Make inpatient handoff info more consistent
What ED nurses convey is biggest 'risk point'
At Baptist Hospital Miami, ED nurses always left a verbal report on inpatients being transferred to the floors using an audio tool.
"Any questions or needs were answered by follow-up phone calls, or in person if indicated," says Donna Sparks, MSN, RN, director of emergency services. "However, we lacked a standardized approach to the specific information we shared."
A team of inpatient and ED staff nurses, managers, transporters, bed control staff, and risk managers conducted an analysis on the handoff communication process when patients are admitted from the ED. Eve Butler, RN, the hospital's director of evidence-based nursing practice, said, "We found our biggest risk point to be the actual information that is provided when a patient is admitted."
For this reason, ED nurses began using the Situation-Background-Assessment-Recommendation (SBAR) format for handoffs. [Editor's note: The ED's SBAR form is included.] "The format has served to provide consistency with pertinent facts, and the template facilitates the communication," says Sparks.
To get ED nurses familiar with the new form, they were asked to listen to a taped report using the tool. "They were asked to fill in the information, as if they were receiving report on the unit," says Butler. "As with all change initiatives, there was some pushback — especially from experienced nurses that felt they did not need such a tool."
To obtain buy-in from resistant ED nurses, the importance of consistent information was emphasized. ED nurses now say that it helps them to organize information. "And inpatient staff say that they are receiving a more complete report," says Butler.
At University of California — Los Angeles Medical Center's ED, nurses have switched to electronic documentation and now use this system as a template for their report. Prior to this, a form developed by a multidisciplinary team was used to standardize the information given to the admitting nurse. [Editor's note: The ED's Acute Care Shift Report form is included.]
The form was developed by a team of ED and inpatient nurses, and it includes diagnosis, allergies, a focused review of systems assessment, past medical and surgical history, the circumstances that brought the patient to the ED, lab and diagnostic test results, and the plan going forward.
Now, however, ED nurses provide this information to receiving nurses using the clinical documentation system. They have a "Nurse View" tab that has all of this information in it, says Deborah A. Keim, BSN, RN, MICN, an administrative nurse in the ED. "We use this to call report from," she says. "When the patient gets flipped to inpatient status in the computer, the floor nurse can open their chart through another system and see the same page."
The new system saves time because all of the information on the patient can be viewed by the ED and receiving nurse. "You still have to decide what to actually say, but all the information is right in front of you," says Keim.
Give last-minute update on your handoff patients
When you give a report on an admitted ED patient to a receiving nurse, the patient's status might change by the time the patient actually arrives at the inpatient unit.
At Barnes-Jewish Hospital in St. Louis, ED nurses give a verbal report by phone before the patient is transported, but they also do a brief face-to-face update when the patient arrives in the intensive care unit (ICU). This extra communication is important, says Jennifer Williams, MSN, RN, ACNS-BC, clinical nurse specialist for emergency services, because "this is the time that the ED nurse can advise the receiving nurse of any changes since they spoke."
Medication rates might have changed, additional tests might have been completed, or additional intravenous fluids might have been given. "There can sometimes be up to an hour that has elapsed prior to arrival on the floor, especially if the ED nurse took the patient to a procedure in between," she explains.
If the patient is going to a procedure area with its own nursing staff, such as interventional radiology, on the way to the ICU, then the ED and ICU nurses meet in the procedure area for a face-to-face report. By taking this step, says Williams, "all are aware of what the patient's status and appearance was at the time of transition."