Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

Handover in Intensive Care

Handover is a frequent and complex task that also implies the transfer of the responsibility of the care. The deficiencies in this process are associated with important gaps in clinical safety and also in patient and professional dissatisfaction, as well as increasing health cost. Efforts to standardize this process have increased in recent years, appearing numerous mnemonic tools. Despite this, local are heterogeneous and the level of training in this area is low. The purpose of this review is to highlight the importance of IT while providing a methodological structure that favors effective IT in ICU, reducing the risk associated with this process. Specifically, this document refers to the handover that is established during shift changes or nursing shifts, during the transfer of patients to other diagnostic and therapeutic areas, and to discharge from the ICU. Emergency situations and the potential participation of patients and relatives are also considered. Formulas for measuring quality are finally proposed and potential improvements are mentioned especially in the field of training.

Evaluation of a Novel Handoff Communication Strategy for Patients Admitted from the Emergency Department

Introduction

Miscommunication during inter-unit handoffs between emergency and internal medicine physicians may jeopardize patient safety. Our goal was to evaluate the impact of a structured communication strategy on the quality of admission handoffs.

Methods

We conducted a mixed-methods, pre-test/post-test study at a 560-bed academic health center with 60,000 emergency department (ED) patient visits per year. Admission-handoff best practices were integrated into a modified SBAR format, resulting in the Situation, Background, Assessment, Responsibilities & Risk, Discussion & Disposition, Read-back & Record (SBAR-DR) model. Physician handoff conversations were recorded and transcribed for the 60 days before (n=110) and 60 days after (n=110) introduction of the SBAR-DR strategy. Transcriptions were scored by two blinded physicians using a 16-item scoring instrument. The primary outcome was the composite handoff quality score. We assessed physician perceptions via a post-intervention survey.

Results

The composite quality score improved in the post-intervention phase (7.57 + 2.42 vs. 8.45 + 2.51, p=.0085). Three of the 16 individual scoring elements also improved, including time for questions (70.6% vs. 82.7%, p=.0344) and confirmation of disposition plan (41.8% vs. 62.7%, p=.0019). The majority of emergency and internal medicine physicians felt that the SBAR-DR model had a positive impact on patient safety and handoff efficiency.

Conclusion

Implementation of the SBAR-DR strategy resulted in improved verbal handoff quality. Agreement upon a clear disposition plan was the most improved element, which is of great importance in delineating responsibility of care and streamlining ED throughput. Future efforts should focus on nurturing broader physician buy-in to facilitate institution-wide implementation.

Closed-Loop Communication Improves Task Completion in Pediatric Trauma Resuscitation

BACKGROUND

Pediatric trauma care requires effective and clear communication in a time-sensitive manner amongst a variety of disciplines. Programs such as Crew Resource Management in aviation have been developed to systematically prevent errors. Similarly, teamSTEPPS has been promoted in healthcare with a strong focus on communication. We aim to evaluate the ability of closed-loop communication to improve time-to-task completion in pediatric trauma activations.

METHODS

All pediatric trauma activations from January to September, 2016 at an American College of Surgeons verified level I pediatric trauma center were video recorded and included in the study. Two independent reviewers identified and classified all verbal orders issued by the trauma team leader for order audibility, directed responsibility, check-back, and time-to-task-completion. The impact of pre-notification and level of activation on time-to-task-completion was also evaluated. All analyses were performed using SAS® version 9.4(SAS Institute Inc., Cary, NC).

RESULTS

In total, 89 trauma activation videos were reviewed, with 387 verbal orders identified. Of those, 126(32.6%) were directed, 372(96.1%) audible, and 101(26.1%) closed-loop. On average each order required 3.85 minutes to be completed. There was a significant reduction in time-to-task-completion when closed-loop communication was utilized (p < 0.0001). Orders with closed-loop communication were completed 3.6 times sooner as compared to orders with an open-loop [HR = 3.6 (95% CI: 2.5, 5.3)]. There was not a significant difference in time-to-task-completion with respect to pre-notification by emergency service providers (p < 0.6100). [HR = 1.1 (95% CI: 0.9, 1.3)]. There was also not a significant difference in time-to-task-completion with respect to level of trauma team activation (p < 0.2229). [HR = 1.3 (95% CI: 0.8, 2.1)].

CONCLUSION

While closed-loop communication prevents medical errors, our study highlights the potential to increase the speed and efficiency with which tasks are completed in the setting of pediatric trauma resuscitation. Trauma drills and systems of communication that emphasize the use of closed-loop communication should be incorporated into the training of trauma team leaders.

LEVEL OF EVIDENCE

This is a prospective observational study with intervention level II evidence.

Do Bedside Visual Tools Improve Patient and Caregiver Satisfaction? A Systematic Review of the Literature

BACKGROUND

Although common, the impact of low-cost bedside visual tools, such as whiteboards, on patient care is unclear.

PURPOSE

To systematically review the literature and assess the influence of bedside visual tools on patient satisfaction.

DATA SOURCES

Medline, Embase, SCOPUS, Web of Science, CINAHL, and CENTRAL.

DATA EXTRACTION

Studies of adult or pediatric hospitalized patients reporting physician identification, understanding of provider roles, patient-provider communication, and satisfaction with care from the use of visual tools were included. Outcomes were categorized as positive, negative, or neutral based on survey responses for identification, communication, and satisfaction. Two reviewers screened studies, extracted data, and assessed the risk of study bias.

DATA SYNTHESIS

Sixteen studies met the inclusion criteria. Visual tools included whiteboards (n = 4), physician pictures (n = 7), whiteboard and picture (n = 1), electronic medical record-based patient portals (n = 3), and formatted notepads (n = 1). Tools improved patients' identification of providers (13/13 studies). The impact on understanding the providers' roles was largely positive (8/10 studies). Visual tools improved patient-provider communication (4/5 studies) and satisfaction (6/8 studies). In adults, satisfaction varied between positive with the use of whiteboards (2/5 studies) and neutral with pictures (1/5 studies). Satisfaction related to pictures in pediatric patients was either positive (1/3 studies) or neutral (1/3 studies). Differences in tool format (individual pictures vs handouts with pictures of all providers) and study design (randomized vs cohort) may explain variable outcomes.

CONCLUSION

The use of bedside visual tools appears to improve patient recognition of providers and patient-provider communication. Future studies that include better design and outcome assessment are necessary before widespread use can be recommended.

Controlled trial to improve resident sign-out in a medical intensive care unit

OBJECTIVE

Poor sign-out or handover of care may lead to preventable patient harm. Critically ill patients in intensive care units (ICU) are complex and prone to rapid clinical deterioration. If clinical deterioration occurs, timeliness of appropriate interventions is essential to prevent or reduce adverse outcomes. Therefore sign-outs need to efficiently transmit key information and provide anticipatory guidance. Interventions to improve resident-to-resident ICU sign-outs have not been well described. We conducted a controlled trial to test the effectiveness of a standardised ICU sign-out process to the usual ICU sign-out.

DESIGN

Prospective controlled trial.

SETTING

A 26-bed medical intensive care unit (MICU) in an urban tertiary academic medical centre.

SUBJECTS

Residents rotating through the MICU.

INTERVENTIONS

ICU-specific written sign-out template.

METHODS

Residents completed postcall surveys assessing satisfaction with verbal and written sign-outs and incidence of non-routine events. Our main outcome of interest was the occurrence of non-routine events.

MAIN RESULTS

Compared with the intervention group, on significantly more nights, night float residents in the control group encountered patients who were sicker than sign-out would have suggested (15.94% vs 43.75%; p<0.0001). On significantly fewer nights, night float residents in the intervention group indicated that either something happened to patients that was unexpected (18.84% vs 36.51%; p=0.023) or they were insufficiently prepared for (4.35% vs 35.94%; p<0.0001). Similarly, on fewer nights, residents in the intervention group indicated that they had to perform interventions that were unplanned or unanticipated (15.9% vs 37.7%; p=0.005).

CONCLUSION

A structured sign-out process compared with usual sign-out significantly reduced the occurrence of non-routine events in an academic MICU.

Parent-Provider Miscommunications in Hospitalized Children

BACKGROUND

Miscommunications lead to medical errors and suboptimal hospital experience. Parent-provider miscommunications are understudied.

OBJECTIVES

(1) Examine characteristics of parent-provider miscommunications about hospitalized children, (2) describe associations among parent-provider miscommunications, parent-reported errors, and hospital experience, and (3) compare parent and attending physician reports of parent-provider miscommunications.

METHODS

Prospective cohort study of 471 parents of 0- to 17-year-old medical inpatients in a pediatric hospital between May 1, 2013 and October 1, 2014. At discharge, parents reported parent-provider miscommunication and type (selecting all applicable responses), overall experience, and errors during hospitalization. During discharge billing, the attending physicians (n = 52) of a subset of patients (n = 217) also reported miscommunications, enabling comparison of parent and attending physician reports. We used logistic regression to examine characteristics of parent-reported miscommunications; McNemar's test to examine associations between miscommunications, errors, and top-box (eg, "excellent") experience; and generalized estimating equations to compare parent- and attending physician-reported miscommunication rates.

RESULTS

Parents completed 406 surveys (86.2% response rate). 15.3% of parents (n = 62) reported miscommunications. Parents of patients with nonpublic insurance (odds ratio: 1.99; 95% confidence interval: 1.03-3.85) and longer lengths of stay (odds ratio: 1.12; 95% confidence interval: 1.02-1.23) more commonly reported miscommunications. Parents reporting miscommunications were 5.3 times more likely to report errors and 78.6% less likely to report top-box overall experience (P < .001 for both). Among patients with both parent and attending physician surveys, 16.1% (n = 35) of parents and 3.7% (n = 8) of attending physicians reported miscommunications (P < .001). Both parents and attending physicians attributed miscommunications most often to family receipt of conflicting information.

CONCLUSIONS

Parent-provider miscommunications were associated with parent-reported errors and suboptimal hospital experience. Parents reported parent-provider miscommunications more often than attending physicians did.

Rates, Predictors and Variability of Interhospital Transfers: A National Evaluation

IMPORTANCE

Interhospital transfer (IHT) remains a largely unstudied process of care.

OBJECTIVE

To determine the nationwide frequency of, patient and hospital-level predictors of, and hospital variability in IHT.

DESIGN

Cross-sectional study.

SETTING

Centers for Medicare and Medicaid 2013 100% Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data.

PATIENTS

Beneficiaries ≥65 years and older enrolled in Medicare A and B, with an acute care hospitalization claim in 2013.

EXPOSURES

Patient and hospital characteristics of transferred and nontransferred patients.

MEASUREMENTS

Frequency of interhospital transfers (IHT); adjusted odds of transfer of each patient and each hospital characteristic; and variability in hospital transfer rates.

RESULTS

Of 6.6 million eligible beneficiaries with an acute care hospitalization, 101,507 (1.5%) underwent IHT. Selected characteristics associated with greater adjusted odds of transfer included: patient age 74-85 years (odds ratio [OR], 2.38 compared with 65-74 years; 95% confidence intervals [CI], 2.33-2.43); nonblack race (OR, 1.17; 95% CI, 1.13-1.20); higher comorbidity (OR, 1.37; 95% CI, 1.36-1.37); lower diagnosis-related group-weight (OR, 2.02; 95% CI, 1.95-2.09); fewer recent hospitalizations (OR, 1.87; 95% CI, 1.79-1.95); and hospitalization in the Northeast (OR, 1.40; 95% CI, 1.27-1.55). Higher case mix index of the hospital was associated with a lower adjusted odds of transfer (OR, 0.36; 95% CI, 0.30-0.45). Variability in hospital transfer rates remained significant after adjustment for patient and hospital characteristics (variance 0.28, P = 0.01).

CONCLUSIONS

In this nationally representative evaluation, we found that a sizable number of patients undergo IHT. We identified both expected and unexpected patient and hospital-level predictors of IHT, as well as unexplained variability in hospital transfer rates, suggesting lack of standardization of this complex care transition. Our study highlights further investigative avenues to help guide best practices in IHT. Journal of Hospital Medicine 2017;12:435-442.

Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports

There is a high risk for death by suicide after discharge from an inpatient mental health unit. To better understand system and organizational factors associated with postdischarge suicide, we reviewed root cause analysis reports of suicide within 7 days of discharge from across all Veterans Health Administration inpatient mental health units between 2002 and 2015. There were 141 reports of suicide within 7 days of discharge, and a large proportion (43.3%, n = 61) followed an unplanned discharge. Root causes fell into three major themes including challenges for clinicians and patients after the established process of care, awareness and communication of suicide risk, and flaws in the established process of care. Flaws in the design and execution of processes of care as well as deficits in communication may contribute to postdischarge suicide. Inpatient teams should be aware of the potentially heightened risk for suicide among patients with unplanned discharges.

The impact of duty cycle workflow on sign-out practices: a qualitative study of an internal medicine residency program in Maryland, USA

OBJECTIVES

Although JCAHO requires a standardised approach to handoffs, and while many standardised protocols have been tested, sign-out practices continue to vary. We believe this is due to the variability in workflow during inpatient duty cycle. We investigate the impact of such workflows on intern sign-out practices.

DESIGN

We employed a prospective, grounded theory mixed-method design.

SETTING

The study was conducted at a residency programme in the mid-Atlantic USA. Two observers randomly evaluated three types of daily sign-outs for 1 week every 3 months from September 2013 to March 2014. The compliance of each observed behaviour to JCAHO's Handoff Communication Checklist was recorded.

PARTICIPANTS

Thirty one interns conducting 134 patient sign-outs were observed randomly among the 52 in the programme.

RESULTS

In the 06:00 to 07:00 sign-back, the night-cover focused on providing information on overnight events to the day interns. In the 11:00 to 12:00 sign-out, the night-cover focused on transferring task accountability to a day-cover intern before departure. In the 20:00 to 21:00 sign-out, the day interns focused on transferring responsibility of their patients to a night-cover.

CONCLUSION

Different sign-out periods had different emphases regarding information exchange, personal responsibility and task accountability. Sign-outs are context-specific, implying that across-the-board standardised sign-out protocols are likely to have limited efficacy and compliance. Standardisation may need to be relative to the specific type and purpose of each sign-out to be supported by interns.

Systematic and organizational issues implicated in post-hospitalization suicides of medically hospitalized patients: A study of root-cause analysis reports

OBJECTIVE

Medical hospitalization is a high risk period for suicide. It is important to understand system-level factors that may be associated with suicide after a medical hospitalization.

METHOD

Retrospective study of root-cause analysis (RCA) reports of suicide occurring within three months of Veterans Administration (VA) medical hospitalization, 2002-2015. We collected patient and system-level factors to characterize events.

RESULTS

There were 96 RCA reports pertaining to suicide within three months of medical hospitalization. A total of 168 root causes for suicide were identified and fell into three major themes including: management of known suicide risk (N=73, 43%), decision making to monitor suicide risk (N=48, 29%), and patient engagement in treatment (N=47, 28%). RCA reports raised concerns that medical teams did not provide mental health treatment when indicated and lacked a standardized process for assessing psychological well-being in patients with a serious medical illness. In 25 cases, patients declined recommended treatment and in 15 cases, patients left against medical advice (AMA).

CONCLUSIONS

Challenges with patient engagement in treatment and lack of standardized processes for assessing and managing suicide risk may play an important role in suicide risk after medical hospitalization. Additional high quality studies are needed to confirm our findings.

A Quality Improvement Approach to Standardization and Sustainability of the Hand-off Process

There is mounting evidence that communication and hand-off failures are a root cause of two-thirds of sentinel events in hospitals. Several studies have shown that non-standardized hand-offs have yielded poor patient outcomes and adverse events. At Stony Brook University Hospital, there were numerous reported adverse events related to poor hand-off during the transfer of patient responsibility from one resident caregiver to the next. A resident-conducted root cause analysis identified lack of a standardized hand-off process and formal training on safe and efficient hand-off among caregivers as key contributing factors. This quality improvement project used the PDSA methodology to test the use of a standardized method, the IPASS mnemonic, and compare it to our conventional hand-off method in our internal medicine residency program. The main goals of this study were to test the feasibility and effectiveness of a standardized I- PASS hand-off and to create a robust sustainability model that includes 1) integration of I-PASS handoff in the Electronic Medical Record (EMR), 2) direct observation of the hand-off process by faculty and senior residents, and 3) surveillance and reporting of hand-off compliance scores. Compared to hand-off with a conventional method, the use of the I-PASS method resulted in significantly fewer reported adverse events (χ2=4.8, df=1, p=0.04). I-PASS was successfully integrated into our EMR system and residents were mandated to use this as the sole method of hand-off. An EMR audit conducted six months after implementation revealed poor compliance, which ultimately led to the creation of a sustainability model that improved overall compliance from 60% to 100%.

A before-after study of multidisciplinary Out-of-Hours handover: combining management and frontline efforts to create sustainable improvement

Objective

The importance of implementation strategy in systems improvement is increasingly recognized and both 'bottom-up' and 'top-down' approaches have significant barriers. A trial of a combined approach involving frontline and managerial staff therefore seems merited. We attempted to improve handover using a Human Factors-based approach integrated with a combined 'top and bottom' implementation strategy.

Design

A before-after study was conducted across 9 months.

Setting

The study was set in a 236 bed district general hospital.

Participants

Participants included any member of staff involved in Out of Hours handover.

Intervention

Existing processes were analysed using Human Factors methods. Changes made were based on this analysis and developed via facilitation between management and frontline staff. These included creating a single multidisciplinary handover, changing the venue, standardizing the meeting structure, developing an standard operating procedure for identifying unwell patients for handover and creating a clinical coordinator role.

Main outcome measures

Meeting attendance, duration, start time efficiency, the type of patients handed over and the transfer of important information were measured pre- and post-intervention.

Results

We found improvement in handover start time (P = 0.002, r = 0) and multidisciplinary participation (P = 0.002, r = -0.534). Handover of unwell patients improved, but not significantly. Communication of plan (P < 0.001, r = 0.14) and pending tasks (P < 0.001, r = 0.30) improved, but diagnosis (P = 0.233, r = -0.05), history (P = 0.482, r = -0.03) and comorbidities (P = 0.19, r = -0.05) did not.

Conclusions

The changes produced greater multidisciplinary participation, a broader focus and improved communication of plans and tasks outstanding. The 'top and bottom' implementation approach appeared valuable. Management involvement was essential for significant changes, while frontline staff involvement facilitated the design of context-specific practical solutions with staff buy-in.

Large-scale implementation of the I-PASS handover system at an academic medical centre

BACKGROUND

Healthcare has become increasingly complex and care delivery models have changed dramatically (eg, team-based care, duty-hour restrictions). However, approaches to critical communications among providers have not evolved to meet these new challenges. Evidence from safety culture surveys, academic studies and malpractice claims suggests that healthcare handover quality is problematic, leading to preventable errors and adverse outcomes. To address this concern, from 2013 to 2016 Massachusetts General Hospital completed phase I of a multifaceted programme to implement standardised, structured handovers across all departments, units and direct care providers.

METHODS

A multidisciplinary Handovers Committee selected the I-PASS handover system. Phase I implementation focused on large-scale training and shift-to-shift handovers. Important features included administrative and clinical leadership support; EHR templates for I-PASS; hospital handover policy revision; varied educational modalities, venues and durations; concomitant TeamSTEPPS training; unit-level I-PASS champions; handover observations; and solicitation of caregiver feedback and suggestions.

RESULTS

More than 6000 doctors, nurses and therapists have been trained. Trended observation scores demonstrate progressive but non-uniform adoption of I-PASS, with significant improvements in the correct sequencing and percentage of I-PASS elements included in handovers. Adoption of Synthesis (readback) has been challenging, with lower scores.

CONCLUSIONS

Comprehensive I-PASS implementation in a large academic medical centre necessitated major cultural change. I-PASS education is straightforward, whereas assuring consistent and sustained adoption across all services is more challenging, requiring adaptation of the basic I-PASS structure to local needs and workflows. EHR I-PASS templates facilitated caregiver acceptance. Initial phase I results are encouraging and the lessons learned should be helpful to other programmes planning handover initiatives. Phase II is ongoing, focusing on more uniform and consistent adoption, spread and sustainability.

Patient safety improvement interventions in children's surgery: A systematic review

BACKGROUND

Adult surgical patient safety literature is plentiful; however, there is a disproportionate paucity of published safety work in the children's surgical literature. We sought to systematically evaluate the nature and quality of patient safety evidence pertaining to pediatric surgical practice.

METHODS

Systematic search of MEDLINE and EMBASE databases and gray literature identified 1399 articles. Data pertaining to demographics, methodology, interventions, and outcomes were extracted. Study quality was assessed utilizing formal criteria.

RESULTS

20 studies were included. 14 (70%) comprised peer-reviewed articles. 18 (90%) were published in the last 4years. 13 (65%) described a novel intervention, and 7 (35%) described a modification of an existing intervention. Median patient sample size was 79 (29-1210). A large number (n=55) and variety (n=35) of measures were employed to evaluate the effect of interventions on patient safety. 15 (75%) studies utilized a checklist tool as a component of their intervention. 9 (45%) studies [comprising handoff tools (n=7); checklists (n=1); and multidimensional quality improvement initiatives (n=1)] reported a positive effect on patient safety. Quality assessment was undertaken on 14 studies. Quantitative studies had significantly higher quality scores than qualitative studies (61 [0-89] vs 44 [11-78], p=0.03).

CONCLUSIONS

Pediatric surgical patient safety evidence is in its early stages. Successful interventions that we identified were typically handoff tools. There now ought to be an onus on pediatric surgeons to develop and apply bespoke pediatric surgical safety interventions and generate an evidence base to parallel the adult literature.

LEVEL OF EVIDENCE

Level IV, Case series with no comparison group.

Feedback and Assessment Tools for Handoffs: A Systematic Review

BACKGROUND

Resident handoff communication skills are essential components of medical education training. There are no previous systematic reviews of feedback and evaluation tools for physician handoffs.

OBJECTIVE

We performed a systematic review of articles focused on inpatient handoff feedback or assessment tools.

METHODS

The authors conducted a systematic review of English-language literature published from January 1, 2008, to May 13, 2015 on handoff feedback or assessment tools used in undergraduate or graduate medical education. All articles were reviewed by 2 independent abstractors. Included articles were assessed using a quality scoring system.

RESULTS

A total of 26 articles with 32 tools met inclusion criteria, including 3 focused on feedback, 8 on assessment, and 15 on both feedback and assessment. All tools were used in an inpatient setting. Feedback and/or assessment improved the content or organization measures of handoff, while process and professionalism measures were less reliably improved. The Handoff Clinical Evaluation Exercise or a similar tool was used most frequently. Of included studies, 23% (6 of 26) were validity evidence studies, and 31% (8 of 26) of articles included a tool with behavioral anchors. A total of 35% (9 of 26) of studies used simulation or standardized patient encounters.

CONCLUSIONS

A number of feedback and assessment tools for physician handoffs in several specialties have been studied. Limited research has been done on the studied tools. These tools may assist medical educators in assessing trainees' handoff skills.

The Missing Record of Mental Status in Written Sign-Outs

OBJECTIVE

The aim of the study was to determine how frequently mental status and mental status changes are documented in the written patient summary ("sign-out") provided to covering physicians.

PATIENTS AND METHODS

This was a retrospective cohort study of general medical patients hospitalized between March 16, 2009, and March 15, 2010, conducted at 2 teaching hospitals. Participants included patients with mental status change adverse events (MSAEs) and their providers. Chart review was performed to identify patients with MSAEs and details about these events. Sign-outs were reviewed for documentation of mental status. Main outcome measures were (1) proportion of patients with MSAEs who had mental status ever recorded in sign-out entries and (2) the proportion of patients with MSAEs whose change in mental status was recorded in the sign-out.

RESULTS

Sixty-eight patients had MSAEs and were included in the sample. Fifty percent of MSAEs were attributed to medications; 75% of these events were first detected by nurses. Only 25% of patients with MSAEs had their change in mental status recorded in sign-outs.

CONCLUSIONS

Recording mental status in written sign-outs is uncommon. Particularly concerning is that patients with MSAEs identified by chart review seldom had sign-outs that reflected those events. Interventions should be designed to increase the recording of this information in sign-outs.

Directly Comparing Handoff Protocols for Pediatric Hospitalists

BACKGROUND AND OBJECTIVES

Handoff protocols are often developed by brainstorming and consensus, and few are directly compared. We hypothesized that a handoff protocol (Flex 11) developed using a rigorous methodology would be more favorable in terms of clinicians' attitudes, behaviors, cognitions, or time-on-task when performing handoffs compared with a prevalent protocol (Situation Background Assessment Recommendation [SBAR]).

METHODS

Using a between-groups, randomized control trial design (Flex 11 versus SBAR) during a pilot study in a simulated environment, 20 clinicians (13 attending physicians and 7 residents) received 3 patient handoffs from a standardized physician, managed the patients, and handed off the patients to the same standardized physician. Participants completed surveys assessing their attitudes and cognitions, and behaviors and handoff duration were assessed through observations.

RESULTS

All data were analyzed using independent samples t tests. For attitudes, "ease of use" ratings were lower for SBAR participants than Flex 11 participants (P < .01), and "being helpful" ratings were lower for SBAR participants than Flex 11 participants (P = .02). For behaviors, results indicate no significant difference in the information acquired between the SBAR and Flex 11 protocols. However, SBAR participants gave significantly less information than Flex 11 participants (P < .01). For cognitions, SBAR and Flex 11 participants reported similar workload except for frustration. For handoff duration, there were no significant differences between the protocols (P = .36).

CONCLUSIONS

The results suggest that Flex 11 is an efficient, beneficial tool in a simulated environment with pediatric clinicians. Future studies should evaluate this protocol in the inpatient setting.

Meta-Analyses of the Effects of Standardized Handoff Protocols on Patient, Provider, and Organizational Outcomes

OBJECTIVE

The overall purpose was to understand the effects of handoff protocols using meta-analytic approaches.

BACKGROUND

Standardized protocols have been required by the Joint Commission, but meta-analytic integration of handoff protocol research has not been conducted.

METHOD

The primary outcomes investigated were handoff information passed during transitions of care, patient outcomes, provider outcomes, and organizational outcomes. Sources included Medline, SAGE, Embase, PsycINFO, and PubMed, searched from the earliest date available through March 30th, 2015. Initially 4,556 articles were identified, with 4,520 removed. This process left a final set of 36 articles, all which included pre-/postintervention designs implemented in live clinical/hospital settings. We also conducted a moderation analysis based on the number of items contained in each protocol to understand if the length of a protocol led to systematic changes in effect sizes of the outcome variables.

RESULTS

Meta-analyses were conducted on 34,527 pre- and 30,072 postintervention data points. Results indicate positive effects on all four outcomes: handoff information (g = .71, 95% confidence interval [CI] [.63, .79]), patient outcomes (g = .53, 95% CI [.41, .65]), provider outcomes (g = .51, 95% CI [.41, .60]), and organizational outcomes (g = .29, 95% CI [.23, .35]). We found protocols to be effective, but there is significant publication bias and heterogeneity in the literature. Due to publication bias, we further searched the gray literature through greylit.org and found another 347 articles, although none were relevant to this research. Our moderation analysis demonstrates that for handoff information, protocols using 12 or more items led to a significantly higher proportion of information passed compared with protocols using 11 or fewer items. Further, there were numerous negative outcomes found throughout this meta-analysis, with trends demonstrating that protocols can increase the time for handover and the rate of errors of omission.

CONCLUSIONS

These results demonstrate that handoff protocols tend to improve results on multiple levels, including handoff information passed and patient, provider, and organizational outcomes. These findings come with the caveat that publication bias exists in the literature on handoffs. Instances where protocols can lead to negative outcomes are also discussed.

APPLICATION

Significant effects were found for protocols across provider types, regardless of expertise or area of clinical focus. It also appears that more thorough protocols lead to more information being passed, especially when those protocols consist of 12 or more items. Given these findings, publication bias is an apparent feature of this literature base. Recommendations to reduce the apparent publication bias in the field include changing the way articles are screened and published.

Standardization of Inpatient Handoff Communication

Handoff communication is identified as an integral part of hospital care. Throughout medical communities, inadequate handoff communication is being highlighted as a significant risk to patients. The complexity of hospitals and the number of providers involved in the care of hospitalized patients place inpatients at high risk of communication lapses. This miscommunication and the potential resulting harm make effective handoffs more critical than ever. Although hospitalized patients are being exposed to many handoffs each day, this report is limited to describing the best handoff practices between providers at the time of shift change.

Teaching Patient Handoffs to Medical Students in Obstetrics and Gynecology: Simulation Curriculum and Assessment Tool

INTRODUCTION

Patient handoffs, the communications required for the safe transfer of patient care, are known to be a common source of medical errors. Simulation exercises are effective techniques for teaching the procedures and patient interaction skills involved in a handoff. We developed a teaching tool that allows students to individually interact with a simulated patient, develop a treatment plan, and practice a handoff to another provider.

METHODS

The curriculum is a flexible instructional tool to teach patient handoffs in the context of a simulated obstetric emergency for learners at the clerkship through first-year obstetrics and gynecology resident levels. The curriculum secondarily teaches management of first-trimester bleeding with acute blood loss and can be adapted to allow advanced learners to practice obtaining informed consent. To evaluate this simulation for educational effectiveness, we developed a faculty observation assessment tool.

RESULTS

The simulation assessments for history taking, fund of knowledge, and interpersonal skills were predictive of subsequent clerkship clinical grades. Eighty percent of students agreed the exercise was realistic, 95% agreed it was relevant to the clinical curriculum, 90% agreed the simulation taught handoff skills, and 73% agreed the simulation increased confidence in handoff skills. Students uniformly found the curriculum to be relevant, realistic, and effective at teaching handoff skills.

DISCUSSION

Use of this curriculum has the potential to improve students' communication skills, handoff performance, and confidence during an obstetrics and gynecology clerkship. The assessment tool may allow early identification of students in need of improvement in communication skills.

Coordination of cancer care between family physicians and cancer specialists: Importance of communication

OBJECTIVE

To explore health care provider (HCP) perspectives on the coordination of cancer care between FPs and cancer specialists.

DESIGN

Qualitative study using semistructured telephone interviews.

SETTING

Canada.

PARTICIPANTS

A total of 58 HCPs, comprising 21 FPs, 15 surgeons, 12 medical oncologists, 6 radiation oncologists, and 4 GPs in oncology.

METHODS

This qualitative study is nested within a larger mixed-methods program of research, CanIMPACT (Canadian Team to Improve Community-Based Cancer Care along the Continuum), focused on improving the coordination of cancer care between FPs and cancer specialists. Using a constructivist grounded theory approach, telephone interviews were conducted with HCPs involved in cancer care. Invitations to participate were sent to a purposive sample of HCPs based on medical specialty, sex, province or territory, and geographic location (urban or rural). A coding schema was developed by 4 team members; subsequently, 1 team member coded the remaining transcripts. The resulting themes were reviewed by the entire team and a summary of results was mailed to participants for review.

MAIN FINDINGS

Communication challenges emerged as the most prominent theme. Five key related subthemes were identified around this core concept that occurred at both system and individual levels. System-level issues included delays in medical transcription, difficulties accessing patient information, and physicians not being copied on all reports. Individual-level issues included the lack of rapport between FPs and cancer specialists, and the lack of clearly defined and broadly communicated roles.

CONCLUSION

Effective and timely communication of medical information, as well as clearly defined roles for each provider, are essential to good coordination of care along the cancer care trajectory, particularly during transitions of care between cancer specialist and FP care. Despite advances in technology, substantial communication challenges still exist. This can lead to serious consequences that affect clinical decision making.

Interfacility Transfers to General Pediatric Floors: A Qualitative Study Exploring the Role of Communication

BACKGROUND

Children with special health care needs often require health services that are only provided at subspecialty centers. Such children who present to nonspecialty hospitals might require a hospital-to-hospital transfer. When transitioning between medical settings, communication is an integral aspect that can affect the quality of patient care. The objectives of the study were to identify barriers and facilitators to effective interfacility pediatric transfer communication to general pediatric floors from the perspectives of referring and accepting physicians, and then develop a conceptual model for effective interfacility transfer communication.

METHODS

This was a single-center qualitative study using grounded theory methodology. Referring and accepting physicians of children with special health care needs were interviewed. Four researchers coded the data using ATLAS.ti (version 7, Scientific Software Development GMBH, Berlin, Germany), using a 2-step process of open coding, followed by focused coding until no new codes emerged. The research team reached consensus on the final major categories and subsequently developed a conceptual model.

RESULTS

Eight referring and 9 accepting physicians were interviewed. Theoretical coding resulted in 3 major categories: streamlined transfer process, quality handoff and 2-way communication, and positive relationships between physicians across facilities. The conceptual model unites these categories and shows how these categories contribute to effective interfacility transfer communication. Proposed interventions involved standardizing the communication process and incorporating technology such as telemedicine during transfers.

CONCLUSIONS

Communication is perceived to be an integral component of interfacility transfers. We recommend that transfer systems be re-engineered to make the process more streamlined, to improve the quality of the handoff and 2-way communication, and to facilitate positive relationships between physicians across facilities.

Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services

BACKGROUND

Dispersion of inpatient care teams across different medical units impedes effective team communication, potentially leading to adverse events (AEs).

OBJECTIVE

To regionalize 3 inpatient general medical teams to nursing units and examine the association with communication and preventable AEs.

DESIGN

Pre-post cohort analysis.

SETTING

A 700-bed academic medical center.

PATIENTS

General medicine patients on any of the participating nursing units before and after implementation of regionalized care.

INTERVENTION

Regionalizing 3 general medical physician teams to 3 corresponding nursing units.

MEASUREMENTS

Concordance of patient care plan between nurse and intern, and adjusted odds of preventable AEs.

RESULTS

Of the 414 included nurse and intern paired surveys, there were no significant differences pre- versus postregionalization in total mean concordance scores (0.65 vs 0.67, P = 0.26), but there was significant improvement in agreement on expected discharge date (0.56 vs 0.68, P = 0.003), knowledge of the other provider's name (0.56 vs 0.86,P < 0.001), and daily care plan discussions (0.73 vs 0.88, P < 0.001). Of the 392 reviewed patient medical records, there was no significant difference in the adjusted odds of preventable AEs pre- versus postregionalization (adjusted odds ratio: 1.37, 95% confidence interval: 0.69, 2.69).

CONCLUSIONS

We found that regionalization of care teams improved recognition of care team members, discussion of daily care plan, and agreement on estimated discharge date, but did not significantly improve nurse and physician concordance of the care plan or reduce the odds of preventable AEs. Our findings suggest that regionalization alone may be insufficient to effectively promote communication and lead to patient safety improvements. Journal of Hospital Medicine 2016;11:620-627. © 2016 Society of Hospital Medicine.

PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors

BACKGROUND

The substantial adverse impact of miscommunication during transitions in care has highlighted the importance of teaching proper patient handoff practices. Although handoff standardization has been suggested, a universal system has been difficult to adopt, given the unique characteristics of the different fields of medicine. A form of standardization that has emerged is a discipline-specific handoff mnemonic: a memory aid that can serve to assist a provider in communicating pertinent information to the succeeding treatment team. A pilot study was conducted in which psychiatry residents were taught a mnemonic to use during their post-call patient handoffs.

METHODS

The PSYCH mnemonic was introduced as a guide to help residents identify key information needed in a psychiatric emergency room handoff: Patient information/ background, S ituation leading to the hospital visit, Y our assessment, Critical information, and Hindrance to discharge. Resident post-call patient handoffs were voice recorded and transcribed for 12 weeks. The transcriptions were divided into three time periods: Time 1 (baseline resident handoff performance), Time 2 (natural progression in resident hand-off performance with experience), and Time 3 (resident handoff performance after training in use of the PSYCH mnemonic).

RESULTS

There was a statistically significant decrease in the mean number of omissions after the intervention (p = 0.049). The decrease in time spent on handoffs after the intervention was not statistically significant. On the basis of a rating scale ranging from 1 (not clear) to 4 (very clear), the residents' rating of their clarity of expectations increased from a mean of 2.79 to 3.83, and their confidence rating increased from a mean of 2.57 to 3.42.

CONCLUSION

The mnemonic helped decrease the residents' handoff omissions. It also helped improve their efficiency, clarity of expectation, and confidence during handoffs.

Reliability of Verbal Handoff Assessment and Handoff Quality Before and After Implementation of a Resident Handoff Bundle

OBJECTIVE

1) To develop validity evidence for the use of the Verbal Handoff Assessment Tool (VHAT) and examine the reliability of VHAT scores, and 2) to determine whether implementation of a resident handoff bundle (RHB) was associated with improved verbal patient handoffs among pediatric resident physicians.

METHODS

In a pre-post design, prospectively audio recorded verbal patient handoffs conducted at Boston Children's Hospital before and after implementation of the RHB were rated using the VHAT, which was developed for this study (primary outcome). Using generalizability theory, we evaluated the reliability of VHAT scores.

RESULTS

Overall, VHAT scores increased after RHB implementation (mean 142 vs 191, possible score 0-500; P < .0001). When accounting for clustering according to resident physician, hospital unit, unit census, and patient complexity, implementation of the RHB was associated with a 63-point increase in VHAT score. Using generalizability theory, we determined that a resident's mean VHAT score on the basis of a handoff of 15 patients assessed by a single observer was sufficiently reliable for relative ranking decisions (ie, norm-based; generalizability coefficient, 0.81), whereas a VHAT score on the basis of a handoff of 21 patients would be sufficiently reliable for high-stakes, standard-based decisions (Phi, 0.80).

CONCLUSIONS

Verbal handoffs improved after implementation of a RHB, although gains were variable across the 2 clinical units. The VHAT shows promise as an assessment tool for resident handoff skills. If used for competency or entrustment decisions, a resident's mean VHAT score should be on the basis of observation of verbal handoff of ≥21 patients.

Real-World Implementation of a Standardized Handover Program (I-PASS) on a Pediatric Clinical Teaching Unit

OBJECTIVE

A standardized handover curriculum (I-PASS) has been shown to reduce preventable adverse events in a large multicenter study. We aimed to study the real-world impact of the implementation of this curriculum on handover quality, duration, and identification of unstable patients.

METHODS

A prospective intervention study was conducted. We implemented the I-PASS curriculum via faculty education and resident workshops. Resident handover on the clinical teaching unit was videorecorded, and written handover documents were collected for 2 weeks before and after the intervention. We examined the inclusion of key elements on handover documents before and after intervention using logistic regression models accounting for multiple handovers per patient. Duration of handover was compared using a linear regression model adjusting for number of patients. Qualitative content analysis was used to describe observable differences in verbal handover recordings and written critical care consultations.

RESULTS

A total of 1275 handovers were included, comprising 364 inpatients. There was a significant increase (P < .05) in 7 of 11 key elements and a significant decrease in written physical examination findings after the intervention. No significant change was found in handover duration. Qualitative video analysis revealed observable differences in handover collaboration and organization. After the intervention, patients with critical care needs overnight were correctly identified as requiring close monitoring during handover.

CONCLUSIONS

Handover training resulted in consistent inclusion of key elements and was characterized by collaboration between participants and improved organization without significant increase in handover duration. Appropriate identification and response to clinically deteriorating patients was also found using the I-PASS model.

Communication and Shared Understanding Between Parents and Resident-Physicians at Night

BACKGROUND AND OBJECTIVE

Communication breakdowns between members of the health care team compromise patient safety and experience. Communication breakdowns with parents, an important but often overlooked part of the health care team, are understudied. Parents may play a particularly important role in nighttime care given decreased staffing and inadequate transitions of care at night. We studied communication breakdowns evidenced by lack of shared understanding between parents and night-team residents about the reason for admission and care plan.

METHODS

We conducted a prospective cohort study of parents (n = 286) and night-team senior residents (n = 34) from May 1, 2013 to October 31, 2013. Parents and residents rated communication and described patients' reason for admission, overall plan, and overnight plan. Two physician investigators independently reviewed (κ = 0.63) resident-parent dyads, assigned subsequently dichotomized 4-point overall agreement scores, and rated plan complexity. Using clustered logistic regression, we evaluated relationships among demographics, plan complexity, and shared understanding. We also examined resident and parent perceptions of shared understanding.

RESULTS

We analyzed data from 257 parent-resident dyads. Among these, 45.1% were rated as lacking shared understanding (agreement score = 1 or 2). In multivariate analysis, higher plan complexity (P < .001) and length of stay (P = .002) were associated with lack of shared understanding; lower parental education was a borderline predictor (P = .05). When surveyed, parents and residents reported that they shared an understanding with one another about care plans in 86.0% and 73.1% of cases, respectively.

CONCLUSIONS

Parents and night-team residents frequently lack shared understanding. Family-centered care initiatives to improve parent-provider communication and shared understanding may help empower parents as partners in safe and high-quality nighttime care.

Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture

Background

The context of the study is the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture (HSOPSC). The purpose of the study is to analyze how different elements of patient safety culture are associated with clinical handoffs and perceptions of patient safety.

Methods

The study was performed with hierarchical multiple linear regression on data from the 2010 Survey. We examine the statistical relationships between perceptions of handoffs and transitions practices, patient safety culture, and patient safety. We statistically controlled for the systematic effects of hospital size, type, ownership, and staffing levels on perceptions of patient safety.

Results

The main findings were that the effective handoff of information, responsibility, and accountability were necessary to positive perceptions of patient safety. Feedback and communication about errors were positively related to the transfer of patient information; teamwork within units and the frequency of events reported were positively related to the transfer of personal responsibility during shift changes; and teamwork across units was positively related to the unit transfers of accountability for patients.

Conclusions

In summary, staff views on the behavioral dimensions of handoffs influenced their perceptions of the hospital’s level of patient safety. Given the known psychological links between perception, attitude, and behavior, a potential implication is that better patient safety can be achieved by a tight focus on improving handoffs through training and monitoring.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1502-7) contains supplementary material, which is available to authorized users.

Protocol to describe the analysis of text-based communication in medical records for patients discharged from intensive care to hospital ward

INTRODUCTION

Effective communication during hospital transitions of patient care is fundamental to ensuring patient safety and continuity of quality care. This study will describe text-based communication included in patient medical records before, during and after patient transfer from the intensive care unit (ICU) to a hospital ward (n=10 days) by documenting (1) the structure and focus of physician progress notes within and between medical specialties, (2) the organisation of subjective and objective information, including the location and accessibility of patient data and whether/how this changes during the hospital stay and (3) missing, illegible and erroneous information.

METHODS

This study is part of a larger mixed methods prospective observational study of ICU to hospital ward transfer practices in 10 ICUs across Canada. Medical records will be collected and photocopied for each consenting patient for a period of up to 10 consecutive days, including the final 2 days in the ICU, the day of transfer and the first 7 days on the ward (n=10 days). Textual analysis of medical record data will be completed by 2 independent reviewers to describe communication between stakeholders involved in ICU transfer.

ETHICS AND DISSEMINATION

Research ethics board approval has been obtained at all study sites, including the coordinating study centre (which covers 4 Calgary-based sites; UofC REB 13-0021) and 6 additional study sites (UofA Pro00050646; UBC PHC Hi4-01667; Sunnybrook 336-2014; QCH 20140345-01H; Sherbrooke 14-172; Laval 2015-2171). Findings from this study will inform the development of an evidence-based tool that will be used to systematically analyse the series of notes in a patient's medical record.

Improving the quality of handover in a liaison psychiatry team

Handover is a high risk point for errors in clinical care, in many cases leading to adverse events or near misses. The timely transfer of accurate and useful information between professionals is vital to ensure quality and safety, and to ensure the transfer of accountability for care.

In this project standards were developed for quality handover between doctors in a liaison psychiatry department. The aim of these were to ensure adequate identification of patients, clear communication of tasks to be completed and relevant risk issues, as well as a guide to the priority of jobs. We measured compliance with these standards for all patients documented in the handover book during three week periods in 2013, 2014 (following delivery of education and guidance on handover to all doctors), and finally in 2015 after implementation of a proforma for handover.

Handover documentation prior to the implementation of standards was of poor quality with significant absences of information. Key information to identify patients was frequently absent, for example hospital number was only recorded in 1% of cases. Only 81% of entries included the reason for the patient's referral, and 27% made no mention of the outstanding tasks for completion. Despite guidance and education of all doctors regarding the standards, there was no consistent improvement in compliance. It was particularly concerning that risk issues were only mentioned in 18% of cases, even when assessed immediately after education was given. Following introduction of the proforma compliance increased with overall completeness of handover improving from 40% to 71%.

Without guidelines handover between shifts is of a poor quality, and often lacks key information to allow colleagues to identify patients and prioritise need. Education of those performing these handovers did not produce any benefits, either immediately following its delivery or in longer term follow up. The implementation of a template to aid clinicians in recording this data did produce improvements and received positive feedback from doctors.

Using the Targeted Solutions Tool® to Improve Emergency Department Handoffs in a Community Hospital

BACKGROUND

There is little evidence for solutions to improve the handoff process between units, particularly from the emergency department (ED) to the inpatient unit. A systematic approach was used to improve the handoff communication process between the ED and the four private physician groups serving Juneau, Alaska, that admit and deliver care to patients of a 73-bed, Level 4 trauma center community hospital.

METHODS

Data were collected in using the Joint Commission Center for Transforming Healthcare's Targeted Solutions Tool (®)(TST(®)) to determine the rate of defective handoff communications and the factors that contributed to those defective handoff communications. Targeted solutions were then implemented to specifically address the identified contributing factors.

RESULTS

A random sample of 107 handoff opportunities was collected during the baseline phase (November 4, 2011- January 12, 2012) to measure performance and identify the contributing factors that led to defective handoffs. The baseline handoff communications defective rate was 29.9% (32 defective handoffs/107 handoff opportunities). The top four contributing factors, together accounting for 69.8% of all the causes of defective handoffs, were inaccurate/incomplete information, method ineffective, no standardized procedures for an effective handoff, and the person initiating the handoff, known as the "sender," lacks knowledge about the patient. After implementation of targeted solutions to the identified contributing factors, the handoff communications defective rate for the "improve" phase (April 1, 2012-July 29, 2012) was reduced from baseline by 58.2% to 12.5% (13 defective handoffs/104 handoff opportunities), p = 0.002; 2-proportions test. The number of adverse events related to hand-off communications declined as the handoff communications defective rate improved.

CONCLUSION

Use of the TST was associated with improvement in the ED handoff communication process.

Development, implementation and evaluation of a patient handoff tool to improve safety in orthopaedic surgery

OBJECTIVE

To develop, implement and test the effect of a handoff tool for orthopaedic trauma residents that reduces adverse events associated with the omission of critical information and the transfer of erroneous information.

DESIGN

Components of this project included a literature review, resident surveys and observations, checklist development and refinement, implementation and evaluation of impact on adverse events through a chart review of a prospective cohort compared with a historical control group.

SETTING

Large teaching hospital.

PARTICIPANTS

Findings of a literature review were presented to orthopaedic residents, epidemiologists, orthopaedic surgeons and patient safety experts in face-to-face meetings, during which we developed and refined the contents of a resident handoff tool. The tool was tested in an orthopaedic trauma service and its impact on adverse events was evaluated through a chart review. The handoff tool was developed and refined during the face-to-face meetings and a pilot implementation. Adverse event data were collected on 127 patients (n = 67 baseline period; n = 60 test period).

INTERVENTION

A handoff tool for use by orthopaedic residents.

MAIN OUTCOME MEASUREMENTS

Adverse events in patients handed off by orthopaedic trauma residents.

RESULTS

After controlling for age, gender and comorbidities, testing resulted in fewer events per person (25-27% reduction; P < 0.10).

CONCLUSIONS

Preliminary evidence suggests that our resident handoff tool may contribute to a decrease in adverse events in orthopaedic patients.

ICU Attending Handoff Practices: Results From a National Survey of Academic Intensivists

OBJECTIVES

To characterize intensivist handoff practices and expectations and to explore perceptions of the patient safety implications of attending handoffs.

DESIGN

Cross-sectional electronic survey administered in 2014.

SETTING

One hundred sixty-nine U.S. hospitals with critical care training programs accredited by the Accreditation Council for Graduate Medical Education.

SUBJECTS

Academic intensivists were recruited via e-mail invitation from a database of 1,712 eligible academic intensivists.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Six hundred sixty-one intensivists completed the survey (completion rate, 38.6%). Responses were received from at least one individual at 147 of 169 unique hospitals (87.0%) represented in the study database. Five hundred seventy-three (87%) respondents reported participating in handoffs at the end of each ICU rotation. A variety of communication methods were used for end-of-rotation handoffs, including in-person discussion (92.9%), telephone calls (83.9%), e-mail messages (69.0%), computer-generated documents (64.6%), and text messages (23.6%). Mean satisfaction with current handoff process was rated as 68.4 on a scale from 0 to 100 (SD, 22.6). Respondents (55.4%) said that attending handoffs should be standardized, but only 13.3% (76/572) of those participating in end-of-rotation handoffs reported using a standardized process. Specific handoff topics, including active clinical issues and resuscitation status, were reportedly discussed less frequently than would be ideal (p < 0.001 for the difference between reported frequency and ideal frequency). In free-text comments, 76 respondents (11.5%) expressed skepticism that attending handoffs were necessary given the presence of residents and fellows and given a lack of agreement about necessary content. Two hundred respondents (30.8%) reported knowing of an adverse event (inappropriate treatment, cardiac arrest, and death) attributable to inadequate attending handoffs.

CONCLUSIONS

ICU attending handoffs in the United States exhibit marked heterogeneity, and intensivists do not agree about the value of attending handoffs. In addition, some intensivists perceive a link between suboptimal attending handoffs, inappropriate treatment, and serious adverse events that warrants further study.

The Modified, Multi-patient Observed Simulated Handoff Experience (M-OSHE): Assessment and Feedback for Entering Residents on Handoff Performance

BACKGROUND

Despite the identification of transfer of patient responsibility as a Core Entrustable Professional Activity for Entering Residency, rigorous methods to evaluate incoming residents' ability to give a verbal handoff of multiple patients are lacking.

AIM

Our purpose was to implement a multi-patient, simulation-based curriculum to assess verbal handoff performance.

SETTING

Graduate Medical Education (GME) orientation at an urban, academic medical center.

PARTICIPANTS

Eighty-four incoming residents from four residency programs participated in the study.

PROGRAM DESCRIPTION

The curriculum featured an online training module and a multi-patient observed simulated handoff experience (M-OSHE). Participants verbally "handed off" three mock patients of varying acuity and were evaluated by a trained "receiver" using an expert-informed, five-item checklist.

PROGRAM EVALUATION

Prior handoff experience in medical school was associated with higher checklist scores (23% none vs. 33% either third OR fourth year vs. 58% third AND fourth year, p = 0.021). Prior training was associated with prioritization of patients based on acuity (12% no training vs. 38% prior training, p = 0.014). All participants agreed that the M-OSHE realistically portrayed a clinical setting.

CONCLUSIONS

The M-OSHE is a promising strategy for teaching and evaluating entering residents' ability to give verbal handoffs of multiple patients. Prior training and more handoff experience was associated with higher performance, which suggests that additional handoff training in medical school may be of benefit.

Improving the quality of the operating room to intensive care unit handover at an urban teaching hospital through a bundled intervention

STUDY OBJECTIVE

To evaluate the efficacy of a bundled intervention to improve the quality of the operating room to intensive care unit (ICU) clinical handover.

DESIGN

Prospective, interventional study.

SETTING

An urban, public teaching hospital with more than 1500 direct postoperative ICU admissions each year.

INTERVENTIONS

A bundled intervention to include the addition of a direct anesthesia provider to ICU nurse telephone report, a mnemonic to standardize the handover process, and improved template for postoperative documentation by the anesthesia team.

MEASUREMENTS

Preintervention (baseline) and postintervention survey data were solicited from key stakeholders, which included anesthesia providers and ICU nursing staff.

MAIN RESULTS

Anesthesia provider and ICU nursing staff satisfaction levels rose significantly following implementation of the bundled intervention. In addition, perceived effectiveness of the handover process and note increased significantly. The satisfaction level of the ICU nurses with respect to the phone report received before patient arrival in the ICU nearly doubled.

CONCLUSIONS

The implementation of a bundled handover intervention was associated with increased stakeholder satisfaction as well as a perception of increased efficacy and quality of the overall handover process and postoperative anesthesia documentation.

One size fits all? Challenges faced by physicians during shift handovers in a hospital with high sender/recipient ratio

INTRODUCTION

The aim of the present study was to investigate the challenges faced by physicians during shift handovers in a university hospital that has a high handover sender/recipient ratio.

METHODS

A multifaceted approach was adopted, comprising recording and analysis of handover information, rating of handover quality, and shadowing of handover recipients. Data was collected at the general medical ward of a university hospital in Singapore for a period of three months. Handover information transfer (i.e. senders' and recipients' verbal communication, and recipients' handwritten notes) and handover environmental factors were analysed. The relationship between 'to-do' tasks, and information transfer, handover quality and handover duration, were examined using analysis of variance.

RESULTS

Verbal handovers for 152 patients were observed; handwritten notes on 102 (67.1%) patients and handover quality ratings for the handovers of 98 (64.5%) patients were collected. Although there was good task prioritisation (information transfer: p < 0.005, handover duration: p < 0.01), incomplete information transfer and poor implementation of nonmodifiable identifiers were observed. The high sender/recipient ratio of the hospital made face-to-face and/or bedside handover difficult to implement. Although the current handover method (i.e. use of telephone communication), allowed interactive communication, it resulted in systemic information loss due to the lack of written information. The handover environment was chaotic in the high sender/recipient ratio setting, and the physicians had no designated handover time or location.

CONCLUSION

Handovers in high sender/recipient ratio settings are challenging. Efforts should be made to improve the handover processes in such situations, so that patient care is not compromised.

A single activity with a practice quality improvement project for faculty and a quality improvement project for residents

PURPOSE

The Next Accreditation System (NAS) requires radiation oncology residents to do a formal quality improvement project during their residency. The American Board of Radiology (ABR) Maintenance of Certification (MOC) program requires certified physicians to complete a Practice Quality Improvement (PQI) project approximately every 3 years. The purpose of our project was to develop a clinical transition of care policy via a process that resulted in quality improvement project credit for residents and PQI credit for participating faculty.

METHODS AND MATERIALS

Approval for project implementation was obtained from the ABR MOC committee. The PQI project consisted of an initial survey to assess resident perception on resident transition of care in our department, formal sign-out training, and 2 postintervention surveys after 1 and 11 months. The primary endpoint was the percentage of questions with ≤1 unfavorable responses. Sign-test was used to determine response difference from neutral.

RESULTS

One hundred percent of surveyed residents completed the preintervention (n = 6), postintervention 1 (n = 7), and postintervention 2 (n = 8) surveys. In the preintervention, postintervention 1, and postintervention 2 surveys, 71.4%, 57.1%, and 57.1% of questions were answered with ≤1 unfavorable response, respectively. The number of questions with ≥75% favorable response was 7 (50%), 7 (50%), and 11 (78.5%) in the preintervention, postintervention 1, and postintervention 2 surveys, respectively (P = .13). A written sign-out template and monthly protected sign-out meetings were instituted. One resident and 3 attending physicians received credit for Accreditation Council of Graduate Medical Education NAS quality improvement and ABR MOC PQI projects, respectively.

CONCLUSIONS

This project shows the feasibility of a combined attending and resident physician effort to improve patient care and fulfill his or her respective ABR MOC PQI and Accreditation Council of Graduate Medical Education NAS requirements. Attending and resident physicians can tailor collaborative projects to fulfill MOC and NAS requirements unique to their subspecialty. Written sign-out templates and protected sign-out time may improve transition of care.

Effects of Information Access Cost and Accountability on Medical Residents' Information Retrieval Strategy and Performance During Prehandover Preparation: Evidence From Interview and Simulation Study

OBJECTIVE

We aimed to examine the effects of information access cost and accountability on medical residents' information retrieval strategy and performance during prehandover preparation.

BACKGROUND

Prior studies observing doctors' prehandover practices witnessed the use of memory-intensive strategies when retrieving patient information. These strategies impose potential threats to patient safety as human memory is prone to errors. Of interest in this work are the underlying determinants of information retrieval strategy and the potential impacts on medical residents' information preparation performance.

METHOD

A two-step research approach was adopted, consisting of semistructured interviews with 21 medical residents and a simulation-based experiment with 32 medical residents.

RESULTS

The semistructured interviews revealed that a substantial portion of medical residents (38%) relied largely on memory for preparing handover information. The simulation-based experiment showed that higher information access cost reduced information access attempts and access duration on patient documents and harmed information preparation performance. Higher accountability led to marginally longer access to patient documents.

CONCLUSION

It is important to understand the underlying determinants of medical residents' information retrieval strategy and performance during prehandover preparation. We noted the criticality of easy access to patient documents in prehandover preparation. In addition, accountability marginally influenced medical residents' information retrieval strategy.

APPLICATION

Findings from this research suggested that the cost of accessing information sources should be minimized in developing handover preparation tools.

Emergency physician awareness of prehospital procedures and medications

Introduction

Maintaining patient safety during transition from prehospital to emergency department (ED) care depends on effective handoff communication between providers. We sought to determine emergency physicians’ (EP) knowledge of the care provided by paramedics in terms of both procedures and medications, and whether the use of a verbal report improved physician accuracy.

Methods

We conducted a 2-phase observational survey of a convenience sample of EPs in an urban, academic ED. In this large ED paramedics have no direct contact with physicians for non-critical patients, giving their report instead to the triage nurse. In Phase 1, paramedics gave verbal report to the triage nurse only. In Phase 2, a research assistant (RA) stationed in triage listened to this report and then repeated it back verbatim to the EPs caring for the patient. The RA then queried the EPs 90 minutes later regarding their patients’ prehospital procedures and medications. We compared the accuracy of these 2 reporting methods.

Results

There were 163 surveys completed in Phase 1 and 116 in Phase 2. The oral report had no effect on EP awareness that the patient had been brought in by ambulance (86% in Phase 1 and 85% in Phase 2.) The oral report did improve EP awareness of prehospital procedures, from 16% in Phase 1 to 45% in Phase 2, OR=4.28 (2.5–7.5). EPs were able to correctly identify all oral medications in 18% of Phase 1 cases and 47% of Phase 2 cases, and all IV medications in 42% of Phase 1 cases and 50% of Phase 2 cases. The verbal report led to a mild improvement in physician awareness of oral medications given, OR=4.0 (1.09–14.5), and no improvement in physician awareness of IV medications given, OR=1.33 (0.15–11.35). Using a composite score of procedures plus oral plus IV medications, physicians had all three categories correct in 15% of Phase 1 and 39% of Phase 2 cases (p<0.0001).

Conclusion

EPs in our ED were unaware of many prehospital procedures and medications regardless of the method used to provide this information. The addition of a verbal hand-off report resulted in a modest improvement in overall accuracy.

Perspectives of clinical handover processes: a multi-site survey across different health professionals

AIMS AND OBJECTIVES

To examine the perspectives of health professionals of different disciplines about clinical handover.

BACKGROUND

Ineffective handovers can cause major problems relating to the lack of delivery of appropriate care.

DESIGN

A prospective, cross-sectional design was conducted using a survey about clinical handover practices.

METHODS

Health professionals employed in public metropolitan hospitals, public rural hospitals and community health centres were involved. The sample comprised doctors, nurses and allied health professionals, including physiotherapists, social workers, pharmacists, dieticians and midwives employed in Western Australia, New South Wales, South Australia and the Australian Capital Territory. The survey sought information about health professionals' experiences about clinical handover; their perceived effectiveness of clinical handover; involvement of patients and family members; health professionals' ability to confirm understanding and to clarify clinical information; role modelling behaviour of health professionals; training needs; adverse events encountered and possibilities for improvements.

RESULTS

In all, 707 health professionals participated (response rate = 14%). Represented professions were nursing (60%), medicine (22%) and allied health (18%). Many health professionals reported being aware of adverse events where they noticed poor handover was a significant cause. Differences existed between health professions in terms of how effectively they gave handover, perceived effectiveness of bedside handover vs. nonbedside handover, patient and family involvement in handover, respondents' confirmation of understanding handover from their perspective, their observation of senior health professionals giving feedback to junior health professionals, awareness of adverse events and severity of adverse events relating to poor handovers.

CONCLUSIONS

Complex barriers impeded the conduct of effective handovers, including insufficient opportunities for training, lack of role modelling, and lack of confidence and understanding about handover processes.

RELEVANCE TO CLINICAL PRACTICE

Greater focus should be placed on creating opportunities for senior health professionals to act as role models. Sophisticated approaches should be implemented in training and education.

Multicenter development, implementation, and patient safety impacts of a simulation-based module to teach handovers to pediatric residents

OBJECTIVE

Teaching and evaluation of handovers are important requirements of graduate medical education (GME), but well-defined and effective methods have not been clearly established. Case-based computer simulations provide potential methods to teach, evaluate, and practice handovers.

METHODS

Case-based computer simulation modules were developed. In these modules, trainees care for a virtual patient in a time-lapsed session, followed by real-time synthesis and handover of the clinical information to a partner who uses this information to continue caring for the same patient in a simulated night scenario, with an observer tallying included handover components. The process culminates with evaluator feedback and structured handover education. Surveys were used before and after module implementation to allow the interns to rate the quality of handover provided and record rapid responses and transfers to the ICU.

RESULTS

Fifty-two pediatric and medicine/pediatric residents from 2 institutions participated in the modules. "Anticipatory guidance" elements of the handover were the most frequently excluded (missing at least 1 component in 77% of module handovers). There were no significant differences in the proportion of nights with rapid response calls (7.24% vs 12.79%, P=.052) or transfers to the ICU (7.76% vs 11.27%, P=.21) before and after module implementation.

CONCLUSIONS

Case-based, computer-simulation modules are an easily implemented and generalizable mechanism for handover education and assessment. Although significant improvements in patient safety outcomes were not seen as a result of the educational module alone, novel techniques of this nature may supplement handover bundles that have been demonstrated to improve patient safety.

Changes in written sign-out composition across hospitalization

BACKGROUND

Inaccurate or incomplete information in the written portion of the patient handoff, or sign-out, may be associated with adverse events in hospitalized patients. Little is known about what information providers actually include in written sign-out documents and how sign-outs change over time.

OBJECTIVES

(1) Provide a descriptive analysis of initial and subsequent hospital day-written sign-out content, and (2) evaluate the relationship between team workload and sign-out composition.

DESIGN

Retrospective review of sign-out documents from a larger observational study of general medicine patients admitted to housestaff and hospitalist teams at 3 hospitals.

MAIN MEASURES

The presence of 13 components of a high-quality sign-out. We performed descriptive analyses and compared initial and subsequent day sign-outs for content.

KEY RESULTS

We reviewed 200 patient hospitalizations (200 initial handoffs, 580 subsequent day handoffs). Initial sign-out entries contained a mean of 7.54 (standard deviation: 2.27) key sign-out components. Subsequent day sign-outs contained a higher percentage of certain key elements but had more vague language. The number of elements present in the sign-out was reduced as patient census increased (r = -0.295, P < 0.01).

CONCLUSIONS

Sign-out composition changes over time, and is associated with workload. Future interventions to improve quality should take these factors into consideration.

Prospective cohort study protocol to describe the transfer of patients from intensive care units to hospital wards

INTRODUCTION

The transfer of patient care between the intensive care unit (ICU) and the hospital ward is associated with increased risk of medical error and adverse events. This study will describe patient transfer from ICU to hospital ward by documenting (1) patient, family and provider experiences related to ICU transfer, (2) communication between stakeholders involved in ICU transfer, (3) adverse events that follow ICU transfer and (4) opportunities to improve ICU to hospital ward transfer.

METHODS

This is a mixed methods prospective observational study of ICU to hospital ward transfer practices in 10 ICUs across Canada. We will recruit 50 patients at each site (n=500) who are transferred from ICU to hospital ward, and distribute surveys to enrolled patients, family members, and healthcare providers (ICU and ward physicians and nurses) after patient transfer. A random sample of 6 consenting study participants (patients, family members, healthcare providers) from each study site (n=60) will be offered an opportunity to participate in interviews to further describe stakeholders' experience with ICU to hospital ward transfer. We will abstract information from patient health records to identify clinical data and use of transfer tools, and identify adverse events that are related to the transfer.

ETHICS AND DISSEMINATION

Research ethics board approval has been obtained at the coordinating study centre (UofC REB13-0021) and 5 study sites (UofA Pro00050646; UBC-PHC H14-01667; Sunnybrook 336-2014; QCH 14-07; Sherbrooke 14-172). Dissemination of the findings will provide a comprehensive description of transfer from ICU to hospital ward in Canada including the uptake of validated or local transfer tools, a conceptual framework of the experiences and needs of stakeholders in the ICU transfer process, a summary of adverse events experienced by patients after transfer from ICU to hospital ward, and opportunities to guide quality improvement efforts.