The American Association of Critical-Care Nurses’ standards for establishing and sustaining healthy work environments identify skilled communication as a standard that creates a safe work environment.1 Good communication also increases satisfaction of patients and their family members and decreases errors, ensuring safe passage for patients. Breakdown in communication was identified as a root cause in more than 65% of 3000 sentinel events analyzed by The Joint Commission.2 Nurse-to-nurse handoff of patient care presents a large risk for potential miscommunication. Therefore, in January 2006, The Joint Commission instituted “Handoff Communication” as a National Patient Safety Goal. Improving communication at handoff begins with a standardized process.3Catholic Health Initiatives (CHI) Franciscan Health System’s Regional Hospital is a 26-bed long-term acute care hospital (LTAC). LTACs play an important role in the continuum of care for chronically critically ill patients. Patients in the intensive care unit (ICU) with multiple comorbid conditions who require additional time to be weaned from mechanical ventilation or are too ill to be transferred to the general medical care area are transferred to an LTAC. This process allows the patient to continue to receive the complex medical care needed while facilitating admissions to the ICUs in the short-stay acute care hospitals. A patient must require an additional 25 days of high-level care to meet criteria for admission to an LTAC. Regional Hospital cares for patients with chronic critical illness who are transferred directly from ICUs of Washington hospitals. The mean length of stay at Regional Hospital is approximately 30 days. In chronically critically ill patients with multiple comorbid conditions, a great deal of information can change during an extended stay. Without a solid communication mechanism, important information can be missed during change-of-shift report.Regional Hospital had transitioned from paper-based charting to an electronic medical record (EMR) system, and staff were struggling with a complete, yet efficient report system using the EMR. Traditionally, change-of-shift report occurred at the nurse’s station or outside the patient’s room. When presented with the opportunity to participate in the American Association of Critical-Care Nurses Clinical Scene Investigator (CSI) program, a team of 4 nurses took on the challenge to improve handoff communication by creating a bedside report (BSR) process customized for an LTAC.The purpose of the CSI project “The BSR Project: Can We Talk?” was to improve communication between nurses by implementing a standardized BSR at change of shift. The structured BSR process included visual confirmation of the information communicated during handoff. Project goals were as follows:A computer-based survey was created to assess the current attitudes of the nurses regarding shift report, their expectations of the process, and their attitudes toward giving report at the patients’ bedside. Paper-based surveys were provided to patients and their families as well, to document their experience and help us understand how we could better serve them. On the basis of these data, a BSR tool was created to guide the EMR process and standardize patient safety checks.The BSR tool combined the Situation Background Assessment Recommendation (SBAR) reporting system and a new project structure from Franciscan Health System called the 5Ps: project, plan, purpose, problems, and precautions. The 5Ps is a format used to guide and structure the flow of information to enhance communication on projects. We reconfigured the 5Ps and merged that structure with SBAR (Figure 1). Informatics identified key screens in the EMR that helped streamline shift-to-shift reporting, thus improving efficiency.In-service training sessions were held to educate nurses about the tool’s design and to outline the BSR process. We explained the value of using the computer at the bedside to verify the information shared. The team demonstrated the process for the staff and then encouraged them during hands-on simulation.Common barriers encountered wherever BSR is implemented (privacy and confidentiality concerns, accessing patients in isolation, reluctance to talk in front of the patient, time management, and anxiety about change) were addressed during staff education. One barrier that the team did not anticipate was the shared opinion that BSR was not something that our hospital needed to do. The consensus among the staff was that our patients’ extended stays allowed nurses to remain informed about our patients, which prevented significant communication failures. However, the old method of shift-to-shift reports resulted in communication failures and compromised patient safety. The CSI team worked diligently to explain how the BSR system supports patient safety by starting at the bedside and helps the oncoming nurse to prioritize the day’s tasks immediately. In addition, we were able to use our fall scores and medication errors to support the rationale for our project.Data were collected from April 2015 to October 2015. We were unable to collect before April 2015 because Regional Hospital affiliated with CHI Franciscan Health System in 2014, changing many of the hospital’s standard systems over time. Outcomes were measured in several areas: nurse and patient satisfaction with communication, number of falls, and number of medication errors. Nurse participation (Figure 2) was monitored throughout the project by using BSR sign-off sheets in each patient’s room. Patient/family and nurse satisfaction were tracked with surveys at measured intervals. After a baseline survey was conducted, additional data were collected 3 months and 6 months after implementation of the BSR process.Data on falls and medication errors were obtained via the hospital’s incident reporting system. Medication errors related to handoff communication decreased 80% (from 5 to 1), and patient falls related to handoff communication decreased 100% (from 2 to 0) after implementation of the BSR system. The surveys revealed a 12% increase in family satisfaction and a 23% increase in patient satisfaction after implementation of the BSR process (Figure 3). The follow-up surveys also showed a 13% increase in nurses’ satisfaction with reports given and a 23% increase in nurses’ satisfaction with reports received.Sustaining BSR remains a challenge. It is easy to slip back into old habits. However, nurses new to Regional Hospital and recently graduated nurses have embraced BSR. These new nurses continue to help the nurses who have been at the hospital for a number of years work this change into a comfortable place in their own practice. Sustainability has also been helped as the hospital’s respiratory therapists have modified their practice to include a version of BSR at their change of shift.The CSI Academy encourages nurses to become agents of change within their institutions. The opportunity to participate in the CSI program allowed us to understand the change process and empowered us to take ownership of our own practice. The CSI process has given us a model to follow in creating practice change driven by bedside nurses, and indeed several other initiatives are underway at Regional Hospital.
Read more
29
