Development and implementation of an oral sign-out skills curriculum

Improvements in Interdisciplinary Communication Following the Implementation of a Standardized Handoff Curriculum: SAFETIPS (Statistics, Assessment, Focused Plan, Pertinent Exam findings, to Dos, If/Thens, Pointers/Pitfalls, and Severity of Illness)

Background Handoffs between medical providers serve a crucial patient safety function. While most published literature on the topic studies the handover process among physicians, robust literature is available on interdisciplinary medical communication. Little is known about the downstream effects of effective physician handover on subsequent physician and nursing interactions. Objective Our objective was to implement a handoff curriculum, SAFETIPS (Statistics, Assessment, Focused plan, pertinent Exam findings, To dos, If/thens, Pointers/pitfalls, and Severity of illness), for pediatric residents and to investigate its impact on nurses' perceptions of resident preparedness, efficiency, and competency. Methods Nurses were asked to score residents in five domains and describe the frequency of nurse-to-resident and resident-to-nurse interruptions. The survey was distributed before and after the SAFETIPS introduction. Results Statistical analysis revealed significant post-intervention mean score increases of one full point in four categories, namely organization and efficiency, communication, content, and clinical judgment. The percentage of nurses using the term "reasonable/relevant" to describe interactions with residents significantly increased from 45% to 76% (p = 0.004). The percentage of nurses reporting that residents gave "unsure response[s]," made decisions that differed from nurses' decisions, and made decisions without family/parental interests significantly decreased by 31 (p = 0.004), 22 (p = 0.034), and 30 (p = 0.002) percentage points, respectively. Conclusion The introduction of a structured handoff curriculum significantly improves communication among residents. This is then associated with improved interactions between residents and nurses.

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.

Physician-to-Nurse Handover: A Systematic Review on the Effectiveness of Different Models

OBJECTIVES

Effective professional communication and accurate transfer of relevant clinical information are crucial components of healthcare delivery. National and international health authorities strongly recommend the adoption of effective handover practice. Still, scant evidence is available on the impact of different multiprofessional handover models.

METHODS

We carried out a systematic review following the Prepared Items for Systematic Reviews and Meta-Analysis guidelines to retrieve, pool, and critically appraise the available evidence on the effectiveness of different physician-to-nurse handover models adopted in inpatient settings.

RESULTS

We identified 1.243 citations searching the databases Medline, Embase, and CINAHL. After screening, 10 studies were included in the review reporting results on the effectiveness of 8 different handover models, measured on 44 different outcomes, grouped into: (1) process of care and efficiency outcomes, (2) patients' outcomes, and (3) healthcare professionals-related outcomes. Overall, applying structured handover tools improve healthcare practice and selected outcomes; however, not only solid evidence on the effectiveness of different handover models is scant but also global consensus is lacking on which standardized measures and indicators to use to assess their impact.

CONCLUSIONS

In times of healthcare delivery models of growing complexity, multiprofessional handover is a key component of care paths. Although there is overall consensus on the need for improving the quality and safety of multiprofessional handover, the evidence on the tools available to achieve it and the metrics to measure their impact is heterogeneous. We urge that rigorous studies are conducted to inform the planning, implementation, and monitoring of effective handover, with the ultimate aim of improving quality of care and patient safety.

A SWIFT Method for Handing Off Obstetrical Patients on the Labor Floor

OBJECTIVE

The aim of this study was to improve patient handoffs on the labor floor.

METHODS

A prospective cohort study of obstetrics residents at Montefiore Medical Center was performed between 2012 and 2014. Labor-floor handoffs were recorded before and after didactic sessions as well as after installation of whiteboards formatted with the mnemonic SWIFT (Subject, Why?, Issues, Fetus, Tasks). Handoff transcripts were evaluated by obstetricians blinded to timing and speaker identity. An intraclass correlation coefficient accounted for evaluator differences. Data analysis was by ordinal logistic regression, the generalized estimating equations method (correlated data), and Bonferroni adjustment (multiple comparisons).

RESULTS

Forty-five handoffs were evaluated (15 each predidactics, postdidactics, and postwhiteboard revision). Higher completeness scores over time were noted for admission reason, labor concerns, and task list (not statistically significant). Comprehensive score increases prelecture to postwhiteboard were seen in handoff clarity (2.81 versus 2.91) and overall quality (2.77 versus 2.81) (not statistically significant). A subanalysis of four residents who gave multiple handoffs over different periods revealed few significant changes over time. Greater interevaluator consistency was noted with more objective elements.

CONCLUSIONS

The mnemonic SWIFT, with formalized curricula for obstetrical resident training focusing on new learners and increased faculty involvement and reinforcement, may result in improvement of handoffs on the labor floor.

Clinical handover and handoff in healthcare: a systematic review of systematic reviews

PURPOSE

The purpose of this systematic review is to appraise and summarize existing literature on clinical handover.

DATA SOURCES

We searched EMBASE, MEDLINE, Database of Abstracts of Reviews of Effects and Cochrane Database of Systematic Reviews.

STUDY SELECTION

Included articles were reviewed independently by the review team.

DATA EXTRACTION

The review team extracted data under the following headers: author(s), year of publication, journal, scope, search strategy, number of studies included, type of studies included, study quality assessment, used definition of handover, healthcare setting, outcomes measured, findings and finally some comments or remarks.

RESULTS OF DATA SYNTHESIS

First, research indicates that poor handover is associated with multiple potential hazards such as lack of availability of required equipment for patients, information omissions, diagnosis errors, treatment errors, disposition errors and treatment delays. Second, our systematic review indicates that no single tool arises as best for any particular specialty or use to evaluate the handover process. Third, there is little evidence delineating what constitutes best handoff practices. Most efforts facilitated the coordination of care and communication between healthcare professionals using electronic tools or a standardized form. Fourth, our review indicates that the principal teaching methods are role-playing and simulation, which may result in better knowledge transfer to the work environment, better health and patients' well-being.

CONCLUSIONS

This review emphasizes the importance of staff education (including simulation-based and team training), non-technical skills and the implementation process of clinical handover in healthcare settings.

Handoffs and Nurse Calls: Overnight Call Simulation for Fourth-Year Medical Students

INTRODUCTION

Interns must be able to give and receive handoffs and use handoff information to respond to calls from nursing staff regarding patient concerns. Medical students may not receive adequate instruction in these tasks and often feel unprepared in this aspect of transitioning to residency. This program simulated an overnight call experience for fourth-year medical students emphasizing handoffs, nurse calls, and medical emergency response.

METHODS

The program utilized a combination of traditional didactics and simulated handoffs, nurse calls, and patient scenarios to allow groups of fourth-year medical students to independently manage a simulated overnight call. The program was designed for students as part of a larger Transition to Residency capstone course.

RESULTS

We ran four sessions over 3 years, with a total of 105 medical student participants. All students reported increased confidence or comfort in their ability to manage handoffs and respond to nurse calls. Students reported that the sessions were helpful and realistic.

DISCUSSION

This program provided fourth-year medical students with a realistic and useful opportunity to simulate handoffs and response to nurse calls, which increased their confidence and comfort. Minor changes were made between iterations of the course with continued positive feedback from medical students. The course is generalizable and can be adapted to the needs and resources of different institutions.

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.

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.

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.

A pilot study to standardize and peer-review shift handoffs in an academic internal medicine residency program: The DOCFISH method

With increased oversight of residency work hours, there has been an increase in shift handoffs, which are prone to medical errors. To date, there are no evidence-based recommendations on essential elements of shift handoffs. We implemented a standardized shift-handoff rubric at an academic medicine residency program. Compliance, resident/faculty perceptions, and surrogate markers of patient safety were measured.Shift-handoff documents were collected January-February 2016 (control) April-June 2016 (intervention). Signouts were scored based on inclusion of seven elements: Daily events, Overnight events, Code status, Follow up tasks, If/then statements, 'sick or stable' and History present illness. The mnemonic 'DOCFISH' was taught in a grand-rounds forum then embedded into a shift-handoff tool within our electronic health record (EHR). Senior residents were assigned to supervise/provide feedback on shift handoffs from April-June 2016. Faculty and resident perceptions regarding quality of shift handoffs was measured by the annual ACGME (Accreditation Council Graduate Medical Education) program survey.Patient safety was measured by number of rapid-response teams (RRT) initiated for unstable vital signs. Handoffs were 74% complete in intervention group and 60% in control group (p < .0001). Median DOCFISH features present in patients that required RRT was 3 of 7 whereas, total post-intervention group had 5 of 7 (p < .001). 'Daily events' and 'follow -up tasks' were less frequent in patients that required RRT (20%, 67% respectively, p < .001).Academic medical centers can implement standardized shift handoffs by embedding high-yield information in an EHR with peer-review. Information during shift changes that may have significant improvement on patient safety includes: 'daily events' and 'follow -up tasks.'

Handover training for medical students: a controlled educational trial of a pilot curriculum in Germany

OBJECTIVE

The aim of this study was to implement and evaluate a newly developed standardised handover curriculum for medical students. We sought to assess its effect on students' awareness, confidence and knowledge regarding handover.

DESIGN

A controlled educational research study.

SETTING

The pilot handover training curriculum was integrated into a curriculum led by the Departments of Anesthesiology and Intensive Care (AI) at the University Hospital. It consisted of three modules integrated into a 4-week course of AI. Multiple types of handover settings namely end-of-shift, operating room/postanaesthesia recovery unit, intensive care unit, telephone and discharge were addressed.

PARTICIPANTS

A total of n=147 fourth-year medical students participated in this study, who received either the current standard existing curriculum (no teaching of handover, n=78) or the curriculum that incorporated the pilot handover training (n=69).

OUTCOME MEASURES

Paper-based questionnaires regarding attitude, confidence and knowledge towards handover and patient safety were used for pre-assessment and post-assessment.

RESULTS

Students showed a significant increase in knowledge (p<0.01) and self-confidence for the use of standardised handover tools (p<0.01) as well as accurate handover performance (p<0.01) among the pilot group.

CONCLUSION

We implemented and evaluated a pilot curriculum for undergraduate handover training. Students displayed a significant increase in knowledge and self-confidence for the use of standardised handover tools and accuracy in handover performance. Further studies should evaluate whether the observed effect is sustained across time and is associated with patient benefit.

Physician's Role in Coordinating Care of Hospitalized Children

The hospitalization of a child is a stressful event for the child and family. The physician responsible for the admission has an important role in directing the care of the child, communicating with the child's providers (medical and primary caregivers), and advocating for the safety of the child during the hospitalization and transition out of the hospital. These challenges remain constant across the varied facilities in which children are hospitalized. The purpose of this revised clinical report is to update pediatricians about principles to improve the coordination of care and review expectations and practice.

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.

Development and Validation of a Tool to Evaluate the Evolution of Clinical Reasoning in Trauma Using Virtual Patients

CONTEXT

Undergraduate medical students at a large academic trauma center are required to manage a series of online virtual trauma patients as a mandatory exercise during their surgical rotation.

PURPOSE

Clinical reasoning during undergraduate medical education can be difficult to assess. The purpose of the study was to determine whether we could use components of the students' virtual patient management to measure changes in their clinical reasoning over the course of the clerkship year. In order to accomplish this, we decided to determine if the use of scoring rubrics could change the traditional subjective assessment to a more objective evaluation.

BASIC PROCEDURES

Two groups of students, one at the beginning of clerkship (Juniors) and one at the end of clerkship (Seniors), were chosen. Each group was given the same virtual patient case, a clinical scenario based on the Advanced Trauma Life Support (ATLS) Primary Trauma Survey, which had to be completed during their trauma rotation. The learner was required to make several key patient management choices based on their clinical reasoning, which would take them along different routes through the case. At the end of the case they had to create a summary report akin to sign-off. These summaries were graded independently by two domain "Experts" using a traditional subjective surgical approach to assessment and by two "Non-Experts" using two internally validated scoring rubrics. One rubric assessed procedural or domain knowledge (Procedural Rubric), while the other rubric highlighted semantic qualifiers (Semantic Rubric). Each of the rubrics was designed to reflect established components of clinical reasoning. Student's t-tests were used to compare the rubric scores for the two groups and Cohen's d was used to determine effect size. Kendall's τ was used to compare the difference between the two groups based on the "Expert's" subjective assessment. Inter-rater reliability (IRR) was determined using Cronbach's alpha.

MAIN FINDINGS

The Seniors did better than the Juniors with respect to "Procedural" issues but not for "Semantic" issues using the rubrics as assessed by the "Non-Experts". The average Procedural rubric score for the Senior group was 59% ± 13% while for the junior group, it was 51% ± 12% (t₍₈₀₎= 2.715; p = 0.008; Cohen's d = 1.53). The average Semantic rubric score for the Senior group was 31% ± 15% while for the Junior group, it was 28% ± 14% (t₍₈₀₎ = 1.010; p = .316, ns). There was no statistical difference in the marks given to the Senior versus Junior groups by the "Experts" (Kendall's τ = 0.182, p = 0.07). The IRR between the "Non-Experts" using the rubrics was higher than the IRR of the "Experts" using the traditional surgical approach to assessment. The Cronbach's alpha for the Procedural and Semantic rubrics was 0.94 and 0.97, respectively, indicating very high IRR. The correlation between the Procedural rubric scores and "Experts" assessment was approximately r = 0.78, and that between the Semantic rubric and the "Experts" assessment was roughly r = 0.66, indicating high concurrent validity for the Procedural rubric and moderately high validity for the Semantic rubric.

PRINCIPLE CONCLUSION

Clinical reasoning, as measured by some of its "procedural" features, improves over the course of the clerkship year. Rubrics can be created to objectively assess the summary statement of an online interactive trauma VP for "procedural" issues but not for "semantic" issues. Using IRR as a measure, the quality of assessment is improved using the rubrics. The "Procedural" rubric appears to measure changes in clinical reasoning over the course of 3rd-year undergraduate clinical studies.

Structured patient handoff on an internal medicine ward: A cluster randomized control trial

BACKGROUND

The effect of a multi-faceted handoff strategy in a high volume internal medicine inpatient setting on process and patient outcomes has not been clearly established. We set out to determine if a multi-faceted handoff intervention consisting of education, standardized handoff procedures, including fixed time and location for face-to-face handoff would result in improved rates of handoff compared with usual practice. We also evaluated resident satisfaction, health resource utilization and clinical outcomes.

METHODS

This was a cluster randomized controlled trial in a large academic tertiary care center with 18 inpatient internal medicine ward teams from January-April 2013. We randomized nine inpatient teams to an intervention where they received an education session standardizing who and how to handoff patients, with practice and feedback from facilitators. The control group of 9 teams continued usual non-standardized handoffs. The primary process outcome was the rate of patients handed over per 1000 patient nights. Other process outcomes included perceptions of inadequate handoff by overnight physicians, resource utilization overnight and hospital length of stay. Clinical outcomes included medical errors, frequency of patients requiring higher level of care overnight, and in-hospital mortality.

RESULTS

The intervention group demonstrated a significant increase in the rate of patients handed over to the overnight physician (62.90/1000 person-nights vs. 46.86/1000 person-nights, p = 0.002). There was no significant difference in other process outcomes except resource utilization was increased in the intervention group (26.35/1000 person-days vs. 17.57/1000 person-days, p-value = 0.01). There was no significant difference between groups in medical errors (4.8% vs. 4.1%), need for higher level of care or in hospital mortality. Limitations include a dependence of accurate record keeping by the overnight physician, the possibility of cross-contamination in the handoff process, analysis at the cluster level and an overall low number of clinical events.

CONCLUSIONS

Implementation of a multi-faceted resident handoff intervention did not result in a significant improvement in patient safety although did improve number of patients handed off. Novel methods to improve handoff need to be explored.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov: NCT01796756.

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.

Trauma morning report is the ideal environment to teach and evaluate resident communication and sign-outs in the 80 hour work week

BACKGROUND

The 80h work week has raised concerns that complications may increase due to multiple sign-outs or poor communication. Trauma Surgery manages complex trauma and acute care surgical patients with rapidly changing physiology, clinical demands and a large volume of data that must be communicated to render safe, effective patient care. Trauma Morning Report format may offer the ideal situation to study and teach sign-outs and resident communication.

MATERIALS AND METHODS

Surgery Residents were assessed on a 1-5 scale for their ability to communicate to their fellow residents. This consisted of 10 critical points of the presentation, treatment and workup from the previous night's trauma admissions. Scores were grouped into three areas. Each area was scored out of 15. Area 1 consisted of Initial patient presentation. Area 2 consisted of events in the trauma bay. Area 3 assessed clarity of language and ability to communicate to their fellow residents. The residents were assessed for inclusion of pertinent positive and negative findings, as well as overall clarity of communication. In phase 1, residents were unaware of the evaluation process. Phase 2 followed a series of resident education session about effective communication, sign-out techniques and delineation of evaluation criteria. Phase 3 was a resident-blinded phase which evaluated the sustainability of the improvements in resident communication.

RESULTS

50 patient presentations in phase 1, 200 in phase 2, and 50 presentations in phase 3 were evaluated. Comparisons were made between the Phase 1 and Phase 2 evaluations. Area 1 (initial events) improved from 6.18 to 12.4 out of 15 (p<0.0001). Area 2 (events in the trauma bay) improved from 9.78 to 16.53 (p<0.0077). Area 3 (communication and language) improved from 8.36 to 12.22 out of 15 (P<0.001). Phase 2 to Phase 3 evaluations were similar, showing no deterioration of skills.

CONCLUSIONS

Trauma Surgery manages complex surgical patients, with rapidly changing physiologic and clinical demands. Trauma Morning Report, with diverse attendance including surgical attendings and residents in various training years, is the ideal venue for real-time teaching and evaluation of sign-outs and reinforcing good communication skills in residents.

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.

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.

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.

Assessing the sustainability of daily chlorhexidine bathing in the intensive care unit of a Veteran's Hospital by examining nurses' perspectives and experiences

BACKGROUND

Daily bathing with chlorhexidine gluconate (CHG) of intensive care unit (ICU) patients has been shown to reduce healthcare-associated infections and colonization by multidrug resistant organisms. The objective of this project was to describe the process of daily CHG bathing and identify the barriers and facilitators that can influence its successful adoption and sustainability in an ICU of a Veterans Administration Hospital.

METHODS

We conducted 26 semi-structured interviews with a convenience sample of 4 nurse managers (NMs), 13 registered nurses (RNs) and 9 health care technicians (HCTs) working in the ICU. We used qualitative content analysis to code and analyze the data. Dedoose software was used to facilitate data management and coding. Trustworthiness and scientific integrity of the data were ensured by having two authors corroborate the coding process, conducting member checks and keeping an audit trail of all the decisions made.

RESULTS

Duration of the interviews was 15 to 39 min (average = 26 min). Five steps of bathing were identified: 1) decision to give a bath; 2) ability to give a bath; 3) decision about which soap to use; 4) delegation of a bath; and 5) getting assistance to do a bath. The bathing process resulted in one of the following three outcomes: 1) complete bath; 2) interrupted bath; and 3) bath not done. The outcome was influenced by a combination of barriers and facilitators at each step. Most barriers were related to perceived workload, patient factors, and scheduling. Facilitators were mainly organizational factors such as the policy of daily CHG bathing, the consistent supply of CHG soap, and support such as reminders to conduct CHG baths by nurse managers.

CONCLUSIONS

Patient bathing in ICUs is a complex process that can be hindered and interrupted by numerous factors. The decision to use CHG soap for bathing was only one of 5 steps of bathing and was largely influenced by scheduling/workload and patient factors such as clinical stability, hypersensitivity to CHG, patient refusal, presence of IV lines and general hygiene. Interventions that address the organizational, provider, and patient barriers to bathing could improve adherence to a daily CHG bathing protocol.

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

OBJECTIVE

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

APPLICATION

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

Tools for structured team communication in pre-registration health professions education: a Best Evidence Medical Education (BEME) review: BEME Guide No. 41

INTRODUCTION

Calls for the inclusion of standardized protocols for information exchange into pre-registration health professions curricula have accompanied their introduction into clinical practice. In order to help clinical educators respond to these calls, we have reviewed educational interventions for pre-registration students that incorporate one or more of these ?tools for structured communication?.

METHODS

Searches of 10 databases (1990?2014) were supplemented by hand searches and by citation searches (to January 2015). Studies evaluating an intervention for pre-registration students of any clinical profession and incorporating at least one tool were included. Quality of included studies was assessed using a checklist of 11 indicators and a narrative synthesis of findings undertaken.

RESULTS

Fifty studies met our inclusion criteria. Of these, 21 evaluated the specific effect of a tool on educational outcomes, and 27 met seven or more quality indicators.

CONCLUSIONS

Pre-registration students, particularly those in the US, are learning to use tools for structured communication either in specific sessions or integrated into more extensive courses or programmes; mostly 'Situation Background Assessment Recommendation' and its variants. There is some evidence that learning to use a tool can improve the clarity and comprehensiveness of student communication, their perceived self-confidence and their sense of preparedness for clinical practice. There is, as yet, little evidence for the transfer of these skills to the clinical setting or for any influence of teaching approach on learning outcomes. Educators will need to consider the positioning of such learning with other skills such as clinical reasoning and decision-making.

The Importance of Fostering Ownership During Medical Training

There is a need to consider the impact of the new resident-hours regulations on the variety of aspects of medical education and patient care. Most existing literature about this subject has focused on the role of fatigue in resident performance, education, and health care delivery. However, there are other possible consequences of these new regulations, including a negative impact on decision ownership. Our main assumption of is that increased shift work in medicine can decrease ownership of treatment decisions and impact negatively on quality of care. We review some potential components of decision ownership in treatment context and suggest possible ways in which the absence of decision ownership may decrease the quality of medical decision making. The article opens with the definition of decision ownership and the overview of some contextual factors that may contribute to the development of ownership in medical residency. The following section discusses decision ownership in medical care from the perspective of "diffusion of responsibility." We question the quality of choices made within narrow decisional frames. We also compare isolated and interrelated choices, assuming that residents make more isolated decisions during their shifts. Lastly, we discuss the consequences of decreased decision ownership impacting the delivery of health care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Physician Transition of Care: Benefits of I-PASS and an Electronic Handoff System in a Community Pediatric Residency Program

BACKGROUND

Miscommunication is a leading cause of adverse events in hospitals. Optimizing the handoff process improves communication and patient safety. We sought to assess how the components of I-PASS (a mnemonic for illness severity, patient summary, action list, situational awareness with contingency planning, and synthesis by the receiver), a standardized handoff bundle, improved the quality of handoffs in a pediatric residency program based in a community hospital.

METHODS

Pediatric residents in a university-affiliated community teaching hospital were observed on the pediatric inpatient floor and in the newborn nursery. One hundred resident handoffs per setting were analyzed in 3 phases, with a total of 600 handoffs assessed. Phase 1 comprised preintervention handoffs before I-PASS; phase 2, initiating I-PASS mnemonic and educational session; and phase 3, implementing a handoff tool, electronic physician handoff (EPH), into the electronic medical record. One attending physician at each setting assessed the handoff process using an 11-item survey. A resident satisfaction survey assessed the resident's experience after phase 3.

RESULTS

Comparing phase 1 with phase 2, there was improved situational awareness with contingency planning (nursery: 12% to 83%, P = .001; floor: 21% to 84%, P = .001). Incidence of tangential conversation decreased in both settings (nursery: 100% to 23%, P = .001; floor: 84% to 11%, P = .001). Comparing phase 2 with phase 3, there was improvement in identification of illness severity (nursery: 62% to 99%, P = .001; floor: 41% to 64%, P = .001) and fewer omissions of important information (nursery: 14% to 0%, P = .001; floor: 33% to 17%, P = .007). A total of 93% of residents found the new EPH system to be beneficial.

CONCLUSIONS

Specific components of a standardized handoff system, including a mnemonic, an educational intervention, and an EPH, improved the clarity and organization of key information in handoff.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

AIM

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

SETTING

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

PARTICIPANTS

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

PROGRAM DESCRIPTION

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

PROGRAM EVALUATION

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

CONCLUSIONS

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

Effect of handoff skills training for students during the medicine clerkship: a quasi-randomized study

Continuity is critical for safe patient care and its absence is associated with adverse outcomes. Continuity requires handoffs between physicians, but most published studies of educational interventions to improve handoffs have focused primarily on residents, despite interns expected to being proficient. The AAMC core entrustable activities for graduating medical students includes handoffs as a milestone, but no controlled studies with students have assessed the impact of training in handoff skills. The purpose of this study was to assess the impact of an educational intervention to improve third-year medical student handoff skills, the durability of learned skills into the fourth year, and the transfer of skills from the simulated setting to the clinical environment. Trained evaluators used standardized patient cases and an observation tool to assess verbal handoff skills immediately post intervention and during the student's fourth-year acting internship. Students were also observed doing real time sign-outs during their acting internship. Evaluators assessed untrained control students using a standardized case and performing a real-time sign-out. Intervention students mean score demonstrated improvement in handoff skills immediately after the workshop (2.6-3.8; p < 0.0001) that persisted into their fourth year acting internship when compared to baseline performance (3.9-3.5; p = 0.06) and to untrained control students (3.5 vs. 2.5; p < 0.001, d = 1.2). Intervention students evaluated in the clinical setting also scored higher than control students when assessed doing real-time handoffs (3.8 vs. 3.3; p = 0.032, d = 0.71). These findings should be useful to others considering introducing handoff teaching in the undergraduate medical curriculum in preparation for post-graduate medical training. Trial Registration Number NCT02217241.

Handoff Practices in Emergency Medicine: Are We Making Progress?

OBJECTIVES

Transitions of care present a risk for communication error and may adversely affect patient care. This study addresses the scope of current handoff practices amongst U.S. emergency medicine (EM) residents. In addition, it evaluates current educational and evaluation practices related to handoffs. Given the ever-increasing emphasis on transitions of care in medicine, we sought to determine if interval changes in resident transition of care education, assessment, and proficiency have occurred.

METHODS

This was a cross-sectional survey study guided by the Kern model for medical curriculum development. The Council of Residency Directors Listserv provided access to 175 programs. The survey focused on elucidating current practices of handoffs from emergency physicians (EPs) to EPs, including handoff location and duration, use of any assistive tools, and handoff documentation in the emergency department (ED) patient's medical record. Multiple-choice questions were the primary vehicle for the response process. A four-point Likert-type scale was used in questions regarding perceived satisfaction and competency. Respondents were not required to answer all questions. Responses were compared to results from a similar 2011 study for interval changes.

RESULTS

A total of 127 of 175 programs responded to the survey, making the overall response rate 72.6%. Over half of respondents (72 of 125, 57.6%) indicated that their ED uses a standardized handoff protocol, which is a significant increase from 43.2% in 2011 (p = 0.018). Of the programs that do have a standardized system, a majority (72 of 113, 63.7%) of resident physicians use it regularly. Significant increases were noted in the number of programs offering formal training during orientation (73.2% from 59.2%; p = 0.015), decreases in the number of programs offering no training (2.4% from 10.2%; p = 0.013), and no assessment of proficiency (51.5% from 69.8%; p = 0.006). No significant interval changes were noted in handoffs being documented in the patient's medical record (57.4%), the percentage of computer/electronic signouts, or the level of dissatisfaction with handoff tools (54.1%). Less than two-thirds of respondents (80 of 126, 63.5%) indicated that their residents were "competent" or "extremely competent" in delivering and receiving handoffs.

CONCLUSIONS

An insufficient level of handoff training is currently mandated or available for EM residents, and their handoff skills appear to be developed mostly informally throughout residency training with varying results. Programs that have created a standardized protocol are not ensuring that the protocol is actually being employed in the clinical arena. Handoff proficiency most often goes unevaluated, although it is improved from 2011.

Half-life of a printed handoff document

BACKGROUND

Printed handoff documents are nearly universally present in the pockets of providers taking inhouse call. They are frequently used to answer clinical questions. However, the static nature of printed documents makes it likely that information will quickly become inaccurate as a result of ongoing management. This increases the potential for medical errors, especially in clinical services which rely heavily on printed documents for ongoing patient management.

OBJECTIVE

To measure the average time to potential inaccuracy, represented as the 'half-life' of printed handoff documents.

DESIGN, SETTING, PARTICIPANTS

Cross-sectional analysis of 100 adult inpatients during a single 24 h period at an academic medical centre in 2014.

MAIN OUTCOME AND MEASURE

The half-life was defined as the time at which half of the patients would be expected to have inaccurate information on a printed handoff document, based on review of orders which populate data fields on these printed handoff documents.

RESULTS

In our sample, the half-life was 6 h on the 12 h night shift and 3.3 h on the day shift. We identified at least on change within the 24 h period for 92% of patients. Most changes (90% n=1411) were medication-related, but the overall distribution of order types was significantly different between day and night (p=0.002).

CONCLUSIONS AND RELEVANCE

The accuracy of printed handoff documents quickly deteriorated over the course of a physician shift. Based on this decay rate, a typical physician getting sign-out on 20 patients overnight can safely assume that the data for 10 of them will be inaccurate or outdated in 6 h and that it will be inaccurate on another two by the morning.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Variation in printed handoff documents: Results and recommendations from a multicenter needs assessment

BACKGROUND

Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking.

OBJECTIVE

To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents.

SETTING

Pediatric hospitalist services at 9 institutions in the United States and Canada.

METHODS

Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices.

RESULTS

Nine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17%) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended.

CONCLUSIONS

Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors.

Piloting a Structured Practice Audit to Assess ACGME Milestones in Written Handoff Communication in Internal Medicine

BACKGROUND

Written communication skills are integral to patient care handoffs. Residency programs require feasible assessment tools that provide timely formative and summative feedback, ideally linked to the Accreditation Council for Graduate Medical Education Milestones.

OBJECTIVE

We describe the use of 1 such tool-UPDATED-to assess written handoff communication skills in internal medicine interns.

METHODS

During 2012-2013, the authors piloted a structured practice audit at 1 academic institution to audit written sign-outs completed by 45 interns, using the UPDATED tool, which scores 7 aspects of sign-out communication linked to milestones. Intern sign-outs were audited by trained faculty members throughout the year. Results were incorporated into intern performance reviews and Clinical Competency Committees.

RESULTS

A total of 136 sign-outs were audited (averaging 3.1 audits per intern). In the first trimester, 14 interns (31%) had satisfactory audit results. Five interns (11%) had critical deficiencies and received immediate feedback, and the remaining 26 (58%) were assigned future audits due to missing audits or unsatisfactory scores. In the second trimester, 21 interns (68%) had satisfactory results, 1 had critical deficiencies, and 9 (29%) required future audits. Nine of the 10 remaining interns in the final trimester had satisfactory audits. Faculty time was estimated at 10 to 15 minutes per sign-out audited.

CONCLUSIONS

The UPDATED audit is a milestone-based tool that can be used to assess written sign-out communication skills in internal medicine residency programs. Future work is planned to adapt the tool for use by senior supervisory residents to appraise sign-outs in real time.

Establishing a conceptual framework for handoffs using communication theory

BACKGROUND

A significant consequence of the 2003 Accreditation Council for Graduate Medical Education duty hour restrictions has been the dramatic increase in patient care handoffs. Ineffective handoffs have been identified as the third most common cause of medical error. However, research into health care handoffs lacks a unifying foundational structure. We sought to identify a conceptual framework that could be used to critically analyze handoffs.

METHODS

A scholarly review focusing on communication theory as a possible conceptual framework for handoffs was conducted. A PubMed search of published handoff research was also performed, and the literature was analyzed and matched to the most relevant theory for health care handoff models.

RESULTS

The Shannon-Weaver Linear Model of Communication was identified as the most appropriate conceptual framework for health care handoffs. The Linear Model describes communication as a linear process. A source encodes a message into a signal, the signal is sent through a channel, and the signal is decoded back into a message at the destination, all in the presence of internal and external noise. The Linear Model identifies 3 separate instances in handoff communication where error occurs: the transmitter (message encoding), channel, and receiver (signal decoding).

CONCLUSIONS

The Linear Model of Communication is a suitable conceptual framework for handoff research and provides a structured approach for describing handoff variables. We propose the Linear Model should be used as a foundation for further research into interventions to improve health care handoffs.

Transitions in Care: When Words Can Save Lives

Among the myriad of skills required of emergency medicine (EM) physicians, communicating concise and effective transitions in care is one of the most critical for patient safety. EM physicians transition care daily, both within their own department and among other specialties. We will discuss the crucial link between care transitions and patient safety, the processes and challenges in the hand-over exchange, and recommend an approach to improve your current system with transitions in care.

Residency training in handoffs: a survey of program directors in psychiatry

OBJECTIVE

The purpose of this study was to investigate how psychiatry programs are addressing the new Accreditation Council for Graduate Medical Education (ACGME) training requirements regarding transitions in patient care effective July 1, 2011.

METHODS

An anonymous online survey was distributed to program directors of general psychiatry residencies within the USA. Survey questions pertaining to the 2011 ACGME handoff requirements focused on training modalities, assessment of competence, and oversight of appropriate handoff procedures. In addition, program directors were asked to share specific challenges in implementing the new handoff regulations as well as their view on how the new regulations would impact patient care.

RESULTS

Of the 177 recipients, 108 completed at least part of the survey (61 % response rate). Only 11.4 % of programs indicated that they did not need to make any changes to their program in order to meet the new guidelines. Approximately a third of survey respondents reported that they did not yet have a formal curriculum in handoffs (32.4 %) and/or did not specifically assess competence at handoffs (30.5 %). Program directors cited the challenge of working with a variety of clinical settings with unique cultures, infrastructure, and policies and procedures and suggested that implementation and ownership of handoff training and assessment should be at the level of the clinical services. Despite these challenges, most program directors agreed that the new ACGME requirements would improve patient care and safety.

CONCLUSIONS

The high frequency of programs without established handoff curricula or competence evaluations highlights the potential value of published resources and tools to provide standardized training and assessment in handoffs. The results also underscore the importance of developing training and assessment in close collaboration with the clinical services and recognizing the need to tailor handoff communications to address the types of transitions that occur within each clinical setting.

Medical school handoff education improves postgraduate trainee performance and confidence

OBJECTIVES

Determine postgraduate first-year (PGY-1) trainees ability to perform patient care handoffs and associated medical school training.

METHODS

About 173 incoming PGY-1 trainees completed an OSCE handoff station and a survey eliciting their training and confidence in conducting handoffs. Independent t-tests compared OSCE performance of trainees who reported receiving handoff training to those who had not. Analysis of variance examined differences in performance based on prior handoff instruction and across levels of self-assessed abilities, with significance set at p<0.05.

RESULTS

About 35% of trainees reported receiving instruction and 51% reported receiving feedback about their handoff performance in medical school. Mean handoff performance score was 69.5%. Trainees who received instruction or feedback during medical school had higher total and component handoff performance scores (p<0.05); they were also more confident in their handoff abilities (p<0.001). Trainees with higher self-assessed skills and preparedness performed better on the OSCE (p<0.05).

CONCLUSIONS

This study provides evidence that incoming trainees are not well prepared to perform handoffs. However, those who received instruction during medical school perform better and are more confident on standardized performance assessments. Given communication failures lead to uncertainty in patient care and increases in medical errors, medical schools should incorporate handoff training as required instruction.

SOUND: a structured handoff tool improves patient handoffs in a pediatric emergency department

INTRODUCTION

Handoff communication is an important contributor to safety and quality in the emergency department (ED). Breakdowns in this process may lead to unsafe conditions or adverse events. The purpose of this study was to test the hypothesis that the quality of patient handoffs in the pediatric ED would improve after implementation of a structured handoff method.

METHODS

In this prospective, observational study, we evaluated the implementation of a structured handoff tool, SOUND, which we developed to standardize the format of handoffs. The tool contains 5 components as follows: Synthesis, Objective Data, Upcoming Tasks, Nursing Input, and Double Check. SOUND was implemented through an online module and provider education. Handoffs were observed before and after implementation of SOUND. Statistical process control was used to measure the effects of the intervention. A successful handoff was defined as one in which 4 of the 5 components were included. As a balancing measure, we calculated mean time per handoff.

RESULTS

We observed 638 handoffs. The implementation of SOUND significantly increased the percentage of successful handoffs. Statistical process control demonstrated continued improvement over time. This improvement was associated with a modest increase in the mean time per patient discussed (52.9 vs 73.0 seconds, P < 0.01).

CONCLUSIONS

It is feasible to standardize patient handoffs in the pediatric ED. The implementation of SOUND improved completeness of handoffs with only a modest increase in the mean time spent discussing each patient. Future study is required to determine if SOUND will prove effective in other ED settings.

Discharge communication from inpatient care: an audit of written medical discharge summary procedure against the new National Health Service Standard for clinical handover

Objective To audit written medical discharge summary procedure and practice against Standard Six (clinical handover) of the Australian National Safety and Quality Health Service Standards at a major regional Victorian health service. Methods Department heads were invited to complete a questionnaire about departmental discharge summary practices. Results Twenty-seven (82%) department heads completed the questionnaire. Seven (26%) departments had a documented discharge summary procedure. Fourteen (52%) departments monitored discharge summary completion and 13 (48%) departments monitored the timeliness of completion. Seven (26%) departments informed the patient of the content of the discharge summary and six (22%) departments provided the patient with a copy. Seven (26%) departments provided training for staff members on how to complete discharge summaries. Completing discharge summaries was usually delegated to the medical intern. Conclusions The introduction of the National Service Standards prompted an organisation-wide audit of discharge summary practices against the external criterion. There was substantial variation in the organisation’s practices. The Standards and the current audit results highlight an opportunity for the organisation to enhance and standardise discharge summary practices and improve communication with general practice. What is known about the topic? The Australian National Safety and Quality Health Service Standards (Standard 6) require health service organisations to implement documented systems that support structured and effective clinical handover. Discharge summaries are an important and often the only form of communication during a patient’s transition from hospital to the community. Incomplete, inaccurate and unavailable discharge summaries are common and expose patients to greater health risks. Junior staff members find completing discharge summaries difficult and fail to receive appropriate education or support. There is little published evidence regarding the discharge summary practices of inpatient health services. What does this paper add? The paper demonstrates that there is substantial variation in practice regarding discharge summaries in a large regional health service. Departments have different processes and vary in the degree of attention and quality assurance provided to discharge summaries. Variable organisation procedures make completing discharge summaries more difficult for junior doctors, who regularly move between departments. Variable practice is likely to increase the risk of absent, untimely, incomplete or incorrect communication between acute and community services, thereby reducing the quality of patient care. It is likely that similar findings would be found in other hospitals. What are the implications for practitioners? To be accredited under the National Safety and Quality Health Service Standards, health organisations must ensure that adequate processes are in place for safe and effective clinical handover. Organisations should reduce the practice variability by standardising processes, monitoring compliance with processes, and training and supporting junior doctors.

Twelve tips to support the development of clinical reasoning skills using virtual patient cases

Clinical reasoning is a critical core competency in medical education. Strategies to support the development of clinical reasoning skills have focused on methodologies used in traditional settings, including lectures, small groups, activities within Simulation Centers and the clinical arena. However, the evolving role and growing utilization of virtual patients (VPs) in undergraduate medical education; as well as an increased emphasis on blended learning, multi-modal models that include VPs in core curricula; suggest a growing requirement for strategies or guidelines that directly focus on VPs. The authors have developed 12 practical tips that can be used in VP cases to support the development of clinical reasoning. These are based on teaching strategies and principles of instructional design and pedagogy, already used to teach and assess clinical reasoning in other settings. Their application within VPs will support educators who author or use VP cases that promote the development of clinical reasoning.

Are attendings different? Intensivists explain their handoff ideals, perceptions, and practices

PURPOSE

What is known about physician handoffs is almost entirely limited to resident practice, but attending physicians ultimately determine care plans and goals of care. This study sought to understand what is unique about attending intensivist handoffs, to identify perceptions of the ideal content and format of intensive care unit (ICU) attending handoffs, and to understand how ideal and reported practices are aligned in the delivery of care.

METHODS

Intensivists in active practice in U.S. adult academic ICUs were purposively sampled and interviewed over 9 months in 2011 to 2012.

MEASUREMENTS AND MAIN RESULTS

Thirty attendings from 15 institutions in nine U.S. states were interviewed. Subjects' specialties included anesthesiology, emergency medicine, internal medicine, and surgery. The "perfect handoff" was described as succinct, included verbal plus written communication, and took place in person. Respondents believed that the attending handoff should be less detailed than resident handoffs. Most attendings participated in handoffs at the end of each ICU rotation (n = 26). Standardized handoff practice was rare (n = 1). Media used for handoffs included combinations of telephone conversations (n = 25), in-person communications (n = 11), e-mail (n = 9), or text message (n = 2). Handoff duration varied from 10 to 120 minutes for 5 to 42 patients. Five of 30 respondents had undergone formal training in how to conduct handoffs.

CONCLUSIONS

A national sample of academic intensivists identified common ideal attributes of attending handoffs, yet their reported handoff practices varied widely. Ideal handoff practices may form the basis of future interventions to improve communication between intensivists.