Dr. Medha Chillal; *Dr. Richard Neal; and Dr. Adrian Plunkett
Paediatric Intensive Care, Birmingham Children's Hospital NHS Foundation Trust
*Corresponding author: Richard.firstname.lastname@example.org
We were interested to read the recent article, "Changes in Medical Errors after Implementation of a Handoff Program," by Starmer et al. (N Engl J Med 2014; 371:1803-1812) about the benefits of I-PASS. The I-PASS system has been adapted for use as a handover tool at the Birmingham Children’s Hospital Paediatric Intensive Care Unit (PICU) over the last year and has undergone iterative modification following feedback surveys to arrive at its current format.
The PICU is a busy unit in a stand-alone children’s hospital. The PICU has expanded progressively over the last few years from 20 beds to the current 31 bed footprint. It accepts patients with a wide range of background conditions, including cardiac, medical, surgical, trauma, and transplant patients. The hospital has an active ECLS programme and is a paediatric Major Trauma Centre.
Prior to I-PASS being introduced, handover was conducted in a sit-down meeting conducted every morning in the conference room adjacent to the PICU. The night medical staff and senior nurses handed over the patient case summaries prior to the day teams then returning to the bedside to perform the daily reviews and tasks. This clearly separated the handover of information taking place between the medical staff from the handover performed by the bedside nurses. The duration of medical handover each morning was between 60 and 90 minutes, but the format enabled the incorporation of teaching opportunities. Due to the expansion of our unit capacity, the PICU was functionally divided into subsections and the ward round handover process was revised.
The introduction of a bedside morning ward round handover was followed by the introduction of the I-PASS structure to the daily handover paperwork and presentation format. It has involved the bedside nurses both in completing aspects of the I-PASS documentation and in sharing information about patient status. The change has led to nurses feeling more involved in the clinical decision-making process and more empowered to take an active role in collaborative care. The majority of staff completing a post-implementation survey reported improvement in nurse engagement and a positive environment for sharing opinions in the rounds. 78% of respondents rated the I-PASS ward round as an improvement over previous rounding arrangements.
I-PASS has added structure to the handover, improving consistency of delivery and reducing interruptions to the flow of the patient ‘story’. The afternoon and evening ward round elements of the form replicate aspects of the morning handover round and create opportunities for formal review of the patient progress through the day. This closed-loop review of the morning plans is particularly helpful for the trainees as it provides an opportunity to regroup with the consultant and the rest of the team.
The traditional handover has an emphasis on the patient’s clinical history and progress, but the minutiae are often overlooked. Although not a standard part of I-PASS, the addition of a checklist component to our I-PASS has highlighted high-risk areas specific to our patient population. This checklist follows a systems approach and also includes duration of lines, urinary catheters, and anticoagulation. This may have contributed to a recent observed reduction in our PICU central venous line infections and a 20% fall in our central-line patient days since the checklist was introduced.