Elsevier

Injury

Volume 40, Issue 4, April 2009, Pages 388-396
Injury

Development of electronic software for the management of trauma patients on the orthopaedic unit

https://doi.org/10.1016/j.injury.2008.10.006Get rights and content

Abstract

Introduction

Continuity of patient care is an essential prerequisite for the successful running of a trauma surgery service. This is becoming increasingly difficult because of the new working arrangements of junior doctors. Handover is now central to ensure continuity of care following shift change over.

The purpose of this study was to compare the quality of information handed over using the traditional ad hoc method of a handover sheet versus a web-based electronic software programme. It was hoped that through improved quality of handover the new system would have a positive impact on clinical care, risk and time management.

Methods

Data was prospectively collected and analyzed using the SPSS 14® statistical package. The handover data of 350 patients using a paper-based system was compared to the data of 357 cases using the web-based system. Key data included basic demographic data, responsible surgeon, location of patient, injury site including site, whether fractures were open or closed, concomitant injuries and the treatment plan. A survey was conducted amongst health care providers to assess the impact of the new software.

Results

With the introduction of the electronic handover system, patients with missing demographic data reduced from 35.1% to 0.8% (p < 0.0001) and missing patient location from 18.6% to 3.6% (p < 0.0001). Missing consultant information and missing diagnosis dropped from 12.9% to 2.0% (p < 0.0001) and from 11.7% to 0.8% (p < 0.0001), respectively. The missing information regarding side and anatomical site of the injury was reduced from 31.4% to 0.8% (p < 0.0001) and from 13.7% to 1.1% (p < 0.0001), respectively. In 96.6% of paper ad hoc handovers it was not stated whether the injury was ‘closed’ or ‘open’, whereas in the electronic group this information was evident in all 357 patients (p < 0.0001). A treatment plan was included only in 52.3% of paper handovers compared to 94.7% (p < 0.0001) of electronic handovers. A survey revealed 96% of members of the trauma team felt an improvement of handover since the introduction of the software, and 94% of members were satisfied with the software.

Conclusions

The findings of our study show that the use of web-based electronic software is effective in facilitating and improving the quality of information passed during handover. Structured software also aids in improving work flow amongst the trauma team. We argue that an improvement in the quality of handover is an improvement in clinical practice.

Introduction

The implementation of the New Deal and the European Working Time Directive has led to a change in working patterns. The traditional ‘on-call’ system has been replaced by a ‘shift system’ in many orthopaedic units. As a result this has led to a reduction in continuity of care, with patients often being looked after by more than one group of doctors on any given day 11.

As the working hours of junior doctors decrease, ‘handover’ (defined as ‘the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis’) is taking place more frequently 10.

Consequently accurate handover of patients has become more important than ever to ensure continuity of patient care and avoid errors caused by information gaps. However, published studies have suggested that the quality of handovers can be poor.26 Crawford et al. assessed the impact of the shift working pattern on documentation in orthopaedic surgery – particularly in patients with hip fractures – using the CRABEL score,8 a published scoring system for auditing medical records. They reported a decrease in the standard of documentation since the introduction of the shift system working pattern in their department.9 Absent or inaccurate handover information during busy on-call periods increases clinical risk; especially when a patient needs urgent or unexpected care. Accurate and comprehensive handovers are key to effective patient management, and most importantly help identify the patients most in need of clinical review.7

There are currently a variety of different handover methods being used in clinical practice. Often a verbal handover is conducted, either in person or by telephone, where the recipient of the handover may or may not take notes to refer to over the course of their shift. In many hospitals it is commonplace for a handover book or folder to be used so that teams can leave messages about patients of particular concern. With this handover method, there may be no verbal contact at all. Increasingly, more formal handover takes place with allocated time during working hours with the use of spreadsheets containing information about all of the patients belonging to that particular team.16

One particular observational study looking at the effectiveness of various handover methods in terms of information retained by doctors demonstrated that ‘verbal alone’ was not an effective handover method, and that use of printed sheets was the most effective way of retaining information.4 Suggestions to improve the quality of handovers include electronic handovers 36, 38 and the development of guidelines for handovers.19 Subsequently The British Medical Association, in conjunction with the General Medical Council,30 NHS Modernization Agency and the Junior Doctors’ committee have recently published guidelines 21 for safe handover, but these are largely based on expert opinion.

We describe the process of developing an electronic handover and patient management database system for junior doctors in the trauma and orthopaedic unit to use in our hospital, a central London tertiary teaching hospital with approximately 700 beds. We go on to compare the quality of information handed over using the traditional ad hoc method of printed sheets versus our web-based structured electronic software and also report on acceptability and benefits, assessed via observations and questionnaires.

Section snippets

Background key ideas and concepts

Underlying the web-based electronic software development project were several key ideas.

Methods

During early 2007 we reviewed handover procedures for trauma patients admitted to our unit. In consultation with both junior and senior doctors and the clinical risk management committee we determined the minimum data and functions for the electronic web-based software program to facilitate handover, effective patient management and reduce clinical risk.

Technical aspects

We used web-based intranet software to design the program. We named the program ‘TraumaPal’©. A user-driven design process was used and functionality reflected the core work of junior doctors working in the trauma and orthopaedic department. The menu screen for TraumaPal is shown in Fig. 1. The tabs at the top of the computer screen on the menu bar represent the basic operating features of the software. A description of each function that is represented on the menu bar is provided to the user.

Results

Overall 707 patients were included in this audit, 357 in the study group (electronic handover) and 350 patients in the control group (paper-based handover). There were 423 males (59.8%) and 284 females (40.2%), with a mean age of 41 years (range 27–62 years; 25 and 75 percentile, respectively. The types of injuries of all patients are illustrated in Table 2. Forty-six patients (6.5%) presented with an open fracture. Overall, 496 patients (70.2%) underwent an operation, while 211 (29.8%) were

Discussion

There are many published examples of cases highlighting poor communication between doctors having serious consequences for patient outcome.22, 11 For this reason, it is well recognised that accurate handover of clinical information is of great importance to patient safety.5 Good quality medical care relies heavily on effective communication between doctors.10

It has been well publicised that Electronic Health Records (EHR) have the potential to improve the accuracy of healthcare documentation

Conflict of interest

The authors of this paper give permission for other healthcare trusts/hospitals to use design concepts described in this paper for non-commercial use. D. Raptis as Director of BioStat IT is the only author with financial interests related to BioStatIT and any future proceeds in relation to TraumaPal. The trademark TraumaPal is copyright protected.

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