Patients at this hospital have a 'ticket to ride'

Handoff problem addressed with form

A new program at Doctors Hospital in Coral Gables, FL, helps move patients seamlessly from one department or unit to another, helping address the challenging issue of handoffs. Patients get a "ticket to ride" whenever they leave their hospital room — be it a transfer to another unit or a round trip down the hall for an X-ray. With checklists for tests, procedures, and nurse's observations, the new peach-colored form helps relay patients between staffers.

Pat Blanco, RN, MPH, CHE, CPHRM, the risk manager at Doctors, first learned of this approach on the National Patient Safety Foundation listserv. "Someone mentioned they were using it, or planning to use it," she recalls.

Blanco felt such a vehicle was important because "patients are handed off so many times throughout the day without a real opportunity to give information and ask and have questions answered."

The classic example, she says, would be a patient going to radiology who is a fall risk — but that information has not been communicated to the technician. "So the tech takes the X-ray, leaves the patient on the table, and comes back and finds the patient on the floor," Blanco suggests.

The technician, she explains, "Will not go through a four-inch chart to find this information. Nurses have a Cardex, and so forth, but when a patient is handed off, what really is needed is that opportunity to give information." The fact that this is one of the Joint Commission's National Patient Safety Goals, she notes, was naturally an important driver in the initiative.

Committee creates forms

Blanco put together a handoff committee, which started to meet in the fall of 2005. She jointly chaired the committee with the manager of one of the patient care units. The members of the committee were nurse clinicians from each unit and other parties Blanco felt had an interest in handoffs — i.e., the managers of radiology and respiratory therapy.

"We met about every two weeks," recalls Blanco. Using the PDCA (plan, do, check, act) rapid cycle approach, "We added a certain set of items, tried the ticket, then after two weeks clinicians would come back and say they needed some more information on the form or that some step was cumbersome and needed to be taken out."

At one point, for example, the committee felt it was important to note whether a patient was a monitor patient. "In the next cycle, it was added, but we noted that when we take the patient out of 'tele' to go somewhere else, you want to call the monitor tech to tell them they were leaving the floor."

The form kept growing, says Blanco. "At first, to indicate precautions, we would just check them off," she says. "Then, next to the box, we would put 'aspiration,' 'bleeding total hip,' or 'knee,' so we knew what kinds of precautions were needed."

It's still a short list, says Blanco, although it is more complete than it was. "We've met many times since the last change, and we have not had any need to add or subtract anything," she notes.

Blanco said she did not need to seek formal approval to institute the new system. "The director of nursing periodically attended our committee meetings and could have said something if she was opposed," she notes. "Since she didn't, we assumed we had nursing's approval."

In addition, the committee took the form "everywhere" — i.e., to a whole series of committees, including QI, as an informational measure.

How the form works

Blanco explains how the "ticket" works in practice. "If a patient needs to go to radiology, the floor calls and says, 'Bring down Mrs. Smith in Room 3427, and call transportation.' Transportation takes the ticket to the floor, finds the patient's nurse, and then fills out the ticket."

The nurse signs the form and the transporter signs the form. (Below the section where the nurse signs the form is a place for comments.) The nurse signs both her name and phone number, so if a radiology tech gets the ticket and does not understand something, he knows exactly who to call. "That's part of the National Patient Safety Goal — to have the opportunity to ask questions and to have those questions answered," Blanco notes.

When the patient leaves radiology and goes back to the room, there is a section for the tech to make comments — such as, "IV infiltrated," or "We could not do the test because the patient was too nervous."

The tech signs his or her name and the transporter signs it again and then sends it back with the patient. The nurse who receives the patient has to sign it again, because the ticket goes back to transportation.

The ticket is used "whenever a patient travels," says Blanco. It's good from midnight to midnight. If a patient travels a second time during the 24-hour period, on the next trip there is a place for the nurse to put additional comments, and the transporters bring back the same ticket.

The earliest version of the ticket was used last November. As of this March, the staff started using the current version.

Positive staff reaction

The staff reaction has been very positive, Blanco says. "They realize its importance," she says. "Transportation knows they can't move a patient without a ticket. Even if a nurse did not want to use it, they would have to do so, but they realize there is a lot of information that should be communicated on some patients when they leave the floor."

The transporters, she continues, have been made to feel they are an important part of the team. "They are not just regarded as robots; they take responsibility for the patients, and they have been made to feel like they are important," Blanco observes.

It is far too early for quantitative proof the ticket has improved safety, "But qualitatively, the nurses feel like if they are sending someone with critical information, it will be readily available to the receiver — and those receivers say they truly appreciate that, when they receive that patient, they have that information. They know if the patient is combative, if they are a falls risk, or if they need a specific amount of oxygen," she says.

Since the receivers have to sign the paper as soon as they have received the patient, "This means they must do an immediate review of the patient," Blanco summarizes.