A nursing initiative to improve patient handoffs began by addressing the root cause of poor transitions from the ED to the ICUs: The nurses didn’t know each other very well, and weren’t concerned with how their actions affected their counterparts on the other unit.
The ED at South Shore Hospital in South Weymouth, MA, has the second-highest volume of patients in the state of Massachusetts, with frequent ED-to-ICU handoffs. But they weren’t going smoothly a few years ago, according to Lisa Nolan, RN, AD, a nurse in the surgical ICU (SICU), and ED nurse Nicole Howley, RN, BSN.
“Throughout the entire hospital, and any hospital I’ve ever been in, it’s difficult to move a patient from the emergency room to anywhere else,” Howley says. “It’s kind of a push-pull because we want them to pull the patient up if they have a room, and they’re busy with their patients.”
Over the years, an animosity built up between the ED and ICU nurses, with rumors and accusations about how one department or the other was at fault, Howley says. Poor handoffs were common as both groups grew frustrated and less cooperative.
“We were a little overwhelmed when we starting looking into handoffs because a lot of the culture of the institution plays into the problem,” Howley says. “There was a lot of history behind what we were trying to change. The expectations on both sides had become a little unrealistic.”
Poor handoffs and patient safety incidents traced to them were common. As part of a quality improvement program offered by the American Association of Critical-Care Nurses (AACN), Nolan and Howley developed a program to improve handoffs. They first had to identify the causes of the process failure, and the most obvious factor was the lack of a formal structure for reporting and handing off patients. They also determined that poor handoffs were caused by each group of nurses not understanding the others’ workload, workflow, and priorities, which resulted in a strained relationship.
They also observed that nurses trying to transfer or receive patients were often interrupted when exchanging information. Nurses also reported that the heavy volume of patients left them feeling always rushed and forced to sacrifice some handoff concerns.
Nolan and Howley developed a quality improvement program and set the primary goal as standardizing handoff communication by using the Situation-Background-Assessment-Recommendation (SBAR) format. (More information on SBAR is available online at http://bit.ly/2daqZpm.) Another important task was improving the relationship between the nursing groups.
The project began with a survey of ED and ICU nurses, which helped pinpoint the problem. (See the survey in this issue.) They realized that much of the antagonism was the result of nurses not knowing or understanding their counterparts, Howley says. If they could get the groups to know each other and understand each other’s situations, they thought that alone would improve the handoff process. Nolan and Howley began by switching jobs for a day so they could see the demands and workflow of each other’s departments.
That opened their eyes to how both sides of the handoff process had misconceptions or false impressions of what was going on in the other department. They saw that when everyone was rushed and pressured, it was easy to attribute problems to the other side’s bad motives, Howley says. Nurses working EDs and ICUs tend to have strong personalities, Nolan says, which made confrontation and criticism the frequent response to a transfer problem.
“When everyone is stressed, everybody thinks they’re working harder than the next person because they don’t understand the demands the other person is facing,” Nolan says. “It’s easy to be self-absorbed and think of only your own work. We’re so busy that we’re always Code Red and people in the ED get focused on moving those people out, without understanding why they can’t sometimes. Likewise, the ICU nurses didn’t understand why the ED nurses were pushing so hard.”
No Criticizing Others
Both nurses reported back to their colleagues about what they learned, and encouraged them to do the same. After some nurses had made the switch for a day, the effects were immediate.
“Putting a face to a person changes everything,” Howley says. “It’s a lot harder to get angry with someone when you know them as a person, someone who is doing the best they can, rather than just a voice on the other end of the phone.”
Howley and Nolan both made a conscious effort to tamp down criticism of the other departments, reminding their colleagues that the nurses on the other floor were nice people doing their best. They were all trying to do good for the patients, they said, so everyone had to find a way to work together.
“I would say, ‘Don’t talk bad about the ICU’ and she would say, ‘Don’t talk bad about the ED,’ Howley says. “We just kept saying that we had to try to be nice and figure out why your situation is not going well. A lot of the time, we could get the nurse to see the other person’s point of view.”
They also encouraged nurses to take their patients to the other unit themselves rather than having someone else do it. While not always possible because of the workload, the face-to-face interaction goes a long way toward maintaining mutual respect, Howley says.
Orientation Includes Shadowing
The hospital also began requiring nurses at orientation take the time to walk in each other’s shoes, Nolan says. During the orientation process, each nurse spends one day shadowing a nurse in the ED or ICU, whichever one is not the one in which they’ll be working. Nolan suggests this is perhaps the best move a hospital can make to build relationships and understanding of each other’s workflow.
To encourage more interaction between the groups of nurses, Nolan and Howley hosted a mixer and chose a football theme because it was during football season. Their chief nursing officer was supportive and approved a budget for an off-site get-together. They named the project: “Tacking Communication: Don’t Fumble the Handoff!”
They invited the ED and ICU nurses and got a good turnout. To keep the groups from huddling together with their own co-workers, Howley and Nolan made sure each table had a mix of nurses from the departments. Each nurse got two drink tickets and there were appetizers and desserts available, because “nurses always respond pretty well to free food,” Nolan says. The event started with ice-breaker games, and then a video demonstrating a good handoff and a bad handoff. The video parodied the animosity that an ED nurse and ICU nurse both might experience in a handoff.
SBAR and Checklist Used
After almost a year of team-building, Howley and Nolan turned their focus to improving the use of SBAR at South Shore. The hospital had implemented the system already, but it was not being used consistently. Howley and Nolan, along with nursing management, encouraged the consistent use of SBAR in every handoff and the nurses cooperated better because they knew each other, Nolan says. Both groups were using SBAR every time, so there was no frustration with one party not cooperating, she says.
The hospital also began using a transfer checklist to ensure procedures were followed and the departments cooperated with each other. (See the checklist in this issue.)
Though the formal project has ended, Howley and Nolan are continuing to encourage good relationships between ED and ICU nurses and the consistent use of SBAR.
Measuring success for the project was challenging because there were few statistics, so Howley and Nolan relied mostly on incident reports that involved handoffs. In the month the project first started, South Shore had 10 incident reports involving handoffs. In the same month two years later, there were zero. With the Association of periOperative Registered Nurses reporting that medical errors cost an average of $8,750 per patient, Howley and Nolan calculated that the project was saving $87,500 per month and $1,050,00 per year.
“We’ve presented the project results at an AACN nursing conference and got a very good response,” Nolan says. “It seems this is problem that is familiar to a lot of hospitals.”