Comunicación en el <i>handoff</i> de terapia intensiva: nexos con la seguridad del paciente

Santos, Grazielle Rezende da Silva dos; Campos, Juliana Faria; Silva, Rafael Celestino da

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REVIEW • Esc. Anna Nery 22 (2) • 2018 • https://doi.org/10.1590/2177-9465-EAN-2017-0268 copiar

Comunicación en el handoff de terapia intensiva: nexos con la seguridad del paciente

Autoría SCIMAGO INSTITUTIONS RANKINGS

Resumen

Objetivo:

Relevar las evidencias científicas sobre la práctica de handoff con respecto a la seguridad de la comunicación sobre el paciente hospitalizado de miembros del equipo de Unidad de Terapia Intensiva.

Método:

Revisión integrativa en las bases Medline, Pubmed, Cinahl y Scopus, con los descriptores: patient handoff, communication, patient safety, critical care, health communication e intensive care unit. Los criterios adoptados fueron: texto completo, portugués/inglés, últimos diez años, nivel de evidencia encima de IV y conformidad con la temática investigada. Quince artículos fueron sometidos a un instrumento estructurado y análisis.

Resultados:

Existen informaciones ausentes, incompletas o incorrectas en el handoff, causadas por la falta de estandarización y preparo para esta actividad, generando procedimientos atrasados, incorrectos o no realizados. El uso de herramientas reduce la cantidad de informaciones omitidas, conversas paralelas y errores, mejorando la satisfacción del equipo.

Consideraciones finales:

Hace necesario promover la comunicación segura en el handoff, con prácticas que garanticen la continuidad de atención.

Palabras clave:
Comunicación en salud; Cuidados intensivos; Seguridad del paciente

Crossings/databases	PubMed	Medline	Cinahl	Scopus
Handoff AND critical care	2	4	0	0
Handoff AND ICU	2	0	1	0
Handoff AND Health communication	1	1	0	1
Handoff AND patient safety	0	0	0	0
Handoff AND communication AND patient safety	3	0	0	0
Total	8	5	1	1

Title	Design	Interventions	Outcomes
A1-Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk¹³13 Berkenstadt H, Haviv Y, Tuval A, Shemesh Y, Megrill A, Perry A, et al. Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk. Chest [Internet]. 2008 Jul; [cited 2018 Feb 9]; 134(1):158-62. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18628218 https://www.ncbi.nlm.nih.gov/pubmed/1862... 2008/Israel Evidence: III	Phase 1: retrospective, analysis of the causes of an adverse event Phase 2: prospective, intervention, quantitative N=390 handoffs (224 pre- and 166 post-intervention)	To describe common flaws in the handoff process based on a retrospective analysis of an event, creating a handoff protocol and nursing team training-based simulations.	After the intervention, the incidence of nurses communicating relevant information during handoffs increased, including patient name, events occurred in the last shift and treatment objectives for the following shift. No changes were found in the incidence of checking monitor alarms and mechanical ventilators.
A2-A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers¹⁴14 Li P, Stelfox HT, Ghali WA. A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. Am J Med [Internet]. 2011 Sep; [cited 2016 Oct 2]; 124(9):860-7. Available from: http://www.amjmed.com/article/S0002-9343(11)00413-X/pdf http://www.amjmed.com/article/S0002-9343... 2011/Canada Evidence: IV	Observational, prospective and quantitative N=112 intensive-care-unit-to-ward patient transfers	To understand the methods and quality of communication in handoffs between physicians in the ICU.	Poor communication resulted in 13 medical errors and chaperone dissatisfaction relative to lack of knowledge about the patient’s clinical condition.
A3-Falling through the cracks: information breakdowns in critical care handoff communication¹⁵15 Abraham J, Nguyen V, Almoosa KF, Patel B, Patel VL. Falling through the cracks: information breakdowns in critical care handoff communication. AMIA Annu Symp Proc [Internet]. 2011 Oct; [cited 2016 Oct 2]; 2011:28-37. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243259/ https://www.ncbi.nlm.nih.gov/pmc/article... 2011/USA Evidence: IV	Qualitative, multi method Audio recordings of 80 handoffs; monitoring work flow of 30-40 professionals;	To investigate communication flaws during handoffs	Two factors contributed to information breakdown: lack of standardized communication during handoffs; inadequate preparation for handoff in the pre-handoff phase.
A4-Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit¹⁶16 Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med [Internet]. 2011 May; [cited 2018 Feb 9]; 12(3):304-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Standardized+multidisciplinary+protocol+improves+handover+of+cardiac+surgery+patients+to+the+intensive+care+unit https://www.ncbi.nlm.nih.gov/pubmed/?ter... 2011/USA Evidence: III	Prospective, interventionist, and quantitative N=69 handoffs	To assess pre- and post-intervention handoffs through direct observation based on a standardized instrument.	Technical errors during handoffs decreased from 6.23 to 1.52; omission of critical information during handoffs fell from 6.33 to 2.38. Teamwork and handoff content improved.
A5-Bridging gaps in handoff: A continuity of care based approach¹⁷17 -Abraham J, Kannampallil TG, Patel VL. Bridging gaps in handoffs: A continuity of care based approach. J Biomed Inform [Internet]. 2012 Apr; [cited 2016 Oct 2]; 45(2):240-54. Available from: http://www.sciencedirect.com/science/article/pii/S1532046411001778?via%3Dihub http://www.sciencedirect.com/science/art... USA/2012 Evidence: IV	Qualitative, multi method N=80 handoffs 30-40 ICU professionals	To identify the nature and intrinsic characteristics of handoff phases and develop a framework for handoff communication in critical care.	Three independent phases of the handoff process were identified: before, during, and after, which can result in the acceptance or rejection of information, or in the need for more information requested by information recipients. 52% of the information was accepted without any discussion, 4% was rejected. The remaining 44% required additional information, and of these, 33% was resolved when one of the team members complemented the information, whereas 11% was not immediately resolved and went into a team-based collaborative problem-solving cycle.
A6-In search of common ground in handoff documentation in an Intensive Care Unit¹⁸18 Collins SA, Mamykina L, Jordan D, Stein DM, Shine A, Reyfman P, et al. In search of common ground in handoff documentation in an Intensive Care Unit. J Biomed Inform [Internet]. 2012 Apr; [cited 2016 Oct 2]; 45(2):307-15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22142947 https://www.ncbi.nlm.nih.gov/pubmed/2214... 2012/USA Evidence: IV	Observational, qualitative and documental N=22 instruments used by nurses and physicians	To understand the structure, functionality, and content of handoff documentation used by nurses and physicians in an intensive care unit setting.	There were overlaps in the documentation used by nurses and physicians. A user-centered semi-structured tool can help communication among professionals and improve patient safety.
A7-Handover patterns: an observational study of critical care physicians¹⁹19 Ilan R, LeBaron CD, Christianson MK, Heyland DK, Day A, Cohen MD. Handover patterns: an observational study of critical care physicians. BMC Health Serv Res [Internet]. 2012 Jan; [cited 2016 Oct 2]; 12:11. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3280171/ https://www.ncbi.nlm.nih.gov/pmc/article... 2012/Canada Evidence: IV	Observational, prospective and quantitative N=21 handoffs	To describe handoff communication patterns used by the participating physicians in an ICU and compare them to widely promoted standardized handoff communication schemes.	Intensive care physicians did not follow the commonly recommended communication standards; i.e., they did not use the same schemes and some elements were scattered and others absent during handoff.
A8-Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs²⁰20 Petrovic MA, Aboumatar H, Baumgartner WA, Ulatowski JA, Moyer J, Chang TY, et al. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. J Cardiothorac Vasc Anesth [Internet]. 2012 Feb; [cited 2016 Oct 2]; 26(1):11-6. Available from: http://www.jcvaonline.com/article/S1053-0770(11)00528-3/pdf http://www.jcvaonline.com/article/S1053-... 2012/USA Evidence: III	Prospective, interventionist, and quantitative N=238 health professionals during 60 patient handoffs.	To assess the impact of implementing a standardized handoff protocol in patient care and team satisfaction.	After the intervention, the presence of all group members at the bedside increased from 0% to 68%. The percentage of lost information on surgery reports fell from 26% to 16%. The protocol reduced the risk of losing information and promoted satisfaction among the perioperative team.
A9-Understanding current intensive care unit nursing handover practices⁹9 Spooner AJ, Chaboyer W, Corley A, Hammond N, Fraser JF. Understanding current intensive care unit nursing handover practices. Int J Nurs Pract [Internet]. 2013; [cited 2016 Oct 2]; 19(2):214-20. Available from: http://onlinelibrary.wiley.com/doi/10.1111/ijn.12058/pdf http://onlinelibrary.wiley.com/doi/10.11... 2013/Australia Evidence: IV	Observational, prospective and quantitative N=20 handoffs involving 40 nurses (20 transferring and 20 receiving)	To assess the content and completeness of the intensive care unit nursing shift-to-shift handoff.	Flaws in communication included: absence of current clinical condition at handoff; discharge and long-term plans were present in 40% of handoffs; reading over charts together with professionals receiving handoffs occurred in 35% of the cases, and cross-referencing data occurred in 40% of the analyzed handoffs.
A10-Failures in transition: learning from incidents relating to clinical handover in acute care²¹21 -Thomas MJ, Schultz TJ, Hannaford N, Runciman WB. Failures in transition: learning from incidents relating to clinical handover in acute care. J Healthc Qual [Internet]. 2013 May/Jun; [cited 2018 Feb 9]; 35(3):49-56. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Failures+in+transition%3A+learning+from+incidents+relating+to+clinical+handover+in+acute+care https://www.ncbi.nlm.nih.gov/pubmed/?ter... 2013/Australia Evidence: IV	Observational, cross-sectional, quantitative, descriptive N=459 events occurred between 2004-2008 in acute care units.	To analyze the characteristics, contributing factors and detection mechanisms of failures associated with handoffs in acute care settings.	The most common failures were: inadequate handoff (28%); omission of critical information about the patient’s condition (19%); and omission of critical information about patient care plan (14%).
A11-Differences in the handover process and perception between nurses and residents in a critical care setting²²22 Mukhopadhyay A, Leong BS, Lua A, Aroos R, Wong JJ, Koh N, et al. Differences in the handover process and perception between nurses and residents in a critical care setting. J Clin Nurs [Internet]. 2015 Mar; [cited 2018 Feb 9]; 24(5-6):778-85. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Differences+in+the+handover+process+and+perception+between+nurses+and+residents+in+a+critical+care+setting https://www.ncbi.nlm.nih.gov/pubmed/?ter... 2014/Singapore Evidence: IV	Quantitative, descriptive N=580 (290 resident physicians and 290 nurses.	To identify differences in handoff practices and perceptions between nurses and residents in critical care units.	Among the providers, nurses were more concerned with the complexity of the patient’s health condition than residents. Among recipients, nurses considered medical history the most useful information (12%), while among residents, the 48-hour care management plan was perceived as the most useful.
A12-Are attendings different? intensivists explain their handoff ideals, perceptions, and practices²³23 Lane-Fall MB, Speck RM, Ibrahim SA, Shea JA, McCunn M, Bosk CL. Are attendings different? Intensivists explain their handoff ideals, perceptions, and practices. Ann Am Thorac Soc [Internet]. 2014 Mar; [cited 2016 Oct 2]; 11(3):360-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Are+attendings+different%3F+Intensivists+explain+their+handoff+ideals%2C+perceptions%2C+and+practices https://www.ncbi.nlm.nih.gov/pubmed/?ter... 2014/USA Evidence: IV	Qualitative, descriptive N=30 intensivists	To characterize attending intensivists handoff practices and determine the ideal aspects of handoffs from the perspective of attending physicians.	Standardized practices were rare. Handoff practices included: telephone conversations, in-person communications, e-mail or text messages. The “ideal handoff”: succinct and organized, face to face, including verbal and written communication about patient trajectory.
A13-Comparative evaluation of the content and structure of communication using two handoff tool: Implications for patient safety²⁴24 Abraham J, Kannampallil TG, Almoosa KF, Patel B, Patel VL. Comparative evaluation of the content and structure of communication using two handoff tools: implications for patient safety. J Crit Care [Internet]. 2014 Apr; [cited 2016 Oct 2]; 29(2):311.e1-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Comparative+evaluation+of+the+content+and+structure+of+communication+using+two+handoff+tools%3A+implications+for+patient+safety https://www.ncbi.nlm.nih.gov/pubmed/?ter... 2014/USA Evidence: III	Interventionist, prospective, quanti-qualitative N=82 handoffs (41 with each tool)	To compare two handoff tools: SOAP and HAND-IT. Groups of five professionals worked with one of the tools for 1 month and then switched.	Comparative assessment between the two handoff tools: SOAP and HAND-IT, showed that HAND-IT generated fewer communication errors.
A14-Transferring patient care: patterns of synchronous bidisciplinary communication between physicians and nurses during handoffs in a critical care unit²⁵25 McMullan A, Parush A, Momtahan K. Transferring patient care: patterns of synchronous bidisciplinary communication between physicians and nurses during handoffs in a critical care unit. J Perianesth Nurs [Internet]. 2015 Apr; [cited 2018 Feb 9]; 30(2):92-104. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Transferring+patient+care%3A+patterns+of+synchronous+bidisciplinary+communication+between+physicians+and+nurses+during+handoffs+in+a+critical+care+unit https://www.ncbi.nlm.nih.gov/pubmed/?ter... 2015/Canada Evidence: IV	Qualitative, descriptive, observational N=40 handoffs	To characterize the flow of information during handoffs and identify patterns of communication between anesthesiologists and nurses in a postoperative critical care unit.	The presence of patient history (42%) and intraoperative events (39%) was more frequent, while patient condition (8%) and care plan (9%) were less so. Searching for information by asking questions was more common regarding patient condition (46%) and care plan (29%).
A15-Face-to-face handoff: improving transfer to the pediatric intensive care unit after cardiac surgery²⁶26 Vergales J, Addison N, Vendittelli A, Nicholson E, Carver DJ, Stemland C, et al. Face-to-face handoff: improving transfer to the pediatric intensive care unit after cardiac surgery. Am J Med Qual [Internet]. 2015 Mar/Apr; [cited 2018 Feb 9]; 30(2):119-25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Face-to-face+handoff%3A+improving+transfer+to+the+pediatric+intensive+care+unit+after+cardiac+surgery https://www.ncbi.nlm.nih.gov/pubmed/?ter... 2015/USA Evidence: III	Prospective, interventionist and quantitative N=79 handoffs	To develop and implement a handoff process, improving forms of communication, which begins in the operating room and ends at the ICU bedside.	Before the handoff instrument, 58% of the professionals believed the process was efficient; 53% felt comfortable asking questions; 19% believed the process improved care. After the intervention, these percentages were 69%, 75%, and 94%, respectively.

Unit of evidence 1: Flaws in communication: cause, nature, and consequences.	Studies identified
Causes of communication flaws: lack of standardization, inadequate preparation for handoff in pre-handoff phase;	A3 and A5
Nature of communication flaws: incomplete, misleading or missing information about care plans, current patient condition, and clinical history;	A9, A10, A14, A11
Consequences of communication flaws: wrong procedures, omitted procedures, and evaluations; delayed care delivery.	A2

Unit of evidence 2: Handoff practices: models and effects of the use of instruments	Studies identified
Models of handoff used in practice: without any given order or structure in relation to recommended standards; with overlaps of tools used by professionals from different areas; use of different handoff formats (bedside, telephone, text messages, emails);	A6, A12, A7
Handoff practices using instruments: positive effects on the amount and type of omitted information; decreased number of errors; team presence and satisfaction, reduced side-talking; perception of professionals about handoff.	A13, A1, A8, A4, A15

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[1] Corresponding author: Rafael Celestino da Silva. E-mail: rafaenfer@yahoo.com.br