ED and Med-Surg Nurses Reduce Communication Failure-Related Safety Events by 68% Since Adopting the I-PASS Handoff Methodology

In October 2021, Carilion Giles Community Hospital (CGCH) was experiencing the effects of poor handoff communication, averaging three communication-related adverse events per month, resulting in extended patient stays, increased adverse events, and increased patient complaints. As a critical access hospital recognized for its quality and patient satisfaction, the CGCH leadership team was determined to find a solution.

Identifying Increased Communication Failures

Without a standardized system for clinician communication, the handoff process at CGCH had become unreliable and inconsistent. The handoff workflow varied from unit to unit; sometimes the emergency department (ED) nurses would use group reports, while the Medical-Surgical unit (Med-Surg) nurses mainly conducted nurse-to-nurse communication without entering the patient’s room. Additionally, there were a few common events at CGCH that led to communication failures:

• Failure to pass information from shift to shift
• Information omitted completely during handoffs
• Medications not logged
• Specimens not collected

Improving Consistency and Reducing Adverse Events

In early 2022, Jennifer Bailey, MHA, BSN, RN, Director of Quality and Patient Safety at CGCH, discovered the I-PASS Handoff Bundle through a grant program. By May 2022, CGCH began partnering with I-PASS to adopt a standardized framework for nurse handoff communication. Bailey prioritizes patient safety and quality initiatives every day and naturally became the hospital’s leading I-PASS champion, playing multiple roles throughout implementation.

The core CGCH and I-PASS team mapped out a customized 12-month implementation plan to meet their program adoption needs and patient safety goals. Ahead of implementation, the leadership team set a goal to utilize I-PASS to reduce communication failure–related events by 20% in one year.

The case study highlights how the CGCH team surpassed their goals and achieved the following results since adopting the I-PASS handoff methodology:

• 68% reduction in communication failure-related safety events
• 90% decrease in reported rate of harms/100 days worked
• 6x more likely for handoffs to be conducted in the desired locations
• 51% increase in handoffs adhering to all 5 mnemonic elements
• 73% of observed handoffs are occurring in the patient room or at bedside in the ED

Reflecting on Success and Looking Ahead

Despite having limited resources and team members, the I-PASS implementation at CGCH was extremely successful. Leadership, as well as the CGCH staff and the I-PASS implementation team, are pleased with the process and ultimate adoption rate of the handoff bundle.

The CGCH team is already realizing the impact of I-PASS on the organization. Early reports indicate that adding “specimen collection” as a hardwired component on the handoff report has contributed to a decreased average length of stay, Bailey noted, adding that CGCH looks forward to realizing the full impact of the I-PASS Handoff Bundle on its bottom line. As CGCH continues the sustainment phase, they have begun conducting transitions from the ED to Med-Surg in the I-PASS structure and are exploring expansion to other facilities in the Carilion system.

Read the full CGCH case study to learn more about the approach CGCH took to successfully implement the I-PASS handoff bundle.