Health Information Technology Support for Safe Nursing Care

The handoff is one of the most critical points in inpatient care: Think of it as a clinical brain dump. When a nurse ends her shift, she updates her replacements on the status of each of her patients' care and outcomes. Incoming staff use this information to devise care for their shift.

Sounds simple? It isn't.

Communication at handoff is far from standardized. In fact, extreme variation in the ways clinicians share information with each other causes an untold number of errors. What's supposed to be a concise briefing may turn into an information overload for incoming staff. However, what they really need are the highlights that will help them quickly understand what care is optimal to achieve desired outcomes over the next shift.

Now a project supported by the Agency for Healthcare Research and Quality (AHRQ) is testing whether a standardized, computerized tool can help nurses not only document patient care and outcomes better but also communicate more effectively and efficiently at handoff. To date, nurses participating in the project report that the new tool -- called HANDS -- has been a boon in terms of documenting patient care. The next step: using HANDS to guide communication at handoff.

"Every patient has a story," says principal investigator Gail Keenan, Ph.D., R.N., of the College of Nursing at the University of Illinois, Chicago. "As a health care provider, you need to be able to get that story quickly and understand it immediately."

"Nurses need to know the big picture rather than get lost in all the details," agrees Dana Tschannen, Ph.D., R.N., field site director for the project. "Used properly," she says, "HANDS should make nurses' jobs easier."

HANDS provides a standardized, electronic "short story" of each patient's care. Essentially, it's a shift-by-shift update of the patient's care plan. The HANDS report reviews the patient's clinical problems, the patient's outcomes, and the interventions provided to address the patient's problems. There are standardized terms in HANDS for more than 160 clinical problems, 400 patient outcomes, and 600 possible interventions.

The HANDS application is available through a secure web link that's password-protected and encrypted. Nurses can create patient plans from their local units and either view them on their computer screens or print them out for use at handoff.

Through the AHRQ grant, Keenan and her colleagues have been implementing the HANDS tool among eight units at four hospitals in Michigan. The researchers wanted to test the instrument in a variety of settings, so they included one university hospital and three community hospitals; the hospitals also vary in size. Participating units include medical, intensive care, surgical (cardiovascular and neurosurgical), and rehabilitation.

Half of the units began the implementation at start up; the other four joined a year later.

The initial goal, Keenan says, was to get nurses using the HANDS tool. To date, compliance is running at about 90 percent -- meaning that 90 percent of all care periods -- patient shifts -- have a HANDS-based care plan.

Feedback from nurses has been very positive, Keenan says. "They like it better than any care planning system they've ever had, and it's easy to use."

But there has been a significant glitch: The nurses aren't using the tool to guide discussions of patient care at handoff.

That's because handoffs are all managed differently, depending on the type of unit, the practice culture of the nursing team, staff experience, the time of day, and the patient involved.

It's not that difficult to standardize charting, Keenan says. But standardizing communication around patient care is an entirely different -- and much more complex -- matter.

"We didn't think that the communication part would be so difficult," says Tschannen. "We initially were very focused on the technology."

Yet she and Keenan are optimistic that HANDS can -- and will be -- accepted by nurses as both a documentation tool and a communication guide.

They're not alone. One of the participating study units isdownsizing; nurses in the new cardiovascular subunit wanted to bring HANDS with them. To that end, they've received training to use HANDS at handoff based on mock patient care scenarios. In these training scenarios, departing shift nurses brief their replacements by referring to the HANDS care plans.

"Once they've done the training, they tell me how much more smoothly it seems to flow and how much less time it takes," says Melissa Ackron, R.N., a quality improvement nurse at the new unit.

In the new unit, each patient room has a computer at the bedside. In this way, nurses can update their HANDS plans while they talk to patients and their family members. The nurses may ask them what their goals are for the day, learn whether they're aware of new medications that the patient may be taking, and gather other information that can be incorporated into the HANDS report. Ackron says that having this type of information can help prevent medical errors.

She notes that use of HANDS at handoff is a requirement in her unit -- one that will be monitored to ensure compliance. In Keenan's view, that's key. "A change like what we're asking for at handoff needs to be mandated or it won't get standardized," she says. "You have to get agreement across the organization."

Keenan's team is working with nurses in two other study units to train them to use the HANDS reports at handoff with mock scenarios. "It's a matter of working with the nurses and helping them move forward," Tschannen says. "The value is there."

Ultimately, Keenan and her core leadership team (co-PI Elizabeth Yakel, project director Mary Mandeville, and Tschannen) are working to make HANDS a vendor-neutral standard for interdisciplinary communication. As such, the HANDS application would connect with any electronic health record and be used to create and communicate the patient's "short story" across the full spectrumof care -- from acute care to home care to ambulatory care settings. Already, more than 200 hospitals across the country have expressed interest in making HANDS their care planning system, she says. Given that level of interest and the team's commitment to continuously improving HANDS, Keenan plans to take two immediate next steps:

1. Complete development needed to make HANDS available commercially at a low cost and able to integrate easily with existing electronic health record systems.
2. Attract additional funding to support continuous refinement and extension of HANDS' capabilities over time.