• Medicines reconciliation
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Transmit Sheet

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Context

The handover process in paediatric intensive care, paediatric cardiac surgery, and at the interface of primary and secondary care (both admission and discharge) have been examined, but not medical paediatric in-patients. This group are significantly different to critical care patients, since the number of patients who are being handed over is significantly higher, with a greater range of potential problems. The TRANSMIT sheet presented here is structured handover sheet for paediatric inpatients, designed and validated (see attached publication) in Alder Hey Children's Hospital, that improved the quality of written information available to out of hour staff, including information about medications.

Aims

It is a single page summary to be completed for each patient by the relevant paediatric team(s) providing care during the week, and filed in the medical notes before the weekend/holiday/when necessary. It replaces the ward round entry in the notes usually taken by the medical team (to ensure that additional workload has not been placed on busy clinicians) and provides prompts to the completing team to improve the quality of information handed over. It contains sections for tasks to be undertaken (e.g. blood tests), and anticipated problems that may occur over the weekend.

Description

There are several areas of the TRANSMIT sheet where this tool can help improve medication safety:i) Medication plan – an opportunity for the team to let the on call staff details of the medication plan (such as, stop antibiotics after x doses). ii) A reminder to the team handing over to ensure there is a full prescription sheet written for the weekend, so that some of the menial tasks (that can affect patient care) are reduced out of hours.iii) Intravenous access – the opportunity to spell out if a transition from iv to oral medication can be tried if the cannula tissues/comes out – or if maintenance of IV therapy is required (perhaps, guidance to just use IM antibiotics in some cases). This can reduce unnecessary cannulas in children, while avoiding the premature conversion of iv to oral in those not ready for it.

Implementation

Pre-implementation: A prospective evaluation of casenotes of paediatric patients (n=119) was undertaken for a) an accurate problem list (compiled within the previous 72 hours), b) a written plan for the weekend team (including anticipated problems). Only 67/119 (56%) casenotes included a recent and accurate problem list, and 75/119 (63%) had a weekend plan.The team electronically developed the sheet, trying to capture all the pertinent information which, following discussion with senior consultants, was adopted straight away. The categories for the title were refined by discussion amongst the group - the acronym flowed from the final areas to be included.    

Suggestions for further implementation

This version was designed for paediatric medical patients, but is used across various specialties in our trust. It could be altered to be more useful in other paediatric specialities. Editable (word .doc) versions are available if required - please email d.hawcutt@liv.ac.uk

Challenges and learning

This was a grass roots programme, led by junior doctors, to improve patient care. As it had the buy in of those using it, support from the consultant body, and led to improvements in the way children were looked after, it was very straightforward to implement.Post-implementation: Two months after implementation, a prospective re-audit of 111 casenotes showed 91/111 (82%) now included an accurate problem list, and 84/111(76%) had weekend plans. Qualitative assessment by the junior doctors also showed it was liked and well used - see accompanying publication.

Quality assurance/MHRA registration

Approved by local trust. Published (BMJ Quality Improvement Reports 2013; u202302.w1137 doi: 10.1136/bmjquality.u202302.w1137)