Addressing floating and patient safety

Running Head: PICOT Review 1

PICOT Review 17

PICOT Evidence Review

University of Maryland Baltimore School of Nursing

Andi Wise

PICOT Evidence Review 1 Evidence Search

Nursing practice strives and demands improvement in quality care and enhance patient safety outcomes. The Joint Commission predicts that two - thirds of sentinel adverse errors are associated with miscommunication between the caregivers during hand-off among the patients (The Joint Commission, 2018). The implication of the handoff is the transfer and acceptance of the responsibility for the care of the critical ill or injured adult. Effective communication enhances this transfer (Halms, 2013). In most cases, crucial information about the care of the patient is lost during changes in shifts (Jukkala, 2012). Thus, we need strategies to enhance the safety and quality of the hand-off process.

Most hospitals lack information standardization that is essential during handoff in intensive care units that translates to inaccuracy in information exchange (Halms, 2013). The situation leads to inconsistent patient care with a high degree of dissatisfaction among the patients as well as the patient safety associated with medical errors. The family members of the patients can also be affected and it can be catastrophic to the patients. Confirming that hand-off occurs at the bedside with patient participation and not at the nurses’ station is an opportunity to promote patient gratification and safety by involving patients and family members to be participants where they can clarify and correct inaccuracies (McMurray, 2011). Therefore, The Joint Commissions and the National Patient Safety Goals suggests the need for improvements in communication effectiveness among the caregivers (The Joint Commission, 2018).

Among the adults in the critical care unit (P), does the handoff among the clinician that incorporate the patients with the family members (I), relative to the handoff that involves the clinician only (C), improve patient safety (O) during the length of stay in the ICU (T).

In the above PICO(T) question, the population, P includes the adult patients in the ICU. The intervention, I is the clinician handoff at the end of the shift that involves the patient and the family members. The standard practice –comparison is the clinician handoff report. The outcomes, O entails the patient safety. Time, T is the length of stay in the ICU.

Description of Search

I have utilized Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases and PubMed at the Health Sciences and Human Services Library of the University of Maryland, to complete the advanced search. The search terms “acute care” or “inpatient” AND “hand-off” or “shift report” AND “patient safety” or “patient satisfaction” were applied during the research. The original search resulted in 229 articles. The result then was limited by peer review and narrowed to the article year range from 2011to 2018 with English language only, which left 107 articles for review. Tile and abstract was reviewed in the 107 articles. A total of 85 articles were excluded due to various reasons cited in PRISMA diagram. The full-text review applied to the remaining 22 articles, there were 17 articles eliminated due to various reasons but not limited to: lack of controlled trial, insufficient result and irrelevant experiment towards PICO question. Conclusively, five articles were eligible and included in the evidence review process.

The current research focuses on particular departments and institutions with much of their emphasis on the convenience use of designs, samples as well as outcome measures. The starting point in the future research in handoff must be the development of the conceptual framework that places the PICOT questions within the theoretical framework on the basis of the previous evidence search. It is also suitable to isolate the articles identified through evidence search that are not particular to the items of the PICOT questions. Only the articles that address all issues as suggested in the PICOT questions can be considered for use in the research.

Reference

Ford, Y., Heyman, A., & Chapman, Y. (2014). Patients’ perceptions of bedside handoff: The need for a culture of always. Journal of Nursing Care Quality, 29(4), 371-378.

Halms, M. A. (2013): Nursing handoffs: Ensuring safe passage for patients. American Journal of Critical Care, 22(2), 158-161

Jukkala, A., James, D., Autrey, P., & Azuero, A. (2012). Developing a standardized tool to

improve nurse communication during shift report. Journal of Nursing Care Quality,

27(3), 240-246.

McMurray, A., Chaboyer, W., Wallis, M., Johnson, J., & Gehrke, T. (2011). Patients’

perspectives of bedside nursing handover. Collegian, 18, 19-26.

The Joint Commission. (2018): The National Patient Safety Goals. Retrieved February 06, 2018 from http://www.jointcommission.org/standards_information/npsgs.aspx

Sand, K., & Sherman, J. (2014). A quantitative assessment of patient and nurse outcomes of

nursing bedside report implementation. Journal of Clinical Nursing, 23, 2854-2863.

Appendix I

PRISMA Search Flow Diagram

Appendix II

Evidence Appraisal Table Template

Study citation:

Ford, Y., Heyman, A., & Chapman, Y. (2014). Patients’ perceptions of bedside handoff: The need for a culture of always.

Journal of Nursing Care Quality, 29(4), 371-378.

Study objective/intervention or exposures compared

Design

Sample (N)

Intervention

Outcomes studied (how measured)

Results

Level

This study identifies patient’s perceptions of the bedside handoff through direct and quantitative measurement. To emphasize bedside handoff with patient engagement not only meets the Joint Commission standards but also contributes to improve patient safety

Quantitative, descriptive study

Borgess medical center in Michigan Inpatient n=103

Inclusion criteria:

At least 18 years of age, fluent in spoken and written English, no Dx of dementia or confusion

Had to spend entire stay on study unit and have experienced at least 3 handoffs

Survey catalogued into 4 variable

-Understanding

-Participation

-Safety

-Satisfaction

Patient’s perceptions of safety, understanding, and satisfaction

8 items using 4 point likert type scale plus 1 open ended comment box

instrument reviewed by nurse experts including CNS, Nurse Managers, Clinical Educators, a PHD nurse researcher

Significant associations between frequency of bedside handoff with safety, understanding of care and satisfaction.

Patient associations of always having bedside report and each survey item ranged from 0.242 to 0.541, p=0.017

Patient associations between rarely having bedside handoff and each item was negative, r=0.488

2

Study Citation:

Halms, M. A. (2013). Nursing handoffs: Ensuring safe passage for patients. American Journal of Critical Care, 22(2), 158-161

To address PICO question: "what effect do standardized nursing handoffs have on patients', clinicians' and financial outcomes

Clinical Evidence review

7 research and QI studies from 2007- 2012

· 4 quality improvement

· 1 prospective observational

· 1 interventional study

1 systematic review

· Face to face, 2 way communication

· Structured written forms, templates, or checklist

· "captures intention" share problems and hypothesis with a predictive diagnosis of the patient's clinical situation

Patient's outcome

· Advanced along clinical pathway (structured face to face)

· Reduced complications-falls (standardized interdepartmental tool

· Reduced adverse event (structured face to face)

Patient's satisfaction

· Higher satisfaction (walking rounds)

· improved understanding of health conditions (patient participation)

According to author this current review is further validation of previous positive finding regarding standardization of nursing handoff.

3

Study citation:

Jukkala, A., James, D., Autrey, P., & Azuero, A. (2012). Developing a standardized tool toimprove nurse communication during shift report. Journal of Nursing Care Quality, 27(3), 240-246.

Study objective/intervention or exposures compared

Design

Sample (N)

Intervention

Outcomes studied (how measured)

Results

Level

To develop and pilot test a standardized tool to improve communication among nurses during shift report

Quantitative Descriptive study

Quasi-experimental; one group pre/post test; Quality improvement project. A communication scale- MICU shift report scale was developed to collect data on nurses perceptions of communication during handover report. Baseline data collected; scale repeated post completion of 3 12hr shifts that utilized report tool developed by QI team

43 RNs participated in the study Inclusion criteria: RN in the MICU and work 2 shifts or more during the 2 week PDSA (Plan-Do-Study-Act) cycle (n=70)

Exclusion criteria: float pool RN or not working for 2 scheduled shifts during the PDSA period

Pre test completed by 43 (61.4%) nurses from a 25 bed MICU in large in a large academic health center (n=77). Posttest completed by 34 nurses (48.5%)

The MICU Shift Report Communication Scale (MSR) collects data on the nurse’s perception of handoff communication during shift report

Three Domains in MSR:

Communication openness, quality of information and shift report

Participates studied via minihuddles or one-on-one interactions

Participants in post-survey shift report scale showed lower scores indicates a more favourable overall perception of the quality and quantity of communication among nurses in the MICU. Following implementation of the new report tool (18.75 vs 17.72; t=2.23; P=0.03) indicating improvement in the perception of communication during handoff.

The intervention group was not statistically different on age (mean=32.7, SD=9.48) or length of work experience

The MICU shift report communication scale may be useful to provide information to support health care organizations and nurse leaders in the evaluation of nurse communication during shift report

· MICU MSR scores ranged from 12-27 (mean=18.78, SD=3.28)

· Scale reliability (Cronbach's alpha=0.79)

2

Study citation:

McMurray, A., Chaboyer, W., Wallis, M., Johnson, J., & Gehrke, T. (2011). Patients’ perspectives of bedside nursing handover. Collegian, 18, 19-26.

Study objective/intervention or exposures compared

Design

Sample (N)

Intervention

Outcomes studied (how measured)

Results

Level

This study examined patients’ perspectives of participation in shift to shift bedside nursing handover.

Qualitative descriptive case study

10 patients in one Queensland hospital.

6 female

4 males

Age (52-74)

Median 68

Inclusion criteria: English speakers, in hospital overnight, able to tolerate 30-60min interview

Exclusion: critically ill or infectious, unable to consent

Face to face interview with 9 questionnaires interview questions or surveys done in addition to the interview about ¾ to 1 hour length of interview regarding bedside handoff including its limitations, patient's existing and potential role in handoff, the role of family members, and issues related to confidentiality

-tape recorded, transcribed, and evaluated using thematic content analysis.

Participants were asked their views about bedside handover during their hospitalization

Dependent variables Participants’s view about bedside handover including its benefits and limitations

Their existing and potential role in hand-off

Family members’ role and issues related to confidentiality

This study was not significantly different on gender, race, age, or length of hospital stay.

This analysis indicated the bedside nursing handover is an ideal practice for implementing a partnership model of care.

· Patient appreciation for participate during handoff

· Bedside handoff enhance accuracy in the information being communicated

Patient preference of Increase nurse- patient interaction during handoff

3

Study citation:

Sand, K., & Sherman, J. (2014). A quantitative assessment of patient and nurse outcomes of nursing bedside report implementation. Journal of Clinical Nursing, 23, 2854-2863.

Study objective/intervention or exposures compared

Design

Sample (N)

Intervention

Outcomes studied (how measured)

Results

Level

To quantify quantitative outcomes of a practice change to a blended form of a bedside nursing report

Quasi-experimental pre-and post implementation design

All patients and RN’s in large university hospital Patients: n= 233 baseline n= 157, 3 months n= 154, 13 months Nurses: n= 148 baseline n= 98, 3 months n= 54, 13 months

Independent variables:

Implementing bedside nursing report at shift change

Dependent variables:

Improved communication, patient safety (falls) and satisfaction

5 point Likert type format

17 open ended questions provided to patients about perception of bedside report after implementation

17 online survey provided to nurses about efficiency, effectiveness, patient safety, teamwork, and demographic data

Statistically significant improvement post implementation in patient safety

Reduced falls from 20 @ baseline to 4 at 13 months

Nurses introductions (p=0.012), encouraging involvement in care (p=0.05), exchanging important information at shift change (p=0.027), and engaging a shift report discussion (p=0.042) effectiveness of communication (p=0.000), promoting patient involvement (p=0.000), and promoting patient safety(p=0.001).

2

Full-text articles assessed for eligibility �(n = 22)

Included

Eligibility

Screening

Identification

See narrative description for keywords and subjects

229 results generated via

search from CINAHL

Inclusion and exclusion criteria applied

�(n = )

122 articles removed by the database software after application inclusion and exclusion criteria

Articles remained for review

Titles and abstracts

�(n = 107)

85 articles excluded:

Lack of relevance to the PICO(T) question (58)

Unavaliable access to full text (27)

17 articles excluded:

Lack of controlled trial (8)

Comparison between unit orientation (not bedside report)(2)

Insufficient results (not patient saftety) (3)

Trials in units or floor other than intensive care (5)