Template for success: using a resident-designed sign-out template in the handover of patient care

Emerging Professional Identity in Patient Hand-Off Routines: A Practical Application of Performative Face Theory

Recent research of healthcare providers identifies the critical role that professional identity plays in the provision of healthcare, interactions within healthcare teams, and healthcare provider perceptions of their work. However, much remains to be known regarding the role of professional identity in routine interactions for emerging healthcare professionals. This study enriches understandings of this particular issue by exploring pediatric residents' experiences with a structured hand-off tool at a children's hospital in the western United States. This study employed qualitative interview methods and iterative interpretive qualitative data analysis. Participants were 20 residents in a children's hospital. Data analysis indicated that the discourses that disseminate negotiations of face can, and often do, take place during patient hand-off, as the statements exchanged between team members can maintain or threaten face and professional identity. We suggest that shifts in organizational culture and training are necessary to optimize the environment in which residents use structured hand-off. Further, the culture and practice of training emerging physicians should include attention to the important role of hand-off as a critical site of professional identity construction and negotiation.

Objective Assessment of the Entrustable Professional Activity Handover in Undergraduate and Postgraduate Surgical Learners

OBJECTIVE

This study used a virtual patient simulation (VPS) to quantifiably and objectively assess undergraduate (UG) to postgraduate (PG) medical learners' acquisition of the entrustable professional activity (EPA) "handover," focusing particularly on the transition to residency. This EPA is critical because it is part of a core competency for UG and PG training in both the United States and Canada, and is essential for patient safety and comprehensive professional communication.

DESIGN

Data were collected from 3 separate groups of participants: 2 UG cohorts from an earlier study, as well as a PG cohort at the beginning of residency. All participants completed the same trauma VPS, which required a free text summary statement that was used as a surrogate for an oral handover. These were collected and scored independently, using previously developed validated rubrics, one procedural and the second semantic.

SETTING

All study participants were from one site. The VPS case was completed online.

PARTICIPANTS

Two different UG groups, one designated junior (N = 52), was studied at the beginning of their clerkship year, a second group, designated senior (N = 30), was studied at the end of their clerkship year. These groups were compared to a third group of PG learners (N = 31) during the initial 2 weeks of their residency. Informed consent was obtained from all participants.

RESULTS

A procedural rubric assessed learners' cognitive knowledge of trauma care-management. A semantic rubric assessed their use of the professional language necessary for a safe and succinct clinical handover communication. An Analysis of Variance comparing scores on the procedural rubric was highly significant with Tukey LSD tests indicating that all 3 groups were significantly different. Students increased their scores on the procedural rubric at each stage of their training. A parallel Analysis of Variance comparing students' scores on the semantic rubric revealed no significant increase in scores, indicating that students did not improve in their capacity to communicate professionally as they progressed through their training.

CONCLUSIONS

Taken together, these results demonstrate that training was successful in teaching cognitive-based procedures, but not effective in teaching professional communication, which is critical to the EPA handover. Greater emphasis needs to be placed on ensuring the acquisition of professional communication skills throughout the continuum of UG and PG clinical activities. Faculty development should serve as a support to assist medical educators to address this requirement. These results also demonstrate that VPS with associated objective and validated rubrics can be used as an assessment methodology to quantifiably measure learner performance with respect to the EPA handover. A similar strategy should be considered across the UG and PG continuum for other EPAs and could form the nexus for further research.

Implementing electronic handover: interventions to improve efficiency, safety and sustainability

PROBLEM

Effective handovers are critical for patient care and safety. Electronic handover tools are increasingly used today to provide an effective and standardized platform for information exchange. The implementation of an electronic handover system in tertiary hospitals can be a major challenge. Previous efforts in implementing an electronic handover tool failed due to poor compliance and buy-in from end-users. A new electronic handover tool was developed and incorporated into the existing electronic medical records (EMRs) for medical patients in Singapore General Hospital (SGH).

INITIAL ASSESSMENT

There was poor compliance by on-call doctors in acknowledging electronic handovers, and lack of adherence to safety rules, raising concerns about the safety and efficiency of the electronic handover tool. Urgent measures were needed to ensure its safe and sustained use.

SOLUTION

A quality improvement group comprising stakeholders, including end-users, developed multi-faceted interventions using rapid PDSA (P-Plan, D-Do, S-Study, A-Act ) cycles to address these issues.

IMPLEMENTATION

Innovative solutions using media and online software provided cost-efficient measures to improve compliance.

EVALUATION

The percentage of unacknowledged handovers per day was used as the main outcome measure throughout all PDSA cycles. Doctors were also assessed for improvement in their knowledge of safety rules and their perception of the electronic handover tool.

LESSONS LEARNT

An electronic handover tool complementing daily clinical practice can be successfully implemented using solutions devised through close collaboration with end-users supported by the senior leadership. A combined 'bottom-up' and 'top-down' approach with regular process evaluations is crucial for its long-term sustainability.

Improving Escalation of Care: Development and Validation of the Quality of Information Transfer Tool

OBJECTIVE

To develop and provide validity and feasibility evidence for the QUality of Information Transfer (QUIT) tool.

BACKGROUND

Prompt escalation of care in the setting of patient deterioration can prevent further harm. Escalation and information transfer skills are not currently measured in surgery.

METHODS

This study comprised 3 phases: the development (phase 1), validation (phase 2), and feasibility analysis (phase 3) of the QUIT tool. Phase 1 involved identification of core skills needed for successful escalation of care through literature review and 33 semistructured interviews with stakeholders. Phase 2 involved the generation of validity evidence for the tool using a simulated setting. Thirty surgeons assessed a deteriorating postoperative patient in a simulated ward and escalated their care to a senior colleague. The face and content validity were assessed using a survey. Construct and concurrent validity of the tool were determined by comparing performance scores using the QUIT tool with those measured using the Situation-Background-Assessment-Recommendation (SBAR) tool. Phase 3 was conducted using direct observation of escalation scenarios on surgical wards in 2 hospitals.

RESULTS

A 7-category assessment tool was developed from phase 1 consisting of 24 items. Twenty-one of 24 items had excellent content validity (content validity index >0.8). All 7 categories and 18 of 24 (P < 0.05) items demonstrated construct validity. The correlation between the QUIT and SBAR tools used was strong indicating concurrent validity (r = 0.694, P < 0.001). Real-time scoring of escalation referrals was feasible and indicated that doctors currently have better information transfer skills than nurses when faced with a deteriorating patient.

CONCLUSIONS

A validated tool to assess information transfer for deteriorating surgical patients was developed and tested using simulation and real-time clinical scenarios. It may improve the quality and safety of patient care on the surgical ward.

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.

Republished: Key characteristics of successful quality improvement curricula in physician education: a realist review

PURPOSE

Quality improvement (QI) is a common competency that must be taught in all physician training programmes, yet, there is no clear best approach to teach this content in clinical settings. We conducted a realist systematic review of the existing literature in QI curricula within the clinical setting, highlighting examples of trainees learning QI by doing QI.

METHOD

Candidate theories describing successful QI curricula were articulated a priori. We searched MEDLINE (1 January 2000 to 12 March 2013), the Cochrane Library (2013) and Web of Science (15 March 2013) and reviewed references of prior systematic reviews. Inclusion criteria included study design, setting, population, interventions, clinical and educational outcomes. The data abstraction tool included categories for setting, population, intervention, outcomes and qualitative comments. Themes were iteratively developed and synthesised using realist review methodology. A methodological quality tool assessed the biases, confounders, secular trends, reporting and study quality.

RESULTS

Among 39 studies, most were before-after design with resident physicians as the primary population. Twenty-one described clinical interventions and 18 described educational interventions with a mean intervention length of 6.58 (SD=9.16) months. Twenty-eight reported successful clinical improvements; no studies reported clinical outcomes that worsened. Characteristics of successful clinical QI curricula include attention to the interface of educational and clinical systems, careful choice of QI work for the trainees and appropriately trained local faculty.

CONCLUSIONS

This realist review identified success characteristics to guide training programmes, medical schools, faculty, trainees, accrediting organisations and funders to further develop educational and improvement resources in QI educational programmes.

Effectiveness of interventions to improve patient handover in surgery: A systematic review

BACKGROUND

Handover of patient care is a critical process in the transfer of information between clinical teams and clinicians during transitions in patient care. The handover process may take many forms and is often unstructured and unstandardized, potentially resulting in error and the potential for patient harm. The Joint Commission has implicated such errors in up to 80% of sentinel events and has published guidelines (using an acronym termed SHARE) for the development of intervention tools for handover. This study aims to review interventions to improve handovers in surgery and to assess compliance of described methodologies with the guidelines of the Joint Commission for design and implementation of handover improvement tools.

METHODS

A systematic review was conducted in line with MOOSE guidelines. Electronic databases Medline, EMBASE, and PsyInfo were searched and interventions to improve surgical handover identified. Intervention types, development methods, and outcomes were compared between studies and assessed against SHARE criteria.

RESULTS

Nineteen studies were included. These studies included paper and computerized checklists, proformas, and/or standardized operating protocols for handover. All reported some degree of improvement in handover. Description of development methods, staff training, and follow-up outcome data was poor. Only a single study was able to demonstrate compliance with all 5 domains guidelines of the of Joint Commission.

CONCLUSION

Improvements in information transfer may be achieved through checklist- or proforma-based interventions in surgical handover. Although initial data appear promising, future research must be backed by robust study design, relevant outcomes, and clinical implementation strategies to identify the most effective means to improve information transfer and optimize patient outcomes.

Development and implementation of an electronic health record generated surgical handoff and rounding tool

Electronic health records (EHR) have been adopted across the nation at tremendous effort and expense. The purpose of this study was to assess improvements in accuracy, efficiency, and patient safety for a high-volume pediatric surgical service with adoption of an EHR-generated handoff and rounding list. The quality and quantity of errors were compared pre- and post-EHR-based list implementation. A survey was used to determine time spent by team members using the two versions of the list. Perceived utility, safety, and quality of the list were reported. Serious safety events determined by the hospital were also compared for the two periods. The EHR-based list eliminated clerical errors while improving efficiency by automatically providing data such as vital signs. Survey respondents reported 43 min saved per week per team member, translating to 372 work hours of time saved annually for a single service. EHR-based list users reported higher satisfaction and perceived improvement in efficiency, accuracy, and safety. Serious safety events remained unchanged. In conclusion, creation of an EHR-based list to assist with daily handoffs, rounding, and patient management demonstrated improved accuracy, increased efficiency, and assisted in maintaining a high level of safety.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Faculty member review and feedback using a sign-out checklist: improving intern written sign-out

PURPOSE

Although residents commonly perform patient care sign-out during training, faculty do not frequently supervise or evaluate sign-out. The authors designed a sign-out checklist, and they investigated whether use of the checklist, paired with faculty member review and feedback, would improve interns' written sign-out.

METHOD

In a randomized, controlled design in 2011, the authors compared the sign-out content and the overall sign-out summary scores of interns who received twice-monthly faculty member sign-out evaluation with those of interns who received the standard sign-out instruction. A sign-out checklist, which the authors developed on the basis of internal needs assessment and published sign-out recommendations, guided the evaluation of written sign-out content and sign-out organization as well as the twice-monthly, face-to-face evaluation that the interns in the intervention group received.

RESULTS

Using the sign-out checklist and receiving feedback from a faculty member led to statistically significant improvements in interns' sign-out. Through regression analysis, the authors calculated a 23% difference in the sign-out content (P = .005) and a 2.2-point difference in the overall summary score (on a 9-point scale, P = .009) between the interns who received sign-out feedback and those who did not. The content and quality of the intervention group's sign-outs improved, whereas the content and quality of the control group's worsened.

CONCLUSIONS

A sign-out checklist paired with twice-monthly, face-to-face feedback from a faculty member led to improvements in the content and quality of interns' written sign-out.

Handing over patient care: is it just the old broken telephone game?

BACKGROUND

Handing over patient care remains a poorly understood process and remains a leading cause of medical error. We sought to examine how hand off delivery methods affect hand off quality and whether improvement would occur over time without formal training.

DESIGN

Three simulated-patient hand offs were developed; each with a distinct delivery method: in-person (IP), video-based (VB), and screen-based (SB). Participants were evaluated up to 4 times, each 6 months apart. During evaluations, residents received the 3 hand offs, answered a sleep and preference questionnaire, and proceeded to hand off the same 3 patients. Sessions were video-reviewed and hand offs scored for quality measures: word accuracy, errors of omission or commission, and appropriateness of clinical judgment. Quality measures among delivery methods and changes over time were compared.

RESULTS

Sixty-eight General Surgery residents (postgraduate year [PGY] 1-2) participated in at least 2 testing sessions, with 13 participating in 4. The IP method was superior to VB and SB for most hand off quality measures (each p < 0.001). With repeated testing, hand off quality measures improved (p < 0.001). However, patient hand offs continued to remain non-optimal, with appropriate judgment present in only 47%-77% of the hand offs. Sleep hours (mean 5 ± 2) were not found to be associated with hand off quality measures (p > 0.05). Most trainees preferred the IP method (73% vs 5% VB, 15% SB, 7% other; p < 0.001).

CONCLUSIONS

There is a need to provide formal training in hand off quality early in residency training. General surgery trainees clearly prefer and performed better, though not perfect, hand offs with the in-person method.