SHARED maternity care: enhancing clinical communication in a private maternity hospital setting

Midwives and visiting medical officers (VMOs) in private practice have a unique relationship within the private hospital setting. The effective exchange of accurate information between them is a fundamental element of patient safety and is vital to the success of the clinical handover process.1-5 The midwife is reliant on information provided by the VMO, as a woman’s recent history and current condition will not always be available in the medical record. Throughout labour, birthing and the postnatal period, the VMO may be reliant on information gathered and communicated by the midwives providing care. This exchange of information sometimes occurs face-to-face, but more commonly occurs via telephone, as VMOs may work in multiple locations.

Thus, the effective transfer of accurate and appropriate patient information is a fundamental element of patient safety and quality care. The accuracy, timeliness and relevance of this information and the style of handover used is vital to the success of the handover process. The SHARED (situation, history, assessment, risk, expectation and documentation) project6 (see below) sought to develop, implement and evaluate a framework and support tools for improving clinical handover in two private maternity hospitals in Brisbane, the Mater Mothers’ Private Hospital (MMPH) and the Mater Private Hospital Redland (MPHR). The MMPH is a tertiary referral hospital birthing about 4500 babies a year. The MPHR is a small (60-bed) hospital that births about 450 babies per year. These hospitals offered an excellent context in which to develop and test a framework for clinical handover to enhance the safety and quality of maternity care.

Women may be admitted to the MMPH or MPHR directly from home or from a VMO’s private rooms. In some cases, critical communication must occur, often at potentially highly stressful times. It is therefore vital that this communication is accurate, up-to-date and relevant.

The Mater Health Services Clinical Handover Project, from February 2008 to February 2009, primarily focused on critical times around two specific points of care:

• Exchange of information (by telephone) between the midwife and the VMO when a change in the woman’s condition occurs; and

• Handover from the recovery nurse or midwife to the unit/ward midwife after caesarean section.

These are times of potentially high risk of an adverse event if communication breaks down.

The SHARED framework is an extension of previous work around a set of key characteristics for clinical handover undertaken by the Mater Health Services’ Clinical Safety and Quality Unit in 2006. These characteristics were represented by the mnemonic SHARE (situation, history, assessment, risk, events). It was anticipated that, once a pilot had been completed, the framework would provide a basis to build handover solutions specific to clinical scenarios and specialties across Mater Health Services.

Following a literature review, it became evident that the concept of “what comes next” was not fully captured by the SHARE framework. To address this, the meaning of “E” was changed to represent “expectations/escalation” rather than “events”, and “D” for “documentation” was added to ensure that this vital component of the clinical handover process was not overlooked.

The modified handover trigger SHARED is a method for enhancing the quality and accuracy of information transferred between health care professionals. Each letter of the mnemonic represents an essential component of clinical handover and highlights the transfer of responsibility and accountability, not simply the transfer of information (Box).

A range of tools was developed to support the SHARED project:

• Poster: a prompt within the clinical work area;

• Swing tag: an easy-to-carry, easy-to-read, double-sided prompt of SHARED and its components;

• Phone handover guide: to remind staff to be fully prepared before communicating around a critical situation or change in patient condition;

• “I SHARED” sticker: placed in the patient’s chart along with documentation of the phone conversation, including expectations and plan of care; and

• Clinical pathway inserts:7,8 to support the postoperative verbal handover process from the recovery room to ward staff.

The project included a pre- and post-study design using clinician surveys, chart audits, patient satisfaction surveys and a review of clinical incident data to measure change in satisfaction, attitudes and practice with handover and documentation.

After the implementation of the SHARED framework, a clinician satisfaction survey showed that most respondents were aware of the SHARED framework and its support tools and found them helpful.

The chart audit demonstrated an improvement (from 13% to 24%) in “adequate overall” documentation after implementation of the SHARED framework, with statistically significant improvements occurring in three of the ten criteria measured (legibility of documentation, time entered, and signature used).

At MPHR, there was no statistically significant change in patient satisfaction with regard to questions on the following issues:

• Communication between doctors and nurses regarding your care; and

• How staff worked together to care for you.

At MMPH, patient satisfaction around “how staff worked together to care for you” improved by 6.9 mean score points and saw this question move from 10th to 19th most important on the priority index of areas for improvement.

It was noted that, throughout the implementation of the SHARED framework, there was an overall reduction in reported clinical incidents in which communication failure was identified as a contributory factor. However, it is well documented that the use of clinical incident data is not a reliable measure, as its accuracy is variable.9

It is anticipated, after refinement of the SHARED support tools, that SHARED will be adopted for use across Mater Health Services to support clinical handover at specific clinical points of care, including end-of-shift medical and nursing handovers.

The SHARED framework serves to remind health care professionals that they are not simply transferring information, but also responsibility and accountability for patient care.

The SHARED graphic