|TABLE 5.2 Sample Daily Goals Sheet|
|TABLE 5.3 Steps to Ensure an Effective Clinical Handover|
ICU Clinical Handover
The clinical handover is a verbal form of communication involving health professionals from one working shift communicating with those of the oncoming working shift. The purpose of the clinical handover is to enable effective transfer of responsibility and accountability from one health professional to another. While clinical handover has been shown to be a major source of communication failure and serious adverse events (30), health professionals rarely receive training in handover processes (31). Over recent years, standard operating procedures for clinical handover have been developed, which are tools (Table 5.3) or mnemonics that enable systematic communication of information with the ultimate goal of reducing communication failure and adverse events (32). A common clinical handover tool is the SBAR, which involves describing the patient’s situation, background, assessment, and recommendation of care (33). Use of these tools helps to ensure important components of the patients’ management and goals of care are addressed at clinical handover (34).
Another important aspect of clinical handover is attempting to involve patients and family wherever possible (35). Patient and family involvement in handover can assist in reducing communication breakdown and help to promote patient-centered care (36). Patients can participate in the conduct of clinical handover when they are nearing discharge from the ICU, which is a time they are likely to be conscious and alert.
Admission and Discharge Practices of ICUs
Consensus guidelines have been developed to provide general information about criteria and procedures for admission and discharge practices (37). These guidelines detail objective clinical parameters to assist health professionals in their decision-making about patient flow to and from the unit. Aside from consensus guidelines, organizational factors, which are closely linked to collaborative care, have been examined for associations between admission and discharge practices of critical care settings and patient mortality (38–40). Such organizational factors include open and closed systems and time of day.
OPEN AND CLOSED SYSTEMS
An organizational factor that has been examined in terms of admission and discharge practices is the open or closed system of care (19). In the open system, various health professionals are present in the unit, but physicians directing patient care have obligations at a site separate from the critical care setting, such as the operating room, or inpatient or outpatient areas. A physician with expertise in critical care may or may not be involved to assist with management of care in an open system arrangement. In a closed system, care is provided by a critical care–based team of physicians, nurses, pharmacists, respiratory therapists, and other health professionals (41).
In a cohort study, the medical records were examined of all consecutive high-risk surgical patients admitted to an ICU from 1996 to 1998 using an open format, and from 2003 to 2005 using a closed format (39). Mortality of patients was 25.7% in the open format group and 15.8% in the closed format group (p = 0.01). Mortality relating to a cardiopulmonary complication was higher in the open format group (12.2%) compared with the closed format group (8.3%; P = 0.02). Results suggest that a closed format was a more favorable environment than an open format in effort to minimize the effects of high-risk surgery.
TIME OF DAY
Another important organizational factor for admission and discharge practices is time of day, with specific attention to weekdays versus weekends and daytime versus nighttime. A cohort study of all 23,134 emergency admissions over a 3.5-year period showed that weekend critical care admissions were associated with an increased adjusted mortality compared with weekday admissions (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.01–1.43) (42). The adjusted mortality was similar for admissions made after business hours compared with those made during business hours (OR 0.98, CI 0.85–1.13). On the other hand, the adjusted risk of death was higher after business hours as compared with during business hours (OR 6.89, CI 5.96–7.96). The time of discharge from the ICU was not associated with additional hospital mortality. In another study involving propensity score matching analysis of 2,891 consecutive patients, nighttime admission was associated with elevated risk of mortality (OR 1.73, CI 1.12–2.74, P = 0.01) (38). These findings provide evidence of the importance played by the organization of critical care services with respect to time of day.
FUNCTIONING AS A TEAM
The integral functioning of a critical care team goes beyond the interactions of health professionals. It also involves developing an understanding of unpredictable events that can lead to clinical crises. Providing support for new team members, monitoring and observing patients for changes in clinical outcomes, and facilitating the involvement of family members are crucial facets for the foundation of a successful collaborative unit.
New Team Members
Specialized health care requires a tailored form of orientation for health professionals entering the critical care setting. Experienced clinicians in critical care are faced with the challenge of how to deliver important information to new team members to facilitate effective learning. This challenge is compounded by difficulties associated with a shortage of appropriately trained nurses and physicians. Comprehensive preparation through orientation programs has been shown to be a vital component for retaining health professionals (43).
Orientation of newly employed health professionals to ICUs should be viewed as a shared responsibility among senior health professionals, educators, and new staff members. Sharing of responsibilities improves the effectiveness of the orientation process because it allows more efficient completion of activities relating to the orientation, promotes collegial relationships, and links knowledge with practice. Orientation should occur through a structured program with defined goals that are agreed on by all individuals concerned (44).
The new staff member needs to be matched with a primary mentor and a secondary mentor, based on their discipline backgrounds, past experiences, attitudes, and learning styles. This matching process should be a strategic rather than a random choice to stimulate critical thinking, encourage open communication, and stimulate further professional development. The designation of a mentor based on random choice often leads to the use of multiple mentors, leading to inconsistent and confusing messages being conveyed (45).
Learning opportunities should be structured using a combined learner-led, theoretical, and clinical program (43). Such a model facilitates the transfer of knowledge to the practice setting. Theoretical reference material provided to the new staff member should include information about unit policies and protocols, roles and responsibilities of various members of the health care team, and the pathophysiology, assessment, and treatment relating to common patient conditions observed in the unit.
Although new staff members are very likely to have a rich array of experiences, experienced mentors are also influenced by the critical care culture in which they are positioned. As a result, new staff members and experienced mentors could be accustomed to performing activities their own way, which may lead to conflict. New staff members may feel that their learning needs and past experiences are not adequately recognized while mentors may feel that their advice is being ignored. By identifying potential problems from the outset, the orientation process can be more individually adapted to the team member’s specific needs, the focus of which is becoming part of the unit. Developing a sense of belonging can help to solidify collaboration between the new staff member and other health professionals.
Monitoring and Observation of Critically Ill Patients
Most patients in critical care require constant monitoring and observation, such as patients with multisystem organ failure, multiple trauma, and adult respiratory distress syndrome. The nurse:patient ratio in many parts of the world is generally 1:2 (18). However, in Australia, the nurse:patient ratio for carrying out nursing activities in ICUs is 1:1. As nurses maintain a constant presence at the bedside, they play a critical role in undertaking regular monitoring of patients, assist in the early diagnosis of impending problems, and recommend appropriate interventions to be administered.
Patients in critical care require clinical parameters to be measured hourly or more frequently if these parameters change quickly. Also important is the close observation of patients through physical methods of inspection, palpation, percussion, and auscultation. Comprehensive judgment should be used in interpreting the significance of information obtained to avoid the complacency that could occur with repetitious documentation of clinical parameters and observations.
Nurses’ knowledge in conducting patient monitoring and observation is largely constructed by their ongoing experiences and education in the critical care context. On the other hand, medical residents and critical care fellows who work in critical care for a limited period have to rely on past experiences and knowledge as their major sources of information, which may not necessarily be compatible with the types of decisions required in critical care. As an illustration, in an ethnographic study on professional relationships (46), a critical care fellow with previous experience in anesthetics was confronted by a situation involving a patient who had gone to the operating room for a duodenal ulcer repair and returned to the critical care setting. Within an hour of the patient’s return, the bedside nurse, who was a clinical nurse specialist, reported to the fellow that the patient was restless, cold, and not breathing well with the ventilator. Based on his past anesthetic experience, the fellow advised the nurse to extubate the patient. The nurse drew on her knowledge of similar patients in critical care and believed that the patient needed additional sedative and analgesic treatment rather than removal of the endotracheal tube. She presented the situation to the critical care attending who agreed with her view and requested that the patient receives further analgesic and sedative medications (5).
Critical care attending physicians are ultimately responsible for less-experienced medical personnel; however, these more-experienced physicians may be present in the unit only during discrete times of the day. Due to their lack of availability, critical care attending physicians may be able to address only a small portion of the educational needs of junior medical team members in explaining the significance of a patient’s clinical parameters and observations. Instead, due to their constant presence in the environment, nurses provide a substantive component of the educational needs of critical care fellows and residents in interpreting data obtained from patient monitoring and observation.
Nurses and physicians collectively provide valuable knowledge in making decisions about information obtained from patient data. It is, therefore, important that any rigid role boundaries between them are broken down (9). Maintaining rigid role boundaries creates distrust and disrespect between nurses and physicians, thereby hindering future progression of informed decision making. In effect, nurses need to be accepted as the “eyes and ears” of all levels of the critical care medical team to extend their perceptual capabilities.
Communication with Family Members
The admission of a critically ill patient is a stressful time for families, especially in the current health care environment of advanced technology, greater sophistication of interventional treatment, and multiple health professionals providing care. This critical care event can adversely affect the functioning of family members and their ability to communicate and understand complex information (47). If miscommunication is allowed to occur, the likely outcomes are care fragmentation, family alienation, and the development of distrustful relationships between family members and health professionals, and among health professionals themselves. Such disagreements can result in poor-quality patient care. Collaboration among health professionals is required for the comprehensive support and involvement of family members. As nurses are continuously present at the bedside, they need to interact regularly with other health professionals involved in direct patient care to synthesize information in a way that can be easily communicated to family members (27).
In a descriptive study involving interviews with family members, and observations of interactions between family members and intensive care staff, Söderström et al. (47) found that initial impressions had a sustained effect on family members and influenced future interactions. Family members who understood explicit information and implicit messages were open in their interactions with staff, adjusted well to the critical care environment and were more accepting of the situation. In other words, a mutual understanding existed between these family members and critical care staff. Explicit information involved details about the rules and policies of the unit, the condition of the patient, and how to behave in front of the patient. There were also implicit messages inherent in the information. For example, the message “you can visit the patient freely” meant “as long as you do not disturb us in our work.” In addition, the message “you can ask questions freely” was conveyed “as long as we find them relevant” (47). Unfortunately, some family members did not fully understand either the explicit information or the implicit messages, and consequently, they either became withdrawn and quiet, or more vocal in their communication by asking many questions. For these individuals, there was a mutual misunderstanding with staff. These family members did not adjust well to the environment and were either ignored or insulted by critical care staff.
It is important that nurses and physicians reflect on how they communicate with family members at initial meetings and in future interactions. Mutual understanding is more likely to occur if information is presented in a clear and unambiguous way. Family members need to have questions answered honestly, and they require regular communication about the patient’s progress and prognosis, treatment received, and changes in patient condition (48). They need to be reassured that health professionals care about the patient and support family members in their coping strategies. Family members should be able to speak with the physician and bedside nurse daily, have flexible visiting hours, be able to assist with simple patient care if desired, and have a place where they can be alone.
Underlying a health care system that is facing pressure to improve efficiency are critical care services, which are predicted to become more important as the population ages, as the boundaries within hospital areas and between health professionals become blurred, and as more specialized technology develops over time. Health professionals need to adapt their approach to collaborative care in a complex and ever-changing health care climate. By themselves, sophisticated technology and treatment are not sufficient to address the needs of patients and families—positive and conducive relationships are the critical drivers for improved care.
- Collaborative care brings about positive outcomes for patients, their families, health professionals, the health care team, and the health care organization.
- The critical care setting is a complex organizational system comprising various health professionals who need to function as an interdependent team.
- The challenge is to understand how the roles and functions of health professionals fit with those of other professions, with the aim of developing solid working relationships.
- Health professionals need to interact with each other effectively using different forms of communication, including the ward round and clinical handover.
- The ward round needs to function as a structured process, occurring at a formally designated time every day.
- A daily goals sheet should be used during ward rounds, with input from nurses, physicians, and other health professionals to summarize the plan of prioritized activities for a patient during the course of a day.
- The clinical handover should be considered a time in which health professionals can develop strategic plans for patient care and share openly their clinical activities with each other.
- Organizational factors such as the presence of an open or closed unit and time of day can impact on collaborative care. These factors can influence patient outcomes in relation to critical care admission and discharge.
- The integral functioning of a critical care team goes beyond the interactions of health professionals.
- Comprehensive preparation through orientation programs is a vital component for retaining newly employed health professionals in the ICU and bringing about collaborative care.
- Because of their constant presence, nurses provide a substantive component of the educational needs of critical care fellows and residents in interpreting data obtained from patient monitoring and observation.
- Collaboration among health professionals is required for the comprehensive support and involvement of family members of patients.