Doctors’ Handovers in the Acute Medical Assessment Unit: A Hierarchical Task

Analysis

This work is funded by

Michelle A. Raduma1

Supervisors: Prof Rhona Flin1, Dr Steven Yule1, Dr David Williams2

University of Aberdeen1, Aberdeen Royal Infirmary, NHS Scotland2

Handovers can be high-risk

• The literature suggests that handovers are a “high –risk” situation that can cause gaps in the continuity of patient care due to communication/ teamwork failures, and can lead to adverse events1

1Cook, R.I., Render, M., & Woods, D.D.(2000). Gaps in the continuity of care and progress on patient safety. British Medical Journal, 320 (7237), 791-794.

Piper Alpha‘I conclude that the leak resulted from steps taken by night-shift maintenance. Unknown to them a pressure safety valve had been removed… removed… the lack the lack of awareness of the of awareness of the removal of the valve removal of the valve resulted in failures in resulted in failures in the communication of the communication of information at shift information at shift handoverhandover earlier in the earlier in the eveningevening and failure in the operation of the permit to work system in connection with the work which had entailed its removal’

(Cullen, 1990, Ch 1, p 1.)

Doctors’ handovers• With the implementation of Working Time Directives

regulating the maximum amount of hours doctors can legally work, there has been an increase in doctors’ shift work.

• Studies in Patient Safety research show that increased shift work amongst doctors has created problems in relation to safe handover practices, such as:

– A lack of good communication between doctors at shift handovers.

– A loss/miscommunication of patient information at shift handover

– Very idiosyncratic and unsystematic handovers

Research study sample

• Teams of doctors transferring primary responsibility for their patients to other teams of doctors.

• Doctors working within the Acute Medical Assessment Unit (AMAU).

Why the AMAU?• AMAUs are:

– Complex work environments because patients admitted have a wide range of conditions or may be undiagnosed

– They experience a large number of patient transfers

– Often where a patient’s journey during their hospital stay begins. It is vital therefore that a continuum of care is maintained, where patients can be moved easily and safely from one point in the system to the next (Royal College of Physicians, 2002).

‘The evidence base for best practice in acute medical care is weaker than it should be and needs to be strengthened. For this to occur, the culture of research and development in acute medical services should be given a higher priority than it has at present.’ (Royal College of Physicians, 2007).

Research objectivesObjectives:

• To understand the doctors’ handover process in hospital settings, specifically in the AMAU by means of a hierarchical task analysis (HTA).

• To identify where patient information is at risk in the handover process.

Hierarchical task analysis (HTA)

To fully describe how a task is done, a detailed account of the activities that are a prerequisite for the successful completion of the task need to be systematically documented.

A systematic analysis of a task that makes it easier to identify where risks and problems in the performance of the task may lie. This enables those specific problems to be targeted for improvement (Shepherd & Stammers, 20032).

2) Shepherd, A. & Stammers, R.B. (2005). In Wilson, J.R. & Cortlett, N (Ed). Evaluation of Human Work 3rd ed. Florida: Taylor & Francis Group

HTA: How to use a dance mat

Documenting the handover process: Data collection

• Raduma, Flin, Yule, & Williams2 identified various methods that have been employed to investigate handovers

– Observations (N= 30)– Interviews (N= 20)– Questionnaires– Critical incident reporting

• To conduct the HTA, a detailed description of activities pre-handover, at handover, and post-handover will be carried out via observations and interviews.

– The result: a hierarchy of steps that represent behaviours that are required to accomplish the task goal.

2) Doctors’ handovers in hospitals: A literature review (Manuscript under review)

Documenting the handover process: Procedure

• The study is being carried out in three stages– Stage 1: Identification of the key tasks and goals of the

doctors’ shift handover (completed)– Stage 2: Construction of the HTA– Stage 3: Re-evaluation of the HTA

Documenting the handover process: Method

• An observation checklist and interview schedule developed based on:– previous methods used in other

handover studies,– a literature review, – and preliminary observations of doctors’

shift handovers (n = 5)

Observation checklist Pre-handover Handover Post-handover

HTA -What should the

outgoing team do?

-Who should be preparing

for handover?

-How should they prepare

for handover?

-Where should they start

preparing for handover?

-When should handover start?

-Where should handover start?

-Who should be present at

handover?

-Who presents the handover and

how is this decided upon?

-How should the doctors start

handover?

-Does incoming team have a

briefing amongst themselves?

-Do the doctors immediately start

the jobs handed over?

Artefacts of

interest

Task

conditions

Whiteboard:

How busy is the

unit?

Any critical

admissions?

Number of staff on

duty?

Other complications?

Patient notes, personal lists,

PDAs, computerised sign-outs,

pre-printed handover sheets:

Where should they get

these items?

When and how should

they be used?

How busy is the unit?

Any critical

admissions?

Number of staff on

duty?

Other complications?

Patient notes, personal lists, PDAs,

computerised sign-outs, pre-printed

handover sheets:

How are these used?

How busy is the unit?

Any critical admissions?

Number of staff on duty?

Other complications?

Observation data

• Shadow doctors as they prepare handover • Attend handover meetings • Shadow doctors after they have received

handover

Observation data: Coding

Interview schedule

Pre-handover phase task elicitation

Before you start preparing for handover, what is the first thing you should do?

When should handover preparation start?

Who should update the patient list?

Handover phase task elicitation

What should you take with you for the handover meeting?

Who should you handover your patients to?

How should you hand these patients over?

When can you ask for clarifications on a patient?

What happens if you cannot attend handover?

Post-handover task elicitation

What does the receiving team do immediately after handover?

What does the outgoing team do immediately after handover?

Interview data: Coding

– Note the main tasks of each handover phase

– Categorise these in terms of:• the goal (e.g. to prepare the handover)• the operation (what the person does to

move towards the goal)• the plan (the conditions under which to act

in order to reach the goal)

– Organise these tasks sequentially

Interview coding example

Goal: What is the first thing you do in preparation for handover?“…making sure I know where the patients are and not handing over people who might have already moved across the other side of the hospital”

Operation: How do you find out where the patients are?“you need to go and look at the list of patients in the red book behind the nurses’ desk and see which patients have gone”

Plan: Do you do that for every patient in the AMAU before the 4pm handover?“…you do that only if the patient has already been assessed …I tend to do it just before the handover, so about 4pm”

Preliminary HTA: Doctors’ handovers in the AMAU

Thank you. Please feel free to ask any

questions. For more information, please

contact me or visit our websitemichelleraduma@abdn.ac.uk

www.abdn.ac.uk/psrg