Assessment and improvement of junior doctor handover in the emergency department.

INTRODUCTION: Effective handover between junior doctors is widely accepted as essential for patient safety. The British Medical Association in association with the National Health Service (NHS) National Patient Safety Agency and NHS Modernisation Agency have produced clear guidance regarding the contents and setting for a safe and efficient handover. We aimed to understand current junior doctor's opinions on the handover process in a London emergency department (ED), with subsequent assessment, and any necessary improvement, of handover practices within the department. METHODS: In a London ED, a baseline survey was completed by the senior house officer (SHO) cohort to gauge current opinions of the existing handover process. Concurrently, a blinded prospective audit of handover practises was conducted. Multiple improvement strategies were subsequently implemented and assessed via Plan-Do-Study-Act (PDSA) cycles. A standard operating procedure was initially introduced and 'rolled out' throughout the department. This intervention was followed by development of an electronic handover note to ease completion of a satisfactory handover. Additional surveys were conducted to continually assess SHO opinion on how the handover process was developing. The final improvement strategy was formal handover teaching at the SHO induction. RESULTS: Baseline audit and SHO survey highlighted several opportunities for improvement. 5 handover components were deemed essential: (1) documented handover note; (2) doctor's names; (3) history of presenting complaint; (4) ED actions; and (5) ongoing plan. The frequency of these components saw significant improvement by completion of the final PDSA. Following SHO rotation, all of the essential components fell, only to recover after the next improvement strategy. CONCLUSIONS: Junior doctors in a London ED were not satisfied with the current SHO handover process, and handover practices were not adequate. While the rotational nature of the SHO cohort makes sustained change challenging, implementation of thoughtful and realistic improvement strategies can significantly improve handover quality.

Expediting the management of cauda equina syndrome in the emergency department through clinical pathway design.

Introduction: Cauda equina syndrome (CES) is a neurosurgical emergency. Early diagnosis with MRI and subsequent surgical decompression surgery can prevent permanent neurological dysfunction. Charing Cross Hospital (CXH) is a tertiary neurosurgical referral centre where in the emergency department (ED), current practice mandated a neurosurgery review prior to requesting MRI. Hypothesis: It was hypothesised that a new clinical pathway, with better coordination from the ED, radiology and neurosurgical teams could reduce the time of presentation to diagnosis or exclusion of CES. Method: Retrospective case-note analysis of patients presenting with back pain to CXH ED over a 3-month period was performed. The primary outcome was the time interval between the patient's arrival to the ED and the MRI preliminary report. Results: The baseline primary outcome was recorded at 8 hours and 16 min (n=30). A new clinical pathway was designed empowering ED senior decision makers to order MRIs prior to neurosurgical review. Two Plan-Do-Study-Act (PDSA) cycles were performed, each measured over a 2-month period. The first PDSA cycle was performed after the pathway was initially launched (n=17), while the second PDSA cycle measured the effect of staff education and active promotion of the pathway (n=17). MRI was requested earlier, waiting and reporting time for MRI were reduced. The exclusion or diagnosis of CES was reduced to 5 hours and 54 min in PDSA 1 and 5 hours 17 min in PDSA 2, a 29% and 36% reduction (p=0.048 and p=0.012, respectively). Conclusion: The clinical protocol was a cost-neutral and sustainable intervention that effectively reduced the time taken to diagnose or exclude CES and ED waiting times.