Category Archives: IT-Shift handover

Shift handover research gets

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Just stumbled across the good news that £500K has been found to fund research in shift handover for healthcare in the UK. The City University’s Centre for HCI Design has been awarded £494,777 to be precise by the Engineering and Physical Sciences Research Council (the UK Government’s leading funding agency for research and training in engineering and the physical sciences):

“While there have been small-scale studies of clinical handover in specific settings, including our own study of a paediatric ward on the ACE project, there is a lack of basic research. We will address this shortcoming in the GHandI project [my note: GHandI = Generic Handover Investigation] with an extensive investigation of handover as it is only by achieving a clear understanding of the ‘work’ that handover accomplishes that we will be able to improve the practice. For example, there is evidence that handover contributes to patient safety by accomplishing work other than the immediate transfer of responsibility for care of the patient.

“It is within this context that the current proposal is situated, the overall aim of which is to conduct a detailed investigation of clinical handover and its contribution to patient safety by developing and evaluating a generic theoretical model of handover and deriving detailed recommendations and prototypes for innovative handover support technology.

“With the support of our collaborators, we plan to study handovers in ten clinical settings, ranging from ambulance ‘retrieval’ services to inter-specialty transfers to shift handovers in paediatric intensive care units.” Be interesting to know whether the WHO Collaborating Centre for Patient Safety Solutions (which recommends SBAR) is one of the collaborators?

There’s also the shift handover research already carried out in Canada to refer to: Transfer of Accountability: Transforming Shift Handover to Enhance Patient Safety, Kim Alvarado, Ruth Lee, Emily Christoffersen, Nancy Fram, Sheryl Boblin, Nancy Poole, Janie Lucas and Shirley Forsyth. (Healthcare Quarterly, 9(Sp) 2006: 75-79).

I guess they’ve also seen the US patient safety tool, the SBAR (Situation-Background-Assessment-Recommendation) technique which “provides a framework for communication between members of the health care team about a patient’s condition. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.”

And of course there is existing tried and tested shift handover solutions currently used in industry such as Lifetrack, “which was developed as part of a sponsored research program involving BP, Honeywell Control and the University of Cambridge. The project spent 2 years understanding the social, communication and information dimensions of shift hand-over and operations logging”. Anything from Cambridge has got to be worth a look too, I would have thought (and indeed I added a posting on Lifetrack, together with one on SBAR, to the Medicexchange Forum).

Shift handover research gets funding

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Just stumbled across the good news that £500K has been found to fund research in shift handover for healthcare in the UK. The City University’s Centre for HCI Design has been awarded £494,777 to be precise by the Engineering and Physical Sciences Research Council (the UK Government’s leading funding agency for research and training in engineering and the physical sciences):“While there have been small-scale studies of clinical handover in specific settings, including our own study of a paediatric ward on the ACE project, there is a lack of basic research. We will address this shortcoming in the GHandI project [my note: GHandI = Generic Handover Investigation] with an extensive investigation of handover as it is only by achieving a clear understanding of the ‘work’ that handover accomplishes that we will be able to improve the practice. For example, there is evidence that handover contributes to patient safety by accomplishing work other than the immediate transfer of responsibility for care of the patient.”It is within this context that the current proposal is situated, the overall aim of which is to conduct a detailed investigation of clinical handover and its contribution to patient safety by developing and evaluating a generic theoretical model of handover and deriving detailed recommendations and prototypes for innovative handover support technology.

“With the support of our collaborators, we plan to study handovers in ten clinical settings, ranging from ambulance ‘retrieval’ services to inter-specialty transfers to shift handovers in paediatric intensive care units.” Be interesting to know whether the WHO Collaborating Centre for Patient Safety Solutions (which recommends SBAR) is one of the collaborators?

There’s also the shift handover research already carried out in Canada to refer to: Transfer of Accountability: Transforming Shift Handover to Enhance Patient Safety, Kim Alvarado, Ruth Lee, Emily Christoffersen, Nancy Fram, Sheryl Boblin, Nancy Poole, Janie Lucas and Shirley Forsyth. (Healthcare Quarterly, 9(Sp) 2006: 75-79).I guess they’ve also seen the US patient safety tool, the SBAR (Situation-Background-Assessment-Recommendation) technique which “provides a framework for communication between members of the health care team about a patient’s condition. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.”

And of course there is existing tried and tested shift handover solutions currently used in industry such as Lifetrack, “which was developed as part of a sponsored research program involving BP, Honeywell Control and the University of Cambridge. The project spent 2 years understanding the social, communication and information dimensions of shift hand-over and operations logging”. Anything from Cambridge has got to be worth a look too, I would have thought (and indeed I added a posting on Lifetrack, together with one on SBAR, to the Medicexchange Forum).

Shift handover & WHO report

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Interested to read on Reuters the WHO report on safety which again underlines the importance of good ward communications. PDF of the ‘Communication During Patient Hand-Overs’ summary here too.

GENEVA (Reuters) – Errors in medical care affect 10 percent of patients worldwide, according to the United Nations health agency, which issued a checklist on Wednesday to help doctors and nurses avoid common mistakes.

The nine key points listed by the World Health Organisation (WHO) include double-checking similar-sounding medication names, ensuring patients are correctly identified, and improving hand hygiene to avoid preventable infections.

“Health care errors affect one in every 10 patients around the world,” WHO Director-General Margaret Chan said in a statement. “Implementing these solutions is a way to improve patient safety.”

The WHO urged health workers to improve communication and assure medication accuracy during transitions in patient care, carefully control concentrated electrolyte solutions, avoid misconnections in catheters and other tubing, use injecting devices only once, and ensure the correct procedure is performed at the right place on the body.

Liam Donaldson, chair of the WHO’s World Alliance for Patient Safety and Chief Medical Officer for Britain, said the checklist should help reduce “the unacceptably high number of medical injuries around the world.”

At any one time, some 1.4 million people worldwide suffer from hospital-acquired infections, according to WHO figures. One in every 136 patients in the United States becomes severely ill as a result of an infection caught in hospital.

“Wrong site procedures” on the body — including errors about the side, organ, implant or person to be operated upon — are infrequent but not rare, the agency said, citing communication breakdowns as the cause of many of these.

Unsafe medical injections, with reused and unsterilised equipment, are believed to occur most often in South Asia, the Middle East and the Western Pacific, a region including China, Japan, Vietnam and Australia.

In sub-Saharan Africa, as many as 18 percent of injections are given with reused syringes or unsterilised needles, increasing the risk of hepatitis and HIV, the WHO said.

Thanks again to Dr William Brody

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Thanks to the President of John Hopkins University in the US, Dr William Brody, I’ve updated my ideas on shift handover systems using wikis with an Medicexchange article based on his ECR presentation calling for a revolution in patient care for radiology. Looking for a possible pic I came across his 2005 RSNA lecture, with the choice phrase “People love innovation, but they dislike change.” I thought that made a lot of sense.

Shift handover process

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I’ve said from the start that I’ll take the development of a shift handover system as far as I could, but it looks like I’m running out of luck. The next week may be make or break. And to be sure such a development is hard work, and I’ve got quite enough on my little silver plate right now. Of course it would be great to make it happen, saving lives and making money, but it’s not in my hands anymore. But then I’ve approached this from the start with a ‘social complexity’ attitude, so that’s not really my problem.

Beware of switching onto auto-pilot

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Article in new British Computer Society journal on Brian Toft’s research (pdf, 74K) into the dangers of automatic behaviour. “Despite using verbal checks to ensure patient safety, healthcare staff make mistakes. One explanation for this is that they respond automatically to questioning without matching their actions to their words.” (Health Informatics Now, Vol 1, No.1, pdf 941K). Or to put it another way using research from the aircraft industry: “It is tempting for the pilot to regard a rapid dismissal of checklist items as indicative of his skill and familiarity with the aircraft, but, if checklists are dealt with in this automatic way, it is very easy for the pilot to see what he expects to see rather than what is there.”  Perhaps worth thinking about for shift handover design too?

Wikis, blogs and podcasts: a new generation of Web-based tools

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This discussion paper looks interesting; I believe Phil Candy at the NHS is thinking along similar lines from the posting on Rod Ward’s blog. Anyhow check it out if that appeals – Wikis, blogs and podcasts: a new generation of Web-based tools forvirtual collaborative clinical practice and education by Maged N Kamel Boulos, Inocencio Maramba and Steve Wheeler.

Abstract
Background: We have witnessed a rapid increase in the use of Web-based ‘collaborationware’ in recent years. These Web 2.0 applications, particularly wikis, blogs and podcasts, have been increasingly adopted by many online health-related professional and educational services. Because of their ease of use and rapidity of deployment, they offer the opportunity for powerful information sharing and ease of collaboration. Wikis are Web sites that can be edited by anyone who has access to them. The word ‘blog’ is a contraction of ‘Web Log’ – an online Web journal that can offer a resource rich multimedia environment. Podcasts are repositories of audio and video materials that can be “pushed” to subscribers, even without user intervention. These audio and video files can be downloaded to portable media players that can be taken anywhere, providing the potential for “anytime, anywhere” learning experiences (mobile learning).

Discussion:
Wikis, blogs and podcasts are all relatively easy to use, which partly accounts for their proliferation. The fact that there are many free and Open Source versions of these tools may also be responsible for their explosive growth. Thus it would be relatively easy to implement any or all within a Health Professions’ Educational Environment. Paradoxically, some of their disadvantages also relate to their openness and ease of use. With virtually anybody able to alter, edit or otherwise contribute to the collaborative Web pages, it can be problematic to gauge the reliability and accuracy of such resources. While arguably, the very process of collaboration leads to a Darwinian type ‘survival of the fittest’ content within a Web page, the veracity of these resources can be assured through careful monitoring, moderation, and operation of the collaborationware in a closed and secure digital environment. Empirical research is still needed to build our pedagogic evidence base about the different aspects of these tools in the context of medical/health education.

Summary and conclusion:
If effectively deployed, wikis, blogs and podcasts could offer a way to enhance students’, clinicians’ and patients’ learning experiences, and deepen levels of learners’ engagement and collaboration within digital learning environments. Therefore, research should be conducted to determine the best ways to integrate these tools into existing e-Learning programmes for students, health professionals and patients, taking into account the different, but also overlapping, needs of these three audience classes and the opportunities of virtual collaboration between them. Of particular importance is research into novel integrative applications, to serve as the “glue” to bind the different forms of Web-based collaborationware synergistically in order to provide a coherent wholesome learning experience.

Back off, man. I’m a scientist.

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More thoughts on shift handover from Tom Campion in the US who looks like he’s been real busy:

..For the first part of the summer I took a class. Since then I’ve been working on research. My research involves the handoff process that physicians go through at the end of their shifts. The literature about handoffs says that processes are not very standardized in hospitals, health systems, or on a national level. Vanderbilt University Hospital has done a pretty good job for the past eight years having a tool in one of the primary information systems where physicians (and sometimes nurse practitioners) maintain free text descriptions of a “case summary” and things “to check” for each patient in their care. This data is then printed out and used as a document of reference for when (and, sometimes, if) an outgoing physician discusses patient matters with an incoming physician. Physicians call this part of the process “sign-out,” and the point of it is to prevent important information from falling through the cracks. Although the tool used at Vandy does a good job, it can be improved so that less information falls through the cracks.

So far I’ve created a web-based version of the tool to replace the old version inside of the primary information system. The new tool resembles the old tool in appearance and functionality. The advantage of a web-based tool over the legacy application is I can add functionality easily and users can access the tool in more ways than one in the future. The new sign-out tool can also share data more freely with other web-based tools in production. Of particular interest in sharing are the “to check” items that physicians record in sign-out.

Because the current “to check” section is a blob of text, the multiple things to actually check are not discrete. If they are made discrete, then from a data perspective they can be treated as separate items, and you can do a whole lot with these items. At this early stage in the project, we’re thinking that most to check items are arranged in a event-time-action manner; that is, “check [some event] at [a certain time] and then [take an appropriate action].” That’s kind of how many of the current to check items are recorded at present in free text. I’m looking to develop a structured way for users to enter this data. This way, to check items will be more explicitly defined, which is a boon for all clinicians. Additionally, a discrete element like time can be used to chronologically sort to check items. To check items recorded at sign-out can also be represented in other information systems, like an electronic whiteboard. The event-time-action orientation of the to check item is pretty much a guess at this point, and things could change, especially for the needs of a specific unit in the hospital.

For my master’s I’m going to attempt to establish that structured data capture of certain to check items is better than the free text method currently in use. I will then create and implement the software enhancements to the web-based sign-out tool to perform structured entry of to check items. I’ll probably pilot this on a given unit to see if people use the structured to checks, and assess if they use structured to check (man, I hope so) and what made them use structured to check (i.e. in what ways does it help them perform the task of sign-out better). and then try it on other units and see what level of customization has to be done for physicians in other specialties to use structured to check in the new tool.

Initially my advisor and I carved out a master’s project where we would automatically create structured to check items from current patient data to try to improve pediatric antbiotic dosing, but a senior faculty member put the brakes on that because the project was too ambitious in scope. For a project about sign-out, the focus has to be on sign-out, not antibiotic management or reminders, he said. And he was right. The reminders project is a huge thing and I might focus on that later. We’ll see. Right now I want to complete my master’s thesis by next August and then move on to dissertation stuff.

I’ve learned to program this summer, which has been pretty cool. The two classes using C++ that I took over the past academic year were very helpful, but this summer is when I really learned to program because I was involved in a project every day. It’s basically the same thing they tell you in class. The language I’ve been using is PHP. I like it. It’s not as tedious as C++, but learning about memory management and objects in C++ really helped prepare me for this. Looking back at the start of the summer when I began to learn PHP compared to now being comfortable with the language, there are, of course, a million things I would have wanted to do differently. I’m learning. It’s great.

The sign-out web application has been implemented and physicians now use it housewide. It’s pretty cool to look at log files and see record of people using something I created. Having created the tool means I also have to fix things that break, and I spent a large part of Friday night and Sunday making sure users could print. The process of understanding a problem, writing code, testing it, implementing it, and maintaining it has been very interesting. Tedious at times, but a great experience.

On the topic of learning, graduate school year two started about three weeks ago. The beginning of ’06-’07 is a lot easier than last year. I understand better what’s expected of me in computer science/quantitative coursework, and I feel like I have a better feel for my interest in the field of biomedical informatics and my role as a graduate student. Last year was just complete and utter shock. I still go through swings of “what the hell am I doing with my life?”, and they’ll no doubt continue, but overall I’m much more calm and focused than a year ago. At least this week.

This post has been rambling. The summer has been fun–at times too fun. My funds have been depleted by the confluence of warm weather and bar tabs. I probably could have gotten more work done and saved more money but oh well. I’m in a good place and I think I’ll get more done this fall. Class this fall will be tough. Algorithms is going to be super hard. The other two classes should be manageable but challenging. I need to stay on top of research stuff, determine my hypotheses, push out features to users, and take some measurements.

Back off, man. I’m a scientist.