November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
In September we talked about the hazards of handoffs (September 30, 2008 Patient Safety Tip of the Week Hot Topic: Handoffs) and our September 16, 2008 Patient Safety Tip of the Week “More on Radiology as a High Risk Area” spoke about many of the hazards of transporting patients to the diagnostic imaging suite. One way to facilitate such handoffs would be to include information on various risks in a structured communication tool for transports like the “ticket to ride” we described in our April 8, 2008 column “Oxygen as a Medication”. Some excellent tools have been developed to improve the handoff processes that take place during such transports.
One of the most interesting papers we’ve seen on ICU transports (Esmail 2006) focuses on development of a standardized decision/communication tool. Though the paper does not report any outcome data, it provides some incredible insights into issues associated with development of such tools. It describes the efforts of a Canadian collaborative project to improve ICU transport safety that arose after 2 incidents of cardiopulmonary arrest that occurred in ICU patients that had been transported to diagnostic imaging areas. It goes through all the steps involved in development of a decision “scorecard” to determine the stability of the patient for such transport and the resources necessary if such transport does take place. They used multiple PDSA cycles to test and revise the tool. Their multidisciplinary performance improvement team began by flowcharting all the steps involved in transporting an ICU patient to diagnostic imaging and back to the ICU. They found 29 steps in all (those steps are all included in a figure in the paper). They scanned the literature to find other guidelines and tools for such transports and utilized these to develop their own tool.
One of the most important lessons from this collaborative was the involvement of a human factors expert and their focus on how humans interact with reading and filling out forms. They collected about 80 forms through their iterative processes and found that many of the forms were too complex and not user-friendly. As a result they progressively simplified the form and sought to include only “show stoppers” as their clear decision points. Originally using the traffic signal metaphor, they had green-yellow-red columns for various levels of safety for transport. But in the final analysis, they moved to a geen-red or go/no-go type format. (Red means that the ICU physician must determine whether the potential benefits of the transport outweigh the risks and, if so, the physician should accompany the patient during the transport). But they note that effective forms accommodate two-way flow of information: instruction to the person filling out the form and collection of information from that person. They cite research that shows form fillers read less than 50% of relevant information such as instructions. And they make the very important distinction between “directed forms” and simple “checklists” Directed forms require a yes/no type of response for each item, forcing a decsion and forcing the form filler to read carefully before coming to that decision. They caution that checklists, on the other hand, often lead to the form filler scanning the list for relevant items and often skipping critical information they might perceive to be irrelevant. (Important: note that most of the Peter Pronovost-type checklists you’ve heard us advocate really fit the “directed forms” format defined in this paper).
Particularly enlightening is their discussion of instructions for form use. They note that instructions are often placed on a face sheet or introductory page and, if they are even read, are often forgotten by the time the form filler gets to the area of the form they apply to. So a good form includes the instructions visually at the point where they are relevant.
The second lesson was their insight that the tool needed to be designed so that a “novice” staff member could use it.
A third lesson had to do with some of the resistance to the form that was encountered at one participating site. That particular site had its diagnostic imaging area located adjacent to the ICU and staff there did not perceive the same pressing needs for such a transport decision tool. We strongly agree with the conclusion of the authors that such proximity likely gives rise to a false sense of security and that adverse events are a danger related to even short transports.
A new paper on use of the “ticket to ride” type checklist as a handoff tool (Pesanka 2008) also just appeared in the Journal of Nursing Quality. Analysis of events occurring during off-unit transports had identified a number of issues, so Pesanka and colleagues at UPMC put together a team to develop a standardized handoff communication tool to be utilized during in-hospital transports. The form they developed utilizes an SBAR format and includes most of the key elements you need to consider during patient transports, with appropriate checkboxes and places for sign-off (initials) by everyone involved in the transport (sending team, transport team, receiving team) at all destinations. Importantly, the UPMC Ticket to Ride includes the patient himself as a key stakeholder and participant in the transport. The tool also does a good job of addressing the issue of adequacy of oxygen therapy during transports and stays off the unit (remember our original discussion of the ticket to ride concept arose because of the frequent problem with oxygen during such trips). Though the tool was originally intended for use during transports to diagnostic imaging, it is now being rolled out as a tool for all sorts of transports system-wide in the UPMC system.
Summarizing from the two papers, there are several keys to developing a “ticket to ride” form:
The Esmail paper and the Pesanka paper provide good examples that you might use for ICU transport decisions and actual transports, respectively. However, rather than just adopting such tools we strongly encourage you to read the articles for the wealth of information they contain about the development of such tools. You will use many of the lessons learned for development of a variety of tools in your organization.
Is Your Patient Ready for Transport? Developing an ICU
Patient Transport Decision Scorecard.
Pesanka DA, Greenhouse PK, Rack LL, Delucia GA, Perret RW, Scholle CC, Johnson MS, Janov CL. Ticket to Ride: Reducing Handoff Risk During Hospital Patient Transport. J Nurs Care Qual. 2008 Aug 26. [Epub ahead of print]