Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out

Improving and Sustaining Resident Physician Handover

Background Handoffs serve a critical patient safety function in the transition between caregivers. In 2006, the Joint Commission on Accreditation of Healthcare Organizations strongly recommended the implementation of "a standardized approach to 'handoff' communications, including an opportunity to ask and respond to questions." Numerous studies have investigated the quality and efficacy of patient handoffs and the utility of structured handoff curriculums, particularly in the context of patient safety and outcomes. Objective The pediatric residents at Penn State Health (PSH) did not utilize a formal written or verbal handoff tool. Our study facilitated the design of a comprehensive handoff curriculum, including verbal and written components, and the implementation of faculty and multidisciplinary care team involvement coupled with resident training and observations. We investigate the impact of this curriculum longitudinally utilizing validated tools completed by external observers as well as the residents themselves. Methods Prior to SAFETIPS being implemented, residents at a mid-sized Pediatric program were observed giving handovers at various intervals to understand baseline habits. Residents were then educated with the SAFETIPS curriculum and again observed. Trained observers of the handover process completed a validated evaluation form concentrating on seven key domains necessary for effective handover and communication; residents involved in the handover also completed a validated evaluation form. Consent for the project was implied with the observer's presence during the process and our study was exempt from full IRB consideration given its quality improvement design. A mix of summary statistics, stacked dot plots, mixed effects regression, and joint F tests were used to analyze data. Results Mean values on all sections of the handover evaluation Likert scale completed by trained observers tended to increase over time; the variance in responses was likewise much smaller at later time periods. Similarly, all sections of the evaluation tools completed by the resident physicians themselves showed significantly increased scores from pre- to post-implementation of our curriculum. Data revealed a plateauing of results toward later time points suggestive of skills mastery and sustained improvements. Conclusion Our findings suggest that the introduction of a structured handoff curriculum correlated with improved communication among residents, and such improvements were sustained over time.

A scoping review of clinical handover mnemonic devices

Since the Institute of Medicine (IOM) published To Err is Human: Building a Safer Health System in 1999, clinical handovers (or handoffs) and their relationship with the communication of patient safety have raised concerns from the public, regulatory bodies, and medical practitioners. Protocols, guidelines, forms, and mnemonic devices have been created to ensure safer clinical handovers. An initial literature search did not find a framework to describe the clinical processes and functions of each mnemonic device and its elements. The absence of a systematic framework could hinder the study across and the reusability of the established clinical handover mnemonic devices. This study aims to develop a universal framework to describe the clinical processes and functions essential for patient safety during handover. We queried PubMed.gov and obtained 98 articles related to clinical handovers. We examined the citing sources of the mnemonics mentioned in these articles. A total of 42 handover mnemonics with 238 elements were identified. Our review noted that there was no taxonomy to describe the clinical functions and process associated with the clinical handover mnemonic devices. We used grounded theory to address this gap and built a new taxonomy from the 42 mnemonics. A researcher read all mnemonics, developed a taxonomy for tagging clinical handover mnemonics, and categorized all mnemonic elements into correct processes and functions. After that, the second researcher, a medical practitioner, examined the taxonomy and made suggested corrections for the labelled functions of all mnemonic elements. Both researchers agreed on the taxonomy and the labelled processes and functions of different mnemonic elements. The taxonomy contains three processes and twenty functions in clinical handovers. Clinical processes like 'medical condition', 'medical history', 'medical evaluation', 'care plan', 'outstanding care/tasks/results', and 'patient information', as an administrative process, were widely adopted in clinical handover mnemonics. Moreover, mnemonic elements on communication manner and information validation had been identified in the list of clinical handover mnemonics. Although we recognize challenges because of both the vast number of clinical handover scenarios and the task of placing them under a few predefined groups, our findings suggest that such a taxonomy, as developed for this study, could assist medical practitioners to devise a clinical handover mnemonic to best fit their workplace.

Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study

BACKGROUND

Handoff miscommunications are a leading source of medical errors. Harmful medical errors decreased in pediatric academic hospitals following implementation of the I-PASS handoff improvement program. However, implementation across specialties has not been assessed.

OBJECTIVE

To determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication.

DESIGN

Prospective Type 2 Hybrid effectiveness implementation study.

SETTINGS AND PARTICIPANTS

Residents from diverse specialties across 32 hospitals (12 community, 20 academic).

INTERVENTION

External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews.

MAIN OUTCOME AND MEASURES

Systematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality.

RESULTS

2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participated. 1942 error surveillance reports were collected. Major and minor handoff-related reported adverse events decreased 47% following implementation, from 1.7 to 0.9 major events/person-year (p < .05) and 17.5 to 9.3 minor events/person-year (p < .001). Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20% vs. 66%, p < .001, n = 4812) and written (10% vs. 74%, p < .001, n = 1787) handoffs, as well as increased frequency of handoffs with high quality verbal (39% vs. 81% p < .001) and written (29% vs. 78%, p < .001) patient summaries, verbal (29% vs. 78%, p < .001) and written (24% vs. 73%, p < .001) contingency plans, and verbal receiver syntheses (31% vs. 83%, p < .001). Improvement was similar across provider types (adult vs. pediatric) and settings (community vs. academic).

A Smart Device for a Preliminary Dental Examination Based on the Internet of Things

The COVID-19 pandemic has threatened the lives of many people, especially the elderly and those with chronic illnesses, as well as threatening the global economy. In response to the pandemic, many medical centers, including dental facilities, have significantly reduced the treatment of patients by limiting clinical practice to exclusively urgent, nondeferred care. Dentists are more vulnerable to contracting COVID-19, due to the necessity of the dentist being close to the patient. One of the precautions that dentists take to avoid transmitting infections is to wear a mask and gloves. However, the basic condition for nontransmission of infection is to leave a safe distance between the patient and the dentist. This system can be implemented by using an Arduino microcontroller, which is designed as a preliminary device by a dentist to examine a patient's teeth so that a safe distance of three meters between the dentist and the patient can be maintained. The project is based on hardware and has been programmed through Arduino. The proposed system uses a small wired camera with a length of five meters that is connected to the dentist's mobile or laptop and is installed on a robotic arm. The dentist can control the movement of the arm in all directions using a joystick at a distance of three meters. The results showed the effectiveness of this system for leaving a safe distance between the patient and the dentist. In our future work, we will control the movement of the arm via Bluetooth, and we will use a wi-fi-based camera.

Who can do this procedure? Using entrustable professional activities to determine curriculum and entrustment in anesthesiology - An international survey

INTRODUCTION

As competency-based curricula get increasing attention in postgraduate medical education, Entrustable Professional Activities (EPAs) are gaining in popularity. The aim of this survey was to determine the use of EPAs in anesthesiology training programs across Europe and North America.

METHODS

A survey was developed and distributed to anesthesiology residency training program directors in Switzerland, Germany, Austria, Netherlands, USA and Canada. A convergent design mixed-methods approach was used to analyze both quantitative and qualitative data.

RESULTS

The survey response rate was 38% (108 of 284). Seven percent of respondents used EPAs for making entrustment decisions. Fifty-three percent of institutions have not implemented any specific system to make such decisions. The majority of respondents agree that EPAs should become an integral part of the training of residents in anesthesiology as they are universal and easy to use.

CONCLUSION

Although recommended by several national societies, EPAs are used in few anesthesiology training programs. Over half of responding programs have no specific system for making entrustment decisions. Although several countries are adopting or planning to adopt EPAs and national societies are recommending the use of EPAs as a framework in their competency-based programs, few are yet using these to make "competence" decisions.

For Residents, by Residents: Developing a Physician Handoff Tool at a University Affiliated Community Hospital

The 80-hour per week work limit resulted in an increased number of patient handoffs. A satisfactory handoff system should optimize the exchange of vital patient information while concisely minimizing error. This project describes our experience and lessons learned in successfully developing and implementing an Electronic Health Record (EHR)-integrated handoff system based on the I-PASS model. The handoff system, termed Physician Handoff, was refined through end-user feedback. End-users were evaluated on the quality of handoff in the following categories: Illness Severity, Patient Summary, Action List, and Situational Awareness. Resulting survey showed high adoption and satisfaction rate with Physician Handoff. Success can be attributed to interdepartmental collaboration, credentialing the users, and recognizing the importance of end-user feedback.

Handoff improvement and adverse event reduction programme implementation in paediatric intensive care units in Argentina: a stepped-wedge trial

BACKGROUND

There are only a few studies on handoff quality and adverse events (AEs) rigorously evaluating handoff improvement programmes' effectiveness. None of them have been conducted in low and middle-income countries. We aimed to evaluate the effect of a handoff programme implementation in reducing AE frequency in paediatric intensive care units (PICUs).

METHODS

Facility-based, cluster-randomised, stepped-wedge trial in six Argentine PICUs in five hospitals, with >20 admissions per month. The study was conducted from July 2018 to May 2019, and all units at least were involved for 3 months in the control period and 4 months in the intervention period. The intervention comprised a Spanish version of the I-PASS handoff bundle consisting of a written and verbal handoff using mnemonics, an introductory workshop with teamwork training, an advertising campaign, simulation exercises, observation and standardised feedback of handoffs. Medical records (MR) were reviewed using trigger tool methodology to identify AEs (primary outcome). Handoff compliance and duration were evaluated by direct observation.

RESULTS

We reviewed 1465 MRs: 767 in the control period and 698 in the intervention period. We did not observe differences in the rates of preventable AE per 1000 days of hospitalisation (control 60.4 (37.5-97.4) vs intervention 60.4 (33.2-109.9), p=0.99, risk ratio: 1.0 (0.74-1.34)), and no changes in the categories or AE types. We evaluated 841 handoffs: 396 in the control period and 445 in the intervention period. Compliance with all items in the verbal and written handoffs was significantly higher in the intervention group. We observed no difference in the handoff time in both periods (control 35.7 min (29.6-41.8) vs intervention 34.7 min (26.5-42.1); difference 1.43 min (95% CI -2.63 to 5.49, p=0.49)). The providers' perception of improved communication did not change.

CONCLUSIONS

After the implementation of the I-PASS bundle, compliance with handoff items improved. Nevertheless, no differences were observed in the AEs' frequency or the perception of enhanced communication.

TRIAL REGISTRATION NUMBER

NCT03924570.

Impact of a blended curriculum on nursing handover quality: a quality improvement project

Context and objective

The negative consequences of inadequate nursing handovers on patient safety are widely acknowledged, both within the literature as in practice. Evidence regarding strategies to improve nursing handover is, however, lacking. This study investigates the effect of a tailored, blended curriculum on nurses’ perception of handover quality.

Methods

We used a pre-test/post-test design within four units of a Belgian general hospital. Our educational intervention consisted of an e-learning module on professional communication and a face-to-face session on the use of a structured method for handovers. All nurses completed this blended curriculum (n=87). We used the Handover Evaluation Scale (HES) to evaluate nurses’ perception of handover quality before and after the intervention. The HES was answered by 87.4% of the nurses (n=76 of 87) before and 50.6% (n=44 of 87) after the intervention. Confirmatory factor analysis was used to assess the validity of the HES.

Results

The original factor structure did not fit with our data. We identified a new HES structure with acceptable or good fit indices. The overall internal consistency of our HES structure was considered adequate. Perception of nurses on Relevance of information showed a significant improvement (M=53.19±4.33 vs M=61.03±6.01; p=0.04). Nurses also felt that the timely provision of patient information improved significantly (M=4.50±0.34 vs M=5.16±0.40; p=0.01).

Conclusion

The applied intervention resulted in an improved awareness on the importance of Relevance of information during handovers. After our intervention, the nurses’ perception of the HES item ‘Patient information is provided in a timely manner’ also improved significantly. We are aware that the educational intervention is only the first step to achieve the long-term implementation of a culture of professional communication based on mutual support.

Early Warning Scores to Predict Noncritical Events Overnight in Hospitalized Medical Patients: A Prospective Case Cohort Study

BACKGROUND

Physicians are often called to evaluate patients overnight with varying levels of clinical deterioration. Early warning scores predict critical clinical deterioration in patients; however, it is unknown whether they are able to reliably predict which patients will need to be seen overnight and whether these patients will require further resource use.

METHODS

A prospective case cohort study of 522 patient nights in a single tertiary care hospital in Vancouver, British Columbia, Canada, was conducted to assess the ability of Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS) to predict patients who will need to be seen overnight by physicians and will require other healthcare resources. Prediction ability was assessed using area under the receiver operating characteristic curve and logistic regression models.

RESULTS

The MEWS and NEWS both significantly predicted which patients needed to be seen overnight, and area under the receiver operating characteristic curves (95% confidence interval) for MEWS and NEWS were 0.72 (0.66-0.78) and 0.69 (0.63-0.76), respectively. Odds ratios (95% confidence interval) for MEWS and NEWS predicting need to be seen overnight were 1.52 (1.34-1.73) and 1.22 (1.14-1.31), respectively.

CONCLUSIONS

Both MEWS and NEWS have fair ability to predict patients who will need to be seen overnight. This may be useful for improving handover and resource allocation for overnight care.

Evidence for validity for the Cognitive Load Inventory for Handoffs

CONTEXT

Patient handovers remain a significant patient safety challenge. Cognitive load theory (CLT) can be used to identify the cognitive mechanisms for handover errors. The ability to measure cognitive load types during handovers could drive the development of more effective curricula and protocols. No such measure currently exists.

METHODS

The authors developed the Cognitive Load Inventory for Handoffs (CLIH) using a multi-step process, including expert interviews to enhance content validity and talk-alouds to optimise response process validity. The final version contained 28 items. From January to March 2019, we administered a cross-sectional survey to 1807 residents and fellows from a large health care system in the USA. Participants completed the CLIH following a handover. Exploratory factor analysis of data from one-third of respondents identified high-performing items; confirmatory factor analysis of data from the remaining sample assessed model fit. Model fit was evaluated using the comparative fit index (CFI) (>0.90), Tucker-Lewis index (TFI) (>0.80), standardised root mean square residual (SRMR) (<0.08) and root mean square of error of approximation (RMSEA) (<0.08).

RESULTS

Participants included 693 trainees (38.4%) (231 in the exploratory study and 462 in the confirmatory study). Eleven items were removed during exploratory factor analysis. Confirmatory factor analysis of the 16 remaining items (five for intrinsic load, seven for extraneous load and four for germane load) supported a three-factor model and met criteria for good model fit: the CFI was 0.95, TFI was 0.93, RMSEA was 0.074 and SRMR was 0.07. The factor structure was comparable for gender and role. Intrinsic, extraneous and germane load scales had high internal consistency. With one exception, scale scores were associated, as hypothesised, with postgraduate level and clinical setting.

CONCLUSIONS

The CLIH measures three types of cognitive load during patient handovers. Evidencefor validity is provided for the CLIH's content, response process, internal structure and association with other variables. This instrument can be used to determine the relative drivers of cognitive load during handovers in order to optimize handover instruction and protocols.

Cross-Cover Curriculum for Senior Medical Students

INTRODUCTION

Cross-cover, the process by which a nonprimary team physician cares for patients, usually during afternoons, evenings, and weekends, is common in academic medical centers. With the advent of residency duty-hour restrictions, cross-cover care has increased, making education in effective cross-coverage an urgent need.

METHODS

We implemented a cross-cover didactic activity composed of 18 interactive cases with 29 senior medical students enrolled in an internal medicine residency preparation course. The curriculum was facilitated by one faculty member and one senior medical resident and utilized think-pair-share learning techniques to discuss an approach to a range of common (both urgent and routine) cross-cover scenarios. We analyzed confidence and feelings of preparedness pre- and postintervention. We also examined differences in medical knowledge based on two multiple-choice written cross-cover cases that addressed both medical management and triage.

RESULTS

This curriculum significantly improved feelings of confidence (from 1.8 to 3.2, p < .0001), reduced anxiety (from 4.5 to 4.1, p < .03), and improved performance in clinical case scenarios (from 82% to 89%, p < .02).

DISCUSSION

This curriculum covered not only the important medical aspects of cross-cover care (e.g., diagnostics and management) but also equally important roles of cross-cover, such as how to effectively triage cross-cover scenarios. The curriculum was well received by students.

Future Directions in Communication in Neurosurgery

Modern-day care of the neurosurgery patient has grown increasingly complex and typically involves a variety of medical team members. Proper communication and transmission of clinical data within the neurosurgery team is required for successful outcomes, especially within the operating room. Effective communication is also critical to the patient-physician relationship and can aid in improving rapport and possibly reducing malpractice lawsuit risk. In addition, interactions exist between practicing neurosurgeons and members of the administration, often focusing on reimbursement and quality issues. Although most physicians would agree that communication between all these stakeholders should improve, certain barriers are present, including the adoption of newer technologies and the lack of formal training. In this article, we review current and projected trends relating to the enhancement of neurosurgical communication at all levels.

Hand-off bundle implementation associated with decreased medical errors and preventable adverse events on an academic family medicine in-patient unit: A pre-post study

To determine the impact of the implementation of a hand-off bundle on medical errors at an inpatient unit of an academic community teaching hospital. Our secondary objective was to determine the research utility of the use of an all-electronic data collection system for medical errors.A retrospective review was conducted of 1290 admissions 6 months before and after implementation of an improved computerized hand-off tool and training bundle. The study took place at an academic community teaching hospital on a Family Medicine inpatient service caring for patients of all ages. The comparison focused on preventable and non-preventable adverse events.A significant decrease in medical errors was noted. Medical error rate dropped from 6.0 (95% CI, 4.2-8.3) to 2.2 (95% CI, 1.2-3.7) per 100 admissions (P < .001). Preventable medical errors dropped from 0.65 (95% CI, 0.18-1.67) to 0.15 (95% CI, 0.03-0.82) per 100 admissions (P = .194). Non-intercepted potential adverse events dropped from 1.30 (95% CI, 0.56-2.57) to 0.44 (95% CI, 0.09-1.30) per 100 admissions (P = .131). Intercepted potential adverse events dropped from 0.98 (95% CI 0.36-2.13) to 0.74 (95% CI 0.24-1.7) per 100 admissions (P = .766) and errors with little potential for harm dropped from 2.77 (95% CI 1.61-4.43) to 0.74 (95% CI 0.24-1.7) per 100 admissions (P = .009).Implementation of a standardized hand-off bundle was associated with a reduction in medical errors despite a low overall event rate. Further studies are warranted to determine the generalizability of this finding, to examine the overall epidemiology of medical errors and the reporting of such events within general medical teaching units.

Systematic Review of Handoff Mnemonics Literature

A systematic review of published English-language articles on handoffs is conducted (1987 to June 4, 2008). Forty-six articles describing 24 handoff mnemonics are identified by trained reviewers. The majority (82.6%) have been published in the last 3 years (2006-2008), and SBAR (Situation, Background, Assessment, Recommendation) is the most frequently cited mnemonic (69.6%). Of 7 handoff research articles, only 4 study mnemonics. All 4 of these studies have relatively small sample sizes (10-100) and lack validated instruments. Only 1 study has obtained IRB approval. Scientifically rigorous research studies are needed to assess the effectiveness of handoff mnemonics. These should be published in the peer-reviewed literature using the Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines.

Associations between early handoffs, length of stay and complications in internal medicine wards: A retrospective study

BACKGROUND

In US healthcare system, handoffs are associated with an increase in medical error and in hospital length of stay. In non-US healthcare systems, this phenomenon has not been well studied. We studied the association between early handoffs (EH) in a non-US internal medicine ward with length of stay (LOS), use of resources, major complication (MC) and discharge to post-acute care (PAC) facility.

METHODS

We conducted a retrospective cohort study on patients admitted to the general internal medicine division. Patients with EH (defined as a transfer of responsibility between primary teams within the first 72 h) were compared with patients without EH. The primary outcome was LOS in the general internal medicine division. Secondary outcomes were the use of resources, the incidence of MC (transfer to intensive care, to intermediate care or death) and discharge to a PAC facility.

RESULTS

We included 11,869 patients, 38% of whom were in the EH group. Patients were 67.7±16.6 years old and 53% were males. EH was independently associated with an increase of LOS (+6.4% [95% CI, 3.5%-9.5%], P < .001) and with an increased rate of MC (OR 1.3 [95% CI, 1.1-1.7], P = .012). In our subgroup analysis, the association between early handoff and LOS and MC rate were not statistically significant when the admission occurred on public holidays and weekends.

CONCLUSIONS

Among patients admitted in our general internal medicine division, early handoffs were associated with significantly higher length of stay and major complication rate, but not in patients admitted during week-ends.

Communication at Transitions of Care

Communication errors during transitions of care are a leading source of adverse events for hospitalized patients. This article provides an overview of the role of communication errors in adverse events, describes the complexities of communication for hospitalized patients, and provides evidence regarding the positive effects of applying high-reliability principles to transitions of care and culture of safety. Elements of effective handoffs and a detailed approach for successful implementation of a handoff program are provided. The role of handoff communication in medical education at all levels, as well as for the interprofessional team, is discussed.

How does training in anesthesia residency shape residents' approaches to patient care handoffs? A single-center qualitative interview study

BACKGROUND

Handoffs are a complex procedure whose success relies on mutual discussion rather than simple information transfer. Particularly among trainees, handoffs present major opportunities for medical error. Previous research has explored best practices and pitfalls in general handoff education but has not discussed barriers specific to anesthesiology residents. This study characterizes the experiences of residents in anesthesiology as they learn handoff technique in order to inform strategies for teaching this important component of perioperative care.

METHODS

In 2016, we conducted a semi-structured interview study of 30 anesthesia residents across all three postgraduate years at a major academic hospital. Interviews were coded by two coders using a grounded theory approach and an iterative process designed to enhance reliability and validity.

RESULTS

Residents cited lack of consistency as a major impediment to proper handoff education. They found the impact of lectures and written materials to be limited. The level of guidance and direction they received from one-to-one attendings was described as highly variable. Residents' comfort in executing handoffs was heavily dependent on location and situation. They felt that coordination among the parties involved in the handoff was difficult to achieve, causing confusion about the importance of handoffs as well as proper protocol. Finally, residents offered opinions on when handoff education should occur during the residency and had several recommendations for its improving, including standardization of key handoff topics.

CONCLUSIONS

In a single center study of anesthesiology resident handoff education, residents exhibited confusion related to a perceived disconnect between the stated importance of effective handoffs and a lack of consensus on proper handoff technique. Standardization of curriculum and framing expectations has the potential to enhance resident handoff training in academic anesthesia departments.

Identifying essential elements to include in Intensive Care Unit to hospital ward transfer summaries: A consensus methodology

PURPOSE

Transitions of care from the intensive care unit (ICU) to a hospital ward are high risk and contingent on effective communication. We sought to identify essential information elements to be included in an ICU to hospital ward transfer summary tool, and describe tool functionality and composition perceived to be important.

MATERIALS AND METHODS

A panel of 13 clinicians representing ICU and hospital ward providers used a modified Delphi process to iteratively review and rate unique information elements identified from existing ICU transfer tools through three rounds of review (two remote and one in person). Qualitative content analysis was conducted on transcribed audio recordings of the workshop to characterize tool functionality and composition.

RESULTS

A total of 141 unique information elements were reviewed of which 63 were identified by panelists as essential. Qualitative content analyses of panelist discussions identified three themes related to how information elements should be considered when developing an ICU transfer summary tool: 1) Flexibility, 2) Usability, and 3) Accountability.

CONCLUSION

We identified 63 distinct information elements identified as essential for inclusion in an ICU transfer summary tool to facilitate communication between providers during the transition of patient care from the ICU to a hospital ward.

Comparative assessment of content overlap between written documentation and verbal communication: an observational study of resident sign-outs

Objective

Effective sign-outs involve verbal communication supported by written or electronic documentation. We investigated the clinical content overlap between sign-out documentation and face-to-face verbal sign-out communication.

Methods

We audio-recorded resident verbal sign-out communication and collected electronically completed ("written") sign-out documentation on 44 sign-outs in a General Medicine service. A content analysis framework with nine sign-out elements was used to qualitatively code both written and verbal sign-out content. A content overlap framework based on the comparative analysis between written and verbal sign-out content characterized how much written content was verbally communicated. Using this framework, we computed the full, partial, and no overlap between written and verbal content.

Results

We found high a high degree of full overlap on patient identifying information [name (present in 100% of sign-outs), age (96%), and gender (87%)], past medical history [hematology (100%), renal (100%), cardiology (79%), and GI (67%)], and tasks to-do (97%); lesser degree of overlap for active problems (46%), anticipatory guidance (46%), medications/treatments (15%), pending labs/studies/procedures (7%); and no overlap for code status (<1%), allergies (0%) and medical record number (0%).

Discussion and Conclusion

Three core functions of sign-outs are transfer of information, responsibility, and accountability. The overlap-highlighting what written content was communicated-characterizes how these functions manifest during sign-outs. Transfer of information varied with patient identifying information being explicitly communicated and remaining content being inconsistently communicated. Transfer of responsibility was explicit, with all pending and future tasks being communicated. Transfer of accountability was limited, with limited discussion of written contingency plans.

The correlation between intensive care unit attending physician continuity of care with financial and clinical outcomes

PURPOSE

"Attending rotations" on intensive care unit (ICU) services have been in place in most teaching hospitals for decades. However, the ideal frequency of patient care handoffs is unknown. Frequent attending physician handoffs could result in delays in care and other complications, while too few handoffs can lead to provider burnout and exhaustion. Therefore, we sought to determine the correlation between frequency of attending shifts with ICU charges, 30-day readmission rates, and mortality rates.

METHODS

We performed a retrospective cohort study at a large, urban, academic community hospital in Baltimore, MD. We included patients admitted into the cardiac or medical ICUs between September 1, 2012, and December 10, 2015. We tracked the number of attending shifts for each patient and correlated shifts with financial outcomes as a primary measure.

RESULTS

For any given ICU length of stay, we found no distinct association between handoff frequency and charges, 30-day readmission rates, or mortality rates.

CONCLUSIONS

Despite frequent handoffs in care, there was no objective evidence of care compromise or differences in cost. Further validation of these observations in a larger cohort is justified.

Improving Information Transfer during Transitions of Care via Standardized Handoffs

Multiple studies have shown the detrimental effect of miscommunication during transitions of care. The aim of this study is to determine whether a certain method of “sign-out” can improve information transmission and thereby reduce medical errors. Surgical interns underwent a 90-minute training session before starting residency in five previously verified methods of sign-out. They were randomly assigned to six groups (five methods and a control group). They were then given seven simulated patient charts with varying levels of medical complexity. They were then instructed to “sign-out” the patients to randomly selected colleagues. The control group did not use any of the previously taught methods and passed on information in a manner of their choosing. None of the methods consistently results in excellent transitions of care. Patient information values ranged from 26 to 40 (depending on complexity). Major points were consistently missed by all methods, but this may have been a component of the time constraint placed on this study. The “SIGNOUT?” method resulted in superior data transmission when compared with the control group (P = 0.0401). The only method that seemed to be significantly inferior was the “9Ds” method (P = 0.0610). The “SIGNOUT?” method leads to the largest amount of relevant information transmitted to the incoming team. There was no statistically significant difference among the other methods. Improvement in “sign-out” modalities and training may improve transmission of relevant patient information, but larger studies are needed to verify the data seen in this small, single-site study.

Are medical students trained in cross-cover?

OBJECTIVES

To examine the current state of cross-cover education in undergraduate medical education and intern perceived readiness to provide cross-cover.

METHODS

An electronic survey was distributed to 126 incoming interns in surgery, internal medicine, family medicine and paediatrics residencies at a single academic centre. Information regarding prior cross-cover training, experience, confidence, and responses to a sample cross-cover case were obtained.

RESULTS

The survey response rate was 69.8% (88 of 126), which included both partial and complete responses. Fifty-seven interns out of 85 (67.1%) had no formal training and 51 (60.0%) had no experience performing cross-cover. They reported feeling unprepared to provide cross-cover, with an average score of 1.8 on a 5-point Likert scale (1, not at all confident; 5, extremely confident). Interns had more confidence in performing cross-cover tasks if they had prior direct cross-cover experience (p = 0.001), and were the least confident in performing the initial evaluation and management of urgent issues (Likert score = 1.6). Scores on the sample case were correlated with the amount of prior experience with patients (p = 0.06). Only 77.7% of interns indicated that they would notify their senior resident in two urgent scenarios. Those who reported higher confidence in knowing when to ask for help were more likely to appropriately notify their senior colleague (p = 0.005). We identified gaps in cross-cover training and in the preparedness of incoming interns CONCLUSIONS: We identified gaps in cross-cover training and in the preparedness of incoming interns. This has important implications for the first day of residency, when interns are often asked to perform cross-coverage, yet feel unprepared to do so and express the greatest concern in urgent cross-cover scenarios. Addressing this curricular gap is crucial in assuring safe cross-cover care.

A Survey of Patient Care Handoff and Sign-Out Practices Among Podiatric Surgical Residency Programs

BACKGROUND

A patient "handoff," or the "sign-out" process, is an episode during which the responsibility of a patient transitions from one health-care provider to another. These are important events that affect patient safety, particularly because a significant proportion of adverse events have been associated with a relative lack of physician communication. The objective of this investigation was to survey podiatric surgical residency programs with respect to patient care handoff and sign-out practices.

METHODS

A survey was initially developed and subsequently administered to the chief residents of 40 Council on Podiatric Medical Education-approved podiatric surgical residency programs attempting to elucidate patient care handoff protocols and procedures and on-call practices.

RESULTS

Although it was most common for patient care handoffs to occur in person (60.0%), programs also reported that handoffs regularly occurred by telephone (52.5%) and with no direct personal communication whatsoever other than the electronic passing of information (50.0%). In fact, 27.5% of programs reported that their most common means of patient care handoff was without direct resident communication and was instead purely electronic. We observed that few residents reported receiving formal education or assessment/feedback (17.5%) regarding their handoff proficiency, and only 5.0% of programs reported that attending physicians regularly took part in the handoff/sign-out process. Although most programs felt that their sign-out practices were safe and effective, 67.5% also believed that their process could be improved.

CONCLUSIONS

These results provide unique information on a potentially underappreciated aspect of podiatric medical education and might point to some common deficiencies regarding the development of interprofessional communication within our profession during residency training.

Evaluation of Computerized Free Text Sign-Out Notes: Baseline Understanding and Recommendations

BACKGROUND: Standardization of sign-out, the transfer of patient information and responsibility between inpatient providers at shift change, is a Joint Commission National Patient Safety Goal intended to improve communication and reduce risk of error. Computerized systems with free text data entry and limited structure allow clinicians to generate sign-out notes in a variety of ways. OBJECTIVES: The literature lacks a systematic exploration of the range of content generated by users of computerized sign-out systems. The goal of this study was to determine if and how clinicians record standardized sign-out information using a system with free text data entry and limited structure. METHODS: Using qualitative methods, we reviewed free text sign-out notes for 730 patient cases across 39 hospital units at an academic medical center. RESULTS: Two categories of information expression emerged from analysis: patient treatment-comprised of patient summaries, awareness items, and action items-and care team coordination-consisting of discharge information, contact information, and social concerns. A third category describing the format of sign-out note content, presentation of information, also emerged. Location and structure of information varied, but sign-out note content for some hospital units exhibited specific characteristics and was relatively standardized. CONCLUSIONS: Findings provide a baseline understanding of computerized free text sign-out note content. Sign-out notes contained a synthesis of data from disparate sources. We recommend formalizing existing unit-specific content standardization and system use patterns to reduce sign-out note variability and improve communication.

Examination to assess the clinical examination and documentation of spine pathology among orthopedic residents

BACKGROUND CONTEXT

The Accreditation Council for Graduate Medical Education (ACGME) guidelines requires residency programs to teach and evaluate residents in six overarching "core competencies" and document progress through educational milestones. To assess the progress of orthopedic interns' skills in performing a history, physical examination, and documentation of the encounter for a standardized patient with spinal stenosis, an objective structured clinical examination (OSCE) was conducted for 13 orthopedic intern residents, following a 1-month boot camp that included communications skills and curriculum in history and physical examination. Interns were objectively scored based on their performance of the physical examination, communication skills, completeness and accuracy of their electronic medical record (EMR), and their diagnostic conclusions gleaned from the patient encounter.

PURPOSE

The purpose of this study was to meaningfully assess the clinical skills of orthopedic post-graduate year (PGY)-1 interns. The findings can be used to develop a standardized curriculum for documenting patient encounters and highlight common areas of weakness among orthopedic interns with regard to the spine history and physical examination and conducting complete and accurate clinical documentation.

STUDY SETTING

A major orthopedic specialty hospital and academic medical center.

METHODS

Thirteen PGY-1 orthopedic residents participated in the OSCE with the same standardized patient presenting with symptoms and radiographs consistent with spinal stenosis. Videos of the encounters were independently viewed and objectively evaluated by one investigator in the study. This evaluation focused on the completeness of the history and the performance and completion of the physical examination. The standardized patient evaluated the communication skills of each intern with a separate objective evaluation. Interns completed these same scoring guides to evaluate their own performance in history, physical examination, and communications skills. The interns' documentation in the EMR was then scored for completeness, internal consistency, and inaccuracies.

RESULTS

The independent review revealed objective deficits in both the orthopedic interns' history and the physical examination, as well as highlighted trends of inaccurate and incomplete documentation in the corresponding medical record. Communication skills with the patient did not meet expectations. Further, interns tended to overscore themselves, especially with regard to their performance on the physical examination (p<.0005). Inconsistencies, omissions, and inaccuracies were common in the corresponding medical notes when compared with the events of the patient encounter. Nine of the 13 interns (69.2%) documented at least one finding that was not assessed or tested in the clinical encounter, and four of the 13 interns (30.8%) included inaccuracies in the medical record, which contradicted the information collected at the time of the encounter.

CONCLUSIONS

The results of this study highlighted significant shortcomings in the completeness of the interns' spine history and physical examination, and the accuracy and completeness oftheir EMR note. The study provides a valuable exercise for evaluating residents in a multifaceted, multi-milestone manner that more accurately documents residents' clinical strengths and weaknesses. The study demonstrates that orthopedic residents require further instruction on the complexities of the spinal examination. It validates a need for increased systemic support for improving resident documentation through comprehensive education and evaluation modules.

Ethnographic analysis on the use of the electronic medical record for clinical handoff

The objective of this study was to understand the social elements of clinical and organizational interactions of the key stakeholders in the specific context of an electronic dashboard used by the emergency department (ED) and inpatient medicine teams at the time of clinical referral and handover. An electronic handover function is utilised at the ED-inpatient interface at this institution and has given clinicians the ability to better communicate, monitor the department and strive to improve patient safety in streamline the delivery of care in the acute phase. This study uses an ethnographic qualitative research design incorporating semistructured interviews, participant observation on the ED floor and fieldwork notes. The setting for this research was in the ED at a tertiary University affiliated hospital. Triangulation was used to combine information obtained from multiple sources and information from fieldwork and interviews refined into useable chunks culminating in a thematic analysis. Thematic analysis yielded five central themes that reflected how the clinical staff utilised this IT system and why it had become embedded in the culture of clinical referral and handover. Efficient time management for improved patient flow was demonstrated, value added communication (at the interpersonal level), the building trust at the ED-inpatient interface, the maintenance of mutual respect across medical cultures and an overall enhancement of the quality of ED communication (in terms of the information available). A robust electronic handover process, resulted in an integrated approach to patient care by removing barriers to admission for medical inpatients, admitted via ED. The value proposition for patients was a more complete information transfer, both within the ED and between departments.

"You Have to Know the End of the Story": Motivations to Follow Up After Transitions of Clinical Responsibility

PURPOSE

Physicians routinely transition responsibility for patient care to other physicians. When transitions of responsibility occur before the clinical outcome is known, physicians may lose opportunities to learn from the consequences of their decision making. Sometimes curiosity about patients does not end with the transition and physicians continue to follow them. This study explores physicians' motivations to follow up after transitioning responsibilities.

METHOD

Using a constructivist grounded theory approach, the authors conducted 18 semistructured interviews in 2016 with internal medicine hospitalist and resident physicians at a single tertiary care academic medical center. Constant comparative methods guided the qualitative analysis, using motivation theories as sensitizing constructs.

RESULTS

The authors identified themes that characterized participants' motivations to follow up. Curiosity about patients' outcomes determined whether or not follow-up occurred. Insufficient curiosity about predictable clinical problems resulted in the choice to forgo follow-up. Sufficient curiosity due to clinical uncertainty, personal attachment to patients, and/or concern for patient vulnerability motivated follow-up to fulfill goals of knowledge building and professionalism. The authors interpret these findings through the lenses of expectancy-value (EVT) and self-determination (SDT) theories of motivation.

CONCLUSIONS

Participants' curiosity about what happened to their patients motivated them to follow up. EVT may explain how participants made choices in time-pressured work settings. SDT may help interpret how follow-up fulfills needs of relatedness. These findings add to a growing body of literature endorsing learning environments that consider task-value trade-offs and support basic psychological needs of autonomy, competency, and relatedness to motivate learning.

Impact of an integrated electronic handover tool on pediatric junior medical staff (JMS) handover

BACKGROUND

Clinical medical handover between doctors forms a critical part of the patient care process. However, with the evolution of junior medical staff (JMS) working conditions, time pressure and increasing clinical and administrative loads mean that quality clinical handover is increasingly important yet more challenging to achieve. This study evaluated the impact of a newly integrated electronic handover tool on JMS adoption and usage of the tool, as well as impacts on the quality (accuracy and redundancy) of handover data, JMS perceived workflow (time management and communication) and JMS satisfaction.

FINDINGS

The majority of JMS surveyed used the tool at 1 (87.0%) and 3 (67.4%) months post implementation. After the introduction of the electronic handover tool, 67.5% of users spent less than 15min updating handover data in the electronic handover tool, compared to just 6.7% prior to the introduction. 28.3% of respondents noted that there was >25% redundant data, compared to more than half (52.2%) prior to introduction of the electronic tool. Overall JMS satisfaction with their handover process was significantly higher post implementation of the integrated electronic handover report (17.4% pre, 80.4% at 1 month, 67.4% at 3 months).

CONCLUSION

A newly introduced integrated electronic medical record handover tool had a high uptake amongst JMS, and resulted in improvement in perceived handover efficiency, a reduction in redundant data entry and improved JMS handover satisfaction.

Resident Workshop Standardizes Patient Handoff and Improves Quality, Confidence, and Knowledge

OBJECTIVES

Residency programs are required to instruct residents in handoff; however, a handoff curriculum endorsed by the Accreditation Council for Graduate Medical Education does not exist. Although curricula are available, we preferred to use a curriculum that could be taught quickly, was easy to implement, and used a mnemonic that resembled current practices at our institution. We designed and implemented a novel handoff educational workshop intended to improve resident confidence and performance.

METHODS

In this observational study, pediatric residents across postgraduate training years during winter 2014-spring 2015 participated in two study segments: a handoff workshop with questionnaires and handoff observations. Co-investigators developed and led an interactive workshop for residents that emphasized a standardized approach using the SIGNOUT mnemonic (see text for definition). The effect of workshop participation on handoff abilities was evaluated using a validated, handoff evaluation tool administered before and after the workshop. Qualitative feedback was obtained from residents using pre- and postworkshop surveys.

RESULTS

Forty-three residents participated in the workshop; 41 residents completed handoff observations. Improvements were noted in clinical judgment (P = 0.02) and organization/communication (P = 0.005). Pre- and postworkshop surveys demonstrated self-perceived increases in confidence, comfort, and knowledge (P < 0.001).

CONCLUSIONS

Improvements in handoffs, particularly in clinical judgment and organization/communication domains, suggest that a more standardized handoff approach is beneficial, especially for postgraduate year 1 residents. The novel, interactive workshop we developed can be taught quickly, is easy to implement, is appropriate for all resident training levels, and improves resident confidence and skill. This workshop can be implemented by training programs across all disciplines, possibly leading to improved patient safety.

A time-motion study of residents and medical students performing patient discharges from general internal medicine wards: a disjointed, interrupted process

Patients are at high risk for adverse events after discharge from a hospital admission. As a critical and often time-consuming aspect of care for hospitalized patients, the purpose of this study was to describe the physician time, events and workflow in performing a patient discharge. On General Internal Medicine (GIM) wards at two academic medical centers in Toronto, a time-motion study was performed on 11 residents and 2 medical students performing 32 patient discharges. Using a paper data collection tool, a research associate aimed to capture the distribution of activities and the nature and frequency of workflow interruptions during patient discharges from the perspective of resident and medical student housestaff. Thirty-two GIM patient discharges by the 13 housestaff were observed over a period of 116 h. Discharges required 69.2 ± 41.2 min of housestaff-dedicated time to complete, but spanned over a mean 3.7 h from start to finish. On average, 32.8 min (47.3%) of time spent on discharges was dedicated to documentation activities; 13.5 min (19.6%) to direct patient communication; 10.8 min (15.6%) to communication with other clinicians and providers; 6.5 min (9.4%) to arranging outpatient care; 5.7 min (8.2%) to time in transit and waiting. For each discharge, housestaff were interrupted a mean of 5.5 times and switched tasks 8.7 times. During the discharge process, housestaff mainly dedicated themselves to documentation activities and focused minimally on direct patient communication. Clinicians were also found to experience several workflow inefficiencies and interruptions. The present study can be used to identify opportunities to improve and further focus efforts in characterizing this dynamic process.

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.

Entrustment of the on-call senior medical resident role: implications for patient safety and collective care

BACKGROUND

The on-call responsibilities of a senior medicine resident (SMR) may include the admission transition of patient care on medical teaching teams (MTT), supervision of junior trainees, and ensuring patient safety. In many institutions, there is no standardised assessment of SMR competency prior to granting these on-call responsibilities in internal medicine. In order to fulfill competency based medical education requirements, training programs need to develop assessment approaches to make and defend such entrustment decisions. The purpose of this study is to understand the clinical activities and outcomes of the on-call SMR role and provide training programs with a rigorous model for entrustment decisions for this role.

METHODS

This four phase study utilizes a constructivist grounded theory approach to collect and analyse the following data sets: case study, focus groups, literature synthesis of supervisory practices and return-of-findings focus groups. The study was conducted in two Academic Health Sciences Centres in Ontario, Canada. The case study included ten attending physicians, 13 SMRs, 19 first year residents and 14 medical students. The focus groups included 19 SMRs. The later, return-of-findings focus groups included ten SMRs.

RESULTS

Five core on-call supervisory tasks (overseeing ongoing patient care, briefing, case review, documentation and preparing for handover) were identified, as well as a range of practices associated with these tasks. We also identified challenges that influenced the extent to which SMRs were able to effectively perform the core tasks. At times, these challenges led to omissions of the core tasks and potentially compromised patient safety and the admission transition of care.

CONCLUSION

By identifying the core supervisory tasks and associated practices, we were able to identify the competencies for the on-call SMR role. Our findings can further be used by training programs for assessment and for making entrustment decisions.

Clinical Information Transfer between EMS Staff and Emergency Medicine Assistants during Handover of Trauma Patients

Introduction Clinical handover by Emergency Medical Services (EMS) staff, as the first people who have contact with trauma patients, in the emergency department (ED), is very important. Therefore, effective communication to transfer clinical information about patients in a concise, rational, clear, and time-bound manner is essential. In Iran, the transfer of necessary information in clinical handover in EDs was carried out orally and without following standard instructions. This study aimed to audit the current clinical handover according to the Identify, Situation, Background, Assessment, and Recommendation (ISBAR) tool and survey the effect of training the ISBAR tool to Emergency Medicine Assistants (EMAs) and EMS staff on improvement of the clinical handover of patients to the ED.

METHODS

This is a clinical audit study in three phases in Imam Hossein Hospital (Tehran, Iran) during 2016. In the first phase, the clinical handover between EMS staff and EMAs for 178 trauma patients admitted to the ED using ISBAR was audited and information was recorded. In the second phase, the correct approach of clinical handover according to the ISBAR tool was taught to EMS staff and EMAs using pamphlets and lectures. In the third phase, again, the clinical handover between EMS staff and EMAs for 168 trauma patients admitted to the ED was audited using the ISBAR tool and information was recorded. At the end, clinical audit assessment indicators of handover were evaluated before and after training.

RESULTS

Clinical audit of the current situation in the ED showed that the clinical handover process does not follow standard ISBAR (0.0%). However, after training, 65.3% of clinical handover processes were performed in accordance with ISBAR. In the current study, there was an increase in all parameters of the ISBAR tool after training, most of which increased significantly compared to the first phase of the study (before the intervention).

CONCLUSIONS

Findings demonstrate that patient handover in the ED did not initially follow the ISBAR standard guideline. After providing education as pamphlets and lectures to EMS staff and EMAs, a high percentage of patient handovers were conducted in accordance with the ISBAR instructions. Fahim Yegane SA , Shahrami A , Hatamabadi HR , Hosseini-Zijoud SM . Clinical information transfer between EMS staff and Emergency Medicine Assistants during handover of trauma patients. Prehosp Disaster Med. 2017;32(5):541-547.

Standardizing Handoff Communication: Content Analysis of 27 Handoff Mnemonics

This study synthesizes information contained in 27 mnemonics to identify what information should be communicated during a handoff. Clustering and content analysis resulted in 12 primary information clusters that should be communicated. Given the large amount of information identified, it would be beneficial to use a structured handoff communication tool developed using a participatory approach. In addition, we recommend local standardization of information communicated during handoffs with variation across settings.

Running Memory for Clinical Handoffs: A Look at Active and Passive Processing

OBJECTIVE

The goal of the present study was to examine the effects of domain-relevant expertise on running memory and the ability to process handoffs of information. In addition, the role of active or passive processing was examined.

BACKGROUND

Currently, there is little research that addresses how individuals with different levels of expertise process information in running memory when the information is needed to perform a real-world task.

METHOD

Three groups of participants differing in their level of clinical expertise (novice, intermediate, and expert) performed an abstract running memory span task and two tasks resembling real-world activities, a clinical handoff task and an air traffic control (ATC) handoff task. For all tasks, list length and the amount of information to be recalled were manipulated.

RESULTS

Regarding processing strategy, all participants used passive processing for the running memory span and ATC tasks. The novices also used passive processing for the clinical task. The experts, however, appeared to use more active processing, and the intermediates fell in between.

CONCLUSION

Overall, the results indicated that individuals with clinical expertise and a developed mental model rely more on active processing of incoming information for the clinical task while individuals with little or no knowledge rely on passive processing.

APPLICATION

The results have implications about how training should be developed to aid less experienced personnel identify what information should be included in a handoff and what should not.

In search of a resident-centered handoff tool: Discovering the complexity of transitions of care

INTRODUCTION

Transfer of a patient's care between providers is a significant potential for medical errors. Given the potential for patient safety breeches we sought to investigate residents' perceptions of handoffs at our institution.

METHODS

Residents completed an online survey assessing the effectiveness of handoffs and what they thought was necessary for safe and informative transition communication. Thematic analysis was used to identify critical themes.

RESULTS

78% of residents reported formal training in handoff delivery. 90% stated they were effective in delivering handoffs; however they scored 41% of handoffs they received as less than effective. 11 themes emerged, the most commonly described requirement was "important events" from the previous shift. Only 16% of residents used an established formal handoff tool.

CONCLUSIONS

In a survey of surgical residents they view themselves as very effective at delivering handoffs, but judge nearly half of handoffs they receive as ineffective. Multiple handoff tools exist but residents rarely use them. In an era of increasing transitions of care, efforts targeting improvement of handoff effectiveness will require education beyond checklists and mnemonics.

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 Hand-Off iNitiation and Evaluation (PHONE) study: A randomized trial of patient handoff methods

BACKGROUND

As residency work hour restrictions have tightened, transitions of care have become more frequent. Many institutions dedicate significant time and resources to patient handoffs despite the fact that the ideal method is relatively unknown. We sought to compare the effect of a rigorous formal handoff approach to a minimized but focused handoff process on patient outcomes.

METHODS

A randomized prospective trial was conducted at a large teaching hospital over ten months. Patients were assigned to services employing either formal or focused handoffs. Residents were trained on handoff techniques and then observed by trained researchers. Outcome data including mortality, negative events, adverse events, and length of stay were collected and compared between formal and focused handoff groups using t-tests and a multivariate regression analysis.

RESULTS

A total of 5157 unique patient-admissions were stratified into the two study groups. Focused handoffs were significantly shorter and included fewer patients (mean 6.3 patients discussed over 6.7 min vs. 35.2 patients over 20.6 min, both p < 0.001). Adverse events occurred during 16.7% of patient admissions. While overall length of stay was slightly shorter in the formal handoff group (5.50 days vs 5.88 days, p = 0.024) in univariate analysis only, there were no significant differences in patient outcomes between the two handoff methods (all p > 0.05).

CONCLUSIONS

This large randomized trial comparing two contrasting handoff techniques demonstrated no clinically significant differences in patient outcomes. A minimalistic handoff process may save time and resources without negatively affecting patient outcomes.

Reduced Resident Work Hours in Urology: The History and Impact of Duty Hour Restrictions

INTRODUCTION

The ACGME first mandated duty hour restrictions for resident physicians in 2003, setting a limit of 80 hours per week. While the goals of this and later reforms were to improve patient care and safety, the outcomes have been mixed. In this review we report on the history of duty hour regulations and how these changes have impacted resident and patient outcomes.

METHODS

A literature search was performed, and articles discussing surgical training, resident duty hours, resident wellness and patient outcomes were reviewed.

RESULTS

After implementation of duty hour restrictions in 2003, the Harvard Work Hours Health and Safety Group published 3 hallmark studies that suggested duty hour restrictions were associated with improved outcomes. A recently published systematic review reported mixed results from the growing body of research. While 71% of the reviewed studies reported improvement in resident wellness, only 4% illustrated an improvement in resident education, 19% reported improved patient safety outcomes and 13% demonstrated improved patient morbidity.

CONCLUSIONS

Resident duty hour restrictions were based on a body of evidence illustrating that fatigue and sleeplessness negatively impact decision making, resident wellness and patient care. While initial outcomes suggested that these regulations resulted in better resident and patient outcomes, more recent evidence suggests otherwise. There is very little urology specific evidence addressing these matters.

Evaluating handoffs in the context of a communication framework

BACKGROUND

The implementation of mandated restrictions in resident duty hours has led to increased handoffs for patient care and thus more opportunities for errors during transitions of care. Much of the current handoff literature is empiric, with experts recommending the study of handoffs within an established framework.

METHODS

A prospective, single-institution study was conducted evaluating the process of handoffs for the care of surgical patients in the context of a published communication framework. Evaluation tools for the source, receiver, and observer were developed to identify factors impacting the handoff process, and inter-rater correlations were assessed. Data analysis was generated with Pearson/Spearman correlations and multivariate linear regressions. Rater consistency was assessed with intraclass correlations.

RESULTS

A total of 126 handoffs were observed. Evaluations were completed by 1 observer (N = 126), 2 observers (N = 23), 2 receivers (N = 39), 1 receiver (N = 82), and 1 source (N = 78). An average (±standard deviation) service handoff included 9.2 (±4.6) patients, lasted 9.1 (±5.4) minutes, and had 4.7 (±3.4) distractions recorded by the observer. The source and receiver(s) recognized distractions in >67% of handoffs, with the most common internal and external distractions being fatigue (60% of handoffs) and extraneous staff entering/exiting the room (31%), respectively. Teams with more patients spent less time per individual patient handoff (r = -0.298; P = .001). Statistically significant intraclass correlations (P ≤ .05) were moderate between observers (r ≥ 0.4) but not receivers (r < 0.4). Intraclass correlation values between different types of raters were inconsistent (P > .05). The quality of the handoff process was affected negatively by presence of active electronic devices (β = -0.565; P = .005), number of teaching discussions (β = -0.417; P = .048), and a sense of hierarchy between source and receiver (β = -0.309; P = .002).

CONCLUSION

Studying the handoff process within an established framework highlights factors that impair communication. Internal and external distractions are common during handoffs and along with the working relationship between the source and receiver impact the quality of the handoff process. This information allows further study and targeted interventions of the handoff process to improve overall effectiveness and patient safety of the handoff.

Who to handover: a case-control study of a novel scoring system to prioritise handover of internal medicine inpatients

BACKGROUND

Handover of patients between care providers is a critical event in patient care. There is, however, little evidence to guide the handover process, including determining which patients to handover.

AIM

Compare the ability of gestalt-based handover with two structured scores, the modified early warning score (MEWS) and our novel iHAND clinical decision support system, to predict which patients will be assessed by a physician overnight.

METHODS

This case-control study included 90 inpatients, comprising 32 patients assessed overnight (cases) and 58 patients not assessed overnight (controls) at a teaching hospital in British Columbia, Canada (May 2012). Gestalt, MEWS and iHAND scores were analysed against patients seen overnight using logistic regression and receiver-operating characteristic (ROC) curves.

RESULTS

Neither current gestalt-based handover practice (odds ratio (OR) 1.50, 95% CI 0.89 to 3.83) nor MEWS (OR 0.96, 95% CI 0.75 to 1.24, area under the ROC curve (AUC) 0.61, 95% CI 0.49 to 0.73) were significantly associated with need to be seen overnight. The iHAND score was associated with need to be seen (OR 1.93, 95% CI 1.24 to 3.02, AUC 0.70, 95% CI 0.60 to 0.81).

CONCLUSIONS

The iHAND score had moderate ability to predict which patients required assessment overnight, while MEWS score and current gestalt approach correlated poorly, suggesting the iHAND score may help prioritisation of patients likely to be seen overnight for handover.

Opportunities for interprofessional input into nurse and physician hand-off communication

PURPOSE

Hand-offs are vulnerable times for hospitalized patients. Nurses and physicians routinely engage in hand-off communication but their communications remains siloed. Our objectives were to identify key information from each profession that would be of use to the other's hand-off process, and to identify facilitators and barriers to obtaining that input.

MATERIALS AND METHODS

We conducted this qualitative study in a medical intensive care unit. Subjects included 8 physicians, 2 advanced practice providers, and 6 nurses. We conducted observations of hand-offs and afternoon rounds as well as semistructured interviews. We analyzed the transcribed interviews and field note observations\ to identify themes of interest using a grounded theory approach.

RESULTS

Physicians were interested in patient data in context, family dynamics, and changing patient condition. Nurses were interested in details about the plan of care and anticipatory guidance. Facilitators of communication included proximity, face-to-face communication, and the electronic medical record. Barriers were busy schedules, inaccurate data, and negative attitudes.

CONCLUSIONS

There are key areas of content that both physicians and nurses would like from the other profession to enhance intensive care unit hand-off communication. Interventions designed to increase interdisciplinary communication should focus on these key areas of content.