Problem

The Royal Cornwall Hospital Trust (RCHT) is a large teaching district general hospital. It serves an estimated population of 500 000 people, which increases with holiday makers during the summer months. The Trust employs approximately 5000 staff and has over 750 beds. In the medical department at the RCHT, there are two verbal handover meetings per day where on call staff come together and discuss acutely unwell and unstable patients. The on call foundation doctor often reviews patients who are medically complex and may have been in hospital for some time, with limited specific handover information. Not all medical patients are handed over verbally, only the patients highlighted as being unwell or at risk of becoming unwell at the time of the meeting. The reviewing doctor is often reliant on the written handover in the notes for patient information. Therefore, there is a need for an accessible, high-quality written handover for weekend on call staff to use to aid decision making around the care of patients over the weekend.

The overall aim of the project was to improve the written handover between weekday ward doctors and out of hours doctors.

We developed the following SMART aims, for completion over an 8-month period:

1. To develop a weekend handover structure for use in the medical notes;

2. To improve the number of notes with a documented weekend plan from 15% to 100%;

3. To improve the number of notes with a documented escalation of care from 10% to 100%;

4. To improve the number of notes with a documented recent summary from 26% to 100%.

Background

A high-quality, effective handover has significant benefits for doctors and patients. The General Medical Council states doctors ’must contribute to the safe transfer of patients between healthcare providers’, which requires doctors to “share all relevant information with colleagues involved in your patients’ care within and outside the team, including when you hand over care as you go off duty”.1 It is our responsibility, as junior doctors, to ensure all relevant information is available and handed over at the weekend. The British Medical Association (BMA) ‘safe handover, safe patients’ guidance, states lapses in information in handover, can and do lead to mistakes being made, which could increase morbidity and mortality.2 A good handover is educational for doctors, reduces stress and improves jobs satisfaction. The BMA advises written handover should include access to up-to-date summaries and management plans for all patients under a team’s care, anticipated problems, to clarify management plans and ensure appropriate review and a list of outstanding tasks with expected completion time.

The Royal College of Physicians have published a guideline on the ’Standards for the Clinical Structure and Content of Patient Records’.3 The information recommended to be available for handover, including for hospital at night and on call teams, should include reason for admission, clinical summary, past medical history, summary of the problems and issues, advanced decisions about treatment, including escalation plan and tasks to be done. The Royal College of surgeons also has very similar advice in their guidelines ‘Safe handover: Guidance from the Working Time Directive working party’.4

Baseline measurement

Our measures for the project were the number of notes with a documented weekend plan, the number of notes with documented escalation of care and the number of notes with a recent summary. We planned to make baseline measurements of these parameters and to monitor them, immediately following intervention (introduction of the weekend handover sticker) and after 1 month to assess effectiveness and sustainability.

One hundred and ten patients’ notes were evaluated (March 2015). The written documentation, in preparation for the weekend, was assessed for the presence of a weekend plan, documented escalation of care and a patient summary within 7 days. Over a weekend, a minimum of 10 patients’ notes were reviewed from each medical specialty. The sample included eight medical specialties (nephrology, endocrinology, respiratory, cardiology, oncology, stroke, neurology, elderly care and gastroenterology) across 11 medical wards. The notes were selected in order of patient beds, that is,  A bay, B bay and so on until the required number were sampled.

For the purposes of this initial assessment, the following were defined as acceptable:

1. A weekend plan was considered to be present if there were any tasks documented to be completed over the weekend (including discharge), with or without a heading of weekend plan, or documentation stating no jobs to be completed over the weekend.

2. Escalation of care was considered to be present if there was any documentation regarding escalation of care or discussion with family and/or relatives about escalation of care. The presence of an ANDO (Allow Natural Death Order) was not accepted as evidence of documentation regarding escalation of care, unless it contained additional written information on escalation, for example, ‘would be considered for non-invasive ventilation’.

3. A documented patient summary (reasons for admission, background, medical history and current problems) within the previous 7 days was deemed acceptable. We opted to exclude all patients who had been in hospital for <7 days because their admission clerking would be a recent summary. Fifty-three of the 110 patients had been in hospital for >7 days and were included in this analysis.

The baseline measurement demonstrated that 15% (16/110) patient notes contained a weekend plan, 10% (11/110) of notes had clear documentation of escalation of care and 26% (14/53) had a patient summary in the last 7 days. The longest time a patient went without a patient summary was 31 days (see online supplementary appendix 1).

Design

The baseline measurement confirmed the written documentation for weekend handover in the medical notes often did not include a weekend plan, escalation of care or recent patient summary. The first stage of the project was to develop an intervention with the aim of improving this and the second stage was to assess its effectiveness.

In designing our intervention, we considered the written handover system operating in the surgical directorate at the same hospital. The surgical department at the Royal Cornwall Hospital use a sticker (see online supplementary appendix 1), completed by the ward team and placed in the patients’ record on a Friday, to document reasons for admission, any procedures, anticipated complications and weekend plan for every patient. It was the experience of the foundation doctors working in surgery that the sticker enabled a thorough and robust written handover for the weekend, making weekend work more controlled, less stressful and more efficient. Therefore, it was felt that the preferred intervention was a sticker, designed for use in acute medicine, based on a system that worked well in another directorate. If successful, this would lead to a congruent system across medicine and surgery in the same hospital. The published Quality Improvement work on weekend handover also provides supporting evidence that a sticker can be used to improve written handover.5–7 Therefore, we opted to develop a sticker, to include key prompts, to improve the written documentation in the patients' notes and increase communication from the weekday team to the weekend on call team. In considering the challenges of this intervention, we recognised the need to use consultation cycles to design in the intervention (a weekend handover sticker), collecting feedback from healthcare professionals, and then use Plan Do Study Act   (PDSA) cycles to test it and build up supporting evidence of its effectiveness. We also recognised that the intervention was a major change and therefore we sought advice from the Governance Lead for Medicine from an early stage and all pilot documents were reviewed by the appropriate Governance Group before use.

Strategy

Development of the weekend handover sticker (April 2015)

We used two consultation cycles to develop the intervention (weekend handover sticker). We asked junior doctors and a consultant nurse (13 people) what information they would like to be included on the weekend handover form. We predicted that they would like a brief overview of the patient and clear weekend plan, the outcome of the consultations were the staff wanted quite detailed information on the handover form and they requested clear documentation of a plan for the weekend, escalation of care and an up-to-date patient summary. This feedback confirmed our aims and measures to be appropriate. There were a few additional requests to include prompts for venous thromboembolism prophylaxis (VTE), warfarin prescription and weekend blood tests. Therefore, the first draft of the weekend handover sticker was a design which included as much information as possible.

Consultation cycle 2 was to further develop the intervention by collecting initial feedback on our design. Verbal feedback was sought on the medical weekend handover sticker from 10 junior doctors.

Feedback was requested on the content, the design and layout and also whether doctors thought it would improve the weekend handover. The feedback was largely positive, most junior doctors thought the sticker would improve the communication between the weekday ward teams and the on call team. The main criticism was that it was busy and contained a lot of information. This could discourage the ward team from completing the form and could be more difficult for the on call teams to read. The extra prompt for VTE prophylaxis was deemed a duplicate prompt because there was already one on the electronic prescribing system used at the hospital. There was concern expressed that it would add a large volume of work on a Friday for the ward staff. There was a lot of discussion and opinions regarding the layout and size, with the majority wanting an A5 size. As a result of the feedback, the form was simplified and reduced to A5 size. We were mindful of the feedback regarding workload for the weekday staff and decided to seek specific feedback on workload for both weekday and weekend staff in the next PDSA cycles.

Lessons and limitations

The development of the medical weekend handover form has been a project that has run over a much longer time period than we initially anticipated. We recognised the need to work within the governance structure of the Medical Directorate; however, we did not anticipate the time that this would add to the duration of the project. As a result of this, some aspects of the project that we had hoped to be able to further develop were put to one side to ensure completion of the core project.

Over the project period, the hospital issued key messages to highlight the importance of an effective handover in response to a Care Quality Commission report. The Trust also introduced a TEP form, while the project was in progress. These changes could both have contributed to some of the improvements we have recorded. In future cycles, we plan to collect baseline data more regularly to allow better correlation between the intervention being tested and the change. We would then be able to monitor improvement using a run chart.

In selecting patient notes for review, we reduced bias by sampling notes from across all medical wards who took part in the PDSA cycles. One to two notes were selected from each ward and specialty, using a consistent sampling method. In the PDSA cycles, we included patients who had been in hospital for under 7 days and their admission clerking was allowed as an up-to-date summary, whereas during baseline data collection we excluded patients who had been admitted within the last 7 days. This may have introduced some negative bias.

Our results can only demonstrate the the weekend handover sticker would improve the written handover in the medical department at RCHT. Other hospitals and departments might have a different handover system or already have a similar process in place.

However, our intervention and our results are an example of a prompt which could be used to improve the documentation in the medical notes prior to the weekend.

One of the ongoing issues that we are still working to address is sustainability. PDSA cycle 2 showed good levels of use of the form over a 3-week period; however during this time, junior doctors were prompted to use the form and sent weekly email reminders. Given the concerns expressed by weekday staff around workload, we are aware that the use of the form may diminish over time. Therefore, we have sought opportunities to present the information at consultant level and to the medical governance leads, to encourage senior support of weekday ward doctors completing the forms.