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Nurse practitioner-based sign-out system to facilitate patient communication on a neurosurgical service: a pilot study with recommendations.

ABSTRACT

Failure to communicate important patient information between physicians causes medical errors and adverse patient events. On-call neurosurgery physicians at the Toronto Western Hospital do not know the medical details of all the patients that they are covering at night because they do not care for the entire service of patients during the day. Because there is no formal handover system to transfer patient information to the on-call physician, a nurse practitioner-based sign-out system was recently introduced. Its effectiveness for communication was evaluated with preintervention-postintervention questionnaires and by recording daily Iogins. There was a statistically significant decrease in number of Iogins after 8 weeks of use (p = .05, Fisher's exact test), and the tool was abandoned after 16 weeks. Modifications identified to improve the system include the ability to sort by attending physician and to automatically populate the list with new patients. Effective communication is important for reducing medical errors, and perhaps these modifications will facilitate this important endeavor.

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The neurosurgical service at the Toronto Western Hospital includes a neurovascular team and a spinal surgery team. Resident physicians on the service are assigned to one of these teams during their rotation, whereas postgraduate fellows are involved only in the daily care of the patients of their supervisor. The on-call physician is either a resident from one of these teams or a fellow. Therefore, although the on-call physician routinely cares for only a portion of the patients during the day, he or she becomes responsible for all of the patients when he or she is on call. No structured verbal or written handover process exists for the on-call physicians when they assume responsibility for the entire neurosurgical service.

The physicians round on their respective patients every morning. Once finished, they are in the operating room or clinic for the remainder of the day. During this time, a group of nurse practitioners (NPs) function as the primary inpatient care providers for this service. They currently send out daily e-mail updates to the entire service, reporting pertinent medical information about the patients that each of them follows. The result is that each member of the neurosurgical service receives multiple e-mails with incomplete patient information. The physician on call is not familiar with the complete medical history of all patients on the service and does not have access to an inclusive, convenient patient sign-out system.

Communication failures during sign-out often lead to uncertainty in decisions on patient care (Arora, Johnson, Lovinger, Humphrey, & Meltzer, 2005). Furthermore, failure in transferring information among physicians is a leading cause of medical errors (Frank, Lawless, & Steinberg, 2007). The Joint Commission in the United States found that breakdown in communication was the leading root cause of sentinel events between 1995 and 2006. An Australian study found that communication errors were the leading underlying cause of adverse events, associated with twice as many deaths as clinical inadequacy (Wilson, Runiciman, Gibberd, Harrison, & Hamilton, 1995).

The number of transfers of patient care to cross-covering and night float house staff has increased recently because of new resident workweek restrictions. In the United States, an 80-hour workweek was mandated in July 2003 for residency programs to maintain their accreditation. This increase in "transfer events," coupled with the new and complex diagnostic tools and more complex treatment options, has contributed to the problem of safe and efficient transfer of care (Van Eaton, Horvath, Lober, & Pellegrini, 2004). Van Eaton, Horvath, Lober, Rossini, and Pellegrini (2005) conducted a randomized, crossover study to evaluate how a Web-based computerized sign-out system would affect patient handover and resident efficiency. The residents reported better sign-out quality (69.6%) and improved continuity of care (66.1%). They also reported improvements in workflow efficiency. Eighty-two percent reported finishing their work sooner, and team rounds were shortened by 1.5 minutes/patient.

Patient handovers also occur among the nursing staff. Nurses communicate with one another during change-of-shift reporting with physicians during morning rounds and to each other and physicians during patient transfer between units or facilities (Communication during patient hand-overs, 2007). Sidlow and Katz-Sidlow (2006) conducted a study in which the nursing staff were provided with the residents' sign-out information. In this study, 19 out of 20 nurses reported that the sign-out program positively affected their ability to care for patients. They also reported that it helped to improve communication between physicians and nurses.

Currently, at the Toronto Western Hospital, general medicine and all of the medical subspecialties are using an intranet-based sign-out system as a means of signing over to cross-covering residents on call. This is a secure system that can be accessed from any of the computers in the hospital and also via the Internet from outside of the hospital. It provides a standardized way of presenting patient information. This system reduces data entry by downloading patient demographic data from the hospital electronic patient record.

The medical residents of most hospital services spend their days on the wards caring for patients and have easy access to the computers to update these lists. On the other hand, neurosurgery residents spend their entire day in the operating room. This is similar to all other surgical specialties; however, neurosurgical cases tend to be longer than the average. As a result of these increased demands, they have less time to consistently update a sign-out list. For this reason, coupled with the fact that the NPs are the primary caregivers during the day and are already taking the time to electronically distribute some patient information, we proposed that an NP-based sign-out system would improve communication of patient information to the on-call resident.

Intervention

Approval was obtained from the Research Ethics Board at the University Health Network (UHN) in Toronto. The ethics board required that participants consent to participate in the study. Participants received a consent form that outlined the background, purpose, and procedure for the project. The form indicated that by completing the necessary surveys they were implicitly giving consent. With the help of Shared Information Management Services (SIMS), the hospital information technology department, the neurosurgery service was added to the preexisting intranet sign-out system at UHN.

Patient information on this system includes name, age, gender, attending physician (staff), code status, medical record number, location (unit, room number), past medical history, date of admission, admission diagnosis, procedure or surgery list, study or laboratory results, allergies, ongoing medical issues, an on-call to-do list, and disposition. This password-protected system was accessible through the intranet from any computer in the UHN and from the Internet with a virtual private network token. Because the NPs were already involved in electronically communicating patient information on a daily basis, they were asked to be primarily responsible for updating patient information to the sign-out list. Other members of the medical team (residents, fellows, and staff) were asked to update the system with new medical issues, anything needed to be done by the on-call resident, and medical information for new patient admissions when on call.

Methodology

An information seminar was held for the neurosurgery service, in which a member of SIMS described and demonstrated how to use the system. A detailed pamphlet with step-by-step instructions and screen shots of the sign-out tool was also provided to participants.

[FIGURE 1 OMITTED]

The effectiveness of this system was evaluated using two methods: (a) a before-and-after questionnaire for all 25 of the medical staff (NPs, residents, fellows, and staff) and (b) recording of the number of times the sign-out system was accessed via the intranet. The questionnaire was established by two of the authors (D.R. and M.B.). The before questionnaire (Appendix A) was completed on the first day the system was available for use. The after questionnaire (Appendix B) was completed after 8 weeks of using the sign-out tool. Twenty-five questionnaires were distributed. The number of times the sign-out system was accessed via the intranet was measured for two intervals--the first 2 weeks and for 2 weeks after 8 weeks of using the system. The questionnaires were handed out during neurosurgery rounds. These were distributed with envelopes with the name and office location of one of the department administrative assistants, and the participants were asked to deposit the questionnaires with her.

Fisher's exact test, t tests, and descriptive statistics were used for result analysis. All statistical calculations were performed using Microsoft Excel and SISA-Binomial, 1997. A p value less than .05 was considered statistically significant.

Results

Data from the questionnaires included the categories strongly agree, agree, neutral, disagree, and strongly disagree. The agree and strongly agree data were extracted together, and the disagree and strongly disagree were also merged. This was done to simplify analysis of the results.

Thirteen of 25 participants returned the preintervention questionnaires. All 13 reported that they would use this tool. Of these, there were 4 NPs, 5 residents, and 4 staff. Nine out of the 13 thought that the tool would enhance effective communication. No participants reported that they thought it would be an ineffective means of improving communication, but 4 gave a neutral response.

Twenty participants (5 residents, 5 fellows, 5 NPs, and 5 staff) completed and returned the postintervention questionnaires. Only 30% (6/20) reported that they had ever entered medical information into the sign-out system. Of these, 5 were NPs and 1 was a fellow. There was a significant difference (p = .002, Fisher's exact test) when comparing the number of NPs to house staff (residents and fellows) who entered data into the system. Eighty percent of the house staff (8/10) and 100% of the NPs reported using the sign-out tool as a reference (p = .429, Fisher's exact test). Only one of the staff physicians reported ever using the system and used it only as a reference. See Figure 1.

Of the participants who reported ever using the system (n = 16), 87.5% stated that the system was accessible. Only 50% reported that this was an effective means of communication, and only 25% thought that the sign-out tool provided a comprehensive summary of patient medical information. Overall, 37.5% (6/15) reported that the sign-out system improved their ability to care for patients and the safety of patients. An interesting finding was that 80% of these were fellows. Please see Table 1 for a complete summary of results.

In addition, the number of daily logins to the sign-out system was measured in the first 2 weeks of the study and for the 2 weeks after the system had been used for 8 weeks. The mean initial daily logins was 13.2 (standard deviation [SD] = 12.00), and the average postintervention daily logins was 5.2 (SD = 4.02). There was a statistically significant decrease in logins after 8 weeks of use (p = .005, one-tailed paired t test).

Discussion

The preintervention questionnaire demonstrated that initially there was a strong interest in using the sign-out system, and this was confirmed by the high number of logins during the first 2 weeks of use. The statistically significant decrease in the number of logins after 8 weeks suggests that there was a problem with the system or implementation of the system. Its subsequent abandonment after 16 weeks of use corroborates this finding.

Residents reported anecdotally, through conversation and comments on the questionnaires, that they were not using the system because it was not kept current enough to be beneficial. The NPs, who were entering most of the patient information, reported that it was difficult to keep up-to-date because the new admissions were not being entered into the system overnight. Therefore, when the physicians conducted morning rounds (prior to the when the NPs start their day), the sign-out list was incomplete because the overnight admissions were missing. They also thought that it was not convenient because they were not able to sort the patients by the attending physician (staff). This meant that the staff, who previously received individual summaries of only their own patients, now had to navigate through a long list (60-75 patients) to obtain the same information. As a result, the staff physicians may have been less supportive of the system, contributing to its overall failure. Furthermore, this inconvenience resulted in the staff continuing to request daily e-mails with clinical information from the NPs. The NPs essentially had to complete the same task twice by maintaining the sign-out system and sending daily e-mails. This overburdened the NPs and contributed to failure of the sign-out system.

In response to these issues, SIMS has already modified the sign-out lists so that they can be sorted by Most Responsible MD, which should make it more convenient to view and use. In addition, SIMS will be building a query that automatically populates the sign-out list with patients on the service. With this change, the NPs will no longer have to manually add new patient information, thereby decreasing their workload. This will provide more time for the NPs to keep the list up-to-date.

Different team members look after different proportions of patients on the service. Unlike the residents, the fellows are only involved in the daily care of the patients of their supervisor (i.e., 1 out of 11 neurosurgery staff at Toronto Western Hospital) and do not participate in daily rounding on all the neurosurgery intensive care unit patients. Therefore, they are least familiar with the entire service and are the most in need of a comprehensive patient handover. Not surprisingly, this group benefited the most from the system. All of them reported using it as a reference. Four out of 5 fellows reported that the system was effective for patient communication and improved workflow while on call, their ability to care for patients, and safety of patients.

On conventional medical services, the residents partake in both sides of the handover--they both maintain the list and use it as a reference when on call (Sachdeva, 2004; Sidlow & Katz-Sidlow, 2006; Van Eaton et al, 2005). The benefits they get by having a reference list while on call likely gives them incentive to maintain the list. One could argue that a contributing factor to the study failure was a lack of incentive for the NPs to maintain the list. That is, because they are not on call (i.e., caring for patients that they are not familiar with), they might derive less benefit from the list. However, their positive response on the preintervention survey and the relatively high number of logins at the beginning of the study suggest that they were motivated to use the sign-out tool, and more likely the issues mentioned earlier with the system led to the failure of the study.

Once optimized, this sign-out tool should be of benefit to the nursing staff and physicians. It will provide them with an updated resource about patient medical issues and should help with communication among themselves and with other healthcare providers and in turn may lead to further reductions in medical errors.

In addition to the problems with the initial version of the sign-out tool, there are several other limitations to this study. The study design depended on the use of two questionnaires (preintervention and postintervention), which are susceptible to poor response rate (e.g., 52% for the first questionnaire) and apathy in answering the questions. With respect to assessing the use of the sign-out tool, only the total number of daily logins could be recorded, not which type of care provider (nurse versus physician) or how many times each provider logged in. Furthermore, the staff physicians had little incentive and were not using the sign-out tool because they were still receiving daily e-mails. Consequently, some NPs may not have been invested in using the sign-out tool because the staff physicians they worked with were indifferent to it. All of these issues further contributed to the failure of the sign-out system.

In summary, the sign-out system is secure and accessible; however, it did not serve as an effective tool for patient communication on neurosurgery in its initial form. In the context of having house staff on call who are not familiar with all the patients on the service and the importance of communication for reducing medical errors, it is imperative to have a system that provides effective handover to the on-call physician. There is already an intranet-based system that functions well on other services at UHN, and perhaps the addition of automated population of the list and sorting by Most Responsible MD will optimize the system for the neurosurgery service to facilitate this important endeavor.
APPENDIX A.

Questionnaire I

Please answer questions using circles, free text or check boxes
as indicated in brackets. Again, participation is entirely
voluntary. You may answer questions at your discretion and
withdraw from the study at time; completing questionnaire will
imply consent for participation in the study.

1. Demographic Data (please circle):

 i. Profession: RN or MD
 ii. Sex: M or F
 iii. Age: 20-30 31-40 41-50 51-60 61+
 iv: Level of Training: PGYI PGY2 PGY3 PGY4
 PGY5 PGY6+
 STAFF NURSE PRACTITIONER

2. Do you think you will use this intranet based sign-out sheet?

 Never Rarely Sometimes Often Always

3. Do you think this will be an effective
tool for communication about patients?

 Strongly Disagree Neutral Agree Strongly
 Disagree Agree

APPENDIX B.

Questionnaire II

Please answer questions using circles, free text or check boxes
as indicated in brackets. Again, participation is entirely
voluntary. You may answer questions at your discretion and
withdraw from the study at any time; completing questionnaire
will imply consent for participation in the study.

1. Demographic Data (please circle):

 i. Profession: RN or MD
 ii. Sex: M or F
 iii. Age: 20-30 31-40 41-50 51-60 61+
 iv: Level of Training: PGYI PGY2 PGY3 PGY4
 PGY5 PGY6+
 STAFF NURSE PRACTITIONER

2. When did you use intranet based sign-out system? (Please check)
 [] To enter patients medical information
 into the system after admission
 [] To update patient medical issues
 [] As a daily reference
 [] Printed off a copy while "on-call"
 [] Accessed from the intranet as reference while "on-call"
 [] Never

3. When "on-call" how often did you access the sign-out list? (Circle)

 Never Rarely Sometimes Often Always N/A

4. The sign-out system is an effective tool
for patient communication. (Circle)

 Strongly Disagree Neutral Agree Strongly
 Disagree Agree

5. The sign-out system improved your workflow while "on-call" (Circle)

 Strongly Disagree Neutral Agree Strongly
 Disagree Agree

6. The sign-out system positively affects your ability
to care for patients. (Circle)

 Strongly Disagree Neutral Agree Strongly
 Disagree Agree

7. The sign-out system improves the safety of your patients. (Circle)

 Strongly Disagree Neutral Agree Strongly
 Disagree Agree

8. This sign-out system is accessible. (Circle)

 Strongly Disagree Neutral Agree Strongly
 Disagree Agree

9. This sign-out system provides a comprehensive
summary of patient medical history. (Circle)

 Strongly Disagree Neutral Agree Strongly
 Disagree Agree


References

Arora, V., Johnson, J., Lovinger, D., Humphrey, H., & Meltzer, D. (2005). Communication failures in patient sign-out and suggestions for improvement: A critical incident analysis. Quality and Safety in Health Care, 14, 401-407.

Communication during patient hand-overs. (2007). Patient safety solutions, volume 1, solution 3. Retrieved August 31, 2008, from WHO Collaborating Centre for Patient Safety Solutions Web site: http://www.ccforpatientsafety.org/30723

Frank, G., Lawless, S., & Steinberg, T. (2007). Improving physician communication through an automated integrated sign-out system. Journal of Healthcare Information Management, 19(4), 68-74.

Sachdeva, A. K. (2004). Invited commentary: Use of information technology to support safe and efficient transfer of care in surgery. Surgery, 136, 14-15.

Sidlow, R., & Katz-Sidlow, R. J. (2006). Using a computerized sign-out system to improve physician-nurse communication. Joint Commission Journal on Quality and Patient Safety, 32, 32-36.

Van Eaton, E., Horvath, K., Lober, W., & Pellegrini, C. (2004). Organizing the transfer of patient care information: The development of computerized resident sign-out system. Surgery, 136, 5-13.

Van Eaton, E., Horvath, K., Lober, W., Rossini, A., & Pellegrini, C. (2005). A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. Journal of the American College of Surgery, 20, 538-545.

Wilson, R., Runiciman, W., Gibberd, R., Harrison, B., & Hamilton, J. (1995). The quality in Australian health care study. Medical Journal of Australia, 163, 458-471.

Suggested Readings

Charlson, M. E., Hollenberg, J. P., Hou, J., Cooper, M., Pochapin, M., & Pecker, M. (2000). Realizing the potential of clinical judgment: A real-time strategy for predicting outcomes and cost for medical inpatients. American Journal of Medicine, 109, 189-195.

Haggerty, J. L., Reid, R. J., Freeman, G. K., Starfield, B. H., Adair, C. E., & McKendry, R. (2003). Continuity of care: A multidisciplinary review. BMJ, 327, 1219-1221.

Hier, D. B., Rothschild, A., LeMaistre, A., & Keeler, J. (2005). Differing faculty and housestaff acceptance of an electronic health record. International Journal of Medical Informatics, 74, 657-662.

Joy, S., & Benrubi, G. (2004). Personal digital assistant use in Florida obstetrics and gynecology residency programs. Southern Medical Journal, 97, 430-433.

Kannry, J., & Moore, C. (1999). Medisign: Using a Web-based signout system to improve provider identification. Proceedings of the American Medical Informatics Association Symposium, 1999, 550-554.

Lasslo, R., Balsbaugh, T., & Malyj, W. (2004). Web-based patient signout system--evolution of a quality improvement tool. In M. Fieschi, et al. (Eds.), Medinfo 2004: Proceedings of the 11th World Congress on Medical Informatics (p. 1707). Amsterdam: IOS Press.

Luo, J., Hales, R. E., Hilty, D., & Brennan, C. (2001). Electronic sign-out using a personal digital assistant. Psychiatric Services, 52(2), 173-174.

Mulvehill, S., Schneider, G., Cullen, C. M., Roaten, S., Foster, B., & Porter, A. (2005). Template-guided versus undirected written medical documentation: A prospective, randomized trial in a family medicine residency clinic. Journal of the American Board of Family Practice, 18, 464-469.

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Quan, S. (2005). Signing on to sign out: Creation of a web-based patient sign-out application. Electronic Health Care, 4(2), 100-102.

Quan, S., & Tsai, O. (2007). Signing on to sign out, part 2: Describing the success of a web-based patient sign-out application and how it will serve as a platform for an electronic discharge summary program. Healthcare Quarterly, 10, 12-124.

Rosenbloom, S. T., Grande, J., Geissbuhler, A., & Miller, R. A. (2004). Experience in implementing inpatient clinical note capture via a provider order entry system. Journal of the American Medical Informatics Association, 11, 310-316.

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Questions or comments about this article may be directed to Deborah L. Rabinovitch, MD, at dlrabinov@hotmail.com. She is a psychiatry resident at the Department of Internal Medicine, Division of Psychiatry, University of Toronto, and rotated at the University Health Network-Toronto Western Division, Canada.

Melinda Hamill, MHSc, is a biomedical engineer and analyst at Shared Information Management Systems, University Hospital Network, Toronto, Canada.

Clauda Zanchetta, MN RN, is a nurse practitioner at the Division of Neurosurgery, University Health Network-Toronto Western Division, Canada.

Mark Bemstein, MD FRCSC, is a neurosurgeon at the Division of Neurosurgery, University Health Network-Toronto Western Division, Canada.
TABLE 1. Results of the Postintervention Questionnaire

 System Effective Tool for Comprehensive
 Accessible Communication Summary

Nurse practitioner 4 2 2
(n = 5)
Resident (n = 5) 4 1 0
Fellow (n = 5) 5 4 1
Staff (n = 1) 1 1 1
Overall (n = 16) 14/16 8/16 4/16

 Improves Improves Ability to Improves Safety
 Workflow Care for Patients of Patients

Nurse practitioner 1 1 0
(n = 5)
Resident (n = 5) 0 1 1
Fellow (n = 5) 3 4 4
Staff (n = 1) 0 0 1
Overall (n = 16) 4/20 6/16 6/16

Note. Number in parentheses represents the number of responders
who indicated that they have ever used the system. Data represent
the number of positive results in each category.
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Author:Rabinovitch, Deborah L.; Hamill, Melinda; Zanchetta, Clauda; Bernstein, Mark
Publication:Journal of Neuroscience Nursing
Geographic Code:1CANA
Date:Dec 1, 2009
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