Authors: P. Barach, L. Pijnenborg, A.A. Göbel, C.J. Kalkman
When a patient’s transition from the hospital to home is less than optimal, the repercussions can be far-reaching — hospital readmission, an adverse medical event, and even mortality. Project HANDOVER, is the first major European study to assess patient transitions. The goal of the study is to identify and study patient handover practices and create standardized approaches to handover communications in 6 European countries (i.e, Sweden, Poland, England, Italy, Spain, Netherlands).
The policy objective of the HANDOVER project was to assess the continuum of clinical care at the primary care hospital interface by informing EU healthcare policy makers and educators about patient transitions. The project HANDOVER developed a standardized toolkit for improving the handoff processes, that can be tailored to meet local and/or institutional needs. The study included a total of 12 hospitals, and has collected data from hundreds of physicians, nurses, patients and hospital managers.
The project aimed to improve patient care in EU member states and in relation to patient mobility and cross border care among European countries. A major outcome of the research was a deeper understanding of how variations in communication, culture, and technology use in nursing and medicine leads to ineffective or suboptimal handoffs.
The discontinuity and variation of care across these EU settings leads to increased handovers poses danger to patients. The handovers we explored and studied are often characterized by communication failures, environmental barriers and adverse care.
The study was a multi-method study (i.e., process maps, surveys, interviews, focus groups, observations) to directly assess patient handovers and shadow physicians and nurses providing care following patient handovers. Our aims were to: (1) Identify the barriers and facilitators in the medical, social and technological contexts where patient handovers takes place; (2) Determine how variations in handoff processes lead to "near misses" and adverse outcomes; (3) Develop and assess tools and training programmes that are needed for implementation of a handoff training program; and, (4) Assess the cost effectiveness of future handover interventions.
We mapped out the patient care handover processes in the different countries (process maps, artefact analysis), developed standardized tools to conduct interviews, focus groups, artefact analyses and develop a shared taxonomy of near miss and adverse patient events.
We interviewed over 192 healthcare providers, and discovered that important and intricate relationships exist among the people, processes, technology, and clinical settings in which handovers occur. Significant differences were seen in the patient discharge, transfer, and rehabilitation processes in each of the 6 countries. We found great variation in practice and a lack of systems appreciation. These relationships have the potential to facilitate or impede the hand-off process and directly impact patient outcomes.
We focused the 2nd part of the study on developing a series of interventions including clinical practice guidelines, best practice indicators and an educational toolbox for under- and postgraduate healthcare trainees. During the second period of the project we continued our work on identification and validation of factors that would constitute the optimal patient care system continuum, and training tools to assist a successful implementation.
The lack of awareness of different professional perspectives, inherent to primary and secondary professional domains, seems to influence the roles and responsibilities in patient diagnosis and treatment. Though most professionals think they carry a shared responsibility in this respect, in practice they do not. Because of multiple assigned roles and unclear responsibilities, especially for nursing professionals, discharge can create barriers in handover as well. We demonstrated that it is common for the general practitioner to play an essential part in the coordination of patient care. Multiple factors, such as the lack of direct contact between professionals, involvement of multiple professionals and the lack of feedback, make it difficult for the general practitioner to fulfil this role excellently and be accountable.
We found that current interventions aimed at improving patient handovers at the hospital-primary care interface fall short in addressing the barriers and facilitators. Effective patient handovers at the hospital-primary care interface are influenced by a large variety of barriers and facilitators. However, effective handover interventions are mostly aimed at improving organizational and technical aspects of the handover process.
The HANDOVER website www.handover.eu was developed with the support and involvement of the whole HANDOVER project team. The site presents the functionalities that were requested by and expected of the group and provides a compendium of information on handover, both in Europe and globally. Information is available in English but also in the native languages of project partners.
The Handover Toolbox www.handover.ou.nl is an interactive platform and a compendium of knowledge about education and training in handovers as well as a library of practices, tools and techniques related to patient handovers. The interactivity of the handover network facilitates the sharing of experiences and practices in handovers. The added value of the toolbox is to emphasize the importance of handovers in the process of care and the significance of education in the field.
Handover, patient safety, results, impact, dissemination, quality improvement