STANDARDIZING communication during patient handoff (shift report) is one of the 2006 National Patient Safety Goals established by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). To meet this goal, nurses in one of our hospital's medical/surgical units decided to adopt a standardized template for handoffs between shifts. The nurse-manager asked me to investigate nursing literature and find a handoff system that would comply with JCAHO standards and unit goals.
Searching the nursing literature for a template, I came up empty-handed. That inspired me to design an original template based on the mnemonic PACE. In this article, I'll explain how we use this template to improve patient safety and quality of care.
Handoff, right and wrong
Performed properly, intershift handoff lets nurses share essential information about patients with the colleagues who'll be accepting responsibility for them, ensuring continuity of care. Performed poorly, though, handoff can convey inappropriate or incomplete information and waste everyone's time. (See Handoff do's and don'ts.) With PACE, we established a standardized approach to ensure accurate and succinct handoffs.
A steady PACE
A patient-centered, systematic template, PACE promotes patient safety and continuity of care from one nursing shift to the next by organizing patient data into these four categories:
- P: Patient/Problem. This includes the patient's name, age, room number, diagnosis, reason for hospital admission, and recent procedures or surgery. Summarizing any medical history that's relevant to her current admission, this category also covers allergies and any restrictions; for instance, it might say “logroll side to side only.”
- A: Assessment/Actions. This section concentrates on nursing assessments and interventions directed to the patient's problem.
- C: Continuing/Changes. By covering continuing needs and potential changes, this section facilitates care planning and continuity of patient care from shift to shift. It focuses on patient care and treatments that must be monitored or followed by the oncoming shift. It also includes recent or anticipated changes in the patient's condition or the plan of care. Examples of these data include lab tests, medications, treatments, testing, appointments, or plans scheduled for the next shift. This category includes any anticipated or recent changes to the plan of care, such as patient-care goals and expected discharge timing and needs.
- E: Evaluation. Nurses complete their handoff report with evaluations of the patient's response to nursing and medical interventions, the effectiveness of the patient-care plan, and the goals and outcomes for the patient. This category also includes evaluation of the patient's response to care, such as progress toward goals.
Following the PACE template, oral handoff reports move smoothly through each category. This template is applicable to various patients and can be used by many types of care providers. The standardized structure helps prevent repetitive, rambling, disorganized, or inappropriate reporting. For an example, see Keeping PACE: A sample report.
Our nurses are encouraged to keep a copy of the template in their pocket and fill in the categories as they work. This helps them to remember important data and to give an organized and complete oral report in an efficient way.
PACE is easy to remember, easy to use, and easy to adapt. In our 21-bed unit at a veterans' hospital, it's become the standard for intershift handoff. Before we began to use PACE, nurses had trouble completing an intershift report in the 30 minutes allotted. PACE has given us a format to follow, which helps to eliminate omissions and reports that are too long, disorganized, or rambling. Having a template to follow is especially helpful to our new nurses because it gives them a guideline of what to include in the report. Even better, more complete reports enhance patient safety.
Keeping PACE: A sample report
Here's a sampling of notes a nurse might keep using a PACE template to improve oral shift report:
P: Room 49, S.J. Lake, 50 y.o. female, s/p stroke 10/6. L-sided weakness, expressive aphasia.Hx: HTN, CAD, type 2 DM, NKDA.N.P.O. HOB up 45 degrees.
A: Aspiration precautions. High fall risk. VS/neuro q4: stable. Lungs clear. Normal active BS.Spo2 94% on 2 liters NC. PTT 65, Heparin gtt @ 1200 units/hr.
C: Next PTT @ 1300.OT later this a.m. re: ADLs.Family meeting @ 1530 w/ SW.Plan: PEG tube placement later this week.Plan: for d/c to LTC facility next week if possible.
E: Communicates well using word board.Denies pain.
HANDOFF DO'S AND DON'TS
- Use a standardized format.
- Conduct handoff in a private setting to maintain patient confidentiality.
- Report in person, if possible, so you can clarify points and answer questions.
- Provide current information.
- Be concise; don't ramble or speculate.
- Don't report irrelevant information.
- Don't make critical or other inappropriate comments about the patient's family or health care provider.
- Don't share information with anyone who doesn't need to know.
GETTING TO GOAL
One 2006 National Patient Safety Goal, set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is to “implement a standardized approach to hand off' communications.” Specifically, the JCAHO says “effective hand off' communications [should] include up-to-date information regarding the patient's/client's/resident's care, treatment and services, current condition and any recent or anticipated changes.”
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