The Weekend Efficiency and Safety Timetable (WEST) project: Weekend handover going WEST?

Introduction

Handovers aim to convey high-quality and appropriate clinical information to oncoming healthcare professionals to allow for the safe transfer of responsibility for patients. Good handovers are essential in providing continuity of care, patient safety and error avoidance. ¹

This project relates to the method of handover from the day teams to the weekend general surgery on-call team for planning the reviews of patients. The on-call surgical team reviews all inpatients over the weekend, i.e. both emergency admissions and pre-existing inpatients. There is potential for misdirection of on-call time towards routine reviews of inpatients, which would impact on the speed of reviewing the emergency admissions or severely ill inpatients.

A structured, standardised and easily accessible way to achieve a safe handover is suggested – The Weekend Efficiency and Safety Timetable (WEST) – allowing for safe triaging of the existing inpatients so that the on-call team time is best directed towards the most unwell patients.

Background

The Royal Cornwall Hospitals NHS Trust is the main provider of acute and specialist care services in Cornwall and the Isles of Scilly. It serves a population of around 500,000 people, a figure that can increase significantly with visitors during the busiest times of the year. The Trust employs approximately 5000 staff and has a budget of approximately £330 million. ²

The Trust has three main sites, including the Royal Cornwall Hospital, Truro, which is a medium sized teaching hospital, West Cornwall Hospital, Penzance and St. Michael’s Hospital, Hayle, both of which are smaller community hospitals that include inpatients and elective operating. There are approximately 750 inpatient beds across all three sites, and some smaller sites where clinics and day care are also held. All acute patients and on-call teams are based at the Truro site.

The surgical on-call team comprises of a variable number of Foundation Year one doctors (depending on the shift), a Senior House Officer (SHO), a general surgery Specialist Registrar (SpR), variable cover from non-resident middle grade/registrar grade doctors in vascular and urological surgery, and non-resident Consultants in general, vascular and urological surgery. The team accepts new acute referrals in upper and lower GI surgery, breast surgery, vascular surgery and urology.

Duties include assessing new referrals to the team, providing a surgical opinion on other patients in the hospital, providing telephone advice to clinicians in the community, running the acute surgical ward, looking after all surgical patients in the hospital under the care of these specialties, attending trauma calls and providing emergency operations. The organisation and duties of the surgical on-call team are comparable with most of the other large NHS hospitals.

There are two modes of handover:

Shift to shift handover of new patients and patients on the surgical unit

The importance of handover in all specialities has been well documented and researched. A study from New Zealand demonstrated that 60.9% of house officers reported that they had encountered a problem at least seven times in their most recent clinical rotation that they could directly attribute to a poor handover. ³

Previously, each surgical team would leave a paper copy of their patient’s list in a common folder, which would be accessed by the weekend on-call team at the start of the Saturday day shift. After a Consultant-led ward round of the acute surgical ward, the registrar and senior house officer or house officer would proceed to review each surgical patient in the hospital and briefly document their findings and plan in the patient’s notes. This would include routine reviews of patients who were, for example, medically fit for discharge and waiting to leave the hospital.

The stimulus for a review of the weekday to weekend handover process occurred after a particularly busy Saturday day shift. With the SpR and SHO reviewing a large number of elective ward patients, it was challenging to safely manage the overall work load, including new patients and pending emergency operations. Being away on this ward round also meant that no middle grade or senior staff were physically present on the acute surgical unit to support junior staff.

Method

The Royal College of Surgeons of England have recommended handover arrangements should be reviewed as part of the clinical governance strategy to ensure they are appropriate. ¹ Therefore, a small informal working group of doctors in the surgical unit was formed, and led by Miss Ionescu. The above issues were discussed, including current methodology and purpose of handover, and ideas for possible improvements and change.

It was felt on-call workload at weekends is generally unpredictable and frequently challenging or not possible to safely review every patient. The on-paper or verbal handover system was inefficient as it was not comprehensive there was no standardisation of information, no unified recording of information and therefore no attributable responsibility. The result on the ground was that all inpatients in the hospital were being reviewed on Saturday and Sunday in an unwieldy, prolonged ward round.

A reliable, reproducible and standardised review system for inpatients from all wards was formulated, based on a computerised record for weekend handover: the WEST.

The following changes were agreed:

WEST would be a computer-based handover, aiming to replace a paper-based or verbal version

A Microsoft Excel spreadsheet template was created for WEST, with sections for each surgical ward (excluding the acute surgical unit, which had its own handover system), including the intensive care unit and space for outlier patients on other wards. Columns were included for patient details, which patient required review and on which day, and which patients required blood tests. The template was placed in a designated folder on the hospital Trust’s computer system, which could be securely accessed doctors. Each Friday, the blank template would be re-saved in that weekend’s dates, and be available for each team to individually upload their patient details and preferences for review, as above.

Findings

WEST was positively received by doctors who had used it, as they preferred the reliability of a computerised list to the verbal and paper-based handover.

WEST provided a standardised, safe and responsible approach to handover, ensuring solid chain of care. It also provided a record of what was handed over; it clearly ascribed clinical responsibility while maintaining patient safety, with plenty of scope for audit aimed at service improvement.

After positive experiences of the newly introduced system, the authors would encourage other departments to review their weekend handover practice, in particular the methods by which elective ‘day teams’ handover over to the on-call team for planned weekend reviews. There is scope for a quantitative assessment before and after introduction of WEST in a handover system within a District General Hospital.