Burns surgery handover study: Trainees’ assessment of current practice in the British Isles

burns 35 (2009) 509–512

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Burns surgery handover study: Trainees’ assessment of current practice in the British Isles Sammy Al-Benna a,1,*, Yazan Al-Ajam b,1, Durayd Alzoubaidi c a

Department of Plastic Surgery and Burn Centre, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany Department of Plastic Surgery, Royal Free Hospital, London, United Kingdom c Renal Unit, Broomfield Hospital, Chelmsford, United Kingdom b

article info

abstract

Article history:

Introduction: Effective handover of clinical information between working shifts is essential

Accepted 15 November 2008

for patient safety. The aim of this study was to identify current practice and trainees’ assessment of handover in the burns units of the British Isles.

Keywords:

Methods: A telephone questionnaire was conducted to trainee burns surgeons (at junior and

Patient handover

senior grades) currently working at all 30 burns surgery units in the British Isles. Information

Burns

regarding timing, location, duration, participation and quality of handover was collated anonymously. Trainees commented on satisfaction with current practice and its perceived safety. Results: A 100% response from all 30 units was obtained. 23/30 units (76.7%) had junior to junior trainee handovers. 17/30 (56.7%) had senior to senior trainee handovers. 19/30 units (63.3%) reported that handover took place with more than one grade of doctor present (range 1–4 grades). 3/30 (10%) reported that handover was bleep-free. 3/30 (10%) had received formal training on good burns handover. 5/30 (16.7%) were working in a unit that operated a ‘‘burns surgeon of the week’’ pattern of emergency cover. Mean satisfaction level was 3.8 out of 5. Those working in ‘‘surgeon of the week’’ teams had significantly higher scores, 4.4 versus 3.68 ( p = 0.037). Other healthcare professionals were present at only 4/30 (13.3%) handovers. Overall 26/30 (86.7%) of trainees judged their current handover practice ‘‘safe’’ (100% in ‘‘surgeon of week’’ group and 84% in the remaining group, p = 0.289). Conclusions: Effective handover remains a keystone in safe and effective communication between doctors. The study highlights areas for improvement in handover practice, including greater involvement of an integrated multidisciplinary team. Those working under the ‘‘surgeon of the week’’ pattern are more satisfied. # 2009 Published by Elsevier Ltd and ISBI.

1.

Introduction

Effective communication lies at the very heart of good patient care. This is acknowledged in the General Medical Council’s Good Medical Practice, in which doctors are to ‘keep colleagues well informed when sharing the care of patients’ [1]. The UK has the second lowest ratio of doctors to patients in Europe, with 1.7/1000 compared with 3.0–5.0/1000 in many * Corresponding author. 1

Both these authors contributed equally to this work. 0305-4179/$36.00 # 2009 Published by Elsevier Ltd and ISBI. doi:10.1016/j.burns.2008.11.008

other countries in the European Union [2]. The European Working Time Directive (EWTD) is part of European Health and Safety legislation seeking to protect the health and safety of workers. Full EWTD application will result in a 48 h ‘‘Maximum Legal Average’’ working week for junior doctors [3]. More significantly, it provides that doctors must not work more than 13 h in each 24-h period and are entitled to 35 consecutive hours rest in every 7-day period or 59 h rest in

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burns 35 (2009) 509–512

every 14-day period [3]. However, the most significant aspect of the Working Time Directive and the case law which has emerged in recent years is that where the daily 13 h limit is exceeded then the doctor concerned will be obliged to take sufficient rest to meet the terms of the Directive and this will obviously have implications for starting times on the following day and will lead to later availability to attend out-patient clinics or operating theatres. This latter aspect is easily the most problematic aspect of the legislation governing working time commitment [3]. Trainee doctors, trusts, and NHS managers all have worries about the effects of the changes. Trainees worry that they can be satisfactorily trained. NHS managers worry about how to deliver a service which remains largely provided by junior doctors, even though the government has made a commitment to a consultant delivered service in the NHS [4]. The reduction in working hours brought about by the implementation of the EWTD and the inevitable change to shift-working patterns, effective handover has come to play a pivotal role in communicating patient information from one group of doctors to another, ensuring continuity of care and patient safety. The document ‘‘Safe handover: safe patients,’’ jointly published by the British Medical Association Junior Doctors Committee, the National Patient Safety Agency and NHS Modernisation Agency, set out guidance on clinical handover [5]. Several studies looking at causation of near misses, especially in the critical care setting have shown ‘communication failures’ as one of the major factors [6,7]. Studies have also been done on handover in Medicine, Trauma and Orthopaedics and General Surgery [8–10], and have shown that current handover arrangements fall short of the ideal set out in the Safe Handover guidelines. To date, there are no published studies relating to handover practice in burns

Table 1 – Handover questionnaire. Do you handover SHO to SHO? Yes/No Do you handover Registrar to Registrar? Yes/No How many medical grades are present at handover? 1 2 3 4 Are other healthcare professionals present during handover? Yes/No Is handover bleep-free? Yes/No Do you have a ‘surgeon of the week’ pattern of emergency cover? Yes/No Have you received formal training on good handover? Yes/No How satisfied are you with your handover (5-point Likert Scale)? 12345 Do you consider your current handover practice safe? Yes/No

units. The aim of this study was to identify current practice and trainees’ assessment of handover in burns units of the British Isles.

2.

Methods

A telephone questionnaire was conducted at trainee burns surgeons (Senior House Officer (SHO) B Junior Resident and Registrar level B Senior Resident) working at all 30 burns units in the British Isles during March 2008. Information regarding levels of doctors at handover, numbers of grades present, participation of healthcare staff and quality of handover was collated anonymously. Bleep-free handover, when pagers are held outside the handover room for the duration of the handover by one of the senior nurses, was also recorded. Trainee satisfaction with both current practice and perceived safety of handover was recorded on a 5-point Likert scale (1 = very dissatisfied with handover, 5 = very satisfied) [11]. The questions are summarised in Table 1. Statistical analysis

Table 2 – Summary of results. Handover SHO to SHO Handover Registrar to Registrar

Yes

No

77% 57%

23% 43%

Number of grades at handover Number of units

Presence of other healthcare professionals?

Surgeon of the week?

Have you received formal training on good handover?

Do you consider your handover practice safe?

1 11 (37%)

2 15 (50%)

Yes

No

13%

87%

Yes

No

17%

83%

Yes

No

10%

90%

Yes

No

87%

13%

3 3 (10%)

4 1 (3%)

5-point Likert Scale (1 = very dissatisfied, 5 = very satisfied) How satisfied are you with your handover?

1 0%

2 0%

3 34%

4 53%

5 13%

burns 35 (2009) 509–512

was performed by unpaired Student’s t-test, and a p-value <0.05 was considered significant.

3.

Results

A 100% response from all 30 units was obtained. 23/30 (76.7%) units had SHO to SHO handovers (Table 2). 17/30 (56.7%) had Registrar to Registrar handovers, with 19 units (63.3%) reporting handover taking place with more than one grade of doctor present (range 1–4 grades) (Table 2). Only 3/30 (10%) of handovers were bleep-free. In addition, only 3/30 (10%) had received formal training on good handover (Table 2). 5/30 (16.7%) units operated a ‘surgeon of the week’ pattern of emergency cover (Table 2). Other healthcare professionals were present at only 4/30 (13.3%) handovers. Overall satisfaction was 3.8 out of 5 (Table 2). Those working in ‘surgeon of the week’ teams had significantly higher scores (4.4 vs 3.68, p = 0.037) (Table 2). Overall 26/30 (86.7%) of trainees judged their current handover practice ‘safe’ (100% in ‘surgeon of the week’ group and 84% in the remaining group, p = 0.289) (Table 2).

4.

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Furthermore, ‘‘Safe handover: safe patients’’ proposes that ‘‘Postgraduate deans and the medical royal colleges should include effective handover practice as an essential criterion for granting educational approval of a training grade post’’ [5]; only 10% received formal training in handover. Effective handover remains the keystone in safe and effective communication between doctors. In a climate of working within shift systems with severe time constraints, the need to have precise and focused handovers has never been more imperative in safeguarding continuity of care. It is time for the Department of Health and National Patient Safety Agency in conjunction with the BMA to follow the recommendations set out in the ‘Safe handover: safe patients’ document and publish standardised guidelines on handover protocol. The results of this study support the recommendations that handover training should be incorporated into hospital induction days and postgraduate curricula.

Conflict of interest statement None of the authors has any financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work.

Conclusion

Much work has been done on handovers in safety-critical settings, such as the recovery room and critical care [12–15], and guidance from professional bodies has been issued on the subject [16,17]. In addition, strategies from other safetysensitive organisations, such as the airline industry and Formula 1, have been adapted for use in medicine to reduce errors and improve transfer of information [18,19]. The importance of comprehensive and precise handover has become of increasing relevance as all burn units adopt a shift-working pattern in order to comply with the EWTD. Unfortunately, current practices fall short of the recommendations set by the ‘‘Safe handover: safe patients’’ document. The ideal model recommends that all grades of medical staff, including the senior nurse, should be present at handover, a target met by only 13% of units. Patterson et al. [20] studied handover practice in 4 settings with high consequences for failure. They found that in order to improve the effectiveness in handovers, interruptions and other distractions should be minimised. This is reflected in the ‘‘Safe handover: safe patients’’ document, which recommends that handovers should be bleep-free, as bleeps are distractions that can disturb the handover process. They are normally held for the duration of the handover by one of the senior nurses outside the handover room; the nurse may interrupt the meeting only for immediate life threatening emergencies. 90% of units failed to provide bleep-free handover. It is recommended that the style of handover needs a clear and structured format with succinct details to ensure satisfactory information exchange. Handover should be led by the most senior clinician. The use of a ‘consultant of the week’ model may improve continuity of care for patients throughout the 7-day period; one in six units had such arrangement. Interestingly, this group also showed significantly higher satisfaction levels ( p = 0.037) than the rest.

references

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