#1Government of Western Australia Department of Health Handover in Western Australia Professor Gary Geelhoed WA Chief Medical Officer Delivering a Healthy WA#2What's the situation? Poor handover communication and documentation significantly contributes to adverse events and even patient deaths The WA Clinical Handover Policy (the policy) mandates the implementation of key principles and a prescribed structure for all handovers initiated within WA Health Clinical Handover services iSOBAR ACSQHC Delivering a Healthy WA#3Background: What's it all about? ▪ Australian Commission on Safety and Quality in Health care Research completed Australia wide showed varied processes for handover affecting the safety of patients. ■ National consensus statement RRCD ■ WA roll out of standard process for giving safe handover - iSoBAR Delivering a Healthy WA Clinical Handover ACSQHC#4Safe Handover: Safe Patients, 2006 Junior Doctors Committee Safe handover: safe patients Guidance on clinical handover for clinicians and managers AMA SAFE HANDOVER: SAFE PATIENTS GUIDANCE ON CLINICAL HANDOVER FOR CLINICIANS AND MANAGERS C NHS Modernisation Agency NHS National Patient Safety Agency BMA Delivering a Healthy WA#5Why now? ■ Increasing complexity ■ Increased handovers ■ Examples of poor communication Blue spells Runover Delivering a Healthy WA Clinical Handover ACSQHC#6Protect the patients ■ Effective handover is vital in protecting patient and client safety. Evidence indicates that ineffective handover can lead to: incorrect treatment delays in diagnosis and treatment adverse events increased length of stay increase in expenditure unnecessary tests, treatments and communications. patient complaints malpractice claims. ■ Standardisation of handover, as part of a comprehensive, system wide strategy will aid effective, concise and inclusive communication in all clinical situations and contribute to improved patient care Delivering a Healthy WA#7Verbal & Telephone handover ■ Have the information ready. Know what you are going to say! ■ : Identify yourself/the patient S: Why are you calling, briefly state the reason/problem. How severe is it? State the admission date and diagnosis O: What are the current observations? Any IV lines/drains ■ B: Information related to the patient. Current Meds, allergies IV fluids, test results (date and time done-comparison to previous results) Resuscitation status. Relevant social information ■ A: What is your assessment? Given the situation, what needs to happen? What are you wanting? Review, advice, orders or transfer? What is the level of urgency? What have you done so far? What is the plan? ■ R & R What has been recommended? Clarify and check the for shared understanding. Who is responsible for what and by when Delivering a Healthy WA Remember to document#8What next? ■ Role out of CH policy - Sept 2011- May 2012 ■ OPH Policy - Oct 2011 Review of patient related handover documentation in all clinical areas. Sept-Dec 2011 Implementation of Escalation stickers for patient notes - Order Clinical, Allied Health and Medical staff to work together on ward based handovers/huddles Oct-Dec 2011 ■ New data system - iSoBAR handover sheet development and trial by Ward 4. Oct 2011- Jan 2012 ■ Roll out of data system education to clinical/provider inc: JMO & CNM after hours groups. Jan-March 2012 ■ Implementation of bedside handover -face to face in all areas- May 2012 May-June 2012 Clinical Handover processes fully operational Audit processes 3 month intervals Delivering a Healthy WA#9What difference will it make? Increase accountability and responsibility of individuals and teams ■ Increase the quality of the handover of information ■ Increase patient safety - reduce adverse events and Clinical incident forms. ■ Improve correct clinical coding - ABF - better funding for Service episode ■ Keep our patients safe! Delivering a Healthy WA#10How are we doing? In 2011/12: ■ 83 patients sustained significant or severe harm as a result of staff miscommunication of clinical information* ■ an additional 728 patients sustained moderate harm* * Based on all CIMS and SAC 1 reports submitted to the Patient Safety Surveillance Unit for the period 1 July 2011 and 30 June 2012 Delivering a Healthy WA#11SAC 1 Data: Clinical Incidents with Communication as a Contributory Factor During July 2011 and June 2012, 76 of 123 (62%) SAC 1 clinical incident investigation reports submitted identified communication as a contributory factor. ◉ ◉ ■ ■ ■ SAC 1 Incidents categories where communication was identified included: The suicide of a patient in an inpatient unit Maternal death or serious morbidity associated with labour or delivery Retained instruments or other material after surgery requiring reoperation or further surgical procedure Haemolytic blood transfusion reaction resulting from ABO incompatibility Procedures involving the wrong patient or body part The absconding of a mental health patient Delay in recognising / responding to clinical deterioration Fetal complications Misdiagnosis and subsequent mismanagement Patient absconding with adverse outcome Unexpected death of a mental health patient Other incidents resulting in serious harm or death of a patient. Sixteen of the 76 reports referred to handover three investigation reports contained the term ISOBAR Delivering a Healthy WA#12WA Clinical Handover Policy ■Involve patient where. practicable ■ Standardised format (iSoBAR) ■ Senior clinician led ■ Include all appropriate staff ■ Document patients of concern Government of Western Australia Department of Health WA Health Clinical Handover Policy 2012 Delivering a Healthy WA Delivering a Healthy WA#13Don't panic ■ Change the culture ■ Not all patients need handover ■ Clinical care must always come first Document Delivering a Healthy WA#14Pea Code 109C40 NFORMATION WACHS GS TMR 550 TELEPHONE COMMUNICATION RECORD aw WA Health Handover Resource Portal http://intranet.health.wa.gov.au/osgh/handover/ SURICAME HOSPITAL CLINICAL HANDOVER TOOL GIVEN NAMES ADMISSION NOTIFICATION WARD ADDRESS Patient Name: Escalation to Medical Review Nurse refering Physiotherapy Department RPH • Referral request received from: DRAFT AFTER HOURS TREATMENT REQUEST FORM Patient Identity(Attach patient sticker): LIME chart developed in WACHS- Great Southern Region Government of Western Australia Department of Health WACHE-Groat Souther Telephone Communication Record Clinician Racelving Hospital Owen Nah ARTES Patient Location: Time of Call Private Referred to: Workers Comp . Respiratory R Date/Time contacted. URN: Reason review requested: Clinical deterioration Patient meeting criteria for escalation Post procedure . Medical Team: 10 S Womed about Patient Situation (Diagnosis and Problem for treatment): Other (specify): BP RR PR Temp: O Cast hour)) GCS BSL 0 Sp02: within normal limits . Observations: Location Pain score: B Nursing actions taken until escala Assessment A Agreed actions until review: R Signature 10 Latest blood results Hh Relevant History: iSOBAR 00 gong quay goog Date of Call Patient Type: Public Admitting Doctor Information received from (Name & Designation Admitting Diagnosis ETA to Ward: Admission Pre-Admission Observation Assessment Findings Relevant History: Osbome Park Hospital Medical Emergency Team ISOBAR Dale Time MT called (MET) Report aerity Person Activating MET Name Designgton Situation Reason for MET call Background Medical history of note Treatment Plan Admission via ED Bed Number Name Direct Admission Obs #observations meet M Admitting Dr. No Observations at time of call Respirations Dogen Saturation Blood Pressure Temperature Consciousness AVPU Vertus LOCS Moin 76 GOS Tot 15 CCS Verbal Action GCS Motor Consultant informed fr tRESTORAT CPR started FE Dutcome and Medical Plan CPR Provide First Defibrillation shock No shock advised 加 bovenous access a 1 intubacion st intuated by 35 Cer CONSCIOUSNESS Vice Personal to Pab deve CLAS COW COM EYES VERBAL -nano 2-10p 3- -sportoully 14 4tonsen 1-mone 2-en 3-aboon wit -- oman SCOREOC MOTOR MET Attending Medical Officer MET Nuse Documenting Apr 2012 Delivering a MR(OPH) 000-MEDICAL EMERGENCY TEAM A simple, step by step handover process that provides a sequential approach to giving and receiving information Armadale Health Service is introducing iSOBAR into all clinical areas during; NOVEMBER 2011 Clinical Champions in your area: Project details- Performance Evaluation Unit ext 2543 or 2526 Delivering a Healthy WA Good communication is at the heart of an effective clinical handover. Standardising the handover process is a simple and effective way to ensure good continuity of patient care. Inadequate handover can lead to adverse events such as; Delays in treatment Patient complaints Litigation Sentinel events BENTLEY HEALTH SERVICE NURSING TRANSFER LETTER NTIFY. DATE: SERRAINGWARD asion Date: ission Diagnosies nstening Nurse Namo Consulent EXT OF RINCONTACT PERSON lamt: Contact Phone Numbers Moled of Tafer: Yes No SITUATION: REASON FORTRANSFER: OBSERVATIONS: Most recent vitales Reag. S302 l@ Handover is i Identify Frequency of BGL monitoring defined as: Introduce yourself and your patient. "... the transfer of professional responsibility and accountability for A TIME ard ETA Problem Date: Phone Number Repens Transport Mode ABO Wazz Otsevation Chart Wegrt Pano si Medical History Favan my Test Results Medications Exmo investigde Management Medication Croers DURSORIAS C2 Flo R Grange Parameters Report Back to Cancun YES NO Tec BACKGROUND: MEDICAL R Paname situation/status Diagnoses and current clinical status. PSYCHOSOCIAL CULTURA Signature Designation. observation Most recent vital signs and clinical assessment some or all aspects of care for a patient, or group of patients, to B background anther person or professional group Pertinent information relevant to the patient-history, meds, results, allergies, risks-falls/ mobility/DVT/skin integrity. Micro alert/ aggression / special needs. on a temporary or professional basis" A agree to a plan/ actions (Australian Medical What is the plan? What needs to happen? Association, 2007) read back / R ready for Clarify and check for shared understanding. Who is responsible for what and by when? discharge Government of Westem Australia Department of Health ISOBAR ALLERGIES: MICRO ALERTS CURRENT MEDICATION: Note: See copy of medication chan and or Doctors discion Matisations son with patie CURRENT NURSING CARE: Yes No Noto, and copy with pation adresingapore Import Note: Send copy with patient & patomy Suppies Location: yes Ne Vites No Yes No PICC pressing Coutput Fluide in progres Date Insened: Drainiest Yo: No CachetariosON. BYEN NO Don MR 194.01 BIT FOR BLACK, PS Kayal Blue Cons The Citat Pe Su