Reduced emergency calls and improved weekend discharge after introduction of a new electronic handover system

Although it is widely accepted that good handover is important for patient safety, there is only limited evidence that improved handover can lead to reduced patient risk.1,2

Written handover transmits information more reliably than informal communication, especially in conjunction with a verbal component.3 Before this initiative, written weekend handover in general medicine at Barwon Health was variable in content and non-standardised, and information was located in a variety of places. Such non-standardised handovers usually only comprised clinical summaries. We felt this was both a risk to our patients and inefficient for the organisation. It was difficult to ensure that key clinical messages were transmitted across multiple shifts of covering doctors. There was constant pressure for patients to be discharged on weekends, and this was difficult to organise unless instructions could be conveyed to the doctors covering the weekend shifts.

We sought to improve our doctor-to-doctor weekend shift handovers through a system where handover components could be entered electronically. We were aware of other systems such as SBAR (situation–background–assessment–recommendation), ISBAR (identify–situation–background–assessment–request) and ISoBAR (identify–situation–observations–background–agreed plan–read back), but felt these were better for direct person-to-person communication of time-critical information requiring immediate action or escalation.4-6 We required a system of communicating written information to multiple staff members, for actioning in the future (over multiple shifts) in a non-urgent and ongoing manner. None of these existing communication systems contained all of the components we required,4,5,7,8 so we set out to develop our own.

Barwon Health is the largest regional health care provider in Victoria, caring for a catchment of about 500 000 people. Its acute site is the Geelong Hospital, which comprises 406 beds, including 69 beds allocated to five general medical units. During the week, each unit is staffed by an intern, a medical registrar and a consultant physician, who participate in a roster to receive all general medical patient admissions and cover each other on weekends. On the weekend, one registrar and one intern cover all new admissions and inpatients for all five units. The average number of general medical patients admitted per day is 11.

Barwon Health is committed to patient safety. A medical emergency team (MET) system was introduced in 2003 to identify patients with a deteriorating condition using standard criteria, and to prevent adverse events.9-11 Since 2007, the MET call rate has been stabilising at about 60 calls per 1000 admissions across Barwon Health, which is consistent with the rate of emergency calls expected in a mature established system,12-15 although the number of MET calls in general medicine had been increasing up to the time of this study. The intensive care registrar enters the details of all MET calls into SLIC, a locally developed comprehensive clinical information and data collection system for the intensive care unit.

Barwon Health uses the BOSSnet clinical information system (Core Medical Solutions). This allows doctors to create customisable lists of their patients, provides access to pathology and imaging results, and contains an electronic medical record comprising scanned documents from previous admissions, outpatient notes and correspondence.

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.

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.

This study had two major aims: first, to measure the frequency and content of written electronic handover in BOSSnet on Friday evenings before and after implementation of the new handover system for general medical inpatients; and second, to measure the effect of the new handover system on patient safety and hospital efficiency over weekends.

There were 2034 general medical inpatients in the 12 months before implementation who met our audit inclusion criteria, and 1731 in the 12 months after implementation.

Our brainstorming session led to a standardised but flexible format for written handover that was practical and easy to use and resulted in immediate and sustained uptake. Involving clinicians in the development of handover systems has been reported to be useful and certainly allowed us to identify components that we otherwise would have missed.16 As a result, the components of the handover have been remarkably stable — we have not identified any new components that we need to include nor found that any of the existing ones are not relevant — since the implementation of the Blue BARRWUE system.

The presence of handover notes in the clinical handover system now approaches 100%, and content has improved. Recording of the individual components has not been universal, but the system is designed to be flexible and we do not expect all handovers to include all components on any weekend. The proportion of handover notes with resuscitation status present has been the lowest, but it must be remembered that this information cannot be added at the time of the handover unless it has already been discussed with the patient. We do find that resuscitation status is recorded for patients for whom it is most relevant.

Weekend discharges have increased since implementation. Weekend MET calls fell in the 12 months after implementation in general medicine but not in the rest of the hospital (by chi-squared analysis). Statistical process control analysis of MET calls was made difficult by the fact that the baseline had been steadily and progressively increasing up to the point of our intervention. Thus, realistically, only about 1 year of data before implementation was worth using as a comparison, but breaking this down into 20 preceding data points made the numbers in each data point very small. The ongoing data and trend line to the end of 2011 strongly suggest that this decline is a real phenomenon. We are not aware of any other changes during this time that might explain the decline.

We believe that the new handover system has had a high sustained uptake as a result of clinical championing by the Head of General Medicine and because of the high value it provides to junior doctors in their daily work.17 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. Junior doctors have said that covering without it is like “flying blind”.

One limitation of this study is that it is historically controlled, and other factors might have affected weekend discharges and MET calls during the follow-up period. Indeed, there is a suggestion that weekend discharges increased just before the new handover system commenced. However, it is unlikely that such increases in weekend discharges would be sustainable without a reliable handover system to underpin them. Some of the improvements may not relate directly to the Blue BARRWUE handover system itself, but to the Friday reminders to complete the handover and combined views in BOSSnet for all patients in the general medical units. The Friday reminders and combined views were developed at the same time as Blue BARRWUE for the purpose of weekend cover.

While the components of the Blue BARRWUE handover system should be broadly generalisable, the results of our implementation probably hinged, at least in part, on having a committed clinical champion and excellent information technology infrastructure. To date, the results of implementation of the program in other parts of Barwon Health have been slower and less reliable without a clinical champion in those areas.

Finally, the “blue” in Blue BARRWUE relates to its colour in BOSSnet specifically, and the acronym may need to be modified for use with other clinical information systems.

1 Computer screen image showing the interface for entering the handover information in the BOSSnet clinical handover system (mock patient data)

2 Proportion of general medical inpatients with a handover note and an updated working diagnosis, and average proportions before implementation of the Blue BARRWUE electronic handover system*

* Proportion of patients with a handover note and proportion of patients with an updated working diagnosis crossed upper control lines after intervention (not shown).

3 Proportion of handover components present in the BOSSnet clinical handover system at 7 pm on Friday evenings in November 2008 and November 2009

4 Proportion of general medical inpatients discharged on weekends from Geelong Hospital before and after implementation of the Blue BARRWUE electronic handover system

5 Proportion of general medical patients for whom MET calls were made on weekends, and trends before and after implementation of the Blue BARRWUE electronic handover system*

* Steady increase in MET calls before implementation and trend in MET calls after implementation did not reach significance by statistical process control analysis.