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Your recently published article by Heller and Hu looking at improving the weekend handover system in their hospital is interesting and thought provoking. They found that they improved the standard of the written handover between weekday and weekend teams by introducing a structured intranet-based handover tool.1
A similar project was recently undertaken at our Orthopaedic Department. Our methodology and reasons for undertaking the quality improvement project were similar.
One part of our intervention was different however, and I wonder if the study’s authors would be interested in incorporating it into their excellent handover tool?
We too developed a handover tool, albeit not as sophisticated as the author’s intranet based tool. We redesigned our Microsoft Word document to be more user friendly, comprehensive and fulfil standards from the BMA and RCS.2,3 Our key addition was that of traffic light colour-coding of patients. We used colours to assign patients to levels of clinical input needed over the weekend.
This served to address one of the most daunting part of the weekend on call, identifying who are the most vulnerable patients.
Patients are assigned to one of three colours, red, amber or green. Red patients are day one post operative or unstable patients, perhaps septic or with difficult to manage fluid balances. Amber patients are stable patients with a higher possibility of becoming unstable, those recently c...
Patients are assigned to one of three colours, red, amber or green. Red patients are day one post operative or unstable patients, perhaps septic or with difficult to manage fluid balances. Amber patients are stable patients with a higher possibility of becoming unstable, those recently converted to oral antibiotics or that required a blood test over the weekend. Green patients are those that are stable, unlikely to need any more than a daily review.
Using this simple colour coding has developed a departmental short hand, allowing juniors to more quickly identify patients they might need senior input for and to lead a ward round more efficiently, making sure the most vulnerable, and time consuming, patients are seen quickly and by a senior decision maker.
Informal feedback from junior and senior clinicians has been positive. Weekday FY1s reported higher levels of confidence about handing over patients for the weekend team. Weekend teams, both locum and substantive staff, reported greater efficiency over the weekend and much less unexpected deterioration of patients.
Much of this type of work has been completed to attempt to improve handovers and it seems a lot has been focused on orthopaedic departmental handovers. I wonder if this is to do with the trend in orthopaedic departments to have often quite frail and unwell patients on the wards which have a lot of input from medical doctors in hours, often a dedicated ortho-geris team, and at the weekends are left with surgical junior doctors and FY1s to manage them raising both potential patient safety concerns and anxiety levels of those looking after them!
Since both of these projects have been undertaken NICE has published new guidance (March 2018) where it makes a recommendation for the use of structured handover tools at all transitions of patient care. Handovers are a critical area for patient safety.2-4 It is very positive that they are the focus of not only large governing bodies but also of grass-roots innovators.
1. RA Heller and L Hu, Making the weekend work: a local quality improvement project to establish and improve the quality of weekend handover. BMJ Open Quality
2. British Medical Association. Safe handover: safe patients. Guidance on clinical handover for clinicians and managers. London: BMA; August 2004. Accessed on 2/7/17 at: https://www.bma.org.uk/
3. Royal College of Surgeons, Safe Handover: Guidance from the working time directive working party, 2007 Accessed on 2/7/17 at: https://www.rcseng.ac.uk/standards-and-research/gsp/domain-3/3-4-continu...
4. NICE guidance 32. Use of structured handovers, March 2018