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Bedside Shift Report Ensures Quality Handoff

Monday October 8, 2007
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Fumbling a baton handoff during a track relay can cost you the race. But botching a handoff during an on-the-job change of shift can have much more serious consequences.

To avoid "dropping the baton" during one of the most critical patient care intervals, healthcare organizations are moving toward standardized change-of-shift procedures, especially bedside shift reporting, that involve off-going nurses, oncoming nurses, and patients. Although the details of bedside shift reporting vary from facility to facility, a successful implementation provides a real-time exchange of information that increases patient safety, improves quality of care, increases accountability, and strengthens teamwork.

In 2006, Catholic Healthcare West (CHW) in partnership with the Studer Group, an outcomes-based healthcare consulting firm, began implementing bedside shift report as part of the nursing bundle — a group of practices (including hourly rounding, bedside shift report, individualized patient care, and discharge phone calls) designed to improve quality, safety, and service.

"Ask me how a life was saved with bedside shift report," Sandy Rush, BSN, MA, FACHE, and patient satisfaction specialist for CHW, likes to say. She then will recount an incident that took place at Chandler Regional Medical Center, a CHW member facility in Chandler, Ariz.

A post-operative patient on patient-controlled analgesia (using morphine) was given anti-nausea medication at 7:10 p.m., just before change of shift. When two nurses entered her room at 7:20 p.m. for the bedside shift report, her respiration rate had dropped precipitously to six. One nurse stayed in the room, and the other obtained and administered naloxone. "The patient woke up, was stable, and it was a great, quality outcome," Rush says. But had the nurses been doing shift report the traditional way — away from the patient — the result could have been tragic.

Real-life anecdotes underscore the critical nature of the shift change and the stakes involved with patient safety. "A picture's worth a thousand words," says Kaye Prost, RN, BSN, director of medical-surgical services at Chandler. "You can look at all the profiles you want to describe skin integrity or IV sites or mental status, but until you go in and address that patient in person, you really don't have a clear, real-time picture of what's going on."

National patient safety goals

Because communication errors account for more than 70% of sentinel events, Goal 2 of the Joint Commission's National Patient Safety Goals for 2008 requires hospitals to "improve the effectiveness of communication among caregivers." Requirement 2E further delineates the need for hospitals to "implement a standardized approach to 'hand off' communications, including an opportunity to ask and respond to questions."

Although the Joint Commission does not require shift report to take place at the patient's bedside, the practice does satisfy the requirement, says Carol Ptasinski, RN, MSN, MBA, senior associate director for the Joint Commission's standard interpretation group. "As long as the communication is there, the exchanging of information and the ability to ask and get your questions responded to in a timely manner — that's what we're looking for," she says. Involving the patient at the bedside also addresses the Joint Commission's Goal 13 to "Encourage the patient's active involvement in their own care as a patient safety strategy."

Bedside shift report

Change of shift at the CHW hospitals starts before the oncoming shift reports. The off-going charge nurse sets up assignments so the new team members know who their patients are as soon as they come in. At change of shift, the charge nurses and managers have a shift huddle, at which necessary introductions are made and pertinent information about the day is reported, such as "The ER is backed up. Expect plenty of admits today."

Once at the bedside, the off-going nurse introduces the oncoming nurse to the patient in a process dubbed "managing up." This introduction eases patient anxiety by highlighting the oncoming nurse's qualifications. "Michael has worked with us for more than 12 years and every time I follow him, patients tell me what a good nurse he is," an off-going nurse might tell a patient. Even if the two nurses don't know each other, Rush says, oncoming nurses' number of years' experience or other attributes may be introduced into dialogue. New graduate nurses may be praised for their most up-to-date knowledge.

Information exchange generally is accomplished in a modified SBAR format: situation, background, assessment, and recommendation. CHW adds a "T" on the end of the acronym for "thanks" as a way to remind staff to thank patients for the opportunity to work with them.

"This [bedside report] gets the nurses in and out and doing their jobs in a more effective timeframe," Prost says. "This helped reduce our incidental overtime."

Knowledge exchange

Before Kaiser Permanente implemented its highly lauded nurse knowledge exchange (NKE) in 2004, at least one nurse there wrote notes for change of shift on a napkin, while patients talked of the "ghost towns" on units while nurses exchanged information while huddled in a conference room.

But as the network has rolled out its standardized NKE across two-thirds of its member facilities with more than 9,000 nurses using the system, workflow has been streamlined and patient safety, satisfaction, and quality of care have improved. "I feel like I'm at the Hilton," one patient said, according to Lisa Schilling, RN, MPH, Kaiser's senior director of healthcare performance improvement.

The Institute for Healthcare Improvement (IHI) has identified NKE as one of the best practices for handoff procedures to improve patient outcomes, Schilling says.

Chris McCarthy, MPH, MBA, director of the Innovation Learning Network for Kaiser and part of the team that developed the new system, says that according to the original pilot metrics, not only did nurse and patient satisfaction improve, but the interval between when the nurses came on shift and first saw their patients also was reduced.

"The time went from approximately 30 to 60 minutes, depending on the unit, all the way down to 11 minutes," McCarthy says. "We shaved off between 20 and 40 minutes, which, in terms of safety, is incredible. Our patients are not being left alone for a long period of time anymore."

Bedside rounds are the cornerstone of NKE. By handling report at the bedside, patients are engaged as active members of the change-of-shift team.

Shift preparation

Off-going charge nurses at Kaiser make the assignments for oncoming nurses; this allows the oncoming shift to begin its work most efficiently.

Nurses use a structured report (typically a modified SBAR dubbed ISBAR, which starts with an introduction) and a shift change data template to convey information to the oncoming nurse. "That is an agreed upon set of data elements that nurses share across shifts," McCarthy says.

Kaiser nurses discuss and document patient goals on a care board in patients' rooms. Goals are written in the patients' words, not the nurse's words. For example, instead of writing "ambulate q4 hrs," nurses might write "walk down the hall after breakfast and lunch."

Although it is a standardized method of communication, NKE leaves room for innovation and adaptation at local levels. At Kaiser's Woodland Hills Medical Center in Woodland Hills, Calif., many units record information for oncoming nurses using the voice care system, says Aileen Oh, RN, MSN, a project manager at Woodland. But with the NKE shift report tools, the voice recordings have become more organized and effective, she says.

After listening to patient summaries, oncoming nurses do bedside shift reports with off-going nurses. Felicitas Amisola-Pacis, RN, a neurotelemetry staff nurse, likes the addition of bedside rounds at change of shift. "You get to see if there's any change from when the report was recorded," she says. "You go in there and reassess the patient with her [the off-going nurse.]" As an added benefit, patients seem less anxious when the change of personnel appears seamless.

The 4Ps

The face-to-face contact between shifts during bedside shift report "improves the intershift relationships that are sometimes a bit rocky," says Ruth Hansten, RN, PhD, MBA, FACHE. As principal consultant of the Port Ludlow, Wash.-based firm Hansten Healthcare PLLC for the last 18 years, she has worked with more than 150 hospitals across the country, many of them on standardizing their change-of-shift practices.

Her method emphasizes the 4Ps (purpose, picture, plan, and part) for exchanging information: "Which is the purpose — why is this patient here? What is he looking for? Picture is the picture of success. What results is he looking for short-term and long-term? The plan — what's the plan? And what part does each shift play?" she asks.

Poor information exchange at shift change used to be one of the biggest complaints among the nurses at Harrison Medical Center in Bremerton, Wash. Just 30 days after the 4Ps were rolled out as a way to standardize information exchange in October 2006, overall satisfaction with shifts reports went from 20% to 88%, and nurses' perception of how well-organized the turnover of patients was went from 30% to 80%, says Megan Erickson, RN, oncology clinical educator at Harrison, one of the nurses who helped introduce the new procedure. Only the ICU does change of shift bedside, but the plan is to eventually have everyone do report bedside, Erickson says.

Many nurses are realizing they have been incorporating many of the 4Ps into their reports already. "They could edit their reports down if they just stuck to the basic 4Ps," Erickson says. Although changing styles is difficult, nurses are realizing that by revising their style to the standardized 4Ps, it tightens their reporting, leaves the oncoming nurse well prepared, and speeds up shift change.

As they bring the method to other units, they are trying to get buy-in from staff by emphasizing that time saving. "If we can help motivate them by telling them how much time it's going to save [and that it will still give] a hand-off of clear, concise information, that's what's going to sell this whole thing," says Julie Gardner, RN, PCCN, patient care supervisor in the progressive care unit.

Ease the transition

Standardizing change of shift and adopting new, efficient methods requires planning, encouragement, and lots of practice. "Education for the staff is most important," says CHW's Rush. "Not only the how, but the why. Connect rationale with what they are doing."

Introduce any new change-of-shift process slowly, tweaking it along the way, advises Kaiser's McCarthy. "If you're trying to introduce a change into your system that you want to spread system-wide, I recommend starting with a high-performing unit — a unit that has few problems with people who like to try new things. Start small and let them build on the innovation."

Ann Federwisch is a freelance writer.