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

Progressive collaborative refinement on teams: implications for communication practices

OBJECTIVES

Medical teaching teams (MTTs) must balance teaching and patient care in the face of three challenges: shifting team membership, varying levels of learners and patient complexity. To support care, MTTs rely on a combination of recurrent oral and written communication practices (genres), such as admission, progress and discharge notes. The purpose of this study was to explore how these genres influence the team's ability to collectively care for patients.

METHODS

This was a multiple case study with data collected through observations and audio-recordings of 19 patient cases focusing on admission review discussions and chart documents throughout the hospitalisation. Participants included 14 medical students, 32 residents and 10 attending physicians rotating through one of three internal medicine MTTs. We used constant comparative analysis to identify recurrent patterns across the multiple cases, which were further elaborated in a return-of-findings focus group.

RESULTS

The MTT genre system facilitated the care of patients through 'progressive collaborative refinement' (PCR): MTTs use case and data reviews to collaboratively and progressively refine their understanding of the patient's problems and develop strategies for addressing them. Progressive collaborative refinement was apparent through modifications made in the documentation. Although modifications were a necessary component, they were not sufficient: some modifications were made without refinement. We characterised incidents of failed modification as 'fragmentation'. Three types were observed: conceptualisation, documentation and continuity of care providers. In most cases, all three were present and interacted to impede PCR.

CONCLUSIONS

Progressive collaborative refinement was used by MTTs to provide the optimal care to patients. Progressive collaborative refinement was impeded by a lack of continuity of care providers and gaps between communication genres that fragmented conceptualisation and documentation. Progressive collaborative refinement can be understood as both an overarching process and a shared but unstated ideal. Through defining and describing PCR, the present findings can be used to improve communication and teaching.

Quality of post-operative patient handover in the post-anaesthesia care unit: a prospective analysis

BACKGROUND

Anaesthesiology plays a key role in promoting safe perioperative care. This includes the perioperative phase in the post-anaesthesia care unit (PACU) where problems with incomplete information transfer may have a negative impact on patient safety and can lead to patient harm. The objective of this study was to analyse information transfer during post-operative handovers in the PACU.

METHODS

With a self-developed checklist including 59 items the information transfer during post-operative handovers was documented and subsequently compared with patient information in anaesthesia records during a 2-month period.

RESULTS

A total number of 790 handovers with duration of 73 ± 49 s was analysed. Few items were transferred in most of the cases such as type of surgery (97% of the cases), regional anaesthesia (94% of the cases) and cardiac instability (93% of the cases). However, some items were rarely transferred, such as American Society of Anesthesiologists physical status (7% of the cases), initiation of post-operative pain management (12% of the cases), antibiotic therapy (14% of the cases) and fluid management (15% of the cases). There was a slight correlation between amount of information transferred and duration of post-operative handovers (r = 0.5).

CONCLUSION

The study shows that post-operative handovers in the PACU are in most cases incomplete. It appears useful to optimise the post-operative handover process, for example by implementing a standardised handover checklist.

Face-to-face handoff: improving transfer to the pediatric intensive care unit after cardiac surgery

The goal was to develop and implement a comprehensive, primarily face-to-face handoff process that begins in the operating room and concludes at the bedside in the intensive care unit (ICU) for pediatric patients undergoing congenital heart surgery. Involving all stakeholders in the planning phase, the framework of the handoff system encompassed a combination of a formalized handoff tool, focused process steps that occurred prior to patient arrival in the ICU, and an emphasis on face-to-face communication at the conclusion of the handoff. The final process was evaluated by the use of observer checklists to examine quality metrics and timing for all patients admitted to the ICU following cardiac surgery. The process was found to improve how various providers view the efficiency of handoff, the ease of asking questions at each step, and the overall capability to improve patient care regardless of overall surgical complexity.

Addressing the Mandate for Hand-off Education

The Accreditation Council for Graduate Medical Education requires that residency programs teach residents about handoffs and ensure their competence in this communication skill. Development of hand-off curricula for anesthesia residency programs is hindered by the paucity of evidence regarding how to conduct, teach, and evaluate handoffs in the various settings where anesthesia practitioners work. This narrative review draws from literature in anesthesia and other disciplines to provide recommendations for anesthesia resident hand-off curriculum development and evaluation.

A systematic review of the literature on the evaluation of handoff tools: implications for research and practice

OBJECTIVE

Given the complexities of the healthcare environment, efforts to develop standardized handoff practices have led to widely varying manifestations of handoff tools. A systematic review of the literature on handoff evaluation studies was performed to investigate the nature, methodological, and theoretical foundations underlying the evaluation of handoff tools and their adequacy and appropriateness in achieving standardization goals.

METHOD

We searched multiple databases for articles evaluating handoff tools published between 1 February 1983 and 15 June 2012. The selected articles were categorized along the following dimensions: handoff tool characteristics, standardization initiatives, methodological framework, and theoretical perspectives underlying the evaluation.

RESULTS

Thirty-six articles met our inclusion criteria. Handoff evaluations were conducted primarily on electronic tools (64%), with a more recent focus on electronic medical record-integrated tools (36% since 2008). Most evaluations centered on intra-departmental tools (95%). Evaluation studies were quasi-experimental (42%) or observational (50%), with a major focus on handoff-related outcome measures (94%) using predominantly survey-based tools (70%) with user satisfaction metrics (53%). Most of the studies (81%) based their evaluation on aspects of standardization that included continuity of care and patient safety.

CONCLUSIONS

The nature, methodological, and theoretical foundations of handoff tool evaluations varied significantly in terms of their quality and rigor, thereby limiting their ability to inform strategic standardization initiatives. Future research should utilize rigorous, multi-method qualitative and quantitative approaches that capture the contextual nuances of handoffs, and evaluate their effect on patient-related outcomes.

Systematic training in internal medicine-pediatrics end of residency handoffs: residency director attitudes and perceived barriers

BACKGROUND

It is unclear why systematic training in end-of-residency clinic handoffs is not universal.

PURPOSES

We assessed Internal Medicine-Pediatrics (Med-Peds) residency program directors' attitudes regarding end-of-residency clinic handoff systems and perceived barriers to their implementation.

METHODS

We surveyed all Med-Peds program directors in the United States about end-of-residency outpatient handoff systems.

RESULTS

Program directors rated systems as important (81.5%), but only 31 programs (46.3%) utilized them. Nearly all programs with (29/31 [93.5%]), and most programs without systems (24/33 [72.7%]) rated them as important. Programs were more likely to have a system if the program director rated it important (p = .049), and less likely if they cited a lack of faculty interest (p = .023) or difficulty identifying residents as primary providers (p = .04).

CONCLUSIONS

Most program directors believe it important to formally hand off outpatients. Barriers to establishing handoff systems can be overcome with modest curricular and cultural changes.

(Re)Introducing communication competence to the health professions

Despite the central role that communication skills play in contemporary accounts of effective health care delivery in general, and the communication of medical error specifically, there is no common or consensual core in the health professions regarding the nature of such skills. This lack of consensus reflects, in part, the tendency for disciplines to reinvent concepts and measures without first situating such development in disciplines with more cognate specialization in such concepts. In this essay, an integrative model of communication competence is introduced, along with its theoretical background and rationale. Communication competence is defined as an impression of appropriateness and effectiveness, which is functionally related to individual motivation, knowledge, skills, and contextual facilitators and constraints. Within this conceptualization, error disclosure contexts are utilized to illustrate the heuristic value of the theory, and implications for assessment are suggested. Significance for public healthModels matter, as do the presuppositions that underlie their architecture. Research indicates that judgments of competence moderate outcomes such as satisfaction, trust, understanding, and power-sharing in relationships and in individual encounters. If the outcomes of health care encounters depend on the impression of competence that patients or their family members have of health care professionals, then knowing which specific communicative behaviors contribute to such impressions is not merely important - it is essential. To pursue such a research agenda requires that competence assessment and operationalization becomes better aligned with conceptual assumptions that separate behavioral performance from the judgments of the competence of that performance.

[Quality of the anesthesiologist written record during the transfer of postoperative patients: Influence of implementing a structured communication tool]

OBJECTIVE

The lack of communication is a major cause of health care errors, especially during patient transfer between practitioners and/or healthcare units, when standardization of communication is a recommended practice. In our study we wanted to assess whether the application of the structured communication SBAR tool could influence the quality of the information written on the progress sheet by the anesthesiologist involved in the transfer of the patient after surgery.

MATERIAL AND METHODS

This is an observational, retrospective, randomized, quality review of the written record made by the anesthesiologist during the transfer of patients from the surgical area to the postoperative recovery unit, by applying a validated list. We evaluated three observation periods: a control period of two months in 2011 (preSBAR) and a second period of two months in 2012 (postSBAR); in the latter two groups of patients were transferred (postSBAR +) or without SBAR (postSBAR-).

RESULTS

The strength of agreement between raters obtained an intraclass correlation coefficient of 0.8459 (p <0.001). There were significant differences in the study group, with highest average score in the group with SBAR (postSBAR + group: mean ± SD 7.56 ± 1.20 versus postSBAR-group: 5.41 ± 2.98, p <0.001) and depending on the anesthesiologist responsible for the intervention participated in the study (mean ± SD: 7.00 ± 1.99, compared to 4.81 ± 3.24 in the non-participants, p <0.001).

CONCLUSIONS

There was an improvement in the quality of written records made in 2012 during the implementation of the SBAR, without the actual application of this instrument appearing to influence it. The anesthesiologists that were involved in new forms of patient safety were also those who made written records of highest quality.

Comparative evaluation of the content and structure of communication using two handoff tools: implications for patient safety

PURPOSE

Handoffs vary in their structure and content, raising concerns regarding standardization. We conducted a comparative evaluation of the nature and patterns of communication on 2 functionally similar but conceptually different handoff tools: Subjective, Objective, Assessment and Plan, based on a patient problem-based format, and Handoff Intervention Tool (HAND-IT), based on a body system-based format.

METHOD

A nonrandomized pre-post prospective intervention study supported by audio recordings and observations of 82 resident handoffs was conducted in a medical intensive care unit. Qualitative analysis was complemented with exploratory sequential pattern analysis techniques to capture the characteristics and types of communication events (CEs) and breakdowns.

RESULTS

Use of HAND-IT led to fewer communication breakdowns (F1,80 = 45.66: P < .0001), greater number of CEs (t40 = 4.56; P < .001), with more ideal CEs than Subjective, Objective, Assessment and Plan (t40 = 9.27; P < .001). In addition, the use of HAND-IT was characterized by more request-response CE transitions.

CONCLUSION

The HAND-IT's body system-based structure afforded physicians the ability to better organize and comprehend patient information and led to an interactive and streamlined communication, with limited external input. Our results also emphasize the importance of information organization using a medical knowledge hierarchical format for fostering effective communication.

Know your client and know your team: a complexity inspired approach to understanding safe transitions in care

Background. Transitions in care are one of the most important and challenging client safety issues in healthcare. This project was undertaken to gain insight into the practice setting realities for nurses and other health care providers as they manage increasingly complex care transitions across multiple settings. Methods. The Appreciative Inquiry approach was used to guide interviews with sixty-six healthcare providers from a variety of practice settings. Data was collected on participants' experience of exceptional care transitions and opportunities for improving care transitions. Results. Nurses and other healthcare providers need to know three things to ensure safe care transitions: (1) know your client; (2) know your team on both sides of the transfer; and (3) know the resources your client needs and how to get them. Three themes describe successful care transitions, including flexible structures; independence and teamwork; and client and provider focus. Conclusion. Nurses often operate at the margins of acceptable performance, and flexibility with regulation and standards is often required in complex sociotechnical work like care transitions. Priority needs to be given to creating conditions where nurses and other healthcare providers are free to creatively engage and respond in ways that will optimize safe care transitions.

Implementation of a computerized patient handoff application

For hospitalized patients, handoffs between providers affect continuity of care and increase the risk of medical errors. Most commercial electronic health record (EHR) systems lack dedicated tools to support patient handoff activities. We developed a collaborative application supporting patient handoff that is fully integrated with our commercial EHR. The application creates user-customizable printed reports with automatic inclusion of a variety of EHR data, including: allergies, medications, 24-hour vital signs, recent common laboratory test results, isolation requirements, and code status. It has achieved widespread voluntary use at our institution (6,100 monthly users; 700 daily reports generated), and we have distributed the application to several other institutions using the same EHR. Though originally designed for resident physicians, today about 50% of the application users are nurses, 40% are physicians/physician assistants/nurse practitioners, and 10% are pharmacists, social workers, and other allied health providers.

Effectiveness of written hospitalist sign-outs in answering overnight inquiries

BACKGROUND

Hospitalists are key providers of care to medical inpatients, and sign-out is an integral part of providing safe, high-quality inpatient care. There is little known about hospitalist-to-hospitalist sign-out.

OBJECTIVE

To evaluate the quality of hospitalist/physician-extender sign-outs by assessing how well the sign-out prepares the night team for overnight events and to determine attributes of effective sign-out.

DESIGN

Analysis of a written-only sign-out protocol on a nonteaching hospitalist service using prospective data collected by an attending physician survey during overnight shifts.

SETTING

Yale-New Haven Hospital, a 966-bed, urban, academic medical center in New Haven, Connecticut with approximately 13,700 hospitalist discharges annually.

RESULTS

We recorded 124 inquiries about 96 patients during 6 days of data collection in 2012. Hospitalists referenced the sign-out for 89 (74%) inquiries, and the sign-out was considered sufficient in isolation to respond to 27 (30%) of these inquiries. Hospitalists physically saw the patient for 14 (12%) of inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]), and clinical changes (26 [21%]). Ninety-five (77%) inquiries were considered to be "somewhat" or "very" clinically important by the hospitalist.

CONCLUSIONS

Overall, we found that attending hospitalists rely heavily on written sign-out to address overnight inquiries, but that those sign-outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign-out is needed to help improve the safety of overnight care.

[Diagnosis of and therapy for hepatocellular carcinoma]

The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence-and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.

Communication in interdisciplinary teams: exploring closed-loop communication during in situ trauma team training

OBJECTIVES

Investigate the use of call-out (CO) and closed-loop communication (CLC) during a simulated emergency situation, and its relation to profession, age, gender, ethnicity, years in profession, educational experience, work experience and leadership style.

DESIGN

Exploratory study.

SETTING

In situ simulator-based interdisciplinary team training using trauma cases at an emergency department.

PARTICIPANTS

The result was based on 16 trauma teams with a total of 96 participants. Each team consisted of two physicians, two registered nurses and two enrolled nurses, identical to a standard trauma team.

RESULTS

The results in this study showed that the use of CO and CLC in trauma teams was limited, with an average of 20 CO and 2.8 CLC/team. Previous participation in trauma team training did not increase the frequency of use of CLC while ≥2 structured trauma courses correlated with increased use of CLC (risk ratio (RR) 3.17, CI 1.22 to 8.24). All professions in the trauma team were observed to initiate and terminate CLC (except for the enrolled nurse from the operation theatre). The frequency of team members' use of CLC increased significantly with an egalitarian leadership style (RR 1.14, CI 1.04 to 1.26).

CONCLUSIONS

This study showed that despite focus on the importance of communication in terms of CO and CLC, the difficulty in achieving safe and reliable verbal communication within the interdisciplinary team remained. This finding indicates the need for validated training models combined with further implementation studies.

Handoffs in general surgery residency, an observation of intern and senior residents

BACKGROUND

Handoffs have become an area of concern as duty-hour restrictions impose an increasing number of shift changes. The objective of this study was to study handoffs in a general surgery residency and identify problems that exist in the current handoff process in preparation for a standardized implemented protocol.

METHODS

A resident researcher observed resident-to-resident handoffs for 5 surgical service teams, Monday through Friday, for the middle 2 weeks of the 3rd month of the academic year. Each handoff was observed for the presence, absence, or inconsistency of code status; anticipated problems; active problems; current baseline status; pending tests or consults; and closed-loop communication.

RESULTS

Thirty-eight residents in 2010 were observed, with a total of 52 handoffs ranging from 1 to 27 minutes in length. Five handoffs (10%) were by phone, 47 handoffs (90%) were observed in person, 10 handoffs (19%) were by senior residents, and 37 handoffs (71%) were performed by junior residents. Of the 47 in-person handoffs, code status was mentioned in 2 (4%), and 6 (12%) were given written notes. Of the 37 intern handoffs, the presence of measured criteria occurred in the following percentages: 59% for anticipated problems, 70% for active problems, 51% for current baseline status, 64% for pending tests or consults, and 81% for closed-loop communication. Of the 10 senior-level handoffs observed, all consistently included the previously mentioned criteria.

CONCLUSIONS

This study demonstrates the lack of consistency and propensity for error in unstructured handoffs among junior residents. The finding that senior-level residents exhibited consistently proficient handoffs demonstrates that handoffs are a learned skill. Therefore, teaching junior residents a structured handoff supervised by senior residents would most likely reduce the inconsistency and error-prone nature of the junior-level handoffs observed in our study.

Leading and managing an emergency department-A personal view

The emergency department (ED) is a "unique operation, optimized to exist at the edge of chaos". It is the responsibility of the leaders and managers of the ED to ensure that their teams work in an environment where they can deliver the best care to their patients. This environment is defined by people, system and place. People are the most important asset of the ED. One of the most important responsibilities of the ED leaders and managers (senior management) is to foster teamwork. They will also have to ensure that communication between team members is optimal and that there is a structure in place for conflict resolution. ED senior management should be aware of their team dynamics and know the "movers and shakers" in their organization. ED systems should be kept simple. One of the core businesses of an ED is contingency planning. ED senior management must plan, prepare, practice, review, analyze, assess and strategize for unexpected events. The ED physical environment has an impact on the flow of care being delivered to her patients. ED senior management must manage change. Change works only if it takes root in the hearts and minds of the organization's people. The quality of the leaders and managers of the ED will determine whether or not, their teams work in an environment where they can deliver the best care to their patients.

Considering Factors of and Knowledge About Patients in Handover Assessment

The healthcare system is moving from one primary physician who assumes responsibility for each patient to a more team-based approach. Thus, assessing team communication is critical. This study characterizes and assesses the quality of hospitalist handover communications at shift change using the literature recommended content and language form elements. Quality handovers should contain the following content: patient identifiers, active issues, and care plans. Quality handovers also should include utterances in the following language forms: explanations, rationales, and directives. Interviews, observation, recording, and conversation analysis of hospitalist handover communications were used. Hospitalist handover utterances were assigned both content and language form codes. The proportion of quality element verbalization across all patient handovers was calculated. In addition, the impact of patient factors (new admission, new problem, acuity level) and handover receiver knowledge on the inclusion of quality elements was examined. The 106 individual patient handovers across 16 handover sessions were recorded. 39% contained all six quality elements. While the majority of handovers contained five out of six quality elements, only 48% included directives. There was also no difference in the inclusion of quality elements based on patient factors or handover receiver knowledge. Hospitalist handovers are lacking in directives. Efforts to improve handovers through enhanced electronic medical record systems and training may need to expand to hospitalists and other attending level physicians.

Sign-out snapshot: cross-sectional evaluation of written sign-outs among specialties

BACKGROUND

Sign-out is the process (written, verbal or both) by which one clinical team transmits information about patients to another team. Poor quality sign-outs are associated with adverse events and delayed treatment. How different specialties approach written sign-outs is unknown.

OBJECTIVE

To compare written sign-out practices across specialties and to determine consistency of content, format and timeliness.

METHODS

The authors evaluated all non-Intensive Care Unit written sign-outs from five inpatient specialties on 18 January 2012, at Yale-New Haven Hospital, focusing on content elements, format style and whether the sign-outs had been updated within 24 h. In our institution, all specialties used a single standardised sign-out template, which was built into the electronic medical record.

RESULTS

The final cohort included 457 sign-outs: 313 medicine, 64 general surgery, 36 paediatrics, 30 obstetrics, and 14 gynaecology. Though nearly all sign-outs (96%) had been updated within 24 h, they frequently lacked key information. Hospital course prevalence ranged from 57% (gynaecology) to 100% (paediatrics) (p<0.001). Clinical condition prevalence ranged from 34% (surgery) to 72% (paediatrics) (p=0.005).

CONCLUSIONS

Specialties have varied sign-out practices, and thus structured templates alone do not guarantee inclusion of critical content. Sign-outs across specialties often lacked complex clinical information such as clinical condition, anticipatory guidance and overnight tasks.

Shifting perceptions: a pre-post study to assess the impact of a senior resident rotation bundle

BACKGROUND

Extended duty hours for residents are associated with negative consequences. Strategies to accommodate duty hour restrictions may also have unintended impacts. To eliminate extended duty hours and potentially lessen these impacts, we developed a senior resident rotation bundle that integrates a night float system, educational sessions on sleep hygiene, an electronic handover tool, and a simulation-based medical education curriculum. The aim of this study was to assess internal medicine residents' perceptions of the impact of the bundle on three domains: the senior residents' wellness, ability to deliver quality health care, and medical education experience.

METHODS

This prospective study compared eligible residents' experiences (N = 67) before and after a six-month trial of the bundle at a training program in western Canada. Data was collected using an on-line survey. Pre- and post-intervention scores for the final sample (N = 50) were presented as means and compared using the t-test for paired samples.

RESULTS

Participants felt that most aspects of the three domains were unaffected by the introduction of the bundle. Four improved and two worsened perception shifts emerged post-intervention: less exposure to personal harm, reduced potential for medical error, more successful teaching, fewer disruptions to other rotations, increased conflicting role demands and less staff physician supervision.

CONCLUSIONS

The rotation bundle integrates components that potentially ease some of the perceived negative consequences of night float rotations and duty hour restrictions. Future areas of study should include objective measures of the three domains to validate our study participants' perceptions.

A preliminary study of the impact of a handover cognitive aid on clinical reasoning and information transfer

OBJECTIVES

To assess the impact of a written cognitive aid on expressed clinical reasoning and quantity and the accuracy of information transfer during resident doctor handover.

METHODS

This study was a randomised controlled trial in an academic paediatric intensive care unit (PICU) of 20 handover events (10 events per group) from residents in their first PICU rotation using a written handover cognitive aid (intervention) or standard practice (control). Before rounds, an investigator generated a reference standard of the handover event by completing a handover aid. Resident handovers were then audio-recorded and transcribed by a blinded research assistant. The content of this transcript was inserted into a blank handover aid. A blinded content expert scored the quantity and accuracy of the information in this aid according to predetermined criteria and these information scores (ISs) were compared with the reference standard. The same expert also blindly scored the transcripts in five domains of clinical reasoning and effectiveness: (i) effective summary of events; (ii) expressed understanding of the care plan; (iii) presentation clarity; (iv) organisation; (v) overall handover effectiveness. Differences between intervention and control groups were assessed using the Mann-Whitney test and multivariate linear regression.

RESULTS

The intervention group had total ISs that more closely approximated the reference standard (81% versus 61%; p < 0.01). The intervention group had significantly higher clinical reasoning scores when compared by total score (21.1 versus 15.9 points; p = 0.01) and in each of the five domains. No difference was observed in the duration of handover between groups (7.4 versus 7.7 minutes; p = 0.97).

CONCLUSIONS

Using a novel scoring system, our simple handover cognitive aid was shown to improve information transfer and resident expression of clinical reasoning without prolonging the handover duration.

Using peers to assess handoffs: a pilot study

BACKGROUND

Handoffs among post-graduate year 1 (PGY1) trainees occur with high frequency. Peer assessment of handoff competence would add a new perspective on how well the handoff information helped them to provide optimal patient care.

OBJECTIVE

The goals of this study were to test the feasibility of the approach of an instrument for peer assessment of handoffs by meeting criteria of being able to use technology to capture evaluations in real time, exhibiting strong psychometric properties, and having high PGY1 satisfaction scores.

DESIGN

An iPad® application was built for a seven-item handoff instrument. Over a two-month period, post-call PGY1s completed assessments of three co-PGY1s from whom they received handoffs the prior evening.

PARTICIPANTS

Internal Medicine PGY1s at the University of Pennsylvania.

MAIN MEASURES

ANOVA was used to explore interperson score differences (validity). Generalizability analyses provided estimates of score precision (reproducibility). PGY1s completed satisfaction surveys about the process.

KEY RESULTS

Sixty-two PGY1s (100 %) participated in the study. 59 % of the targeted evaluations were completed. The major limitations were network connectivity and inability to find the post-call trainee. PGY1 scores on the single item of "overall competency" ranged from 4 to 9 with a mean of 7.31 (SD 1.09). Generalizability coefficients approached 0.60 for 10 evaluations per PGY1 for a single rotation and 12 evaluations per PGY1 across multiple rotations. The majority of PGY1s believed that they could adequately assess handoff competence and that the peer assessment process was valuable (70 and 77 %, respectively).

CONCLUSION

Psychometric properties of an instrument for peer assessment of handoffs are encouraging. Obtaining 10 or 12 evaluations per PGY1 allowed for reliable assessment of handoff skills. Peer evaluations of handoffs using mobile technology were feasible, and were well received by PGY1s.

Review of computerized physician handoff tools for improving the quality of patient care

BACKGROUND

Computerized physician handoff tools (CHTs) are designed to allow distributed access and synchronous archiving of patient information via Internet protocols. However, their impact on the quality of physician handoff, patient care, and physician work efficiency have not been extensively analyzed.

METHODS

We searched MEDLINE, PUBMED, EMBASE, CINAHL, the Cochrane database for systematic reviews, and the Cochrane central register for clinical trials, from January 1960 to December 2011. We selected all articles that reported randomized controlled trials, controlled clinical trials, controlled before-after studies, and quasi-experimental studies of the use of CHTs for physician handoff for hospitalized patients. Relevant studies were evaluated independently for their eligibility for inclusion by 2 individuals in a 2-stage process.

RESULTS

The literature search identified 1026 citations of which 6 satisfied the inclusion criteria. One study was a randomized controlled trial, whereas 5 were controlled before-after studies. Two studies showed that using CHTs reduced adverse events and missing patients. Three studies demonstrated improved overall quality of handoff after CHT implementation. One study suggested that CHTs could potentially enhance work efficiency and continuity of care during physician handoff. Conflicting impacts on consistency of handoff were found in 2 studies.

CONCLUSIONS

The evidence that CHTs improve physician handoff and quality of hospitalized patient care is limited. CHT may improve the efficiency of physician work, reduce adverse events, and increase the completeness of physician handoffs. However, further evaluation using rigorous study designs is needed.

Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program

BACKGROUND

Poor quality handoffs have been identified as a major patient safety issue. In residency programs, problematic handoffs may be an unintended consequence of duty-hour restrictions, and key data are frequently omitted from written handoffs because of the lack of standardization of content.

OBJECTIVE

Determine whether an intervention that facilitates face-to-face communication supported by an electronic template improves the quality and safety of handoffs.

DESIGN

Before-after trial.

PARTICIPANTS

Thirty-nine interns providing nighttime coverage over 132 intern shifts, representing ∼9,200 handoffs.

INTERVENTIONS

Two interventions were implemented serially-an alteration of the shift model to facilitate face-to-face verbal communication between the primary and nighttime covering physicians and an electronic template for the day-to-night handoff.

MEASUREMENTS

Overall satisfaction and handoff quality were measured using a survey tool administered at the end of each intern shift. Written handoff quality, specifically the documentation of key components, was also assessed before and after the template intervention by study investigators. Interns used the survey tool to report patient safety events related to poor quality handoffs, which were validated by study investigators.

RESULTS

In adjusted analyses comparing intern cohorts with similar levels of training, overall satisfaction with the new handoff processes improved significantly (p < 0.001) post intervention. Verbal handoff quality (4/10 measures) and written handoff quality (5/6 measures) also improved significantly. Study investigators also found significant improvement in documentation of key components in the written handoff. Interns reported significantly fewer reported data omissions (p = 0.001) and a non-significant reduction in near misses (p = 0.056), but no significant difference in adverse events (p = 0.41) post intervention.

CONCLUSIONS

Redesign of shift models common in residency programs to minimize the number of handoffs and facilitate face-to-face communication, along with implementation of electronic handoff templates, improves the quality of handoffs in a learning environment.

Participation and experience of third-year medical students in handoffs: time to sign out?

BACKGROUND

Although interns are expected to be competent in handoff communication, it is currently unclear what level of exposure, participation, and comfort medical students have with handoffs prior to graduation.

OBJECTIVE

The aim of this study is to characterize passive and active involvement of third-year medical students in the major components of the handoff process.

DESIGN

An anonymous voluntary retrospective cross-sectional survey administered in 2010.

PARTICIPANTS

Rising fourth-year students at two large urban private medical schools.

MAIN MEASURES

Participation and confidence in active and passive behaviors related to written signout and verbal handoffs during participants' third-year clerkships.

KEY RESULTS

Seventy percent of students (n = 204) responded. As third-year medical students, they reported frequent participation in handoffs, such as updating a written signout for a previously admitted patient (58 %). Students who reported frequent participation (at least weekly) in handoff tasks were more likely to report being confident in that task (e.g., giving verbal handoff 62 % vs. 19 %, p < 0.001). Students at one site that did not have a handoff policy for medical students reported greater participation, more confidence, and less desire for training. Nearly all students believed they had witnessed an error in written signout (98 %) and almost two-thirds witnessed an error due to verbal handoffs (64 %).

CONCLUSIONS

During their third year, many medical students are participating in handoffs, although reported rates differ across training environments. Medical schools should consider the appropriate level of competence for medical student participation in handoffs, and implement corresponding curricula and assessment tools to ensure that medical students are able to effectively conduct handoffs.

Critical incidents in a tertiary care clinic for internal medicine

Background

Reducing medical errors has become an international concern. Population-based studies consistently demonstrate inacceptable high rates of medical injury and preventable deaths. Thus, electronic critical incident reporting systems are now increasingly used in hospitals, predominantly in anesthesia. However, studies systematically analyzing critical incidents are scarce. Our aim was to describe content and causes of critical incidents in our Clinic for Internal Medicine.

Results

We retrospectively analyzed all critical incidents reported during a 54-months period. Between implementation and analysis, 456 incidents were reported anonymously in the commercially available platform-independent, web-based critical incident reporting system. All incidents were analyzed according to the reporting profession, time point during hospitalization process, content and potential causes.

Most incidents occurred on medical wards (80%). The most frequent type of incidents was medication errors (62%). These incidents primarily occurred when prescribing and/or administering drugs (30% and 29% of medication errors respectively). So-called, human errors’, i.e. occurring without apparent external factor, were the most frequently indicated cause of critical incidents (56%) followed by insufficient communication (26%). These problems primarily occurred between different groups of health care professionals and between different departments. The described types and reasons of critical incidents remained stable during the observation period.

Conclusions

The findings of our analysis of the character and type of critical incidents occurring in a tertiary care clinic for internal medicine reported in an anonymous, voluntary, electronic reporting system suggest that strategies to improve communication and medication delivery are most promising to avoid critical incidents.

Answering questions on call: pediatric resident physicians' use of handoffs and other resources

BACKGROUND

Little is known in the literature about the types of questions being asked of on-call housestaff and the resources used to provide answers.

OBJECTIVE

To characterize questions being asked of pediatric interns on call and evaluate their use of written handoffs, verbal handoffs, and other resources.

DESIGN/METHODS

Prospective direct observational study.

SETTING

Inpatient wards at an academic tertiary care children's hospital.

PARTICIPANTS

Pediatric interns.

RESULTS

Trainees were asked 2.6 questions/hour (interquartile range: 1.4-4.7); most involved medications (28%), general care plans (27%), diagnostic tests/procedures (22%), diet/fluids (15%), and physical exams (9%). Interns reported using information provided in written or verbal handoffs to answer 32.6% questions (written 7.3%; verbal 25.3%). Other resources utilized included general medical knowledge, the medical record, and parental report. Questions pertaining to diet/fluids were associated with increased written handoff use (odds ratio [OR]: 3.64, 95% confidence interval [CI]: 1.51-8.76), whereas having worked more consecutive nights was associated with decreased written handoff use (OR: 0.29, 95% CI: 0.09-0.93). Questions regarding general care plans (OR: 2.07, 95% CI: 1.13-3.78), those asked by clinical staff (OR: 1.95, 95% CI: 1.04-3.66), and questions asked of patients with longer lengths of stay (OR: 1.97, 95% CI: 1.02-3.80) were predictive of verbal handoff use.

CONCLUSIONS

Pediatric housestaff face frequent questions during overnight shifts and frequently use information received during handoffs to provide answers. A better understanding of how handoffs and other resources are utilized by housestaff could inform future targeted initiatives to improve trainees' access to key information at night.

Sustainability and effectiveness of a quality improvement project to improve handoffs to night float residents in an internal medicine residency program

BACKGROUND

Handoff is the process in which patient care is transitioned from one provider to another. In teaching hospitals, handoffs are frequent, and resident duty hour restrictions have increased the use of night float staff. To date, few studies have focused on long-term sustainability and effectiveness of a handoff quality improvement project.

OBJECTIVE

The objective of our resident-driven quality improvement project was to evaluate the effectiveness and sustainability of a standardized template for handoff quality in a community hospital internal medicine program.

METHODS

We used a multistep continuous quality improvement approach. Problems in the handoff process were identified through process mapping and anonymous needs assessment of the residents. A group of residents and faculty identified problems during biweekly discussions, created a standardized template, and adopted a new handoff process. We audited handoffs and surveyed residents at 3 and 9 months after implementation to assess effectiveness and sustainability.

RESULTS

Before the intervention, only 40% of residents reported regular morning handoff. Using the standardized template, statistically significant, sustained improvements were seen in morning handoff frequency (59% preintervention, 90% at 3 months, 89% at 9 months), along with decreases in unreported overnight events (84% preintervention, 58% at 3 months, 50% at 9 months) and uncertainty about decisions because of poor handoffs (72% preintervention, 49% at 3 months, 37% at 9 months). Statistically significant decreases in missed content (69%-46%) and copy-and-paste behavior (78%-38%) at 3 months were not sustained.

CONCLUSIONS

We demonstrated sustained improvements in unreported events and uncertainty caused by poor handoffs. Initial improvements in missed content and copy-and-paste behavior that were not sustained suggest a need for ongoing reinforcement and monitoring of handoff quality.

Creating a culture of safety within operative neurosurgery: the design and implementation of a perioperative safety video

OBJECT

Surgical and medical errors result from failures in communication and handoffs as well as lack of standardization in clinical protocols and safety practices. Checklists, simulation training, and teamwork training have been shown to decrease adverse patient events and increase the safety culture of surgical teams. The goal of this project was to simplify and standardize perioperative patient safety practices and team communication processes within operative neurosurgery through the creation of an educational safety video targeted at a neurosurgical provider audience.

METHODS

A multidisciplinary group consisting of neurosurgeons, anesthesiologists, nurses, neuromonitoring specialists, quality champions, and a professional video production company met over several months in an iterative process to 1) determine the overall objectives of the video, 2) decide on the content and format of the video, 3) modify the proposed content and format based on stakeholder feedback, and 4) record the video and complete final revisions during postproduction.

RESULTS

The video was launched within the authors' institution in July 2012 in conjunction with ongoing research projects to study the effects of the video on 1) multidisciplinary providers' knowledge of perioperative safety practices, 2) provider safety attitudes and safety culture in the operating room, and 3) provider behavior in performing predetermined elements of the preoperative timeout and postoperative debrief.

CONCLUSIONS

The neurosurgical perioperative safety video can serve as a national model for how quality champions can drive changes in safety culture and provider behavior among multidisciplinary perioperative patient care teams. Ongoing research is being performed to assess the impact of the video on provider knowledge, behavior, and safety attitudes and culture.

Quantifying the impact of cross coverage on physician's workload and performance in radiation oncology

PURPOSE

To quantitatively assess the difference in workload and performance of radiation oncology physicians during radiation therapy treatment planning tasks under the conditions of "cross coverage" versus planning a patient with whom they were familiar.

METHODS AND MATERIALS

Eight physicians (3 experienced faculty physicians and 5 physician residents) performed 2 cases. The first case represented a "cross-coverage" scenario where the physicians had no prior information about the case to be planned. The second exposure represented a "regular-coverage" scenario where the physicians were familiar with the patient case to be planned. Each case involved 3 tasks to be completed systematically. Workload was assessed both subjectively (perceived) using National Aeronautics and Space Administration-Task Load Index (NASA-TLX), and objectively (physiological) throughout the task using eye data (via monitoring pupil size and blink rate). Performance of each task and the case was measured using completion time. Subjective willingness to approve or disapprove the generated plan was obtained after completion of the case only.

RESULTS

Forty-eight perceived and 48 physiological workload assessments were obtained. Overall, results revealed a significant increase in perceived workload (high NASA-TLX score) and decrease in performance (longer completion time and reduced approval rate) during cross coverage. There were nonsignificant increases in pupil diameter and decreases in the blink rate during cross-coverage versus regular-coverage scenario. In both cross-coverage and regular-coverage scenarios the level of experience did not affect workload and performance.

CONCLUSIONS

The cross-coverage scenario significantly increases perceived workload and degrades performance versus regular coverage. Hence, to improve patient safety, efforts must be made to develop policies, standard operating procedures, and usability improvements to electronic medical record and treatment planning systems for "easier" information processing to deal with cross coverage, while recognizing strengths and limitations of human performance.

Identifying intensive care unit discharge planning tools: protocol for a scoping review

BACKGROUND

Transitions of care between providers are vulnerable periods in healthcare delivery that expose patients to preventable errors and adverse events. Patient discharge from the intensive care unit (ICU) to a medical or surgical hospital ward is one of the most challenging and high risk transitions of care. Approximately 1 in 12 patients discharged will be readmitted to ICU or die before leaving the hospital. Many more patients are exposed to unnecessary healthcare, adverse events and/or are disappointed with the quality of their care. Our objective is to conduct a scoping review by systematically searching the literature to identify ICU discharge planning tools and their supporting evidence-base including barriers and facilitators to their use.

METHODS AND ANALYSIS

Systematic searching of the published health literature will be conducted to identify the existing ICU discharge planning tools and supporting evidence. Literature (research and non-research) reporting on the tools used to facilitate decision making and/or communication at ICU discharge with patients of any age will be included. Outcomes will include adverse events and provider and patient/family-reported outcomes. Two investigators will independently review the abstracts (screen 1) to identify those meeting the inclusion criteria and then independently assess the full text articles (screen 2) to determine if they meet the inclusion criteria. Data collection will include information on citations and identified tools. A quality assessment will be performed on original research studies. A descriptive summary will be developed for each tool.

ETHICS AND DISSEMINATION

Our scoping review will synthesise the literature for ICU discharge planning tools and identify the opportunities for knowledge to action and gaps in evidence where primary evidence is necessary. This will serve as the foundational element in a multistep research programme to standardise and improve the quality of care provided to patients during ICU discharge. Ethics approval is not required for this study.

Learning from incident reports in the Australian medical imaging setting: handover and communication errors

OBJECTIVE

To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence.

METHODS

71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging.

RESULTS

Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%).

CONCLUSION

The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings.

ADVANCES IN KNOWLEDGE

Handover and communication errors are prevalent in medical imaging. System-wide changes that facilitate effective communication are required.

'He did what? Well, that wasn't handed over!' Communicating risk in mental health

Mental health inpatient units are dynamic, complex environments that provide care for patients with heterogeneous ages, diagnoses and levels of acuity. These environments commonly expose clinicians and patients to many potential risks. Despite extensive research into risk assessment, prediction and management, no study has investigated how risk information is communicated at handover in acute mental health settings. Given the pivotal role handover plays in informing risk management, this evidence gap is significant. This paper reports on a study that investigated the practices of communicating risk at handover in an Australian acute mental health inpatient unit. The aim of this research was to identify the frequency and type of risk information communicated between nursing shifts, and the methods by which this communication was performed. A secondary aim was to identify effective and ineffective risk communication practices. This study involved an observational design method using a 14-item Clinical Audit Tool derived from handover principles outlined by World Health Organization. Five hundred occasions of patient handover were observed. Few risk information items were observed to be communicated in any method. Risk communication practice was inconsistent, and a key recommendation from the study is the use of standardized handover tools that ensures risk information is adequately reported.

Development of a handoff evaluation tool for shift-to-shift physician handoffs: the Handoff CEX

BACKGROUND

Increasing frequency of shift-to-shift handoffs coupled with regulatory requirements to evaluate handoff quality make a handoff evaluation tool necessary.

OBJECTIVE

To develop a handoff evaluation tool.

DESIGN

Tool development.

SETTING

Two academic medical centers.

SUBJECTS

Nurse practitioners, medicine housestaff, and hospitalist attendings.

INTERVENTION

Concurrent peer and external evaluations of shift-to-shift handoffs.

MEASUREMENTS

The Handoff CEX (clinical evaluation exercise) consists of 6 subdomains and 1 overall assessment, each scored from 1 to 9, where 1 to 3 is unsatisfactory and 7 to 9 is superior. We assessed range of scores, performance among subgroups, internal consistency, and agreement among types of raters.

RESULTS

We conducted 675 evaluations of 97 unique individuals during 149 handoff sessions. Scores ranged from unsatisfactory to superior in each domain. The highest rated domain for handoff providers was professionalism (median: 8; interquartile range [IQR]: 7-9); the lowest was content (median: 7; IQR: 6-8). Scores at the 2 institutions were similar, and scores did not differ significantly by training level. Spearman correlation coefficients among the CEX subdomains for provider scores ranged from 0.71 to 0.86, except for setting (0.39-0.40). Third-party external evaluators consistently gave lower marks for the same handoff than peer evaluators did. Weighted kappa scores for provider evaluations comparing external evaluators to peers ranged from 0.28 (95% confidence interval [CI]: 0.01, 0.56) for setting to 0.59 (95% CI: 0.38, 0.80) for organization.

CONCLUSIONS

This handoff evaluation tool was easily used by trainees and attendings, had high internal consistency, and performed similarly across institutions. Because peers consistently provided higher scores than external evaluators, this tool may be most appropriate for external evaluation.

It's not about pager replacement: an in-depth look at the interprofessional nature of communication in healthcare

BACKGROUND

Institutions have tried to replace the use of numeric pagers for clinical communication by implementing health information technology (HIT) solutions. However, failing to account for the sociotechnical aspects of HIT or the interplay of technology with existing clinical workflow, culture, and social interactions may create other unintended consequences.

OBJECTIVE

To evaluate a Web-based messaging system that allows asynchronous communication between health providers and identify the unintended consequences associated with implementing such technology.

DESIGN

Intervention-a Web-based messaging system at the University Health Network to replace numeric paging practices in May 2010. The system facilitated clinical communication on the medical wards for coordinating patient care. Study design-pre-post mixed methods utilizing both quantitative and qualitative measures.

PARTICIPANTS

Five residents, 8 nurses, 2 pharmacists, and 2 social workers were interviewed. Pre-post interruption-15 residents from 5 clinical teams in both periods.

MEASUREMENTS

The study compared the type of messages sent to physicians before and after implementation of the Web-based messaging system; a constant comparative analysis of semistructured interviews was used to generate key themes related to unintended consequences.

RESULTS

Interruptions increased 233%, from 3 pages received per resident per day pre-implementation to 10 messages received per resident per day post-implementation. Key themes relating to unintended consequences that emerged from the interviews included increase in interruptions, accountability, and tactics to improve personal productivity.

CONCLUSIONS

Meaningful improvements in clinical communication can occur but require more than just replacing pagers. Introducing HIT without addressing the sociotechnical aspects of HIT that underlie clinical communication can lead to unintended consequences.

Supplementing cross-cover communication with the patient acuity rating

BACKGROUND

Patient hand-offs at physician shift changes have limited ability to convey the primary team's longitudinal insight. The Patient Acuity Rating (PAR) is a previously validated, 7-point scale that quantifies physician judgment of patient stability, where a higher score indicates a greater risk of clinical deterioration. Its impact on cross-covering physician understanding of patients is not known.

OBJECTIVE

To determine PAR contribution to sign-outs.

DESIGN

Cross-sectional survey.

SUBJECTS

Intern physicians at a university teaching hospital.

INTERVENTIONS

Subjects were surveyed using randomly chosen, de-identified patient sign-outs, previously assigned PAR scores by their primary teams. For each sign-out, subjects assigned a PAR score, then responded to hypothetical cross-cover scenarios before and after being informed of the primary team's PAR.

MAIN MEASURE

Changes in intern assessment of the scenario before and after being informed of the primary team's PAR were measured. In addition, responses between novice and experienced interns were compared.

KEY RESULTS

Between May and July 2008, 23 of 39 (59 %) experienced interns and 25 of 42 (60 %) novice interns responded to 480 patient scenarios from ten distinct sign-outs. The mean PAR score assigned by subjects was 4.2 ± 1.6 vs. 3.8 ± 1.8 by the primary teams (p < 0.001). After viewing the primary team's PAR score, interns changed their level of concern in 47.9 % of cases, their assessment of the importance of immediate bedside evaluation in 48.7 % of cases, and confidence in their assessment in 43.2 % of cases. For all three assessments, novice interns changed their responses more frequently than experienced interns (p = 0.03, 0.009, and <0.001, respectively). Overall interns reported the PAR score to be theoretically helpful in 70.8 % of the cases, but this was more pronounced in novice interns (81.2 % vs 59.6 %, p < 0.001).

CONCLUSIONS

The PAR adds valuable information to sign-outs that could impact cross-cover decision-making and potentially benefit patients. However, correct training in its use may be required to avoid unintended consequences.