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Creating a safe, reliable hospital at night handover: a case study in implementation science
  1. Annette McQuillan1,
  2. Jane Carthey2,
  3. Ken Catchpole3,
  4. Peter McCulloch4,
  5. Deborah A Ridout5,
  6. Allan P Goldman1
  1. 1Cardiothoracic Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
  2. 2Great Ormond Street Hospital NHS Foundation Trust, London, UK
  3. 3Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, USA
  4. 4Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
  5. 5Centre for Paediatric Epidemiology and Biostatistics, UCL Institute of Child Health, London, UK
  1. Correspondence to Dr Jane Carthey, Consulting, 34 Ravensmede Way, London W4 1TF, UK jcarthey_gosh{at}


Background We developed protocols to handover patients from day to hospital at night (H@N) teams.

Setting NHS paediatric specialist hospital.

Method We observed four handover protocols (baseline, Phases 1, 2 and 3) over 2 years. A mixed-method study (observation, interviews, task analysis, prospective risk assessment, document and case note review) explored the impact of different protocols on performance.

Intervention In Phase 1, a handover protocol was introduced to resolve problems with the baseline H@N handover. Following this intervention, two further revisions to the handover occurred, driven by staff feedback (Phases 2 and 3).

Results Variations in performance between handover protocols on three process measures, start time efficiency, total length of handover, and number of distractions and interruptions, were identified. Univariate regression analysis showed statistically significant differences between handover protocols on two surrogate outcome measures: number of flagging omissions and the number of out of hours deteriorations (p=0.04 for Phase 3 vs Phase 1 for both measures (CI 1.04 to 4.08; CI 1.03 to 4.33), and for Phase 3 vs Phase 2 (p=0.006 and p=0.001 (CI 1.22 to 5.15; CI 1.62 to 9.0)), respectively). The Phase 1 and 2 handover protocols were effective at identifying patients whose clinical condition warranted review overnight. Performance on both surrogate outcome measures, length of handover and distractions, deteriorated in Phase 3.

Conclusions A carefully designed prioritisation process within the H@N handover can be effective at flagging acutely unwell patients. However, the protocol we introduced was unsustainable. In a complex healthcare system, sustainable implementation of new processes may be threatened by conflicting goals.

  • Hand-off
  • Healthcare quality improvement
  • Human factors
  • Implementation science
  • Communication

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