A survey of handoff practices in emergency medicine

The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS

BACKGROUND AND OBJECTIVES

Despite the American College of Emergency Physicians and American Academy of Pediatrics recommendations for standardised handoffs in the emergency department (ED), few EDs have an established tool. Our aim was to improve the quality of handoffs in the ED by establishing compliance with the I-PASS handoff tool.

METHODS

This is a quality improvement (QI) initiative to standardise handoffs in a large academic paediatric ED. Following review of the literature and focus groups with key stakeholders, I-PASS was selected and modified to fit departmental needs. Implementation throughPlan-Do-Study-Act cycles included the development of educational materials, reminders and real-time feedback. Required use of I-PASS during designated team sign-out began in June 2016. Compliance with the handoff tool and handoff deficiencies was measured through observations by faculty trained in I-PASS. As a balancing measure, time to complete handoff was monitored and compared with preintervention data.

RESULTS

Compliance with I-PASS reached 80% within 6 months, 100% within 7 months and sustained at 100% during the remainder of the study period. The average percent of omissions of crucial information per handoff declined to 8.3%, which was a 53% decrease. Average percentage of tangential information and miscommunications per handoff did not show a decline. The average handoff took 20 min, which did not differ from the preintervention time. Survey results demonstrated a perceived improvement in patient safety through closed-loop communication, clear action lists and contingency planning and proper patient acuity identification.

CONCLUSIONS

I-PASS is applicable in the ED and can be successfully implemented through QI methodology contributing to an overall culture of safety.

Triaging Inpatient Admissions: an Opportunity for Resident Education

In the context of internal medicine, "triage" is a newly popularized term that refers to constellation of activities related to determining the most appropriate disposition plans for patients, including assessing patients for admissions into the inpatient medicine service. The physician or "triagist" plays a critical role in the transition of care from the outpatient to the inpatient settings, yet little literature exists addressing this particular transition. The importance of this set of responsibilities has evolved over time as health systems become increasingly complex to navigate for physicians and patients. With the emphasis on hospital efficiency metrics such as emergency department throughput and appropriateness of admissions, this type of systems-based thinking is a necessary skill for practicing contemporary inpatient medicine. We believe that triaging admissions is a critical transition in the care continuum and represents an entrustable professional activity that integrates skills across multiple Accreditation Council for Graduate Medical Education (ACGME) competencies that internal medicine residents must master. Specific curricular competencies that address the domains of provider, system, and patient will deliver a solid foundation to fill a gap in skills and knowledge for the triagist role in IM residency training.

Transition of Care Practices from Emergency Department to Inpatient: Survey Data and Development of Algorithm

Introduction

We aimed to assess the current scope of handoff education and practice among resident physicians in academic centers and to propose a standardized handoff algorithm for the transition of care from the emergency department (ED) to an inpatient setting.

Methods

This was a cross-sectional survey targeted at the program directors, associate or assistant program directors, and faculty members of emergency medicine (EM) residency programs in the United States (U.S.). The web-based survey was distributed to potential subjects through a listserv. A panel of experts used a modified Delphi approach to develop a standardized algorithm for ED to inpatient handoff.

Results

121 of 172 programs responded to the survey for an overall response rate of 70.3%. Our survey showed that most EM programs in the U.S. have some form of handoff training, and the majority of them occur either during orientation or in the clinical setting. The handoff structure from ED to inpatient is not well standardized, and in those places with a formalized handoff system, over 70% of residents do not uniformly follow it. Approximately half of responding programs felt that their current handoff system was safe and effective. About half of the programs did not formally assess the handoff proficiency of trainees. Handoffs most commonly take place over the phone, though respondents disagree about the ideal place for a handoff to occur, with nearly equivalent responses between programs favoring the bedside over the phone or face-to-face on a computer. Approximately two-thirds of responding programs reported that their residents were competent in performing ED to inpatient handoffs. Based on this survey and on the review of the literature, we developed a five-step algorithm for the transition of care from the ED to the inpatient setting.

Conclusion

Our results identified the current trends of education and practice in transitions of care, from the ED to the inpatient setting in U.S. academic medical centers. An algorithm, which guides this process, is proposed to address the current gap in the standardized approach to ED to inpatient handoffs that were identified in the survey’s assessment of needs.

Adapting the I-PASS Handoff Program for Emergency Department Inter-Shift Handoffs

INTRODUCTION

Academic emergency department (ED) handoffs are high-risk transfer of care events. Emergency medicine residents are inadequately trained to handle these vital transitions. We aimed to explore what modifications the I-PASS (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) handoff system requires to be effectively modified for use in ED inter-shift handoffs.

METHODS

This mixed-method needs assessment conducted at an academic ED explored the suitability of the I-PASS system for ED handoffs. We conducted a literature review, focus groups, and then a survey. We sought to identify the distinctive elements of ED handoffs and discern how these could be incorporated into the I-PASS system.

RESULTS

Focus group participants agreed the patient summary should be adapted to include anticipated disposition of patient. Participants generally endorsed the order and content of the other elements of the I-PASS tool. The survey yielded several wording changes to reflect contextual differences. Themes from all qualitative sources converged to suggest changes for brevity and clarity. Most participants agreed that the I-PASS tool would be well suited to the ED setting.

CONCLUSION

With modifications for context, brevity, and clarity, the I-PASS system may be well suited for application to the ED setting. This study provides qualitative data in support of using the I-PASS tool and concrete suggestions for how to modify the I-PASS tool for the ED. Implementation and outcome research is needed to investigate if the I-PASS tool is feasible and improves patient outcomes in the ED environment.

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.

Ready for Discharge? A Survey of Discharge Transition-of-Care Education and Evaluation in Emergency Medicine Residency Programs

This study aimed to assess current education and practices of emergency medicine (EM) residents as perceived by EM program directors to determine if there are deficits in resident discharge handoff training. This survey study was guided by the Kern model for medical curriculum development. A six-member Council of EM Residency Directors (CORD) Transitions of Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to program residency directors via the CORD listserve and/or direct contact. There were 119 responses to the survey, which were collected using an online survey tool. Over 71% of the 167 American College of Graduate Medical Education (ACGME) accredited EM residency programs were represented. Of those responding, 42.9% of programs reported formal training regarding discharges during initial orientation and 5.9% reported structured curriculum outside of orientation. A majority (73.9%) of programs reported that EM residents were not routinely evaluated on their discharge proficiency. Despite the ACGME requirements requiring formal handoff curriculum and evaluation, many programs do not provide formal curriculum on the discharge transition of care or evaluate EM residents on their discharge proficiency.

Interunit handoffs from emergency department to inpatient care: A cross-sectional survey of physicians at a university medical center

BACKGROUND

Emergency department (ED) to inpatient physician handoffs are subject to complex challenges. We assessed physicians' perceptions of the ED admission handoff process and identified potential barriers to safe patient care.

METHODS

We conducted a cross-sectional survey at a 627-bed tertiary care academic medical center. Eligible participants included all resident, fellow, and faculty physicians directly involved in admission handoffs from emergency medicine (EM) and 5 medical admitting services. The survey addressed communication quality, clinical information, interpersonal perceptions, assignment of responsibilities, organizational factors, and patient safety. Participants reported their responses via a 5-point Likert scale and an open-ended description of handoff-related adverse events.

RESULTS

Response rates were 63% for admitting (94/150) and 86% for EM physicians (32/37). Compared to EM respondents, admitting physicians reported that vital clinical information was communicated less frequently for all 8 content areas (P < 0.001). Ninety-four percent of EM physicians felt defensive at least "sometimes." Twenty-nine percent of all respondents reported handoff-related adverse events, most frequently related to ineffective communication. Sequential handoffs were common for both EM and admitting services, with 78% of physicians reporting they negatively impacted patient care.

CONCLUSION

Physicians reported that patient safety was often at risk during the ED admission handoff process. Admitting and EM physicians had divergent perceptions regarding handoff communication, and sequential handoffs were common. Further research is needed to better understand this complex process and to investigate strategies for improvement.

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.