Assessment of Care Transitions (ACT)

Dr. Ayse P. Gurses Dr. Mahiyar Nasarwanji

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Objectives• To provide a list of good practices during

transitions of care

• To introduce the Assessment of Care Transitions (ACT) tool and describe when/how to use it

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Handoff reports• Patients are particularly vulnerable during

handoffs – Incorrectly communicated information– Information not communicated at all

• Appropriate measures for evaluating effectiveness of handoffs still need to be established and validated1

1. Solet DJ, Norvell JM, Rutan GH, et al., Acad Med, 2005.

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Our Focus • Identify good practices for handoffs• Concentrates on transfers from– OR ICU – ICU Floor

• Some many not apply to a specific type of transition

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Good Practice Guidelines• Too much variance observed in care

transitions• Need to follow a concrete guideline to ensure

better safety processes are followed

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ACT (Assessment of Transitions)

• See document attached in email

• Good practice findings led to a peer-to-peer evaluation tool (ACT)

• Face validity: Expert review completed– ACT reviewed by 6 clinical experts, 4 nonclinical experts not directly

involved in its development

• Will validate it using the Delphi Method – Let Ayse Gurses- agurses1@jhmi.edu know if you would like to

participate as an expert in our Delphi study)

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Methodology

• Literature review• Field studies in 4 sites – One human factors engineer+ one clinician

• Expert opinions

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ACT• Part I- Organizational Level Assessment• Part II – Specific Handoff Level Assessment– Pre-transfer – Telephone handoff– Physical transfer of patient– Pre verbal handoff report– Verbal handoff report– Post verbal handoff reporting

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ACT Tool  Yes No N/AOrganization assessment  1. Does the organization have a published handoff or transfer policy? 

a. If yes, is all staff aware of it? b. If yes, does staff know where to find it?

2. Have staff received evidence-based training on               a. General patient safety and quality?              b. Systems based / or the science behind patient safety and quality?              c. Handoffs and transfers and their importance?               d. How to meet patient/family needs related to handoffs and transfers?              e. Other (e.g. TeamSTEPPS, non–didactic training)? :  Please specify:  ________________________ 3. Have data on the following topics been collected, summarized and disseminated within the past year at 

the sending and receiving units?  a. Coordination between units (Transitions of care survey or internally developed survey)

i. If yes, have the results been used to improve coordination? b. Teamwork between units (Teamwork across units tool or internally developed survey) 

i. If yes, have the results been used to improve teamwork?  4. Does your hospital adequately consider device compatibility between and across units when making 

purchasing decisions? 5. Are handoff checklists or tools currently used during transitions of care?

a. If yes, was the checklist or tool developed with input from all key players (including receiving and sending units)? b. If yes, are the sending and receiving units use the same checklist? c. If yes, has the checklist or tool been reviewed and / or updated within the past year?

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ACT: At the Organizational LevelGood Practices• Handoff policy : Exists and all staff are aware of it and know where to locate• Adequate and appropriate training on care transitions and handoffs• Consider compatibility of devices across units when making purchasing decisionsACT

1. Does the organization have a published handoff or transfer policy? a. If yes, is all staff aware of it?b. If yes, does staff know where to find it?

2. Have staff received evidence-based training on a. General patient safety and quality?b. Systems based / or the science behind patient safety and quality?c. Handoffs and transfers and their importance? d. How to meet patient/family needs related to handoffs and transfers?e. Other (e.g. TeamSTEPPS, non–didactic training)? : Please specify:_______________4. Does your hospital adequately consider device compatibility between and across units

when making purchasing decisions?

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ACT: At receiving unit prior to verbal handoff

• Room ready for patient on arrival• At least one nurse in addition to the primary nurse should be present to receive the patient

(dependent on patients condition)• When transferring cables and lines

– Cables and lines should be transferred sequentially– Warning should be provided prior to disconnecting– No more than a 30s disruption

Pre verbal handoff assessment13. Was the room ready for the patient on arrival (i.e., bed lowered, chair in room set up for patient, suction equipment available, O2 regulator in place)?14. Was there at least one nurse present in addition to the primary nurse when the patient arrived at the receiving unit to help stabilize the patient?17. If lines, tubes and cables were transferred to a new monitor,

a. Were all key parameters visible throughout, with less than a 30s disruption?a. Was a verbal warning provided prior to disconnecting the key line, tube,

wire or cable?

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ACT• Part I: The Organizational assessment – should be carried out once every 6 months

• Part II: Specific Handoff Level Assessment– 10-20 random care transitions should be

evaluated every 6 months (or as interventions/ changes to the handoff process are introduced)

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Who should collect data with ACT?

• Select an observer who is familiar with the care transition of interest. – Ideal observer: One with a clinical and/or human factors background

with some experience in conducting or studying handoffs

• Will shadow the patient from about 10-30 minutes prior to the transfer process to about 10 minutes after the conclusion of the verbal portion of the handoff

• The observer should not be involved in the transition.

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We Need Your Help!• Please identify 1-2 people who can be site champions 

for the OR-ICU and ICU-floor transitions– Clinicians, quality improvement or human factors specialists– Familiar with the handoff process– Willing to conduct observations– Will be acknowledged for their contributions as the “Handoff 

Improvement Champions” Group in the related publication.– Can only improve handoffs if we collaborate and learn from

each other! • Lessons learned (good practices, things to avoid) from various sites

will be shared (without any identifiable information)

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Please Identify your Handoff Site Champions!

• Please send us the contact information by August 30th via email (csts@jhmi.edu):– Will have a special session to work with the

Handoff Champions Group on the logistics of the ACT Tool, how to use it, etc.

• EVERYONE: Please review the ACT tool and send Ayse Gurses (agurses1@jhmi.edu) any of your comments/additions/edits, etc. THANKS SO MUCH!

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Handoff/Transitions of Care Toolkit

• New material – Assessment of Care Transitions (ACT) – Participatory user centered design approachUpcomingto tool / checklist development

• Reinforcement– Teamwork across unit tool  – Barrier identification and mitigation tool Upcoming

• Currently implemented– Transitions of care survey – Part of HSPOS – Relational Coordination

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Thank you!

Ayse P. Gurses, Ph.D. agurses1@jhmi.edu

Mahiyar Nasarwanji, Ph.D. mnasarw1@jhmi.edu