title: Republished: creating a safe, reliable hospital at night handover: a case study in implementation science.
abstract: BACKGROUND
  We developed protocols to handover patients from day to hospital at night (H@N) teams.
  
  
  METHODS
  NHS paediatric specialist hospital.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.affiliation: Cardiothoracic Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
authors.forename: Annette
authors.initials: A
authors.lastname: McQuillan
authors.affiliation: Great Ormond Street Hospital NHS Foundation Trust, London, UK.
authors.forename: Jane
authors.initials: J
authors.lastname: Carthey
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, USA.
authors.forename: Ken
authors.initials: K
authors.lastname: Catchpole
authors.affiliation: Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: McCulloch
authors.affiliation: Centre for Paediatric Epidemiology and Biostatistics, UCL Institute of Child Health, London, UK.
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Ridout
authors.affiliation: Cardiothoracic Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
authors.forename: Allan P
authors.initials: AP
authors.lastname: Goldman
keywords: Communication; Hand-off; Healthcare quality improvement; Human factors; Implementation science