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Implementing IPASS Handoff to Improve Patient Safety in Pediatric Critical Care Transport

Published:January 16, 2023DOI:https://doi.org/10.1016/j.amj.2022.12.009

      Abstract

      Introduction

      The aim of this study was to implement a standardized, hospital-based bedside handoff report (IPASS [Illness severity, Patient summary, Action items, Situational awareness, and Synthesis]) in prehospital pediatric critical care transport to increase patient safety by eliminating the risk of misreporting or omitting critical patient care information received before arrival at a tertiary care center. The setting for this project was a level 1 pediatric trauma center in the Southern United States.

      Methods

      Pre- and postsurveys were used to assess staff perception of clinical handoff comprehensiveness and satisfaction with the use of a standardized IPASS handoff tool.

      Results

      Improvement was identified in 6 of 8 survey items. Team members were better able to hear all the information provided in the handoff, the format was functional, and physical transfers of patients from the transport team to the ED went more smoothly. Overall, satisfaction of the handoff process increased by 80%.

      Conclusion

      Many factors contribute to patient safety events and errors in health care, with communication failures contributing to the majority. Overall, findings support the use of standardized IPASS handoffs in pediatric critical care transport to promote patient safety, increase comprehension of patient information, and increase staff satisfaction.
      Ineffective or incomplete nursing handoff between staff members negatively impacts patient safety in the acute care setting.
      • Birmingham P
      • Buffum MD
      • Blegen MA
      • Lyndon A
      Handoffs and patient safety: grasping the story and painting a full picture.
      A successful nursing handoff that is structured and standardized within an organization can improve patient outcomes as well as other key nursing metrics such as reducing duplicate medication administration, increasing patient satisfaction, and increasing staff satisfaction.
      • Bukoh MX
      • Siah CR.
      A systematic review on the structured handover interventions between nurses in improving patient safety outcomes.
      Failure to discuss pertinent symptoms and treatments provided to the patient often leads to missing information that is critical for reducing patient harm.
      • Birmingham P
      • Buffum MD
      • Blegen MA
      • Lyndon A
      Handoffs and patient safety: grasping the story and painting a full picture.
      ,
      • Troyer L
      • Brady W.
      Barriers to effective EMS to emergency department information transfer at patient handover: a systematic review.
      Clinical research suggests that nursing handoff between shifts is often viewed as a routine exchange of information. However, communication failures, interruptions, omission of information, and lack of attentiveness account for many breakdowns in nursing handoff.
      • Tobiano G
      • Ting C
      • Ryan C
      • Jenkinson K
      • Scott L
      • Marshall AP.
      Front-line nurses’ perceptions of intra-hospital handover.
      Other factors that complicate handoffs include differences between unit priorities when transferring the patient from one unit to another.
      • Tobiano G
      • Ting C
      • Ryan C
      • Jenkinson K
      • Scott L
      • Marshall AP.
      Front-line nurses’ perceptions of intra-hospital handover.
      ,
      • Kear TM.
      Patient handoffs: what they are and how they contribute to patient safety.
      Errors are less likely to occur if handoff is completed at the patient's bedside using a standard approach.
      • Groves PS
      • Manges KA
      • Scott-Cawiezell J.
      Handing off safety at the bedside.
      ,
      • Costedio E
      • Powers J
      • Stuart TL.
      Change-of-shift report: from hallways to the bedside.
      Pediatric critical care handoffs are associated with a higher risk, increasing with each transfer of care until reaching the tertiary care center.
      • Troyer L
      • Brady W.
      Barriers to effective EMS to emergency department information transfer at patient handover: a systematic review.
      ,
      • VanGraafeiland B
      • Foronda C
      • Vanderwagen S
      • et al.
      Improving the handover and transport of critically ill pediatric patients.
      There is significant evidence that suggests a consistent approach to handoff and the use of a standardized handoff tool promote patient safety and facilitate good communication techniques.
      • Rosenthal JL
      • Doiron R
      • Haynes SC
      • Daniels B
      • Li STT.
      The effectiveness of standardized handoff tool interventions during inter- and intra-facility care transitions on patient-related outcomes: a systematic review.
      One such handoff tool is the IPASS (Illness severity, Patient summary, Action items, Situational awareness, and Synthesis), which includes key elements of nursing handoffs, including patient summary, action planning, and nurse synthesis of the information provided.
      • O'Rourke J
      • Abraham J
      • Riesenberg LA
      • Matson J
      • Lopez KD.
      A Delphi study to identify the core components of nurse to nurse handoff.
      Created by a group of pediatric specialists in 2010, the IPASS was developed to address pediatric-specific gaps in handoffs of care.
      • Starmer AJ
      • Spector ND
      • Srivastava R
      • et al.
      Changes in medical errors after implementation of a handoff program.
      When used in a structured format, the IPASS in the pediatric setting was shown to increase compliance, decrease interruptions in handoff, and reduce errors.
      • O'Rourke J
      • Lopez KD
      • Riesenberg LA
      • Abraham J.
      Comparison of a nurse-nurse handoff mnemonic with real-world handoffs.
      The objective of this study was to implement a standardized, hospital-based bedside handoff report (IPASS) in prehospital pediatric critical care transport to increase patient safety and decrease the risk of misreporting or omitting critical patient care information gathered before patients’ arrival at a tertiary care center. This project aligns with current hospital-wide initiatives by implementing and evaluating a structured IPASS handoff between the transport team and the emergency department (ED) to use both verbal and written tools to increase communication techniques and the retention of information sharing as well as a multidisciplinary team approach to patient handoffs. This extends the hospital's use of structured handoffs to the prehospital and ED settings.

      Methods

      Study Setting and Population

      The setting for this project was a level 1 pediatric trauma center in the Southern United States serving a rural population where access to pediatric care is limited. The transport team works directly for the state's only pediatric health care system, transporting pediatric and neonatal patients to tertiary care from referring hospitals both in and out of state. The transport team is composed of a registered nurse and a registered respiratory therapist supported by in-depth protocols and medical control from the pediatric intensive care unit on-duty attending critical care medicine physician. The modes of transport consist of rotor wing, fixed wing, and ground ambulance transportation, and the total volume of annual transports is approximately 2,000 patients per year. Patients transported to the ED consist primarily of traumatic injuries or other general surgery complaints requiring rapid evaluation and stabilization by the trauma team or other surgical subspecialties.
      The implementation period for this study included handoffs on all patients (aged 8 days and older) transported by the specialized pediatric critical care transport team to the pediatric level 1 trauma center ED.

      Data Collection

      Anonymous pre- and postsurveys were adapted with permission from peer-reviewed articles to measure satisfaction and comprehensiveness of the IPASS handoff process.
      • Caruso TJ
      • Marquez JL
      • Wu DS
      • et al.
      Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration.
      • Petrovic MA
      • Aboumatar H
      • Baumgartner WA
      • et al.
      Pilot implementation of a perioperative protocol to guide operating room–to–intensive care unit patient handoffs.
      • Benton SE
      • Hueckel RM
      • Taicher B
      • Muckler VC.
      Usability assessment of an electronic handoff tool to facilitate and improve postoperative communication between anesthesia and intensive care unit staff.
      The anonymous surveys were distributed in electronic format to all ED nurses and medical staff as well as the medical crew for the transport team. Pre-existing e-mail distribution groups were used to reach all eligible staff.

      Study Design

      This quality improvement project used a pre-post design to evaluate the perception of comprehensiveness and satisfaction with the IPASS handoff. In the past year, staff members were assigned online education about the IPASS from the hospital's education department. Institutional review board approval was obtained from the local site before implementation and was deemed a quality improvement project not human subject research.

      Survey

      Each study participant completed an 8-question survey to assess staff perception of clinical handoff comprehensiveness and satisfaction with the use of a standardized IPASS handoff tool. Surveys were distributed in REDCap (Vanderbilt University, Nashville, TN) via a link received in their dual-verification, password-protected work e-mail. Presurveys were sent out 2 weeks before implementation of the IPASS handoff start date to obtain baseline data. The questions were in statement format and ranked as follows: always (4), sometimes (3), rarely (2), and never (1). Demographic information about role (ED nurse, ED medical staff, or transport team) and years of service was included in the survey. This demographic information was used to identify trends and patterns to determine whether there is a correlation between role or years of service in relation to the handoff process change. Postsurveys were sent out after the 2-month implementation period and were active for a 2-week period to allow study participants to record their responses. All participants in the handoff (both the transport team and the ED team) were surveyed.

      Statistical Analysis

      Data were analyzed using SPSS version 29 (IBM Corp, Armonk, NY). Provider characteristics are depicted in Table 1, showing greater participation and higher years of service (mean) in the presurvey compared with the postsurvey. The presurvey was collected almost equally from the ED (51%) and the transport team (49%), showing a fair representation of each role in the evaluation of the handoff process. The postsurvey was composed mostly of transport team members (59%), with fewer responses from the ED (41%).
      Table 1Provider Characteristics
      VariablePre (n = 39)Post (n = 22)
      Role, n (%)
       ED nurse11(28.2)7 (31.8)
       ED medical staff9 (23.1)2 (9.1)
       Transport team19 (48.7)13 (59.1)
      Years of service, mean ± SD13.39 ± 9.7711.95 ± 8.58
      ED = emergency department; SD = standard deviation.

      Results

      In total, surveys were sent to the following groups: ED nurses (91); ED medical staff (approximately 50) including pediatric emergency medicine attendings, pediatric emergency medicine fellows, and advanced practice registered nurses; and the transport team (29) including 15 transport nurses and 14 transport respiratory therapists.
      Each survey item was compared between pre- and postintervention using Mann-Whitney U tests because the data set was of ordinal ranking. The findings are displayed in Table 2 and show statistically significant results in 6 of the 8 survey items based on P values < .05 (survey item numbers 1-4, 6, and 7). In addition, clinically meaningful and noteworthy results were identified in 7 survey items (survey items numbers 1-4 and 6-8). Of those items, 4 directly indicated an improvement in staff satisfaction (survey item numbers 1 and 6-8), whereas the other 3 items (survey items numbers 2-4) depicted staff perception of comprehensiveness. Survey item number 6 demonstrated the highest level of improvement and that staff members would recommend using the IPASS handoff to their coworkers (P < .001). Team members were better able to hear all the information provided in the handoff (survey item number 2, P = .03), the format was functional (survey item number 7, P = .01), and physical transfers of patients from the transport team to the ED went more smoothly as indicated by an increase in median scores (survey item number 8). Overall, staff satisfaction with the handoff process increased (survey item number 1, P = .04).
      Table 2Mann-Whitney U Test Results
      Survey ItemPre (n= 39)Post (n = 22)z ValueP Value
      Median (IQR)Median (IQR)
      I am satisfied with the handoff between the ED and Angel One transport team.
      A satisfaction domain item
      3 (2-4)3 (3-4)−2.06.039
      I could hear all of the report.
      A comprehensiveness domain item.
      3 (3-4)4 (3-4)−2.19.029
      Handoff start and end were clear.
      A comprehensiveness domain item.
      3 (2-4)4 (3-4)−2.11.035
      Disruptions interrupted the handoff.
      A comprehensiveness domain item.
      3 (3-3)3 (2-3)−2.75.006
      This handoff helps me to be more effective.
      A satisfaction domain item
      4 (3-4)4 (3-4)−1.92.055
      I would recommend this handoff process to a coworker.
      A satisfaction domain item
      3 (2-4)4 (4-4)−3.48<.001
      This handoff works the way I want it to work.
      A satisfaction domain item
      3 (2-4)4 (3-4)−2.61.009
      Physical transfers went smoothly.
      A satisfaction domain item
      3 (2-4)4 (3-4)−1.48.139
      IQR = interquartile range.
      Scale is never (1), rarely (2), sometimes (3), and always (4); IQR is displayed as P25 -P75.
      a A satisfaction domain item
      b A comprehensiveness domain item.
      Project fidelity was assessed using data collected from the transport team electronic health record. Transport nurses are required to document in a yes/no field whether the IPASS handoff was completed with the receiving ED multidisciplinary team. Forty-one patients were transported by the pediatric critical care transport team to the pediatric level 1 trauma center during the implementation period, and IPASS documentation was marked “yes” for all 41 transports. The modes of transport for patients during this implementation period included 26 rotor wing transports, 15 ground ambulance transports, and 0 fixed wing transports.

      Discussion

      Descriptive statistics from the demographic data yielded remarkable and surprising findings. Staff members reported a mean of 13.39 years of service in the presurvey and 11.95 years in the postsurvey, which was higher than expected. With high levels of staff turnover (primarily due to the coronavirus disease 2019 pandemic) and an increase in the number of new graduate nurses, an anticipated higher response rate from the new nurses who might be more receptive to quality improvement was expected. Reaching the more experienced staff suggests that we were able to influence the culture of the handoff process in a way that allows experienced nurses to be role models and guide the newer nurses, ensuring the process continues over time.
      Another surprising finding included the decrease in scores regarding disruptions in the handoff process (survey item number 4, P = .01). Although the results of this survey item demonstrated continued room for improvement, the results could be suggestive of highlighting a problem not previously recognized. Although team members did not see this as an issue in the presurvey results, an increased awareness of an overstimulated environment allowed the staff to watch for these disruptions, which could explain the decrease in the postsurvey scores.

      Written IPASS Form

      An IPASS form was created based on research suggesting that nurses retain written information better than a prepopulated report from the electronic health record.
      • Buus N
      • Hoeck B
      • Hamilton BE.
      Nurses’ shift reports: a systematic literature search and critical review of qualitative field studies.
      ,
      • Johnson M
      • Cowin LS.
      Nurses discuss bedside handover and using written handover sheets: bedside handover - strengths and weaknesses.
      This form was designed as an aid for information retention and structured to strictly follow the IPASS format. The form was completed by the transport registered nurse and given to the ED nurse after the verbal handoff was completed. Additionally, this form assisted in creating a more comprehensive medical record by allowing for referring hospital and transport data to be input into the “prehospital” section of the electronic health record. Consistent use of the written form brought the IPASS structure to the forefront as well as promoting collaboration and sustainability of the handoff between the ED and transport teams.

      Multidisciplinary Approach

      Medical institutions recognize the value of gathering the entire team (physicians, nursing, respiratory, and so on) to the bedside during patient escalations of care. Similarly, in patient handoffs, having the entire team available supports optimal comprehension of prior events and future interdisciplinary care planning. This practice decreases confusion and creates the opportunity for all team members to ask questions and hear reports at the same time.
      • Fealy G
      • Donnelly S
      • Doyle G
      • et al.
      Clinical handover practices among healthcare practitioners in acute care services: a qualitative study.
      A future quality improvement opportunity would be to address multidisciplinary attendance, involvement, and patient outcomes related to the IPASS handoff process.

      Limitations

      There were limitations in this study, including the small sample size and the low response rates. During the implementation period, only 41 of a total 349 patients transported were taken to the ED, leaving fewer than expected interactions to solidify the new standardized handoff process. Shifting the time frame from summer to fall decreased the expected volume of patients. Staff burnout from the COVID-19 pandemic affected staff engagement and response rates. Necessary changes in patient protocols and decreased staffing along with record-setting patient volumes and increased patient acuity took precedence over staff involvement with this quality improvement project.

      Conclusion

      Many factors contribute to errors in health care, with communication failures contributing to a significant number. One strategy to avoid these errors is to focus on accurate communication both by the speaker and the receivers during patient care handoffs. This includes creating a quiet space for handoff to occur and ensuring that the appropriate caregivers are present.
      Feedback from the transport team was overwhelmingly positive, portraying that handoff felt more complete and held the transport team to a higher level of care and accountability. The addition of a written IPASS tool aided in the success of this project by bringing the IPASS structure to the forefront of patient care interactions, promoting collaboration and sustainability. Statistical and clinical significance support implementing standardized IPASS handoffs in pediatric critical care transport to promote patient safety, increase the comprehension of patient care information, and increase staff satisfaction with the handoff process.

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