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

Approach to acute agitation in the pediatric emergency department

PURPOSE OF REVIEW

The complexity of pediatric mental and behavioral health (MBH) complaints presenting to emergency departments (EDs) is increasing at an alarming rate. Children may present with agitation or develop agitation during the ED visit. This causes significant distress and may lead to injury of the child, caregivers, or medical staff. This review will focus on providing safe, patient-centered care to children with acute agitation in the ED.

RECENT FINDINGS

Approaching a child with acute agitation in the ED requires elucidation on the cause and potential triggers of agitation for optimal management. The first step in a patient-centered approach is to use the least restrictive means with behavioral and environmental strategies. Restraint use (pharmacologic or physical restraint) should be reserved where these modifications do not result in adequate de-escalation. The provider should proceed with medications first, using the child's medication history as a guide. The use of physical restraint is a last resort to assure the safety concerns of the child, family, or staff, with a goal of minimizing restraint time.

SUMMARY

Children are increasingly presenting to EDs with acute agitation. By focusing primarily on behavioral de-escalation and medication strategies, clinicians can provide safe, patient-centered care around these events.

Checking all the boxes: a checklist for when and how to use checklists effectively

Checklists are a type of cognitive aid used to guide task performance; they have been adopted as an important safety intervention throughout many high-risk industries. They have become an ubiquitous tool in many medical settings due to being easily accessible and perceived as easy to design and implement. However, there is a lack of understanding for when to use checklists and how to design them, leading to substandard use and suboptimal effectiveness of this intervention in medical settings. The design of a checklist must consider many factors including what types of errors it is intended to address, the experience and technical competencies of the targeted users, and the specific tools or equipment that will be used. Although several taxonomies have been proposed for classifying checklist types, there is, however, little guidance on selecting the most appropriate checklist type, nor how differences in user expertise can influence the design of the checklist. Therefore, we developed an algorithm to provide guidance on checklist use and design. The algorithm, intended to support conception and content/design decisions, was created based on the synthesis of the literature on checklists and our experience developing and observing the use of checklists in clinical environments. We then refined the algorithm iteratively based on subject matter experts' feedback provided at each iteration. The final algorithm included two parts: the first part provided guidance on the system safety issues for which a checklist is best suited, and the second part provided guidance on which type of checklist should be developed with considerations of the end users' expertise.

Delays in treatment and disposition attributable to undertriage of pediatric emergency medicine patients

BACKGROUND

Triage, the initial assessment and sorting of patients in the Emergency Department (ED), determines priority of evaluation and treatment. Little is known about the impact of undertriage, the underestimation of disease severity at triage, on clinical care in pediatric ED patients. We evaluate the impact of undertriage on time to disposition and treatment decisions in pediatric ED patients.

METHODS

This was a case control study of ED visits for patients <22 years of age, with an assigned Emergency Severity Index (ESI) score of 4 or 5, and associated hospital admission, nebulized treatment, supplemental oxygen, and/or intravenous (IV) line placement, between January 1, 2018, to June 30, 2022. Controls were sampled from a pool of patient visits with an ESI score of 3, matched by intervention, disposition, and date and hour of arrival. Primary outcome measures were time to order of intervention (nebulized treatment, oxygen administration, or IV placement) and time to disposition decision. A secondary outcome measure was return visits requiring admission or emergency intervention within 14 days of the index visit. Continuous variables (time to orders) were analyzed using Wilcoxon rank sum test and dichotomous outcomes (return visits) were compared using odds ratios with 95% confidence intervals. Analysis was performed with Python v3.10.

RESULTS

The final analysis included 7245 undertriaged patients. Undertriaged patients had longer times to orders for nebulized treatments, (p < 0.001) IV placement, (p < 0.001) and admission (p < 0.001) when compared to controls. There were no significant differences in time to supplemental oxygen delivery and time to discharge compared to controls. Undertriaged patients were more likely to experience a return visit requiring admission or emergency intervention (OR 3.74, 95% CI 3.32,4.22).

CONCLUSIONS

Undertriage in the pediatric ED is associated with delays in care and disposition decisions and increases likelihood of return visits.

Standardized evaluation of hand-off documentation of ICU boarders in the emergency department

Objective

The boarding of ICU patients in the emergency department (ED) represents a considerable risk to patient safety. This study aims to describe the generation of a rubric to ensure the fidelity of vital, written hand-off between ED teams.

Methods

We performed a mixed methods design to develop a scoring rubric to evaluate written hand-off communication of medical ICU boarders between ED teams during the COVID-19 pandemic. The primary outcome was the quality of the written hand-off as agreed upon by the inter-user agreement. Our secondary outcome included variability in written quality as a function of the number of separate and distinct ED teams at the point of the transition of care.

Results

There was a moderate inter-user agreement with rubric scoring (κ = 0.70 [95% confidence interval, 0.66-0.75]). The overall trend noted that several key elements, including code status, performed interventions, and contingency planning, were infrequently documented.

Conclusions

We effectively created a quality assurance tool for ED ICU boarders that ensures relevant and vital information is relayed between ED teams. Our analysis demonstrated that all relevant information is only sometimes present in the hand-off.

A scoping review of clinical handover mnemonic devices

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

Implementation of ED I-PASS as a Standardized Handoff Tool in the Pediatric Emergency Department

INTRODUCTION

Communication, failures during patient handoffs are a significant cause of medical error. There is a paucity of data on standardized handoff tools for intershift transitions of care in pediatric emergency medicine (PEM). The purpose of this quality improvement (QI) initiative was to improve handoffs between PEM attending physicians (i.e., supervising physicians ultimately responsible for patient care) through the implementation of a modified I-PASS tool (ED I-PASS). Our aims were to: (1) increase the proportion of physicians using ED I-PASS by two-thirds and (2) decrease the proportion reporting information loss during shift change by one-third, over a 6-month period.

METHODS

After literature and stakeholder review, Expected Disposition, Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver (ED I-PASS) was implemented using iterative Plan-Do-Study-Act cycles, incorporating: trained "super-users"; print and electronic cognitive support tools; direct observation; and general and targeted feedback. Implementation occurred from September to April of 2021, during the height of the COVID-19 pandemic, when patient volumes were significantly lower than prepandemic levels. Data from observed handoffs were collected for process outcomes. Surveys regarding handoff practices were distributed before and after ED I-PASS implementation.

RESULTS

82.8% of participants completed follow-up surveys, and 69.6% of PEM physicians were observed performing a handoff. Use of ED I-PASS increased from 7.1% to 87.5% ( p < .001) and the reported perceived loss of important patient information during transitions of care decreased 50%, from 75.0% to 37.5% ( p = .02). Most (76.0%) participants reported satisfaction with ED I-PASS, despite half citing a perceived increase in handoff length. 54.2% reported a concurrent increase in written handoff documentation during the intervention.

CONCLUSION

ED I-PASS can be successfully implemented among attending physicians in the pediatric emergency department setting. Its use resulted in significant decreases in reported perceived loss of patient information during intershift handoffs.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Prospective Type 2 Hybrid effectiveness implementation study.

SETTINGS AND PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME AND MEASURES

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

RESULTS

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

Implementation of a standardized handoff system (I-PASS) in a tertiary care pediatric hospital

OBJECTIVE

The handoff is the act of transferring information and responsibility among healthcare providers, and it is critical for the patient safety and the quality of service. The aim of this study was to evaluate the implementation of a standardized medical handoff system [I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver)] and assess the effect on the amount and quality of the information transmitted during medical handoffs in a pediatric ward.

METHODS

In a prospective intervention study, physicians (staff and residents) who work in 12- or 24-h shifts in the pediatric ward of a single tertiary care Brazilian hospital were eligible. Those who agreed to participate were trained in an online session (lecture plus simulation). Medical handoffs were recorded pre- and post-intervention (training) to compare the amount and quality of information transmitted in handoffs.

RESULTS

The handoff standardization significantly increased the number of relevant information delivered for 12 out of the 16 items assessed without increasing, in seconds, the handoff duration (45.9 vs. 48.0; p=0.349). The protocol training and the following discussion about communication resulted in greater focus and attention among participants during transfers, decreasing time spent with interruptions and communication unrelated to the patient (18 vs. 2.7%). Regarding the I-PASS elements, there was an increase in the number of action lists and contingency plans reported (31 vs. 81% and 16 vs. 73%, respectively; p<0.001 for both).

CONCLUSION

Standardization brought greater efficiency and objectivity to handoffs. It increased the quantity and quality of the information transmitted while successfully drawing attention to the most important points.

I-PASS enhances effectiveness and accuracy of hand-off for pediatric general surgery patients

BACKGROUND

I-PASS is a validated and standardized hand-off protocol shown to reduce medical error and improve hand-off efficiency in the pediatric medical population. Our aim was to evaluate the feasibility, effectiveness, accuracy and resident satisfaction of implementing I-PASS on a pediatric surgery service.

METHODS

A prospective intervention Quality Improvement (QI approved) study was utilized to evaluate resident written and verbal hand-offs before and after implementation of I-PASS on a pediatric surgery service at a tertiary center. Anonymous surveys were completed by residents following each observation. Results were analyzed using T or Mann-Whitney U Tests and Chi Square.

RESULTS

A total of 49 written tools and 50 verbal hand-offs were compared pre-and post I-PASS implementation. With I-PASS, increased written accuracy was observed in the documentation of the patient summary (p < 0.05). Accuracy in the verbal hand-off of illness severity, patient summary, contingency plan, action list and synthesis also improved (p < 0.05); but duration of hand-off increased (p < 0.01). Post implementation surveys of residents demonstrated an increased understanding of patient management (p < 0.05).

CONCLUSION

Implementing I-PASS on a pediatric surgery service with modifications catered to surgical patients, improved the effectiveness and accuracy of written and verbal patient hand-offs and increased provider satisfaction and preparedness.

LEVEL OF EVIDENCE

Level II.

Improving Verbal Handoff for Patients Admitted From the Pediatric Emergency Department to Medical Inpatient Services: A Trainee-Led Quality Improvement Intervention

OBJECTIVE

Transitions of care are a well-identified source of adverse events. At our academic tertiary children's hospital, no standardized verbal handoff is used in the emergency department with a lack of education provided to clinicians on handoff. We aimed to increase the percent of handoffs from the pediatric emergency department to inpatient medical services including 7 critical elements and increase clinician score of individual handoffs and overall clinician satisfaction with handoff key components.

METHODS

Study occurred from Fall 2017 through Winter 2019. After collecting baseline data, a modified I-PASS tool was visually integrated into work areas. Tool education was performed by brief lecture, with iterative education occurring cyclically. Handoff assessment and clinician satisfaction surveys were then recollected. Outcome measures included clinician scores of individual handoffs and overall satisfaction with handoff. Process measure was percent handoffs including 7 critical elements. Balancing measure was handoff length in minutes.

RESULTS

Clinician satisfaction scores improved from baseline (response rate, 38%) to postintervention (response rate, 30%) in efficiency (57%-69%), detail (57%-66%), and safety (55%-64%). Clinician scores of individual handoffs improved from 66% rating very good or excellent at baseline to 77% postintervention. Handoff time did not increase. Percent handoffs with all 7 critical elements did not show improvement.

CONCLUSIONS

Trainee-led implementation of handoff standardization increased clinician satisfaction and clinician score of individual handoffs without compromising handoff length. Although feasibility can be a challenge, trainee-led quality improvement is meaningful and should be promoted and valued in graduate medical education, despite limitations.

Attending-Provider Handoffs and Pediatric Emergency Department Revisits

OBJECTIVE

The objective of this study was to determine if intradepartment attending-provider transitions of care (handoffs) during a pediatric emergency department (ED) encounter were associated with return ED visits resulting in hospitalization.

METHODS

We analyzed ED encounters for patients younger than 21 years discharged from a single pediatric ED from January 2013 to February 2017. We classified an encounter as having a handoff when the initial attending and discharging attending differed. Our primary outcome was a revisit within 72 hours resulting in hospitalization. Our secondary outcomes were any revisit within 72 hours and revisits resulting in hospitalization with potential deficiencies in care. We compared outcome rates for ED encounters with and without provider handoffs, both with and without adjustment for demographic, clinical, and visit characteristics.

RESULTS

Of the 177,350 eligible ED encounters, 1961 (1.1%) had a return visit resulting in hospitalization and 6821 (3.9%) had any return visit. In unadjusted analyses, handoffs were associated with an increased likelihood of a return visit resulting in hospitalization (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.26-1.70) or any return visit (OR, 1.20; 95% CI, 1.10-1.31). However, after adjustment, provider handoffs were not associated with return ED visits resulting in hospitalization (OR, 0.96; 95% CI, 0.81-1.13) or any return ED visits (OR, 1.00; 95% CI, 0.90-1.10).

CONCLUSIONS

Provider handoffs in a pediatric ED did not increase the risk of return ED visits or return ED visits with deficiencies in care after adjustment for demographic, clinical, and visit factors.

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.

Initiation of a Night Float System in an Otolaryngology Residency: Resident Perception and Impact on Operative Volume

OBJECTIVES

Evaluate resident perception on implementation of a night float (NF) system to an otolaryngology residency program. We compared these perceptions to Accreditation Council for Graduate Medical Education (ACGME) case log data.

METHODS

A retrospective anonymous survey was sent to residents and alumni graduating between 2015 and 2023. Deidentified ACGME case log information was then examined for key indicator (KI) cases from post graduate year (PGY) 2 and PGY5.

RESULTS

Thirty (93.8%) residents and alumni responded. Residents with NF answered more positively compared to those without NF on following duty hour violations: 80-hour work week, 1-in-7 days off, 1 call every 3 days, adequate time between shifts, and allotted time after a 24-hour shift. Residents most commonly agreed that NF has improved patient care, resident education, and resident morale. Although residents with NF were neutral on PGY2 case volume effects, they disagreed that it affected overall case volume. The only KIs that differed for both PGY2 and PGY5s were airway cases (P = .004 vs P = .002) and bronchoscopy (P = .02 vs P = .006), which were significantly higher for those with NF. Thyroid surgery was the only KI higher for the residents without NF and spanned all PGY levels.

CONCLUSION

Residents and alumni agreed that NF implementation had a positive effect on duty hour violations. The NF system does not have significant impact on case volume.

LEVEL OF EVIDENCE

IV Laryngoscope, 2021.

Delays in antibiotic redosing: Association with inpatient mortality and risk factors for delay

OBJECTIVE

Although timely administration of antibiotics has an established benefit in serious bacterial infection, the majority of studies evaluating antibiotic delay focus only on the first dose. Recent evidence suggests that delays in redosing may also be associated with worse clinical outcome. In light of the increasing burden of boarding in Emergency Departments (ED) and subsequent need to redose antibiotic in the ED, we examined the association between delayed second antibiotic dose administration and mortality among patients admitted from the ED with a broad array of infections and characterized risk factors associated with delayed second dose administration.

METHODS

We performed a retrospective cohort study of patients admitted through five EDs in a single healthcare system from 1/2018 through 12/2018. Our study included all patients, aged 18 years or older, who received two intravenous antibiotic doses within a 30-h period, with the first dose administered in the ED. Patients with end stage renal disease, cirrhosis and extremes of weight were excluded due to a lack of consensus on antibiotic dosing intervals for these populations. Delay was defined as administration of the second dose at a time-point greater than 125% of the recommended interval. The primary outcome was in-hospital mortality.

RESULTS

A total of 5605 second antibiotic doses, occurring during 4904 visits, met study criteria. Delayed administration of the second dose occurred during 21.1% of visits. After adjustment for patient characteristics, delayed second dose administration was associated with increased odds of in-hospital mortality (OR 1.50, 95%CI 1.05-2.13). Regarding risk factors for delay, every one-hour increase in allowable compliance time was associated with a 18% decrease in odds of delay (OR 0.82 95%CI 0.75-0.88). Other risk factors for delay included ED boarding more than 4 h (OR 1.47, 95%CI 1.27-1.71) or a high acuity presentation as defined by emergency severity index (ESI) (OR 1.54, 95%CI 1.30-1.81 for ESI 1-2 versus 3-5).

CONCLUSIONS

Delays in second antibiotic dose administration were frequent in the ED and early hospital course, and were associated with increased odds of in-hospital mortality. Several risk factors associated with delays in second dose administration, including ED boarding, were identified.

Best Practices in Patient Safety and Communication

Emergency medicine is a high-risk area of medical practice, with a high rate of preventable adverse events. This is multifactorial, hinging on the myriad system and processes issues that complicate emergency care. Strong teamwork and communication have been identified as critical components for safe care in emergency medicine. Health care professionals and leaders within emergency medicine can implement solutions aimed at cultivating a strong safety culture, creating processes and system-based approaches to improve patient safety. This article provides an overview of the evidence-based approaches to improve patient safety and communication.

Implementing receiver-driven handoffs to the emergency department to reduce miscommunication

BACKGROUND

Miscommunications during care transfers are a leading cause of medical errors. Recent consensus-based recommendations to standardise information transfer from outpatient clinics to the emergency department (ED) have not been formally evaluated. We sought to determine whether a receiver-driven structured handoff intervention is associated with 1) increased inclusion of standardised elements; 2) reduced miscommunications and 3) increased perceived quality, safety and efficiency.

METHODS

We conducted a prospective intervention study in a paediatric ED and affiliated clinics in 2016-2018. We developed a bundled handoff intervention included a standard template, receiver training, awareness campaign and iterative feedback. We assessed a random sample of audio-recorded handoffs and associated medical records to measure rates of inclusion of standardised elements and rate of miscommunications. We surveyed key stakeholders pre-intervention and post-intervention to assess perceptions of quality, safety and efficiency of the handoff process.

RESULTS

Across 162 handoffs, implementation of a receiver-driven intervention was associated with significantly increased inclusion of important elements, including illness severity (46% vs 77%), tasks completed (64% vs 83%), expectations (61% vs 76%), pending tests (0% vs 64%), contingency plans (0% vs 54%), detailed callback request (7% vs 81%) and synthesis (2% vs 73%). Miscommunications decreased from 48% to 26%, a relative reduction of 23% (95% CI -39% to -7%). Perceptions of quality (35% vs 59%), safety (43% vs 73%) and efficiency (17% vs 72%) improved significantly post-intervention.

CONCLUSIONS

Implementation of a receiver-driven intervention to standardise clinic-to-ED handoffs was associated with improved communication quality. These findings suggest that expanded implementation of similar programmes may significantly improve the care of patients transferred to the paediatric ED.

Development and implementation of a standardised emergency department intershift handover tool to improve physician communication

BACKGROUND

Structured handover can reduce communication breakdowns and potential medical errors. In our emergency department (ED) we identified a safety risk due to variation in quality and content of overnight handovers between physicians.

AIM

Our goal was to develop and implement a standardised ED-specific handover tool using quality improvement (QI) methodology. We aimed to increase the proportion of patients having adequate handover information conveyed at overnight shift change from a baseline of 50%-75% in 4 months.

METHODS

We used published best practices, stakeholder input and local data to develop a tool customised for intershift ED handovers. Implementation methods included education, cognitive aids, policy change and plan-do-study-act cycles informed by end-user feedback. We monitored progress using direct observation convenience sampling.

MEASURES

Our outcome measure was proportion of adequate patient handovers (defined as >50% of handover components communicated per patient) per overnight handover session. Tool utilisation characteristics were used for process measurement, and time metrics for balancing measures. We report changes using statistical process control charts and descriptive statistics.

RESULTS

We observed 49 overnight handover sessions from 2017 to 2019, evaluating handovers of 850 patients. Our improvement target was met in 10 months (median=76.1%) and proportion of adequate handovers continued to improve to median=83.0% at the postimprovement audit. Written communication of handover information increased from a median of 19.2% to 68.7%. Handover time increased by median=31 s per patient. End-users subjectively reported improved communication quality and value for resident education.

CONCLUSIONS

We achieved sustained improvements in the amount of information communicated during physician ED handovers using established QI methodologies. Engaging stakeholders in handover tool customisation for local context was an important success factor. We believe this approach can be easily adopted by any ED.

Developing an emergency medicine handoff tool: an electronic Delphi approach

BACKGROUND

Handoffs at the end of clinical shifts occur with high frequencies in the emergency department setting and they pose an increased risk to patients. There is a need to standardize handoff practices. This study aimed to use an electronic Delphi method to identify the core elements essential for an emergency department physician to physician handoff and propose a framework for implementation.

METHODS

An electronic Delphi-style study with a national panel of board-certified emergency physicians in Saudi Arabia. The panel was conducted over four rounds. The first to identify elements relevant to the end of shift handoff and categorize them into domains, while the remaining three to score and debate individual elements.

RESULTS

Twenty-five board-certified emergency physicians from various cities and practice settings were enrolled. All panelists completed the entire Delphi process. Thirty-two elements were identified and classified into 4 domains. The top five rated handoff elements were patient identification, chief complaint history, clinical stability, working diagnosis, and consulting services involved. Panel scores showed convergence as rounds progressed and the final list of elements had a high-reliability score (Cronbach's alpha 0.93).

CONCLUSIONS

This study yielded an itemized and ranked list of elements that are easy to implement and could be used to standardize patient handoffs by emergency physicians. While this study was conducted on an emergency medicine panel, the methods used may be adapted to develop standardized handoff frameworks that serve different disciplines or practice settings.

Handover of Patients From Prehospital Emergency Services to Emergency Departments: A Qualitative Analysis Based on Experiences of Nurses

BACKGROUND

During the transfer of patients, both ambulance and hospital emergency service professionals need to exchange necessary, precise, and complete information for an effective handover. Some factors threaten a quality handover such as excessive caseload, patients with multiple comorbidities, limited past medical history, and frequent interruptions.

PURPOSE

To explore the viewpoint of nurses on their experience of patient handovers, describing the essential aspects of the process and areas for improvement, and establishing standardized elements for an effective handover.

METHODS

A qualitative research method was used.

RESULTS

Nurses identified the need to standardize the patient transfer process by a written record to support the verbal handover and to transmit patient information adequately, in a timely manner, and in a space free of interruptions, in order to increase patient safety.

CONCLUSIONS

An organized method does not exist. The quality of handovers could be enhanced by improvements in communication and standardizing the process.

Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care

Pediatricians render care in an increasingly complex environment, which results in multiple opportunities to cause unintended harm. National awareness of patient safety risks has grown since the National Academy of Medicine (formerly the Institute of Medicine) published its report "To Err Is Human: Building a Safer Health System" in 1999. Patients and society as a whole continue to challenge health care providers to examine their practices and implement safety solutions. The depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to reveal a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification and diagnostic error. Pediatric health care providers in all practice environments benefit from having a working knowledge of patient safety language. Pediatric providers should serve as advocates for best practices and policies with the goal of attending to risks that are unique to children, identifying and supporting a culture of safety, and leading efforts to eliminate avoidable harm in any setting in which medical care is rendered to children. In this Policy Statement, we provide an update to the 2011 Policy Statement "Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care."

Location, Location, Location: The Association Between Imaging Setting and Follow-Up of Findings of Indeterminate Malignant Potential

PURPOSE

To evaluate the relationship between patient location at time of imaging and completion of relevant imaging follow-up for findings with indeterminate malignant potential.

METHODS

We used a mandatory hospital-wide standardized assessment categorization system to analyze all ultrasound, CT, and MRI examinations performed over a 7-month period. Multivariate logistic regression, adjusted for imaging modality, characteristics of patients, ordering clinicians, and interpreting radiologists, was used to evaluate the relationship between patient location (outpatient, inpatient, or emergency department) at the time of index examination and completion of relevant outpatient imaging follow-up.

RESULTS

Relevant follow-up occurred in 49% of index examinations, with a greater percentage among those performed in the outpatient setting compared with those performed in the inpatient or emergency department settings (62% versus 18% versus 17%, respectively). Compared with examinations obtained in the outpatient setting, examinations performed in the emergency department (adjusted odds ratio [aOR] 0.07; 95% confidence interval [CI], 0.03-0.19) and inpatient (aOR 0.14; 95% CI, 0.09-0.23) settings were less likely to be followed up. Black patients and those residing in lower-income neighborhoods were also less likely to receive relevant follow-up. Few lesions progressed to more suspicious lesions (4.6%).

CONCLUSIONS

Patient location at time of imaging is associated with the likelihood of completing relevant follow-up imaging for lesions with indeterminate malignant potential. Future work should evaluate health system-level care processes related to care setting, as well as their effects on appropriate follow-up imaging. Doing so would support efforts to improve appropriate follow-up imaging and reduce health care disparities.

Handoff Tool Enabling Standardized Transitions Between the Emergency Department and the Hospitalist Inpatient Service at a Major Cancer Center

Communication failures during patient handoff can lead to serious errors. A quality improvement team created a standardized handoff tool/process (DE-PASS: Decisive problem requiring admission, Evaluation time, Patient summary, Acute issues/action list, Situation unfinished/awareness, Signed out to) for admitting patients from the emergency department (ED) to the hospitalist inpatient service of a tertiary cancer center. DE-PASS mirrors the institution's ED workflow, stratifies patients as stable/urgent/emergent, and establishes requirements for verbal and email communications between providers. Comparison of preintervention and postintervention results from the 1-month pilot revealed that within a 24-hour period, DE-PASS reduced the number of intensive care unit transfers by 58% ( P = .393), the number of rapid-response team calls by 39% ( P = .637), and time to inpatient order by 31% ( P = .004). ED physicians' and hospitalists' satisfaction with DE-PASS increased. Reduction in intensive care unit transfers was sustained after the pilot ( P = .029). DE-PASS feasibility was evidenced by 100% uptake. By stratifying patients by risk level, DE-PASS reduced admission-to-evaluation times for unstable patients, potentially improving patient safety.

Standardized Reporting System Use During Handoffs Reduces Patient Length of Stay in the Emergency Department

Background

Emergency department (ED) shift handoffs are potential sources of delay in care. We aimed to determine the impact that using standardized reporting tool and process may have on throughput metrics for patients undergoing a transition of care at shift change.

Methods

We performed a prospective, pre- and post-intervention quality improvement study from September 1 to November 30, 2015. A handoff procedure intervention, including a mandatory workshop and personnel training on a standard reporting system template, was implemented. The primary endpoint was patient length of stay (LOS). A comparative analysis of differences between patient LOS and various handoff communication methods were assessed pre- and post-intervention. Communication methods were entered a multivariable logistic regression model independently as risk factors for patient LOS.

Results

The final analysis included 1,006 patients, with 327 comprising the pre-intervention and 679 comprising the post-intervention populations. Bedside rounding occurred 45% of the time without a standard reporting during pre-intervention and increased to 85% of the time with the use of a standard reporting system in the post-intervention period (P < 0.001). Provider time (provider-initiated care to patient care completed) in the pre-intervention period averaged 297 min, but decreased to 265 min in the post-intervention period (P < 0.001). After adjusting for other communication methods, the use of a standard reporting system during handoff was associated with shortened ED LOS (OR = 0.60, 95% CI 0.40 - 0.90, P < 0.05).

Conclusions

Standard reporting system use during emergency physician handoffs at shift change improves ED throughput efficiency and is associated with shorter ED LOS.

Novel Transfer of Care Sign-out Assessment Tool in a Pediatric Emergency Department

OBJECTIVE

Transfer of care sign-outs (TOCS) for admissions from a pediatric emergency department have unique challenges. Standardized and reliable assessment tools for TOCS remain elusive. We describe the development, reliability, and validity of a TOCS assessment tool.

METHODS

Video recordings of resident TOCS were assessed to capture 4 domains: completeness, synopsis, foresight, and professionalism. In phase 1, 56 TOCS were used to modify the tool and improve reliability. In phase 2, 91 TOCS were used to examine validity. Analyses included Cronbach's alpha for internal structure, intraclass correlation and Cohen's kappa for interrater reliability, Pearson's correlation for relationships between variables, and 95% confidence interval of the mean for resident group comparisons.

RESULTS

Cronbach's alpha was 0.52 for internal structure of the tool's subjective rating scale. Intraclass correlation for the subjective rating scale items ranged from 0.70 to 0.80. Cohen's kappa for most objective checklist items ranged from 0.43 to 1. Content completeness was significantly correlated with synopsis, foresight, and professionalism (Pearson's r ranged from 0.36 to 0.62, P values were <0.001). House staff senior residents scored higher (on average) than interns and rotating senior residents in synopsis and foresight. Also, house staff interns scored higher (on average) than rotating senior residents in professionalism. House staff senior residents scored higher (on average) than rotating senior residents in content completeness.

CONCLUSIONS

We provide validity evidence to support using scores from the TOCS tool to assess higher-level transfer of care comprehension and communication by pediatric emergency department residents and to test interventions to improve TOCS.