Background: Communication failure between healthcare providers is the leading cause of sentinel events. To emphasize the critical need to improve such communication, TJC cited improving effectiveness of communication as one of the National Patient Safety Goals. Handoff tools have been used to improve communication, however, in its review TJC found that over 1/3 of patient handoff tools that are currently used are defective. Foreground: Currently, transfer times have been reported to be delayed at the facility. Currently no standardized handoff tool exists for critically ill patients being admitted to the intensive care unit (ICU) from the emergency department (ED). EBP Framework: Rosswurm and Larrabee’s EBP model was used to guide the project in conjunction with Battey’s Humanizing Nursing Communication Theory and Ethics of Humanizing Nursing Communication. Methods: The project manager held an educational in-service for staff of the ED and ICU to educate about the revised hand off tool that was implemented. Data was collected prior to implementation on current transfer times through TeleTracking, the patient tracking software in place at the facility. The revised transfer tool was implemented for one month. During the month, times were tracked weekly and at the end of one month time. An overall comparison was done to evaluate effectiveness off the handoff tool. Results were disseminated to staff during regularly scheduled staff meetings. Feedback was gathered at that time from participants and anonymously via a suggestion box. Data was analyzed with the help of clinical mentor. Results: The baseline data, with a sample size of 963 admissions, had a mean transfer time of 1:33 (HH:MM). During the project implementation period there were 202 admissions which ended having an average time of 1:45, a 12 minute increase from the baseline sample. When looking at the data by week, the times decrease from week 1 compared to week 4. Using MiniTab statistical software to compare week 1 times to week 4, no statistical difference was noted between the transfer times in week 1 and those in week 4. While no statistical difference was noted, clinical significance was noted in comments from participants. Conclusion: The implementation of the hand off tool did not decrease transfer times. Feedback gathered from the nursing staff included comments that the handoff report went more smoothly, less clarifying questions had to be asked, all pertinent information was given during the handoff, and the verbal report was more organized.
