A Technology-based Quality Improvement Approach to Increasing Nurse-physician Communication

Purpose/Objectives: Communication failures are the root cause of >70% of sentinel events. Errors in nurse-physician communication particularly increase the risk of patient morbidity and mortality. Our global aim was to improve nurse-physician interprofessional communication and situational awareness. Our SMART aim was to increase resident and nursing perceived awareness of 3 handoff components after pediatric hospital medicine family centered rounds to >70% in 1 month and sustain for 4 months.

Design/Methods: We interviewed key interdisciplinary stakeholders at our 323-bed academic urban free-standing children’s hospital to inform our fishbone diagram (Fig. 1), failure mode effect analysis, and key driver diagram.

Interventions included: 1) a pre-rounds huddle to prioritize rounding order; 2) a standardized summary of the medical plan for the day at the end of each patient’s rounds; 3) use of an innovative IT tool integrated with the electronic medical record that alerts nurses when physicians are rounding on their patients (RoundAboutTM); 4) standardized post-rounds text communication to nurses when not present on rounds; 5) interdisciplinary process education.

Our outcome measure assessed “perceived awareness,” the percentage of pediatric residents and bedside nurses who indicated ‘Agree’ or ‘Strongly Agree’ for all three 3 handoff components when surveyed on randomly selected patients. Handoff components included ‘I know the problems we are trying to address,’ ‘I know the plan of care for today,’ and ‘I know when to escalate,’ measured on a 7-point Likert scale. Process measures assessed the percentage of rounding encounters attended by nurses and summarized by residents based on surveys completed by attending physicians during rounds. Our balancing measure assessed the average time in minutes (m) spent on rounds per patient, recorded on the attending physician survey. We analyzed pre- and post-intervention data using two-tailed t-tests.

Results: We collected baseline data over two weeks and the project continued for a total of four months. We observed a shift in nurse perceived awareness after initiating standardized text communication two weeks post-intervention. Nurse perceived awareness (Fig. 2) significantly increased (mean 71% at baseline, 84% post-intervention, p<0.05). Resident perceived awareness (Fig. 2) remained >70% throughout. Nursing attendance on rounds significantly increased (mean 53% at baseline, 72% post-intervention, p<0.01). Frequency of rounds summary did not change significantly (mean 81% at baseline, 88% post-intervention, p>0.05). Average rounding time did not change significantly (mean 15m at baseline, 14m post-intervention, p>0.05).

Conclusion/Discussion: Residents consistently reported high levels of perceived awareness. Baseline variability in nurse perceived awareness suggests that residents did not consistently and/or effectively communicate with nursing colleagues. We successfully implemented multiple interventions to improve nurse-physician communication and nurse perceived awareness of 3 patient handoff components. Further analysis will be needed to evaluate the direct impact on patient safety.