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1. .  What are your top concerns regarding bedside shift report between the ED and med-surg units, and how would you improve on these?

2. Do you agree or disagree to incorporate eSBAR hand-off with the patient's EHR? Justify your answer.

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An effective standardized handoff reporting is part of the patient care through the transition of critical information and serves as a basis for the continuance of medical services. Furthermore, it is associated with increased patient safety and staff satisfaction and improvement in clinical performance (Uhm, et al., 2018)

While the following the objectives, metrics, process analysis, and implementation of the new workflow design addresses the loopholes in communication between ER nurses and Med-Surg nurses, detecting and preventing occurrence of errors along the workflow process will require an ongoing assessment and surveillance for further development.

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Article: Implementing a New EMR. How Should We Train the Staff?

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Article: Implementing a New EMR. How Should We Train the Staff?

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Background Information

Transitioning from an existing to a new Electronic Medical Record (EMR) while the surgical schedule of a busy perioperative department keeps running as usual can be daunting for nurses and other staff. While user training is part of the EMR implementation process, and crucial to ensure a smooth transition, its content might not be tailored to the role and responsibilities of the nurses involved. Feedback from perioperative nurses on the Virtual Live Training (VLT) provided by the EMR vendor, and its effectiveness to assist nurses documenting patient care on the new EMR, revealed that additional educational support was required. This project focused on the staff education initiative taken by designated unit EMR super-users to ensure Pre and Postoperative nurses' readiness to document patient care in the new EMR by Go Live day.

Objectives of Project

* Identify and meet nurses' learning needs related to the use of the new EMR after the VLT

* Ensure training delivery method is effective for all perioperative areas

* Ensure perioperative nurses' readiness to document patient care independently on the new EMR

* Ensure a smooth transition from existing to new EMR, while making sure patient care is not compromised

Process of Implementation

Developed EMR in-person training curriculum to support vendor's virtual live training. Created a training timeline based on goals. Prioritized super-users in-person training. Tailored in-person training sessions to the nurses' role, pre and postoperative nurses training was conducted separately. Established training schedules, location and staffing. Developed an EMR resource digital folder. Build a Smart Sheet to capture documentation/workflow issues and view solutions. Use patient case scenarios to assess nurses' competency documenting patient care from admission to discharge in new EMR.

Statement of Successful Practice

Increased nurses' satisfaction with to face-to-face training. Postoperative nurses reported increased satisfaction with in-person class content being tailored to postop care. Improved nurses' performance documenting most aspects of patient care in the new EMR. Improved understanding of new pre/postoperative workflows.

Implication for Advancing the Practice of Perianesthesia Nursing

Adjusting EMR training based on nurses' feedback, tailoring training content to nurses' role, and prioritizing super-user training, have proved to be effective training strategies to assist our perianesthesia nurses to ensure a successful EMR transition.

View full text

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Implementing a New EMR. How Should We Train the Staff?

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Transitioning from an existing to a new Electronic Medical Record (EMR) while the surgical schedule of a busy perioperative department keeps running as usual can be daunting for nurses and other staff. While user training is part of the EMR implementation process, and crucial to ensure a smooth transition, its content might not be tailored to the role and responsibilities of the nurses involved.

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Managing The ‘Go live’ With New Workflows

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Managing The ‘Go live’ With New Workflows

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To manage the “go-live” of this new workflow, there will be additional nurses available (superusers) as well as some IT members available to answer any questions or concerns mentioned by the nursing staff. There will be an online resource guide with videos tutorials and simulated EHR systems to practice with as well as printed resource guides posted in several locations throughout both units. Both guides will have visuals and common questions and answers posted as well as contact information if any concerns arise.

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Training Individuals On New Workflows and Processes

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Training Individuals On New Workflows and Processes

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Individuals will be trained on the new workflows and processes in a series of online and live in-person classes hosted by certified, experienced employees.  The in-person classes will include “mock” handoff reporting between nurses and the related outcomes.  Necessary adjustments will be made to parts of the training processes to help employees with different learning methods and/or arrange for employee input and modify training as needed.

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New workflows and processes should be tested by constructing a diagram or map for the new design to be implemented.  After this design is tested, it may be necessary to tweak changes until the desired handoff report is found. The needs of the healthcare organization will need to be consistently evaluated as well as the readiness of the team to implement the new changes. Workflows and processes may need to be tested and redesigned multiple times as the needs of the organization change in order to achieve the desired handoff that is beneficial.

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Process Mapping - The Best Way to Improve Processes

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An analysis of their workflow process and handoff process is crucial to understand how both operate in their current form, and this can be done through process mapping. Once all areas have been identified and evaluated, the next step will be for the team to address the issues found and collaborate on the refinement of the processes, which includes  removing the steps that have a negative impact on the processes and/or steps that have no negative or positive impact at all as well as the collaboration between all team members who will use the process in their daily operations to determine what high optimization of these processes resembles and what adjustments are needed to create that visual.

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The ED RN using the new SBAR tool instead of the transfer form within the EHR. The ED RN will then call a report to the med-surg nurse with the SBAR tool to ensure key safety points are not missed during the handoff process.

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Goal: Be less disruptive as possible to the current ER workflow via enhancing the EHR’s ability to bring information from multiple sources into one SBAR form that the ED RN must use to provide a full handoff report to the Med-Surg RN.

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Currently, when a non-critically ill patient enters the ER information is gathered from various sources and placed in the EHR.  When the patient is then admitted, the ER RN then fills out a transfer form that includes limited information.  The ER RN then may call the med-surg RN to give a handoff report, but this is not required. The med-surg RN must then go through the EHR to find out necessary important information. This process can be time consuming and cumbersome.

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Article: Reflecting On The Communication Process in Healthcare

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Article: Reflecting On The Communication Process in Healthcare

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The team working on this project will include the ER nurse manager, a group of 5 ER nurses, 5 medsurg nurses, at least 3 medsurg managers, 3 superusers, two nurse informaticists, IT manager, a nurse educator, and two people from administration.

ER nurse(s) test out new product and give feedback

ER Nurse Manager to share relevant information to staff regarding training

MS Nurse(s) test out new product and give feedback

MS nurse Managers share relevant information to staff regarding training

IT Leader to focus on the design, redesign, troubleshoot any issues along the way

Superuser(s) to test the first versions of new product and to train users

The project start date is October 1st , 2022. The projected project charter approval date is October 20th, 2022. The intended project completion date is November 13th, 2022.

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Benefits of Internal and External Customers

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Benefits of Internal and External Customers

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Internal: ER and Med-Surg Nurses

Handoff reports are quick, efficient, and safe.

Easier and quicker identification of important patient information

Allows for prompt intervention if patient's level of care needs transfer to more appropriate unit

External: Patients

Decreased boarding times in the ER and increases continuity of care (Aronson, et al., 2021)

Increased direct patient care (Aronson et al., 2022).

Increased patient satisfaction

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Metric #3: Compliance to the standardized format in delivering handoff reports from ER nurses. 

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Metric #3: Compliance to the standardized format in delivering handoff reports from ER nurses. 

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Goal: 100% compliance rate of ER nurses.

This will be measured by tracking the number of times in which the nurses make use of the standardized handoff format which is merged in the patient's EHR. This will be automatically computed once the ER nurses opens the window or tab for the standardized handoff report in the patient’s EHR.

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Metric #2: Improve accuracy of information between ER nurses and Medical-Surgical nurses. 

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Metric #2: Improve accuracy of information between ER nurses and Medical-Surgical nurses. 

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Goal: accurate and complete handoff reporting of patient’s care received in the ER department with 0% errors or missed items.

Percent error will be determined through a pop-up checklist that is provided to the receiving nurse or the Med-Surg while receiving the report. Missed reports are considered as errors.

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Metric #1: Standardized structure (eSBAR) and content for handoff reports that is incorporated in the patient’s electronic health record (EHR).

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Metric #1: Standardized structure (eSBAR) and content for handoff reports that is incorporated in the patient’s electronic health record (EHR).

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Goal: utilize a standardized format for a smoother flow of information between ER nurses and Med-Surg nurses with a rate of 100% improvement.

A survery and Likert scale will be used to measure the satisfaction rate from ER and Med Surg nurses in using the standardized format (eSBAR) for handoff reports that is integrated in a patient's EHR.

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The scope of this project will focus on the handoff process from the emergency room to medical surgical units.  This includes intake forms in the EHR, nurse to nurse reporting, and the policies  and workflows surrounding this process.  The first step would be to find out what staff should be included in the project and the final step would be evaluating metrics and seeing if the change has led to better results.

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Handoff report communicates vital information regarding the plan and health status of a patient to ensure a continuity of care throughout a patient’s hospital stay. Miscommunication between healthcare providers such as inaccurate documentation of patient care or experiencing limited availability of patient information in the EMR, can lead to breaches in patient safety and produce negative impacts on a patient’s health status as well as the hospital organization itself.

Examples of these impacts include

Inaccurately monitoring a patient’s health status over time improperly treating a patient's ailments and diseases

Sentinel events

Disruption the continuity of care a patient receives

Improper payments from CMS due to missing or inadequate documentation (Hailey, 2021)

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Additional Benefits from the creation and implementation of the standardized handoff communication tool include the tracking of outcomes from handoff reporting between the ER and the med-surg units such as:

Equipment-related issues

Transfers of unstable patients or patients not proper for transfer

Instances of isolation precautions not being communicated

Rapid responses within 12 hours of admission or unplanned ICU transfer within 12 hours of admission.

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Article: Positive Impacts of Electronic hand-off systems designs on Nurses’ communication effectiveness

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Article: Positive Impacts of Electronic hand-off systems designs on Nurses’ communication effectiveness

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Aim

Different designs of electronic hand-off systems might have different levels of effectiveness; this study validated the effectiveness of systems with an Identify, Situation, Background, Assessment and Recommendation (ISBAR) design to one without such a design.

Background

Adverse consequences in hospital commonly occur when there are breakdowns in the transmission of information between team members. To ensure information accuracy and consistency, some Taiwan hospitals implemented electronic hand-off systems. However, the effectiveness of such systems was not investigated.

Methods

A quasi-experiment was conducted to the nurses of two Taiwan case hospitals, one with ISBAR and the other with non-ISBAR design systems and 200 questionnaires were used to collect data.

Results

The respondent rate was 72%. Using system with ISBAR design, nurses can enhance their communication effectiveness and further increase their individual benefits at hand-off. Using a non-ISBAR hand-off system, communication effectiveness depends solely on the nurses' individual cognitive and expressive ability.

Conclusion

System with ISBAR design can ensure effective information transmission among nurses for care continuity and prevention of adverse events.

Implications for Nursing Management

Ensuring the design of electronic systems is adequate, nursing managers can save nurses' time and effort while using the system to perform their regular work effectively and gain competitive advantage.

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Positive Impacts of Electronic hand‐off systems designs on Nurses' communication effectiveness

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Different designs of electronic hand-off systems might have different levels of effectiveness; this study validated the effectiveness of systems with an Identify, Situation, Background, Assessment and Recommendation (ISBAR) design to one without such a design. Adverse consequences in hospital commonly occur when there are breakdowns in the transmission of information between team members.

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Similar studies done using this process have led to quicker movement of patients from ER to med-surg units, which in turn frees up the ER nurses for more critical patients and allows more timely administration of live-saving antibiotics and pain medications (Potts et al., 2018).

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Aronson, T. M., Oertle, S. E., & Piscotty Jr., R. J. (2021). Key characteristics of a successful EHR-supported e-handoff tool: A systematic review. Online Journal of Nursing Informatics, 25(1), 4–1.

McGrath, J. K., Elertson, K. M., & Morin, T. (2020). Increasing patient safety in hemodialysis units by improving handoff communication. Nephrology Nursing Journal, 47(5), 439–446. https://doi.org/10.37526/1526-744X.2020.47.5.439

Potts, L., Ryan, C., Diegel-Vacek, L. & Murchek, A. (2018). Improving patient flow from the emergency department utilizing a standardized electronic nursing handoff process. JONA: The Journal of Nursing Administration, 48 (9), 432-436. doi: 10.1097/NNA.0000000000000645

Sermersheim, E. R., Moon, M. C., Streelman, M., McCullum-Smith, D., Fromm, J., Yohannan, S., & Powell, R. (2020). Improving patient throughput with an electronic nursing handoff process in an academic medical center: A rapid improvement event approach. The Journal of Nursing Administration, 50(3), 174–181. https://doi-org.ju.idm.oclc.org/10.1097/NNA.0000000000000862

Uhm, J.Y., Lim, E.Y., & Hyeong, J. (2018). The impact of a standardized inter-department handover on nurse’s perceptions and performance in Republic of Korea. Journal of Nursing Management, 26(8), p. 933-944. https://doi.org/10.1111/jonm.12608

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The Result of Poor Handoff Communication

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The Result of Poor Handoff Communication

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Poor Hand-Off Communication Leads to Jennifer Nibarger's Death

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Research shows that the information for handoff reports between the ER and Med-Surg units is not standardized nor consistent. This leads to a huge impact on the safety and flow of patient care. Having a standardized report process can result in a focused reliable information being passed along and less chance of critical information being missed (Sermersheim et al., 2020).

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This project will focus on implementing an electronic SBAR (eSBAR) handoff report for ER nurses and med-surg nurses to utilize with the med-surg patients. The eSBAR that can be used will be the patient summary, an existing tool within the EHR system.

By providing a common language tool for communicating relevant patient information, staff can thoroughly communicate essential patient data, information, and knowledge to ensure the safe continued continuity of care and significantly decrease the breaches in patient safety during the transfer of care, and aid in reaching the goal of safe patient communication and improving handoff communication (McGrath et al., 2020).

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The primary focus of this project is to operationalize a standardized handoff communication format for the emergency department and medical-surgical units.

A workflow issue resolution is needed to produce a more effective handoff report during these patient transfers.  By having a standardized and effective handoff report that includes all necessary components, there is considerably improved patient care when the patient arrives at the Med-Surg unit.

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Introduction:  The Importance of HandOff

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Introduction:  The Importance of HandOff

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Handoff report is performed when the transferring nurse relays important information to the receiving nurse. It may include:

Reason for Admission

Relevant History

Plan of Care

IV access

Medications given

Test results, and more.

Currently in Lakeland Regional Hospital, there is not currently any form of handoff report technically required between the ER and Med-Surg units.

This can delay care, leaves room for errors, and is a patient safety risk.