The introduction of an electronic system for handover notes has improved weekend discharge rates and reduced emergency calls at Barwon Health in Geelong.
In a paper published recently in the Medical Journal of Australia (MJA), Barwon Health's Boloor Rao, Gail Lowe and Andrew Hughes detail a project to test whether using an electronic handover system between week and weekend shifts can improve hospital efficiency and patient safety.
The new system was introduced in 2009 at the 406-bed Geelong Hospital, which has 69 beds allocated to five general medical units. As the authors write, during the week each unit is staffed by an intern, a medical registrar and a consultant physician. On the weekend, one registrar and one intern cover all new admissions and inpatients for all five units.
Handover between shifts was predominantly done verbally, so the hospital wanted to assess whether it could improve weekend shift handovers through a system where handover components could be entered electronically.
Barwon Health uses the BOSSnet clinical information system, which contains an electronic medical record and allows doctors to create customisable lists of patients and access pathology and imaging results.
It also uses CSC's i.PM patient administration system and a locally developed clinical information and data collection system for the intensive care unit called SLIC, into which the intensive care registrar enters the details of all medical emergency team (MET) calls.
“Useful handover information already in BOSSnet includes: patient name, date of birth, unique identifier, admission date, unit and specialist, working diagnosis and a free-text box for handover notes,” the authors write.
“Covering doctors print patient lists including the above information and recent test results at the start of a shift and access information electronically through the day as required.”
However, the team wanted to further improve handover, so it devised a new system it calls Blue BARRWUE. “Blue” stands for the colour of the patient's working diagnosis when it is updated in BOSSnet.
“B” stands for background to the working diagnosis, which includes a summary of the presenting history, social situation, other active problems, examination findings, investigation results, procedures and management plan.
“A” stands for alerts – when a doctor hands over a patient, he or she alerts the covering doctor to the patient's condition, such as “UNSTABLE”. The first “R” is for resuscitation status, and the second for requests that the doctor doing the handover is asking the covering doctor.
The “W” signifies to the handover doctors “who is to do what and when”. “U” is to remind doctors to do updates over the weekend, and “E” is for the executable discharge plan, which includes criteria for discharge, who is to see the patient and discharge them, along with information on the discharge prescription and a follow-up plan.
To prepare for the new system, reminders were put in place including automatic paging on Friday afternoon. A shared view of a combined list of inpatients belonging to all five general medical units was developed to be printed out by covering doctors at the beginning of their shift, and teams were encouraged to update their handovers daily as a shared responsibility between intern and registrar.
“This task took about 5-10 minutes at the end of each day,” the authors write. “Particular emphasis was placed on Friday handovers to ensure that plans were in place for the weekend for covering doctors to act on.
“Electronic reports were developed to monitor completion rates. New doctors received training in using the system … [and] nurses on the medical wards began printing and reading the handovers to help them plan for weekends.”
Before implementation of the new system, just under 50 per cent of patients had a handover note in BOSSnet. After the implementation, this had risen to 95 per cent. Before the implementation, eight percent of patients had an updated working diagnosis, versus 57 per cent after the implementation. The amount of content in the handover also increased.
The team saw a six per cent rise in the number of weekend discharges, and a two per cent reduction in the number of MET calls.
“The handover is quick and easy to enter into the system, it is flexible and highly visible, and junior doctors use it as an aide-mémoire on their daily rounds and when referring patients, writing discharge summaries and covering difficult shifts,” the authors write. “Junior doctors have said that covering without it is like 'flying blind'.”
Dr Hughes, director of the Department of General Medicine at Barwon Health and its service redesign unit, said many doctors were accessing the handover notes on mobile devices such as iPads and mobile phones.
“Standard BOSSnet works perfectly on iPads connected to the hospital's WiFi and many doctors use them to access lists and results whilst on their rounds,” Dr Hughes said. “The handover notes are accessible and updateable in exactly the way described in the article as this is the standard system.”
Ann Larkins, CIO and director of information services at Barwon Health, said the hospital was deploying BOSSnet via a mobile app, as well as a Citrix receiver using the Cisco VXI platform.
The mobile app is a “simplified BOSSnet” that is useful for looking up results one-handed on ward rounds, Dr Hughes said.
“BOSSnet mobile is simplified so it only has the patient lists with the diagnosis – blue if it has been updated – and linking to all the patients' results but without the other functionality of BOSSnet,” he said.
“I was having a discussion with my registrar last week for example about a patient with alcoholic liver disease and I mentioned we better check if he had had all the screening tests for other causes of liver disease.
“We were in the patient's room and were talking with the nurses and the intern, and the registrar said he had checked the patient's notes and he hadn't had the tests.
“I said he might have had them in a previous admission so we had better check but the registrar said straight back that 'no, he hasn't had any of these tests since 2003'. This was all from his iPhone without moving an inch while we were having a discussion.”
Dr Hughes said some doctors still preferred to print out a paper list that they carry with them and write on. They can check the BOSSNet mobile for the latest results as they do their rounds, sometimes using the iPad version, he said.
“Ultimately it adds up to a flexible system. Some junior doctors prefer the iPad version but many more commonly use a paper patient running list that they can scribble on.
“I still encourage them to routinely go through their list at the end of each day and update their handovers as a discipline and to be honest, doing the whole lot at once in this way is still probably easiest on a physical keyboard.”
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