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Abstract
High-quality hand therapy is critical to maximising functional capacity and optimising overall outcomes following hand injuries. Therapy delivery requires clear communication between surgeons and occupational therapists. At Sunnybrook Health Sciences Centre (SHSC), Canada’s largest tertiary care centre, suboptimal communication is a significant barrier to efficient hand therapy delivery in acute multisystem trauma patients. A baseline audit at SHSC found that 41% of hand therapy orders required clarification and 35% of patients waited over 24 hours before their order was fulfilled. In many cases, communication errors created unacceptably long delays that were suspected by surgeon stakeholders to impede patient outcomes. This highlighted an opportunity for investigation and system improvement.
Using process mapping methodology, we outlined standard process involved in patient care and identified barriers to successful communication. We collaborated with key stakeholders to codesign a standardised template for care orders. We aimed to improve order clarity and consistency with the goal of reducing the incidence of clarification and delays.
Postimplementation, the percentage of hand therapy orders requiring clarification was decreased to 24%. The number of patients waiting over 24 hours for therapy was also reduced; however, further investigation is required to verify this finding. In addition, essential order components were more consistently and comprehensively included. Next steps of this work include expanding the use of the order template outside of the multisystem trauma population and improving the communication of hand therapy at discharge from hospital.
- Transitions in care
- Surgery
- Occupational Therapy
- Quality improvement
- Communication
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplementaly information. Not applicable.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Effective communication between teams is critical for precise care delivery. This is especially true in the context of multisystem trauma, where patients receive complex care for a variety of competing issues.
WHAT THIS STUDY ADDS
This project demonstrates an approach to standardise communication practices in the delivery of hand therapy to multisystem trauma patients. It provides a framework for integrating stakeholder insight into a codesigned order template.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The order template and improvement methodology used to design it may serve as a guide for other sites aiming to optimise communication between teams.
Problem
Hand therapy is an essential component of care following hand trauma. Delivery of hand therapy is especially challenging in multisystem trauma patients, who have complex and competing care priorities, requiring coordination among a broad network of providers.1 2 In this population, precise, consistent and accurate communication between teams is critical to avoid delays or errors in hand therapy delivery.
At Sunnybrook Health Sciences Centre (SHSC), the largest and busiest regional trauma centre in Canada, stakeholder input from surgeons and occupational therapists (OTs) highlighted problems with the delivery of hand therapy in the multisystem trauma population. Concerns were raised that the initiation of hand therapy was often delayed, splint fabrication was inconsistent and hand injuries were being neglected during rehabilitation, leading to suboptimal patient outcomes. These concerns were validated by a baseline evaluation of hand therapy orders. A hand therapy order is the directive issued by surgeons to initiate and guide therapist’s treatment plans for a patient. The order is the main channel of communication between surgery and therapy teams and is written in paper charts at our institution. This evaluation identified that 35% of multisystem trauma patients waited longer than 24 hours before their hand therapy order was fulfilled, with 13% waiting over 72 hours. Forty-one per cent of hand therapy orders required multiple clarifications and 4% of therapy delivery needed revision due to incorrect execution, suggesting that care delay was due to poor communication between surgeons and hand therapists. This confirmed a significant quality problem impacting a large patient group, with approximately 44% of annual trauma patients seen at SHSC presenting with a concurrent hand injury. While it was acknowledged that staffing shortages and intensive workloads were factors contributing to this challenge in quality hand therapy delivery, unreliable and inconsistent communication between care teams was determined a root cause and presented a realistic first target for improvement. The project initially aimed to reduce the proportion of patients waiting longer than 24 hours for hand therapy to 10%; however, this goal was revised as we gained a better understanding of the problem.
Background
Hand therapy consists of a combination of protective splinting and progressive exercises to restore hand function following trauma. Common indications include hand fractures, joint dislocations, tendon lacerations, burns and peripheral nerve injuries. Hand therapy varies considerably according to the patient’s injury(ies) and requires detailed attention to each structure in the hand. Consistent delivery of hand therapy as early as possible after most injuries is critical to optimising functional capacity and active range of motion postinjury.3–5 When hand therapy is not delivered appropriately, patients are more likely to experience reduced function, difficulties with activities of daily living and financial instability.6 Disability from hand trauma contributes to substantial productivity loss and is one of the most economically costly injuries to society and healthcare.7
At the project site, hand trauma is managed by plastic surgeons, and inpatient hand therapy is delivered by OTs. While ineffective and inconsistent communication between surgeons and OTs was purported to be the primary contributor to inadequate quality of hand therapy delivery, this had not been confirmed through formal investigation. To gain insight into the problem, we conducted virtual one-on-one interviews with key stakeholders involved in the care of multisystem trauma patients with concomitant hand injuries (n=3 surgery residents, n=3 plastic surgeons, n=6 OTs, n=1 patient care coordinator, n=1 rehabilitation physician) to develop a detailed understanding of the current reality of care delivery and identify opportunities for improvement. Interviews underwent content analysis and were used to develop a process map that summarises clinical activities from the time of admission at SHSC through discharge to outpatient rehab (figure 1). Interviews were conducted until there was saturation of ideas. While non-traditional, this approach to process mapping was selected due to the constraints of the COVID-19 pandemic.
Process map summarising baseline model of care prior to implementation of hand therapy order template. OTs, occupational therapists.
Process mapping revealed that hand therapy orders were non-standardised and often unclear, which created confusion among OTs and hindered the efficient delivery of therapy. In most cases, orders were handwritten on a blank order form by resident physicians following a brief discussion with the most responsible physician. With limited instruction and no prompting template, residents reported difficulty constructing comprehensive hand therapy orders. Some expressed that their knowledge of hand therapy was not congruent with the complexity of injuries presenting at the site. As a result, they failed to specify necessary details or highlight pertinent information. The lack of clarity conveyed in written orders resulted in downstream challenges at the point of order completion, which was exacerbated by limited hand therapy expertise among OTs serving the trauma population. The OTs reported difficulty interpreting orders and commonly required clarification of the therapy plan. Due to physical separation between teams and competing priorities, the practice of contacting, clarifying and revising orders with the surgeon team created significant delays. For context, trauma patients are geographically located in multiple intensive care units (ICU) and inpatient wards, and often return for follow-up management as an outpatient. This contributes to further challenges in facilitating cohesive communication across various settings and teams.
From this investigation, it was clear that one of the main drivers of inefficiency and delay was poor communication and lack of standardisation. Following codesign sessions with key stakeholders, it was deemed necessary to re-evaluate how orders were completed and determine how their content could be standardised to improve clarity and reduce delays using quality improvement methodology. This article followed the Standards for Quality Improvement Reporting Excellence guidelines, which provide a consistent and reliable structure to document findings in healthcare improvement.8
Measurement
A baseline, retrospective assessment of hand therapy orders for multisystem trauma patients presenting with a concomitant hand injury between January 2019 and March 2022 was completed. Data were collected for every third patient, resulting in 122 file reviews, for which 46 encounters received hand therapy and were included in our analysis. Therapy orders were evaluated for the presence of the following components, identified as essential to clear communication of hand therapy instructions: intervention description, splint type and location, joints/fingers included in splint, exercise recommendations, level of function and weight-bearing status (online supplemental file 1). Overall, splint type and location were the most reliably reported component to a hand therapy order (85% included), while exercise recommendation and weight-bearing status were commonly missing (33% and 7% included, respectively). The electronic medical record was then used to measure the time interval between order placement and therapy delivery; incidences of clarification were noted. Thirty-five per cent of patients experienced delays of greater than 24 hours between therapy order placement and care delivery, with 13% of patients experiencing delays greater than 72 hours. Forty-one per cent of orders required clarification, with an average 1.6-day wait time for cases requiring clarification in comparison to a 0.9-day wait time for cases that did not. In a few instances, clarification required an unacceptably long period of 4–5 days before resolution and delivery of care.
Supplemental material
After the implementation of the order form, medical record numbers of multisystem trauma patients presenting with a concomitant hand injury were recorded. Hand therapy orders for each patient were reviewed and incidences of clarification were documented. Orders were assessed for comprehensiveness against the same criteria evaluated at baseline. Weekly online surveys were distributed to residents, surgeons and therapists to assess the perceived impact of this quality improvement initiative on each group’s satisfaction and experience with hand therapy delivery (online supplemental files 2 and 3). Surveys also served to provide continual feedback regarding our intervention which was implemented in subsequent plan-do-study-act (PDSA) cycles. The PDSA cycle is an effective method to implement and revise a standardised communication tool.9
Design
Our initial goal was to decrease the time to hand therapy delivery. However, given the number of variables contributing to the problem and the limited duration of our project, we opted for the following as our primary aim: to decrease the proportion of cases requiring clarification by 50% over a 10-week study period.
Codesign sessions were held with key stakeholders (surgeons, residents, OTs) to review the process map, examine significant sources of inefficiency and delay, and develop an actionable improvement plan. We sought to increase the likelihood of successful adoption of our quality initiative by directly involving key stakeholders in the development and design, as stakeholders offer insight into the practicality, convenience and demand for innovation.
Given cost and time constraints, the most efficient, practical, and effective solution was felt to be standardising hand therapy orders by creating a digital hand therapy plan template to augment the hand therapy orders. This template would provide residents with an organised framework to construct comprehensive hand therapy orders that consistently delivered all pertinent information and did not require clarification. Through multidisciplinary collaboration, the unique needs of each stakeholder group were identified and incorporated into the template. The template was accessible to physicians through the hospital’s electronic medical record and displayed in chronological order among other patient documents. It consisted of a series of multiple-choice, fill-in-the-blank and text box options. We sought to test and iterate the template on trauma patients with concomitant hand injuries presenting to SHSC over a 10-week period. To increase implementation success, we limited our initial implementation phase to the trauma ward and ICU.
The main concern with standardisation of hand therapy orders was misuse of generic order sets that offer convenience and efficiency but fail to represent the complexity of each patient. We also hoped to avoid contributing to the ever-growing administrative burden placed on modern healthcare providers. As a result, the template was designed to be a concise but inclusive outline with few prefabricated options, requiring detailed input from the user. While moderately onerous and technically challenging for residents to complete, we believed this format would encourage discussion between residents and surgeons, and facilitate hand therapy education. In an effort to ease the initial transition, we liaised with surgeons to enlist support for residents learning to complete the template.
Weekly online surveys were distributed to residents, surgeons and OTs via email throughout the project to generate feedback regarding the effectiveness, clarity, and user experience of the template. We also hosted informal meetings with key stakeholders to review progress. This feedback was incorporated into iterative PDSA cycles to continually improve the initial template design and optimise the order process. Compliance was measured by monitoring the proportion of eligible cases for which the hand therapy template was used.
Strategy
Our SMART aim was to improve the clarity and consistency of hand therapy orders to decrease the proportion of cases requiring surgeon clarification by 50% in 10 weeks. Overall, we completed four PDSA cycles (figure 2). A new cycle was initiated when sufficient feedback was received to warrant modification of the existing template or plan.
Run chart summarising the percentage of cases requiring clarification, per week of the implementation. The target clarification rate (21%) according to our SMART aim is shown in green. The start of each PDSA cycle is labelled. PDSA, plan-do-study-act.
PDSA cycle 1: The first cycle (n=7 cases) aimed to implement the template into the electronic medical record and attain successful adoption. After launch of the template, we hosted an orientation for plastic surgery residents and identified an OT champion to familiarise therapists. Initial feedback indicated that resident workload had increased as a result of the template, partly because residents were unnecessarily duplicating the template in writing. We also learnt that certain components of the template were extraneous, while certain essential elements were missing. Lastly, the title ‘Hand Therapy Template’ was reported to be confusing, as it was commonly mistaken for an OT note. Improved from baseline, the proportion of cases needing clarification was 20% across the cycle. However, it appeared reliance on written paper orders continued to persist, with some OTs failing to acknowledge the electronic template. We had not yet achieved successful implementation due to persistent usability issues.
PDSA cycle 2: The second cycle (n=6 cases) was directed towards improving adoption of the template and refining its content. We started by removing redundant components and adding prefilled options to reduce resident workload and support compliance. For example, the ‘position of safety,’ a commonly used splinting position, was added as an option. We also removed components that were commonly left blank or believed to be non-essential. We added a disclaimer to the template denoting that completion of each component was not necessary if irrelevant to the case. We hoped these changes would motivate compliance, even if users lacked knowledge of certain details. We explained to residents that it was not necessary to duplicate the template as a written order, a misunderstanding that likely arose due to poor instruction during the orientation. The template was renamed ‘hand therapy physician protocol’ to eliminate confusion. Lastly, we met with the OT champion to promote use of the template. Contrary to our efforts, the clarification rate during this cycle rose to 33%; however, we felt satisfied that teams were aware of the template and were using it regularly. At this stage of the project, it became challenging to attain feedback from stakeholders, as some had lost interest. We learnt that almost all templates were now being completed by a single resident. This was not a sustainable approach, as residents continually rotated in and out of the project site.
PDSA cycle 3: The third cycle (n=4 cases) was designed to re-engage stakeholders and continue to improve order clarity. We added in-person interviews with key stakeholders from the surgery and OT teams to supplement online surveys and improve feedback. From this, we gained helpful insight into the workflow established by the current junior resident and modified the template to make their efforts more efficient. For example, adding selections for commonly used items and revising wording of frequently misinterpreted components. As a result, the rate of clarification was reduced to 25%. While not a significant improvement from baseline, the template was now being incorporated into regular practice. With the knowledge gained from stakeholder interviews, we planned to assist the incoming team of residents with a helpful set of recommendations.
PDSA cycle 4: The fourth and final cycle (n=6 cases) focused on facilitating the successful transition of new residents and achieving lasting improvement to order clarity. On arrival, we met with incoming residents during the first week of their orientation to introduce the project, familiarise them with the template, and share helpful tips generated from the previous resident. With this guidance and a well-prepared OT group, the clarification rate was further reduced to 17%. In addition, we received verbal feedback from OT staff indicating that orders were noticeably improved from baseline and far easier to interpret.
Results
Our primary outcome measure was the proportion of orders requiring clarification, which served as an indicator of enhanced communication. Across the entire duration of the project, the overall clarification rate was reduced to 24% compared with the baseline value of 41% (figure 3). Initially, the incidence of clarification varied significantly; however, it remained consistently low for the last 4 weeks of implementation. This was in-line with survey results from OTs, which indicated that satisfaction with order clarity increased and stabilised towards the last month of implementation, and corresponded with our observation that adoption improved towards the later PDSA cycles.
Comparison of baseline and postimplementation hand therapy orders.
With regard to the content of hand therapy orders, we achieved improved rates of inclusion for various critical care components. The percentage of orders reporting weight-bearing status surged from 7% to 70%. The portion of orders offering basic exercise recommendations increased from 33% to 74%. Lastly, the share of orders clearly specifying splint type and location improved from 85% to 96%. As a whole, this objectively indicated that the detail, quality and comprehensiveness of communication were superior to baseline.
As hypothesised, increasing clarity of hand therapy orders translated to reduced care delay. In contrast to a baseline measure of 35%, only 14% of multisystem trauma patients waited longer than 24 hours to receive hand therapy following implementation of the template. Moreover, no patients waited longer than 48 hours. This improvement, while substantial, is limited by the short duration of the project and the small sample size. Further investigation is necessary, as many external factors contribute to care delays and it is not possible to verify that the template was solely responsible for this result. For example, staffing reduction on weekends often contributed to unmodifiable care delays.
Lessons and limitations
Limitations of stakeholder availability due to intensive workloads, attributed to high patient volumes, strongly influenced the project. We were cognizant of mitigating extra work generated by implementation of a new template and designed our approach accordingly. As a result, implementation success and measurement accuracy were compromised. For example, to reduce the burden of the template for residents, we repeatedly refined and reduced the quantity of content included, which may have decreased the amount of detail communicated in orders. A similar approach was taken for survey design, where most questions were constructed as 5-point Likert scales. This made it difficult to capture the true complexity of perspectives offered by stakeholders but increased the feedback rate. To accommodate for this, we scheduled additional interviews with key stakeholders from each team.
Local contextual factors also impacted implementation. When constructing the template, several conveniences, such as drop-down selections, tick-boxes and personalised formatting were not available in the hospital’s currently operating electronic medical record system. We received multiple requests for these features and agree it would have improved user experience and functionality of the template further. We were also unable to circumvent the hospital’s paper order policy. To comply, residents were required to sign a paper order to officialise each digital template. This meant an additional step and additional time, which impeded adoption. Fortunately, the project site is currently transitioning to a fully electronic order system, which will improve the user-interface of the template and eliminate the need for written order confirmation. Finally, implementation was disrupted by the turnover of residents. However, with adequate preparation and support for this transition, the incoming team integrated seamlessly with the existing project. This indicated that the introduction of new stakeholders partway through implementation can bolster interest and reignite efforts.
The strongpoint of our project resided in careful process mapping. We invested significant time and accumulated various stakeholder perspectives to ensure our understanding was accurate, complete and reliable. From this, we were able to quickly and confidently determine the most expedient intervention to mediate the root cause of the problem. As a result, our PDSA cycles focused on refining the original solution rather than testing alternative approaches.
Conclusion
Hand therapy is an essential component of functional recovery following hand injury but was delivered in suboptimal fashion in multisystem trauma patients at the project site. Our team developed a map of care delivery, identified problems within the process and implemented an order template to improve communication between teams. Although we successfully decreased the incidence of order clarification and reduced care delay, we fell short of our initial goal. A longer duration of implementation is required to further evaluate the success of the order template. As teams become more comfortable with its use, we plan to expand its application to other inpatient settings where hand therapy is delivered. In addition, we are working with technology staff to optimise the features and functionality of the template. Given that patients are the only individuals consistently present across the continuum of hand therapy care, we hope to incorporate patient perspectives into future iterations to empower ownership of personal health information and bolster quality of information transfer.
Throughout the project, there was indication that communication of hand therapy at discharge was also complicated by lack of clarity and detail. This is a critical issue, as multisystem trauma patients are commonly discharged to rehabilitation facilities that require clear instruction to provide adequate ongoing therapy. Next steps include a thorough investigation of this process and development of a quality initiative to improve care through this transition.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplementaly information. Not applicable.
Ethics statements
Patient consent for publication
Acknowledgments
We would like to thank Dr. Abi Sriharan for her support.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @NerveSurgeon
Contributors All authors contributed to and approved this manuscript. Study design (JD, TM, AM and KB), data collection (TM, GH and ET), data analysis and interpretation (JD, TM and AM), draft manuscript (JD and TM), final manuscript (JD, TM, KB, GH, ET, PB and AM). JD is responsible for the overall content as guarantor.
Funding Academic Health Science Centre Alternative Funding Plan (AHSC AFP) Innovation Fund; SHS-22-011.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.