Improving Labor & Delivery Shift Report

Transcription

1 Improving Labor & Delivery Shift Report Adapt This Tool for Your Clinical Setting to Aid in Patient Care

2 Jacy Elm, RN, BSN Sitting at the nurses station, I flip through the admission notes, prenatal records and pages of doctors orders stashed in my patients charts. As I sort through the information, I simultaneously receive report from another nurse, describing the patients histories, reviewing the care and major events of the past shift and detailing their current conditions. Sticky notes pasted and paper-clipped to the charts act as reminder notes for medication administration times. Though the report information seems immense and complex, I am acutely aware of its crucial effect on patient care and I listen intently trying to soak up the information. After clarifying a few minor points, the nurse breathes a furtive sigh of relief and hustles out into the morning air. Though the unit bustles with the morning rush, I feel somewhat

3 alone with my four patients: two expectant mothers and two unborn infants, whose forward-marching fetal heart monitor tracings adorn the computer screen before me. As I watch the contractions rise and fall and monitor the reactions of the fetal heart rates, I organize my thoughts to mentally plan and prioritize my next actions. What time is that antibiotic due for Mrs. Johnson s group B strep? Or is it Mrs. Smith who has the group B strep? How long has it been since my patients cervixes were checked? Since their bladders were emptied? Which one is having the boy? In a sudden quandary of thought, I delve once again into the patients charts and begin adding to the assortment of summarizing sticky notes. Change of shift report is a critical time in patient care settings. Here, nurses communicate significant data regarding patients to enable other nurses to provide competent and effective care with continuity. The report must be broad enough to encompass the holistic and long-term goals of the patient, yet specific enough to cover priority tasks and individualized needs. However, though the shift report is an imperative part of ensuring quality patient care, it can be treated lightly, seem disorganized or otherwise poorly handled, thereby disabling an on-coming nurse s ability to assess and plan and, in turn, jeopardize patient care. Time constraints, lack of organization or simple thoughtlessness can have disastrous effects if key information is not transferred to the receiving nurse. Missing or incorrect elements will affect the assessments, evaluations, decisions and actions of the nurse, which then create larger problems including increased liability, and more important, decreased patient safety. Change of shift report must be carefully and thoroughly completed to avoid the negative consequences of deficient communication and to promote continuity, effectiveness and competency in nursing care. Exploring Reporting Shift report is the exchange that occurs when nurses communicate information about patients so that the nurse who is just beginning shift will be able to effectively plan care for the Jacy Elm, RN, BSN, is a staff nurse at Utah Valley Medical Center in Provo, UT. DOI: / unit s patients (Dowding, 2001; Lamond, 2000). This exchange of important patient information serves as a passing of the baton to the on-coming nurse, enabling her to plan for and perform necessary nursing care. A nurse must be aware of the problems, complicating factors and available resources to effectively care for a patient. Thus, shift report, the means by which the nurse must gain such vital information, has a direct effect on patient care (Dowding, 2001; Lamond, 2000). An effective shift report must be both efficient and thorough so that it minimizes time away from patient care but is sufficient to provide the exchange of vital information. Successful shift report increases the quality of patient care, and as such, patient satisfaction improves while risk of hospital and nurse liability decrease (Antonik, LaMonica, & Lim, 1999; Dowding, 2001; Lamond, 2000). Shift report in labor and delivery nursing is especially important, as the exchange must include both general health concerns and information specific to intrapartum care. A shift report tool can aid labor and delivery changes to empower nurses to better plan and deliver quality patient care. Addressing pertinent general and maternal-fetal issues in ways that support information retention, a shift report tool can help eliminate miscommunications and errors of omission. Thus, through the creation and implementation of a labor and delivery shift report tool designed according to general shift report guidelines, specific maternal-fetal complications and factors affecting memory and learning, nurses can effectively increase patient privacy and the quality of patient care, decrease hospital and nurse liability and increase nurse and patient safety. Working With a Reporting Tool The implementation of a reporting tool can enable nurses to give accurate, complete and organized reports, thereby empowering receiving nurses to provide competent, focused and quality care (see Figure 1 for a sample reporting tool). First, a report tool can guide the conversation between nurses and serve as the basic format for what a shift report should be and do. Next, a labor and delivery report tool can address specific maternal-fetal issues and risk factors. Report tools can be designed to use pertinent graphics in a way that promote their usability and help aid in remembering the information. 56 AWHONN Lifelines Volume 8 Issue 1

4 Figure 1. Sample Shift Reporting Tool Room Name Age Gravida/Para Doctor GBS BOW Dil/Eff Epid IV Monitors EDC/Gest. Age Prenatal Record Available? Y N Med Hx Maternal/Fetal Complications Fluids/Infusions 06/18 07/19 08/20 09/21 10/22 11/23 Rubella: Psych/Social Blood Type: Meds 12/00 13/01 14/02 15/03 16/04 17/05 Allergies: Room Name Age Gravida/Para Doctor GBS BOW Dil/Eff Epid IV Monitors EDC/Gest. Age Prenatal Record Available? Y N Med Hx Maternal/Fetal Complications Fluids/Infusions 06/18 07/19 08/20 09/21 10/22 11/23 Rubella: Psych/Social Blood Type: Meds 12/00 13/01 14/02 15/03 16/04 17/05 Allergies: February March 2004 AWHONN Lifelines 57

5 Box 1. Learn More About HIPPA Centers for Medicare & Medicaid Services (2002): Health Data Management (2003): html/hipaa/hipaa.cfm Health Information and Management Systems Society (2003): HIPAAdvisory (2003): HIPAA comply (2003): HIPAA direct (2002): Hipaainfo.net (2003): HIPAA Links (2003): netcom.com/~ottx4/hipaa.htm or HIPAA.ORG (2003): Management Systems Consulting, Inc. HIPAA glossary (2003): Public Law Health Insurance Portability & Accountability Act of 1996: Strategic National Implementation Process (2002): U.S. Department of Health & Human Services Office for Civil Rights HIPAA (2003): U.S. Department of Health & Human Services Office of the Assistant Secretary for Planning and Evaluation (2003): U.S. Department of Health & Human Services Office of the Assistant Secretary for Planning and Evaluation Subscribe to HIPAA-REGS list (2003): U.S. Medicine Institute HIPAA: usminstitute.org/hipaa.html Washington Publishing Company (2003): The current nursing literature speaks very little about the importance of a reporting tool, but it does reveal essential aspects of a shift report. By using these factors, an intuitive reporting tool can be structured. First, a client s name, age and consultant are usually the first three facts mentioned in a shift report (Dowding, 2001; Lamond, 2000). Hence, these three facts are placed on the top line of the form, where they can be easily seen and accessed. Next, the patient's reason for admission is commonly discussed (Dowding, 2001; Yurkovich & Smyer, 1998). In labor and delivery, dilatation and effacement or the rupture of membranes are common causes for admission and are thus placed appropriately on the second line, immediately below the patient s name. Immediate interventions upon admission is an associated topic discussed here, which is reflected with the presence of topic boxes including the placement or lack of an epidural, the presence of an IV and the monitors in use. Pertinent labor and delivery assessment information, such as gravidity, parity, group B strep status, due date and gestational age, are also recorded in the first two lines to promote early discussion and easy visibility of such essential facts (Hall, Swart, Grove, & Odendaal, 2001; Walling, 1997). Significant medical history, psychosocial issues and current patient problems are usually discussed next. Hence, medical and obstetrical history, psychosocial issues and current maternal/ fetal complications can be the next topics outlined in the report tool. Finally, the information regarding the patient s fluid status and medications is explained (Dowding, 2001; Yurkovich & Smyer, 1998). Therefore, the last two topic boxes give space for the recording of such information, with relevant facts, including blood type and allergies attached. Hence, the report tool incorporates the basic needs of a labor and delivery report to promote delivery of competent, holistic care. In designing the tool for use in our clinical setting, two extra features were added. First, a box that provides information about the availability of a prenatal record for the patient was added at the suggestion of nursing staff. Such information was stated as most pertinent when calling the doctor, thus giving the topic box its position on the form directly below the name of the doctor. Second, an outlined schedule of a typical 12-hour shift allows the nurse to both plan and record events. The underlying purpose of the shift report is to exchange information such that the receiving nurse will be able to effectively plan patient care (Dowding, 2001; Lamond, 2000). Hence, the hourly schedule, adapted for both day and night shifts, allows for such planning, thereby facilitating the purpose of the shift report. HIPPA Considerations Report tools have become increasingly more important since the Health Insurance Portability & Accountability Act of 1996 (HIPAA). Among other standards, HIPAA requires health providers and insurers to implement measures to protect the confidentiality of individually identifiable health information (HIPAA Primer, 2003) (see Box 1). As a result, hospitals and other health care providers have been forced to do away with central stations used to organize patient information. Where a large board might have previously displayed each patient s full name, gravidity and parity, dilatation and other facts, now stands only an anonymous first name and blank spaces for available beds. With such measures enacted to meet the April 14, 2003, Privacy Rule compliance date (HIPAA Primer, 2003), report tools have become even 58 AWHONN Lifelines Volume 8 Issue 1

6 more practical and beneficial. Where a nurse can no longer use the central board, she may use the tool as a pocket reference, instead of wasting time on a scavenger hunt through the pages of a patient s chart. Thus, the report tool can be a means of promoting HIPAA compliance, assisting nurses in providing both quality care and patient confidentiality. Following a patient s discharge from the unit, report tools need to be stored or destroyed according to organizational guidelines to meet HIPPA regulations. If the report tool will not become part of a patient s permanent medical record, it must be destroyed to meet HIPPA. Enhancing Retention and Learning Several factors known to increase retention and learning are incorporated into the tool s design. First, the use of the report tool allows the receiving nurse to be an active participant in the report by making notes in an organized fashion, rather than a passive listener, thereby increasing information retention (Pinto & Zeitz, 1997). Next, by receiving report in both a visual and auditory way, along with the additional benefit of writing, retention of the report information is aided (De Haan, Appels, Aleman, & Postma, 2000). Graphics help organize the tool and call attention to pertinent information as it is used or needed (Tractinsky & Meyer, 1999). The organization of the topics further contributes to information retention. The orderly presentation of subjects in the tool coincides with the logical flow of the verbal shift report, thereby promoting rational organization and easy access to information. Accordingly, the tool groups related topics, such as information related to the reason for admission (ruptured membranes, dilitation and effacement) and medications with allergies. This chunking of topics promotes information retention and the activation of appropriate nursing care schema (Dowding, 2001; Lamond, 2000). Thus, the report tool not only incorporates the essential characteristics of a labor and delivery shift report but also considers the implications of factors affecting memory and learning. References Antonik, G., LaMonica, S. D., & Lim, M. (1999). Notes from the field: A written report tool shrinks ED stays. Nursing Management, 30(10), 47. De Haan, E. H. F., Appels, B., Aleman, A., & Postma, A. (2000). Inter- and intramodal encoding of auditory and visual presentation of material: Effects of memory performance. Psychological Record, 50(3), Dowding, D. (2001). Examining the effects that manipulating information given in the change of shift report has on nurses care planning ability. Journal of Advanced Nursing, 33(6), Hall, D. R., Swart, R., Grove, D., & Odendaal, H. J. (2001). The influence of maternal age on pregnancy outcome in patients with early onset, severe pre-eclampsia. Journal of Obstetrics and Gynaecology, 21(3), HIPAA Primer. (2003). HIPAAdvisory [Online]. Retrieved May 27, 2003, from HIPAAprimer1.htm Lamond, D. (2000). The information content of the nurse change of shift report: A comparative study. Journal of Advanced Nursing, 31(4), Pinto, A. J., & Zeitz, H. J. (1997). Concept mapping: A strategy for promoting meaningful learning in medical education. Medical Teacher, 19(2), Tractinsky, N., & Meyer, J. (1999). Cartjunk or goldgraph? Effects of presentation objectives and content desirability on information presentation. MIS Quarterly, 23(3), Walling, A. D. (1997). Maternity care by physicians and certified nurse-midwives. American Family Physician, 55(4), Yurkovich, E., & Smyer, T. (1998). Shift report: A time for learning. Journal of Nursing Education, 37(9), February March 2004 AWHONN Lifelines 59