St George’s Healthcare NHS Trust

Using information technology to improve handover between medical teams and ensure continuity of patient care.

Background

St George’s Healthcare is a large teaching hospital in London predominantly based around a single site of nearly 1,000 beds. The trust has performed well against the Working Time Directive targets by embracing new rotas and ways of working using the flexibility in staffing numbers that a large teaching hospital can provide. However, structuring work in new ways has thrown up a series of challenges which have needed to be addressed. One of the key challenges that St George’s needed to address was the aspect of handover between medical teams.

The challenge

In the past, with junior staff working long hours on call, handover was carried out informally as the same physician would usually follow a patient over the course of several days and ensure continuity of care during their on call.

With the trust adopting new shift rotas and the Hospital at Night approach, this was no longer the case. During the course of a day, three different teams (day, evening and night) look after patients in any one area of the hospital and a new approach to handover was essential to ensure continuity of care across the day. With St George’s having nine separate general medical teams alone a solution that could be adopted across the hospital was required.

An IT solution

When it was decided to introduce the Hospital at Night team system, work on an effective handover system was built in to the planning stages. The junior doctors and wider Hospital at Night team were consulted on what they needed in order to make handover work for them - a simple yet effective system for ensuring handover was needed at St Georges and the answer quickly became clear. "We were inspired by attempts we had seen at other trusts to adopt an IT based aid to handover", says Dr Adrian Draper, consultant physician, "We were lucky in that our patient record system is good and our IT infrastructure is up to date. We knew it would provide an audit trail that paper based systems just couldn’t guarantee across so many teams."

The trust’s IT team were then asked to make the medical teams ideas work. The solution is a relatively simple, easy to use feature that is based as part of the EPR system within internet explorer. In simple terms:

• A Hospital at Night button was created on the EPR system - the section is accessed by a single click by any member of staff who can simply add notes that the next team on shift need to know about patients

• The notes are available as a list and is then permanently available to any team member who logs in and can be printed off to give an audit based trail of messages and handover notes.

• The page automatically refreshes to keep it up to date.

"The system runs from the EPR and is very easy to access and use," explains Dr Draper, "It’s simple to add a note and you can be confident that the next team will get that message as it’s there in black and white on the screen."

Reviewing the changes

The system has worked well and has become part of the Hospital at Night process at St Georges. The system has been continually developed by the staff involved as it has been introduced and is seen as being much better than any paper based system. One of the challenges is that the EPR system doesn’t yet take in live admissions data for emergency admissions but that would have been a challenge for any paper or IT based system.

Outcomes and impacts

Overall, staff at St Georges feel that the handover tool has helped introduce systems to protect the patients and help make their new team working solutions to WTD to bed in. As Dr Draper explains; "As a doctor you like to be able to check on a patient regularly and know when they might need help. This gives us a list of potential problems and helps ensure that you know which patients to see and why. It gives the staff and patients security."

The system is also seen as being more reliable than previous ways of handing over. The messages are put in an accessible place in real time with an audit trail showing that that has happened.

Five key lessons from St Georges

1. Involve – Make sure the system is designed by clinicians who have to use it. Find out what they want and then put it into practice. Consult them on it’s use once in place.
2. Ease of use – Make the system as easy to use as possible. Don’t overcomplicate it – St Georges have a system that needs just one or two clicks to add tasks and notes.
3. Infrastructure – IT solutions only work if the infrastructure is in place and there is access to good PCs for the medical teams.
4. Finance – You need to secure some backing to introduce these solutions. Gaining medical director support was crucial for St Georges and gave the backing needed.
5. Flexibility – Although this system was based around Hospital at Night, it is flexible and could be used without Hospital at Night.