One hospital's solution to safer patient transfers

In the acute care ward at LDS Hospital, a white board prompts nursing staff to "please turn in your brain after your shift."

Hospital gallows humor? Not quite.

The hand-scrawled message is a reminder of the Intermountain Healthcare facility's role in a national experiment to improve patient transfers. And "the brain" is a term coined by nurses to describe the chart they helped create to ensure that "must have" patient information travels with them. Conventional charts contain information such as vital signs, lab results, diagnoses and intake of prescription drugs. The hospital's nurses found a way to condense the most critical, updated information into a portable format.

"The biggest challenge was changing the way nurses do reporting," said Lynn Colgren, a nurse who worked on the pilot project. "Before, we all had our own way of keeping track of patients. But when we sat down in a room, we found there was a lot of consensus on what nurses said they had to know in a handoff; not nice to know, but have to know. The tool standardizes things so we're all on the same page."

Patient transfers, or handoffs, may seem second-nature. But studies show they're prone to errors, whether they be from the emergency department up to the floor, from the operating room to recovery or from the hospital to a long-term care facility. Busy clinicians may omit information during a shift change or a patient might arrive unconscious without family members in tow.

"With ER transfers you don't always get face-to-face contact with the doctor. And sometimes family members who have stood vigil go home when they know a loved one is stable and hospitalized," said Colgren.

The brain, a legal-size piece of paper with blank fields for providers to fill with codes and notes, is considerably low-tech. But electronic record-keeping takes money and sophisticated programming.

Registered nurse Candice Hoyal imagines the tool may one day be adapted for use with handheld computers and says, "It's something I almost can't live without."

Before checking in on Robert Louis Elliston who was hospitalized for pancreatitis, Hoyal marks up "the brain," noting new radiology results, Elliston's blood pressure, special dietary concerns and his pain level.

"On a scale of one to 10, how is your pain today?" Hoyal asks Elliston upon entering his room. "We've been trying to arrive at an optimal dose of morphine, which will be helpful for the next shift nurse to know," she explains.

Communication breakdowns can cause delays in care, longer hospitalizations and even greater harm than a little discomfort.

A 2005 study by the Joint Commission found 70 percent of medical errors are caused by communication breakdowns, half of them during handoffs. The typical teaching hospital has thousands of handoffs each day, according to estimates by the commission, which accredits and certifies health care centers.

To address the problem, the commission tasked 10 hospitals — including LDS Hospital, Mayo Clinic, Johns Hopkins, Massachusetts General, and Stanford University Hospital & Clinics — with improving communications.

Some zeroed in on hospital-to-hospital transfers. LDS focused on inter-department moves and is one of five hospital partners to deliver up findings, said Klaus Nether, at the commission's Center for Transforming Health Care.

When the project began in 2009, "senders," the providers handing off a patient, reported bungled communications 21 percent of the time, Nether said."Receivers" were dissatisfied 37 percent of the time, Nether said. But so far five hospitals, including LDS, have been able to reduce communication problems by 50 percent.

Eventually the commission will share proven tools with other health centers free of charge.

LDS medical director Scott Hansen hopes his hospital's home-cooked fix will be adopted by other Intermountain facilities. He acknowledges that gauging whether it works hinges on the subjective opinion of providers, some of whom weren't convinced there was a problem to begin with.

But nurse administrator Todd Neubert said it's now the standard. "If something goes wrong with a patient stay, that's the first thing I'll ask; 'How was the handoff?'"