Bedside Reporting

Regis Student NursesMelanie Bartels, Erin Hoffman, Perry Horner, Natasha Montoya,

Sarah Osag & Karina Rodriguez

What is a Handoff Report?

● Communication between shifts & caregivers● A complex “transfer of information (along with authority & responsibility) during

transitions in care across the continuum; to include an opportunity to ask question, clarify & confirm.” (Friesen, White & Byers, p. 2-1)

● Purposeo Convey essential information related to patient care. o Improved continuity of care & therapeutic goal achievement.o Ensure safe transfer of care to a competent & qualified nurse.o Opportunity for education, debrief, socialization, planning, organization &

teamwork.

The Details ● Many types of nursing reports / handoffs

o Shift change, Unit transfer, Unit to diagnostic area, Discharge / interfacility, Medication transfer reports

● Methodso Patient involvement? o From memory or with notes / brain sheeto Verbal - with or without notes

Bedside, telephone, audio recording, o Nonverbal

Handwritten bedside notes, electronic reports, computer printouts● Influences

o Culture of the organization - open communication? non-hierarchical? who they turn to for assistance.

o Nurse experience - report ability, knowledge of what to include, resources for assistance.

Poor Handoff: Why does it matter?

● Components of a poor handoffo Omission of important informationo Distractiono Limited / Illegible documentation & Lack of transfer form useo Incomplete records or medication reconciliationo Poor accessibility to informationo Limited guidelines

● Consequences:o Reduced therapeutic progression.o Increased likelihood of adverse patient outcome.o Essential information is not relayed.o Compromised patient safety & lower quality of care.

● Unit customization required.● Protocols / Standardized process & steps of hand off report .

o Mnemonic Checklists 5 P’s - Patient/project, plan, purpose, problems & precautions A.I.D.E.T - Acknowledge, Introduced, Duration, Explanation & Thank you

● Attainment of Goalso Increased accuracy & inclusion in information.o Improved patient & nursing staff satisfaction.o Improved patient safety & outcome.

An Effective Handoff

PICO QuestionPopulation: Patients and nurses on med/surg floors

Intervention: Bedside Reporting

Comparison: Report given outside patient’s room

Outcome: Increase in patient safety, satisfaction, & outcome. Increase in nurse satisfaction.

Research question:• On hospital med/surg floors, does patient safety, satisfaction, and outcome

as well as nurse satisfaction increase when nurses do bedside report versus report given outside the patient’s room?

Research Methods● Databases:

CINAHL, EbscoHost, MEDLINE, and PubMed

● Keywords: bedside report, shift report,

report, safety, nurse satisfaction, patient satisfaction

● Inclusion Criteria: Articles within 5 years, peer reviewed,

evidence-based practice, studies performed within inpatient hospitals

Levels of Evidence

Level Qualitative or

Quantitative

Sources Theoretical or Conceptual framework

Sample size, Target population, & Setting

Instrument

Level 1

Quantitative &

Qualitative

Vines, et. al. 2014

Hildegard Peplau’s interpersonal relations theory & Kurt Lewin’s

theory of planned change

9 articles chosen for review.Inclusion criteria: 2006-present, hospital

clinical care settings, adult patient population, relevance/purpose statement

Items measured: patient & RN satisfaction.

Academic Search complete, Article fast, CINAHL, Cochrane, MEDLINE,

PubMed, WorldCat

Level 1

Quantitative &

Qualitative

Sherman, et. al.2013

Rosswurm larrabee model for EBP

change.

12 articles chosen for review.Inclusion criteria: 1975-2011,

Sample size not identified in 6/12. 5/12 quantified data.

CINHAL, PubMed

Level 3

Quantitative &

Qualitative

Dearmon, et. al2013

Transtheoretical Model of behavior

change.Transforming Care at the Bedside (TCAB)

national initiative

University affiliated Academic Health Sciences Center (regional Level 1 trauma),

med/surg floor.Control unit =

30 beds, 25 RN’s, non-bedside reportTCAB unit =

35 beds, 30 RN’s, bedside report

Staffing data, nurse activity data, Institutional monthly reports, patient telephone survey, individual staff

interviews, focus groupsMean, SD, t-test, Wilcoxon

test, time series plots, p= .05

Levels of Evidence

Level Qualitative or

Quantitative

Sources Theoretical or Conceptual framework

Sample size, Target population, &

Setting

Instrument

Level 4

Quantitative & Qualitative

Evans, et. al.2012

Grounded theory 6 month pilot study: 32-bed med/surg unit at University of

Michigan (8 beds used)

Log books, observations, standard operating procedure (SOP), script, time

spent on report, nurse satisfaction survey, team audit,

Baseline data compared with post implementation data.

Criteria for bedside report: 30 min. or less, verbal, at bedside, pt. flow sheet, joint

environmental safety scan of room.

Level 6

Qualitative Maxson, et. al.2012

Grounded theory

60 patients, 30 before practice change, 30 after practice

change, 15 nurses w/ avg. 2 years experience

Survey to patients and staff nurses

Levels of Evidence

Critique of Evidence

● Applies to population

● Research question clearly defined

● Methods appropriate for studies

● Articles within the last 3 years

● Variety: Four different levels of evidence used

Results of Research: Nurse Impacts

Advantages:● Better prioritization & preparedness at the beginning of the shift● Increased satisfaction and accountability● Environmental safety scan ● Decreased use of subjective language during report, such as unclear

acronyms, abbreviations forbidden by hospital policy ● Decreased report time

o A 2006 study found that implementation decreased overtime by 100 hours in the first 2 pay periods & that handoff would only take 2-5 min per patient.

Disadvantages :● Nurses were slow to adopt the new process and needed constant

reinforcement.● Some patients monopolized the time so patient teaching

regarding report was needed.● Nurses were concerned about HIPAA violations for patients not

in private rooms.

Results of Research: Nurse Impacts

Benefits• Improved Patient Satisfaction / Perceptions

o HCAHPS & Press Ganey scores increased post-implementationo Direct patient care begins sooner in shift o Felt informed of plan & of health care team members for the dayo Felt involved in care, included in treatment decisionso Faster discharge times

• Patient Safetyo Decreased patient falls during shift changeo Decreased medication errors\o Improved timeliness of dressing & IV replacement

Results of Research: Patient Impact

Disadvantages

• Medical jargon can be difficult for patients to understand

• Tiring repetition of information

• Patient anxiety related to hearing about their illness & incorrect information

• Lack of privacy

Results of Research: Patient Impact

Results of Research: Patient Impacts

Vines et al (2014) Research:

● 32-Bed Surgical Unit: “Eight months after initiation, HCAHPS scores showed bedside report increased in client satisfaction within three key areas of communication: 1) nurses kept patients informed (56-99%), 2) staff worked well together to provide care (98-99%) and 3) staff included patients in decisions regarding treatment (58-97%)” (Anderson & Mangino, 2006)

● 24-Bed Telemetry Unit: “Press-Ganey satisfaction scores showed initiation of bedside report contributed to a 4.4% increase in overall client satisfaction and a 5.5% increase in client perceptions of being informed.” (Freitag & Carroll, 2011)

● 592-Bed Acute Care Hospital: “Within 6 months of implementation, HCAHPS scores within nursing communication increased 8%, confirming the positive influence of bedside report on client satisfaction.” (Reinbeck & Fitzsimmons, 2013)

Sherman, Sand-Jecklin & Johnson (2013) Findings:

● 34-Bed Progressive Care Unit: Patient falls decreased (between 7am and 7:30am) from 8 falls in the 6-month period pre-implementation to 1 fall in the 6 month period post-implementation.

(Athwal et al, 2009)

Summary

● Published literature is highly positive but findings are not generalizable.

● Each study focused on diff potential benefits but there has been little reproduction.

● Other facilities may have had negative findings that were not published.

● Implementation requires a substantial change in how experienced nurses give report & unsuccessful implementation could be the result of an inherent problem with the bedside report process.

● Positive finding suggest beside nursing report may lead to improvements in patient outcomes, as well as patient & nursing satisfaction.

● Published evidence is highly anecdotal in nature

● Risks associated with this practice change are relatively low.

● More QUANTITATIVE research with adaquate sample sizes & details of previous method of handoff report.

● Comparative research related to bedside report’s impact on staff overtime, patient falls, discharge times, med errors, dressings & IV replacement times.

● What is the relationship between:o Whiteboard use during bedside report & patient / nurse satisfactiono Bedside report & the activation of rapid response / code teams

● Are there styles of bedside or hybrid report that are more effective than others?

Future Research Needs

P2: A Case Study

Current Similarities:

o AIDET implemented

o Offgoing & oncoming nurse greet patient together for introductions.

- Oncoming nurse introduces self & updates whiteboard & reviews basic plan of care for the day - Offgoing nurse says goodbyes

P2: A Case Study

Current Differences:

o Exchange of information between shifts performed away from patient bedside.

o Patient not involved.

o Friendly hand-off sheets are utilized.

Does the evidence justify changes at Rose?

● Patient Preference-o Ratings from the hopsital compare tool on Medicare.gov report:

Patients who reported that their nurses "Always" communicated well- Rose Medical Center average: 77%- National & Colorado Average: 79%

● Scientific evidence- o Research suggests that bedside reporting has a positive impact on patient

outcome & satisfaction.o Additional research needed.

● Clinical experience-o AIDET is currently in use at Rose

Implementation of Bedside Report on P2

Prior to implementation● Unit protocol of information included in bedside report.

o AIDET, 5 P’s, friendly hand-off sheet, reporting by exception, NPSF bedside report model, etc.

● Launch date set 1 to 2 months out in order for preperation.● Staff Training

o Computer training for all staff prior to launch dateo Charge nurses & mentors implement hands on training for nurseso Discussions & updates in morning huddles

Implementation of Bedside Report on P2

During implementation & ongoing

● Inform patient population of upcoming changeo Posters, website, newsletter, etc.

● Monitor feedback from nurses, patients, and administrators.

● Evaluate time spent, impact on patient safety/outcome and satisfaction among nurses & patients.

● Make necessary changes to improve initial process.

● Reevaluate: Does bedside reporting have a positive impact?

Steps to Implement Change

● Are we Ready to Change?● Gather Multidisciplinary Team

o Hospital & Nurse leaders, unit nurses, etc.o Patients & family members

● Identify Facilititators & Barriers to Successo Formulate Plan to Overcome Barriers

● Define Standardized Bedside Report Procedure● Inform & Train Staff● Implementation● Evaluation & Refinement● Reassess

http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool2.html

● Barriers to Changeo Comfort with current methods of handoff report.o Reduced time for socializationo Unsure of what to do & sayo Concerns related to talking about condition/disease in front of patient or familyo Increased time to complete shift change

● Facilitators of Changeo Opportunity to increase patient satisfaction scoreso Poor communication of information at shift changeo Chance for improved prioritizationo Increased frequency & interaction with the patient & familyo Most nurses agree that bedside reporting has the potential to improve patient care

Transition to Bedside Reporting

Patient participation• Upon admission, educated on bedside report

& what to expect. • Made aware of upcoming report

30 – 60 minutes before shift change.

Bedside Report• AIDET guides interaction.• SBAR format• Verification of information• Patient involvement • Individualized goal setting• Outline of the day’s plan of care

Successful Report

National Paitent Safety Foundation(Currier, Joshi, & O’Brien, 2011)

Vines et al (2014) Research, Continued:

● “Bedside report significantly impacted responses. Clients and family members reported that nurses made sure they knew who their nurse was and included them in shift report discussion.” (178 clients, 72 family members) (Sand-Jecklin & Sherman, 2013)

● “For 6 months post implementation, client satisfaction scores increased by an average of 11.1 points (Press-Ganey instrument). Longitudinal results (23 months after initiation of bedside reporting) showed an increase of 6.9 points. (20 bed health center) (Wakefield et al, 2012)

Maxson et al (2012) Findings - Sample of 60 patients:

● Patient Likert Scale survey results improved when patients were asked about their satisfaction with; a) being involved in plan of care communication, b) being informed , and c) experiencing open communication, teamwork and professional behaviors in report. (Pre-implementation mean 1.5-2.0, Post-implementation mean of 1.0)

Appendix A: Additional Patient Impact Data

Evans et al (2012) - 32 Bed University of Michigan Hospital med-surg unit:

● “Improved prioritization: most acute patients are seen first after report, patients are seen within the first half hour of the shift and oncoming nurses are able to visualize the patient themselves rather than rely on colleague comments.”

● “Many nurses believe the process violates patient confidentiality and they are not comfortable with bedside report.”

● “Patients were more involved in their care and able to identify their caregivers for the shift, promoting client satisfaction. Bedside report increased direct care time to patients.”

Sherman, Sand-Jecklin & Johnson (2013):

● Time decreased from 30-60 minutes in between nurses coming on shift and the first patient being seen to 11 minutes. (Federwisch, 2007)

Appendix A: Additional Patient Impact Data, cont.

• Bedside Report Using SBAR : https://www.youtube.com/watch?v=dCLp8Kiiv1A

• Nurse Bedside Report/Handoff: https://www.youtube.com/watch?v=Leq_FV-gY7w

• Bedside Handover: https://www.youtube.com/watch?v=hbxPR-ra6RE

• Bedside Report Workshop Video: https://www.youtube.com/watch?v=IdIMfmKsnBg

Appendix B: Bedside Report Example Videos

ReferencesCurrier, A., Joshi, M.S., & O’Brien, K. (2011). Bedside Change of Shift Reporting: A Strategy to Increasing Patient Safety. NPSF. Retrieved

from: http://www.npsf.org/wp-content/uploads/2011/11/PLS_1110_MJ.pdf

Dearmon, V., Roussel, L., Buckner, E. B., Mulekar, M., Pomrenke, B., Salas, S., & ... Brown, A. (2013). Transforming Care at the Bedside (TCAB): Enhancing Direct Care and Value-added Care. Journal Of Nursing Management, 21(4), 668-678. doi:10.1111/j.1365-2834.2012.01412.x

Evans, D., Grunawait, J., McClish, D., Wood, W., & Friese, C. R. (2012). Bedside Shift-to-Shift Nursing Report: Implementation and Outcomes. MEDSURG Nursing, 21(5), 281-292.

Friesen MA, White SV, Byers JF. Handoffs: Implications for Nurses. Rockville, M.D.: Agency for Healthcare Research and Quality 2008 [updated 2008; cited 2008 April 23]; Available from: http://www.ahrq.gov/qual/nurseshdbk/docs/FriesenM_HOIN.pdf.

Maxson, P., Derby, K., Wrobleski, D., & Foss, D. (2012). Bedside nurse-to-nurse handoff promotes patient safety. Medsurg Nursing: Official Journal Of The Academy Of Medical-Surgical Nurses, 21(3), 140-144.

Sherman, J., Sand-Jecklin, K., & Johnson, J. (2013). Investigating Bedside Nursing Report: A Synthesis of the Literature. MEDSURG Nursing, 22(5), 308-318.

Vines, M. M., Dupler, A. E., Van Son, C. R., & Guido, G. W. (2014). Improving Client and Nurse Satisfaction Through the Utilization of Bedside Report. Journal For Nurses In Professional Development, 30(4), 166-173. doi:10.1097/NND.0000000000000057

Wakefield, D. S., Ragan, R., Brandt, J., & Tregnago, M. (2012). Making the transition to nursing bedside shift reports. Joint Commission Journal on Quality and Patient Safety, 38(6), 243-253.

Thank You