Improving information transfer

The Centre of Research Excellence in Patient Safety will examine attributes of communication that will either facilitate or produce barriers to delivering safe care. Techniques such as simulation and video taping of clinical encounters will be used in conjunction with human factors engineering concepts as tools to assist in understanding how adverse incidents occur. The use of real-life and simulated situations will test the transition of theory into practice.

Trauma Reception and Resuscitation Project

Investigators: Nathan Farrow, Mark Fitzgerald
Background: The Trauma Reception & Resuscitation (TR&R) Project tested the hypothesis that the implementation of real-time, computer-prompted algorithms in the first half hour of major trauma management would result in a measurable reduction in management errors. An interventional study employing a randomised controlled trial was used to measure the effect of real-time, computer prompted, evidence-based algorithms on algorithm deviation and error occurrence during trauma resuscitation. Computer assisted video audit allowed objective identification of algorithm deviation and error. Data analysis demonstrated that real-time decision support improved protocol compliance and significantly decreased errors of omission during the initial resuscitation of major trauma patients.
Aims: The TAC funded Trauma Reception & Resuscitation (TR&R) Project tested the hypothesis that the implementation of real-time, computer-prompted algorithms in the first half hour of major trauma management would result in a measurable reduction in management errors.
Methods: This was an interventional study 0f 1187 severely injured patients employing a randomised controlled trial was used to measure the effect of real-time, computer prompted, evidence-based algorithms on algorithm deviation and error occurrence during trauma resuscitation. Computer assisted video audit allowed objective identification of algorithm deviation and error.
Results: Computer aided decision support for Medical and Nursing Trauma Teams improved protocol compliance and significantly decreased errors of omission during the initial resuscitation of major trauma patients. This is a ‘world first’ study that demonstrates that computer-aided decision support reduces errors during the initial resuscitation of major trauma patients. Introduction of this technology is expected to reduce morbidity and mortality of the severely injured. Shock management errors reduced by 26% and the need for blood transfusion was significantly reduced (p<0.0001).
Status: Completed
Publications:

1. Lee G, Farrow N, Fitzgerald M, Cameron P, Bystrzycki A, Gocentas R, McNeil J. Innovative technology to improve trauma patient outcomes – the trauma reception and resuscitation project. Australasian Emergency Nursing Journal 2005; 8(3) 122-3.
2. Mark Fitzgerald, Rob Gocentas, Linas Dziukas, Peter Cameron, Colin Mackenzie, Nathan Farrow. Using video audit to improve trauma resuscitation – time for a new approach. Can J Surg, June 2006;49(3):208-11.
3. Mark Fitzgerald, Adam Bystrzycki, Nathan Farrow, Peter Cameron, Thomas Kossmann, Michael Sugrue, Colin Mackenzie. Trauma Reception & Resuscitation. ANZ J Surg, 2006:76(8):725 -28.
4. Mitra B, Mori A, Cameron P, Fitzgerald M, Street A, Bailey M. Massive Transfusion and Trauma Resuscitation. Injury. 2007 Sep;38(9):1023-9.
5. Colin F. Mackenzie, Yan Xiao, Fu-Ming Hu, Jacob Seagull, Mark Fitzgerald. Video as a Tool for Improving Tracheal Intubation Tasks for Emergency Medical and Trauma Care. Ann Em Med. 2007 Oct;50(4):436-442.
6. Fitzgerald M, Mackenzie C F, Marasco S, Hoyle R, Kossmann T. Pleural Decompression and Drainage during Trauma Reception and Resuscitation. Injury 2008 Jan:39;9-20.
7.  Mark Fitzgerald, Nathan Farrow, Pamela Scicluna, Angela Murray, Yan Xiao, Colin F. Mackenzie. 'Challenges to Real-Time Decision Support in Health Care', Chapter in - Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: New directions and alternative approaches. Vol. 2. Culture and Redesign. AHRQ Publication No. 08-0034-2. Rockville, MD: Agency for Healthcare Research and Quality; August 2008

Enhancing communication transfer between the Ambulance Service and the Emergency Department

Investigators:Patrick I, Evans SM, Fitzgerald M, Cameron PA, McCabe N.
Project Coordinator:Dr Sue Evans
Background:Communication errors are costly, both in human and economic cost. Clinical handover provides a particularly vulnerable period for communication errors.  The transfer of information between paramedics and the trauma team in the receiving hospital offers unique challenges to achieving effective handover.  There is often little time to document extensive information about the patient’s condition in transit to hospital resulting in substantial dependence on memory by paramedics when providing a verbal handover. The complex nature of trauma events  and the time critical nature of transmitting information to multiple people with many interruptions, coupled by the need for receiving trauma teams to rely on memory when paper documentation is not present increases risk that information will be lost or misinterpreted.In recognition of the need to transmit information succinctly and methodically paramedics are taught to handover using a format known as MIST.  We do not know (a) whether the MIST format is used effectively and meets the needs of the receiving trauma team; or (b) the extent to which information loss occurs when information is handed over from paramedics to trauma team members, in an Australian context. Evidence demonstrates that early transmission of critical information through mobile networks improves communication between paramedics and treating medical teams and results in patients receiving more timely treatment on arrival in the ED  The VACIS has been developed as an electronic medical record for use by paramedics in Australia. Work is underway to enable information to be transmitted in advance by paramedics to receiving hospital IT systems.  However, currently no work has been done to evaluate what information would best assist clinicians in receiving hospital provide better patient care and how this can most effectively be done by paramedics.
Aims:This project will advance trauma care and practice by:

• Assessing current practice with regard to handover of information between paramedics and the trauma team. The educational benefit of this project is significant. Currently the quality of the handover process between paramedics and the trauma team is not well evaluated. No published studies have been undertaken in an Australian context to identify whether verbal handover is performed consistently and effectively.
• Providing a framework to assist paramedics in ensuring that there is congruence between what paramedics believe should be handed over and what trauma team members want to know.
• Informing a body of work which will ensure that vital information is transmitted in a timely manner and displayed in the receiving hospital trauma bay so that it can be accessed by all members of the trauma team and used to enhance decision making. Currently if members of the trauma team are not present when verbal handover is provided by paramedics, information relating to pre-hospital care might not be accessible until the full written report is provided by the paramedics. This occurs, on average, 20 minutes after arrival in the hospital.  Even when trauma team members are present at the time of handover, much of the information transmitted verbally is not retained by the trauma team.  Only 36% of information being handed over verbally by the paramedic is recalled by the treating physician. The more severe the trauma, the less likely it is that recall of information will occur.  Physicians are more likely to recall details of the crash scene (46%), than they are of the patients’ health status (34%) or information about their pre-hospital management (30%).
• Informing a body of work which is designed to improve coordination of care in the ED. It is hypothesized that real-time transmission of data will increase situational awareness of the patient’s condition on arrival in the ED. This has potential to improve coordination of care.   This has been demonstrated in the University of Maryland Medical Center, where wireless transmission of data to the ED resulted in better coordination of care and decreased need for labour-intensive voice communication.

Results: Please see REPORT
VACIS Telecommunication Technology Reports
Feasibility Report
CHI Report on Voice recognition for VACIS Tablets
Status:Project completed 2008. 
Publications: (Submitted)
Staff:Ms Angela Murray,Ms Sue Smith,Dr Sue Evans
Student/s: N/A
Contact Person:Dr Sue Evans - sue.evans@monash.edu

Clinical Handover – Maternity Health Care

Project Coordinator: Dr Georgiana SM Chin 
Investigators: Professor Peter Cameron, Dr Narelle Warren; Associate Professor Louise Kornman
Aims: This project will identify the key requirements for effective and safe clinical handover to inform future research and interventions to improve the process of clinical handover.
Method: This project will be undertaken in maternity health care and will advance current knowledge of how to effectively improve communication of critical information between staff. While this study will be implemented primarily in the Birth Suite setting it is anticipated that the findings will have elements which have general application to other areas of clinical practice. The project involves literature review, audit in incident report data and stakeholder perceptions study (interview, focus group and survey data) and ethnographic study of Birth Suite shift handover. The information that is obtained from this study is to assist in the better understanding of clinical handover through the identification of the factors that enhance and degrade safety around this process. This information is to assist in future research and improvement strategies in clinicial handover.
Interim Results:
Incident report data. A retrospective review of 4.5 years of  consecutive incident reports at an Australian metropolitan tertiary maternity hospital revealed that 4.4% of reported incidents involved clinical handover with the primary problem reported being issues surrounding the information communicated. Handover was also seen to provide a protective mechanism in some incidents by identification of the problem/s through the clarification of management plans at handover.
Stakeholder Perceptions: Patients. Maternity patients are aware that handover takes place. They wish that their name be handed over, information handed over to be relevant and relating to them on a personal level (e.g. concerns that they express to staff, how they were coping or feeling), discussions regarding their care that occurred between them and the clinician and to reflect at least an awareness of the presence of a birth plan authored by the patient. They felt that information that might result in bias against the patient is best excluded from the handover. Half of the patients interviewed expressed a preference for handover to be performed in the Birth Room although those who did not wish to be present in the handover did not want to be distracted from their labour or increase stress by the handover. Some felt that patients not being present in the handover increased the safety and efficacy of the handover by allowing for more open discussion. Clinicians. Further thematic analysis of data currently taking place.
Ethnographic Study of Birth Suite Shift Handover. Preliminary results show that global  multidisciplinary/ obstetric handover is quite distinct from global midwifery shift handover. Multidisciplinary/obstetric handover is diverse with regards to elements such as setting and leadership of handover. There is a greater consistency observed in the same elements of handover applied to the midwifery global shift handover. There were some similarities in purpose and utility of the handover (e.g. information transfer, continuity of care and ensuring safe and good care) between both groups of global shift handover but some differences as well. Strategies to enhance safety around the shift handover were also reported by participants and directly observed.
Status: Data analysis and write up.
Publications:
Chin GSM, Warren N, Kornman LH, Cameron P. Comparing multidisciplinary/ obstetric and midwifery Birth Centre shift handovers to inform handover improvements. 14^th Annual Congress of the Perinatal Society of Australia and New Zealand (PSANZ) Oral Abstract A018. J Paediatr Child Health. 2010; 46 (s1): 12.
Jeffcott SA, Evans S, Cameron P, Chin GSM, Ibrahim JI. Improving measurement in clinical handover. Qual Saf Health Care. 2009; 18(4): 272-277.
Conferences/ Seminars:
Chin GSM, Warren N, Kornman L, Cameron P. Building resilience around  Birth Centre shift handovers from a multidisciplinary perspective. Paper presented at: The Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG)  Annual Scientific Meeting; 2010 March 21 -24; Adelaide, Australia.
Chin GSM, Warren N, Kornman L, Cameron P. Comparing obstetric/ multidisciplinary and midwifery Birth Centre shift handovers to inform handover improvements. Paper presented at: 14^th Annual Congress of the Perinatal Society of Australia and New Zealand (PSANZ); 2010 March 28-31; Wellington, New Zealand.
Chin GSM, Jeffcott S, Kornman L, Cameron P. Patient perceptions of obstetric clinical handover (Pilot Study). Poster session presented at: 5^th Australasian Conference on Safety and Quality in Health Care; 2007 August 6-8; Brisbane, Australia.
Chin GSM. Transitions in care - Obstetric Clinical Handover. The study, observation and improvements in Obstetric Clinical Handover to improve the efficacy and patient safety in this practice. Paper presented at: 5^th Meeting on Quality Improvement and Patient Safety Research; 2007 April 16-17;  Lisbon, Portugal.
Chin GSM. The challenges of handover research. Paper presented at: NHMRC Centre for Research in Patient Safety (CRE-PS) Clinical Handover Workshop; 2007 February 24; Brisbane, Australia.
Students: Georgiana SM Chin
Contact: Georgiana SM Chin - gschi1@student.monash.edu

Managing interruptions and distractions in anaesthesia practice

Optimizing Trauma Team Performance (OTTP)

Project Coordinator: Shelly Jeffcott
Investigators: Peter Cameron, Shelly Jeffcott, Mark Fitzgerald, Nathan Farrow, Stuart Marshall
Background:  Recent acknowledgement of the importance of “non technical” skills, like decision making and leadership, has resulted in a proliferation of team training in both real and simulated healthcare settings.  However, there remain many unknowns regarding ideal team interactions in high-risk settings such as trauma.
Aims: To measure and investigate how team communication and coordination contribute to overall team effectiveness in the trauma resuscitation setting. To inform the development of training and education programs to improve team performance across the Victorian State Trauma System (VSTS)
Method: Methods include (1) video audit of 50-100 videos of the first 30 minutes of trauma resuscitation; (2) interviews and focus groups with a range of trauma professionals; and, (3) the linking of team scores as measured through the video audit with patient outcomes as collected through the Victorian State Trauma Outcomes Measurement Registry (VSTORM).
Results: Pending
Status: Design / Implementation
Staff: Shelly Jeffcott
Publications: Jeffcott S., Mackenzie C.  (2008). Measuring team performance in healthcare: Review of research and implications for patient safety. Journal of Critical Care, 23(2), 188-196.
Contact Person: Shelly Jeffcott, shelly.jeffcott@monash.edu