handover process

The number of medical emergency calls (MERTs) decreased significantly after the introduction of the formal after-hours clinical handover process.

“We changed the guidelines for defining a MERT around the same time we introduced the improved handover processes, so we don’t know that it’s the sole cause of the decrease in MERTs,” says Mary, “However, we think it’s interesting to note that only the number of after-hours MERTs have decreased, while in-hours MERTs have more or less remained the same. That probably tells us something.”

Just nine months after introducing PFM’s Medical Handover tool to the multidisciplinary team’s handover meetings, they’ve seen staggering developments:

  • A 30% decrease in the number of after-hours MERTs recorded.
  • 100% compliance by doctors when recording and monitoring patients of concern using PFM.
  • All after-hours MERTs are reviewed every morning by the daytime clinical staff – which was not standard procedure prior to the introduction of the formal clinical handover process.
  • Increased compliance with the use of the formal handover templates by the multidisciplinary team.
  • A cultural change within the team with improved communication and collaboration. Nurses have even commented that following the formal procedures around hand-overs, senior doctors seem to prioritise after-hours MERTs more often than before.

“We’d like to spread this throughout the organisation and implement this as a hospital-wide business process 24 hours a day,” said Anthony.

“We’ve achieved such great staff compliance with the new handover tool and process,” said Mary. “We’re looking to add the new after-hours handover responsibilities to the job descriptions so we can sustain that level of compliance long term.”

As a part of the team at Health IQ, I can say we are all extremely proud to have played a role in improving the after-hours multidisciplinary handover processes at Royal Brisbane and Women’s Hospital.

If you’d like to learn more about RBWH’s journey, or are experiencing any of the issues described above, please call me on 03 9425 8012 or send me an email to dave.piggott@healthiq.com.au.

Dave Piggott is the Executive Director of Health IQ, and is focused on helping Australian health services achieve better visibility and communication within and across their hospitals. Dave has over 20 years’ experience in Health IT. A graduate of the Australian Institute of Company Directors (AICD) and with a Masters in Open Systems (IT), Dave has worked extensively in the Patient Flow area, and helped over 30 Australian hospitals to improve their flow of patients.

 

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