Bring on the weekend - Improving the quality of junior doctor weekend handover

Abstract

While it is widely recognised that communication and handover are a fundamental component in providing safe clinical care for hospital patients (1,2.3). The Royal College of Physicians found that the majority of hospital doctors are dissatisfied with the standard of their handovers (4). These findings were mirrored by the junior staff at the Royal United Hospital, who felt that the weekend handover was inadequate, and detrimental to patient safety.A group of eight junior doctors at the Royal United Hospital, Bath utilised The Model For Improvement to systematically analyse and improve various aspects of the weekend handover system. Handover sheets from a subset of wards were assessed to observe direct effects of staged interventions over a nine month period, allowing small-scale testing prior to widespread implementation of a standardised intranet-based weekend handover. The effects of interventions were evaluated using a predesigned scoring system and data was collected continuously throughout the project.Over a nine month period the quality of handovers improved significantly from 76% to 93% (p <0.01): a success which was supported by a 100% improvement in formal feedback collected from hospital doctors and highlighted by the desire of senior staff and directors to implement the system throughout the trust. Using The Model For Improvement a group of junior doctors were able to introduce and develop a standardised weekend handover system that met their requirements. A structured, efficient and auditable system has been successfully produced which improves the quality and safety of patient care. ProblemWeekend handover of ward based patients at the Royal United Hospital (RUH), Bath, lacked structure and organisation. Under the original system it was the role of the junior doctors working on each ward to generate a list of jobs to be completed over the course of the weekend -ranging from routine blood tests to patient reviews. These lists would be left in the medical or surgical admissions unit on a Friday evening, ready for the doctor covering the wards to collect on Saturday morning. There was neither a standardised form to be completed or guidance on what details to provide, nor was there any backup or record of the jobs to be completed. As a result handovers varied significantly in format, detail, appropriateness and ultimately safety.Every weekend junior doctors working on ward cover were met with the same problems: lack of patient identifiers, insufficient detail to allow appropriate prioritisation, illegible handwriting, poor description of the job to be executed, inadequate guidance on how to act upon certain findings, incorrect location of the patient and excessive pieces of paper to carry (Fig. 4). As a consequence, doctors were finding that they had insufficient time to review all their patients and complete all their jobs. Many critical jobs were missed causing the doctors a great deal of stress and putting patients' safety at risk.

Improving Weekend Out Of hours Surgical Handover (WOOSH)

“…All of the studies have shown that the format of the intervention whether it is a hospital database, electronic system, sticker or weekend proforma all improve the handover on a weekend and ultimately patient safety. 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 One study that used an electronic system reported up to 2 months before implementation of the new handover system could occur 6 , with other studies failing to comment how electronic systems affected the implementation of a new handover process. 5 , 8 , 9 .…”

“…They felt more empowered as they felt able to ask a diagnosis and further management plan for a patient, without the apprehension of asking a question that they felt they should have known. This ultimately improved the quality of medical information available, a factor widely reported 4 , 5 , 10 …”

“…However, they rely upon technology being readily available and training users to utilise the programme to their best ability. 5 , 6 , 8 , 9 Moreover, there are usually costs associated with purchasing and ongoing product licensing. In comparison, paper handovers placed in patient's notes incur negligible cost, are accessible, easy to use and require no training.…”

Improving surgical weekend handover

“…Concerns about the safety and efficacy of in-hospital weekend handover are long-standing and have been addressed by junior staff at other hospitals in other quality improvement projects ( 6 , 7 , 8 , 9 , 10 , 11 , 12 ). Systems that are entirely paper based have been identified as disorganised, lacking in information and often illegible ( 6 , 7 , 9 ). Electronic systems on the other hand, with information available to the weekend team on a shared drive on any hospital computer, have been shown to improve handover and are crucially easier to audit ( 9 , 10 , 11 ).…”

“…Systems that are entirely paper based have been identified as disorganised, lacking in information and often illegible ( 6 , 7 , 9 ). Electronic systems on the other hand, with information available to the weekend team on a shared drive on any hospital computer, have been shown to improve handover and are crucially easier to audit ( 9 , 10 , 11 ). It has been noted, however, that electronic handover systems may be difficult to implement unless commercial software is purchased and installed ( 11 ).…”