Improving availability and accuracy of the junior doctors' on-call handover through digitalisation

Clinical handovers from out-of-hours activity are essential for relaying information about events such as new admissions, outstanding or complete investigations, physical health reviews, ward jobs and risk. This information enables the day team to effectively prioritise and follow-up any necessary tasks.Junior doctors at a hospital site in the London Borough of Newham were aware that the existing handover system, constituted of a word document circulated via email, was lacking robustness and that the handover was not sent out reliably on a daily basis.Quality improvement (QI) methods including process mapping, PDSA ('Plan, Do, Study, Act') cycles, driver diagrams and run charts were used to understand the issue, create a more robust process and measure the improvements made, all supported by regular QI project meetings. The change ideas included moving from an informal Microsoft (MS) Word document, which was emailed out, to an Excel spreadsheet stored centrally on MS Teams. Column headers were added for admissions, ward jobs, seclusion reviews, matters relating to mental health law and Accident and Emergency (A&E) assessments, as well as defined columns for outstanding jobs and standard tasks that need to be completed for all admissions. Responsibility for circulating the handover list was given to the incoming day duty doctor if the night doctor was too busy, with admin support to chase the circulation of the handover. Results were studied for the following 18 months.The percentage of handovers being appropriately sent out increased from a median of 80% to 100% during the project period, and the availability of handover data where the data were visible to doctors on MS Teams but had not been sent out also increased from a median of 80% to 100%. The system was deemed safe, effective and easy to use, and has already been replicated at neighbouring hospitals.

Improving handoff with the implementation of I-PASS at a tertiary oncology hospital

BACKGROUND

Lack of consistent and standardised handoffs is a leading cause of patient harm. With increased census in our hospital medicine (HM) service, failure to handoff using a standardised method has the potential to cause significant patient harm. We used a quality improvement methodology to standardise an existing and validated handoff tool within our HM team to improve handoff communication among providers and improve patient safety.

METHODS

A quality improvement team was charged with studying handoff communication among HM teams and between day and night shift providers at a tertiary oncology hospital. Multiple plan-do-study-act cycles were conducted, and process flow maps, root cause analysis and an affinity diagram were developed based on feedback from the HM team. The quality improvement team developed a plan to implement I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency plan, and Synthesis by receiver) as the standardised handoff tool to be used among the providers in HM at the end of shift and for handoff to the nocturnal covering service. Rates of I-PASS use were collected before and after several educational interventions to encourage use of I-PASS and were displayed in a control chart. After the I-PASS interventions, HM providers were surveyed twice to evaluate the secondary outcomes: the tool's impact on workflow, perceptions of patient safety, ease of use and satisfaction with I-PASS. Survey results were compared using Fisher exact tests.

RESULTS

The HM team's rate of use of I-PASS handoffs increased from 23% to 72%, an improvement of 68%. By the end of the quality improvement project, I-PASS use had increased to 90%. No significant differences were detected in the reported duration of handoffs after I-PASS implementation (on average <5 min per patient, p=0.205). Provider perceptions of handoff quality, efficiency, communication errors and the I-PASS tool's effectiveness were satisfactory.

CONCLUSION

We used a quality improvement methodology to encourage the HM team's adoption of a validated handoff tool. Adherence to the standardised handoff tool significantly improved workflows and facilitated communication between the day and night shift teams.

Turn that frown upside down: implementation of a visual cue improves communication during emergency department to inpatient hand-offs

When a patient is admitted to the hospital from the emergency department (ED), the ED clinician passes on relevant clinical information to the admitting team to transition care, a process known as patient hand-off and commonly referred to as 'calling report'. This information exchange between clinical teams is not only important for care continuity but also signifies a transition of care.However, there are unique challenges in this hand-off process given the unpredictability of the busy ED environment, ED boarding and discontinuity in physician, nursing and transportation workflows. These challenges create the potential for gaps in communication and can create patient safety concerns, particularly if a patient is transported to an inpatient bed before hand-off takes place.We set out to determine whether introducing a visual cue on the electronic health record (EHR) ED trackboard to communicate that report had been given would improve hand-off compliance. We sought to improve the utility of the visual cue and compliance of calling report prior to patient transport through a series of several Plan Do Study Act (PDSA) cycles.Baseline compliance using the 'Report Called' button prior to implementation of our visual intervention was 9.8%. With staff education alone, compliance rose to 41.3%. However, with an easily recognisable visual cue highlighted on the trackboard and an improved workflow compliance immediately rose to >97% and has been sustained for 84 months. Additionally, we have had zero reported incidents of patients being transported to a hospital bed before physician report was called since implementation.Our study demonstrates that simple visual cues and incorporation of a user-friendly process in the workflow can improve compliance with ensuring report is called prior to patient transfer from the ED. This may have a positive impact on physician communication and patient safety during the admission process.

Nearly All Cancer Survivors Return to Primary Care

BACKGROUND

During cancer treatments, patients often defer primary care and comorbidity management, which may not be optimal for overall health when patients transition into survivorship. We sought to quantify primary care utilization among cancer survivors who are ≥2 years post cancer treatments.

METHODS

951 cancer survivors were included in this national, prospective cohort study using the Regional Geographic and Racial Differences in Stroke (REGARDS) data.

RESULTS

Nearly all (91.6%) cancer survivors had at least 1 annual PCP visit and most (54.6%) had a PCP as their dominant provider.

CONCLUSION

These findings underscore the urgent need for smooth handoffs from oncology back to primary care.

Implementation and Analysis of an Institution-Wide EHR-Integrated Handoff Note

EHR-Integrated Handoff Notes are becoming increasingly prevalent, especially among inpatient clinical service teams composed of physicians in training (resident physicians). We describe the implementation of such a tool at our institution, and then describe the usage of the tool, as well as changes made to its content, structure, and format, years after original implementation. We also describe frequency and temporal distribution of updates made to free text elements of the Handoff Note. At the initial implementation there were three versions available; medical/surgical, pediatric, and ICU. Years after implementation, 57% of clinical service teams continue to utilize the note, including all medical, pediatric, behavioral health, obstetrics/gynecology, and neurology services, as well as most surgical services, that serve as "primary" teams. Several interesting changes were noted to the content and structure of the Handoff Note, namely that more complicated versions were abandoned in favor of simpler versions. The Patient Summary and To Do free text boxes are updated an average of 1.0 and 1.6 times per day. Around 60% of updates to both free text boxes occur between 12 pm - 5:59 pm, likely in preparation for the daytime-nightime team handoff.

A Smartphone App for Bedside Recording of Nursing Handovers in Haemodialysis Units

The purpose of this study is to present the design, development and initial evaluation of a smartphone software (mobile app), for the needs of nursing bedside shift reporting and documentation. The app records and process nursing handovers concerning haemodialysis patient data, and it runs on Android smartphones, offering a structured and friendly user interface. Data are collected, processed, stored and accessed easily, quickly and securely by authorized users. The evaluation, based on discussions and semi-structured interviews with a group of nurses, showed positive feedback on the user interface, structure and functions of the prototype. It can be a useful and efficient tool for the reporting and communication needs between nurses. Conclusions about the limitations of the study and future developments are reported.

Designing Shift Handoff Software: Clinical Learners and Design Students Collaborate Using the "Design Thinking" Process

Handoffs in patient care responsibilities between practitioners are common in the hospital setting. Because inadequate communication can lead to patient harm, professional organizations have published recommendations and practical guides to support standardized workflow. However, currently available electronic medical record (EMR) tools rarely provide the requisite functionality to support work and often suffer from major usability flaws. Our internal medicine residency program sponsored a quality improvement initiative to improve the design of handoff tools. To support this initiative, our medical informatics program collaborated with a school of architecture and design to identify requirements and ideate interface prototypes. In this article, we describe how we used Design Thinking principles and methods to inform our product design lifecycle, create novel designs, and teach inter-professional students health systems science concepts.

Anesthesiology Handoff Simulation Case: A Handoff From Intensive Care Unit to Operating Room for Anesthesiology Learners

INTRODUCTION

Handoffs have been shown to be a potential cause of communication failures, leading to possible inefficiencies and patient harm. We noticed that our CA-1 residents were struggling with patient handoffs and designed this simulation to improve their handoff skills.

METHODS

This anesthesiology-specific simulation introduced learners to the perioperative handoff process. We designed it for anesthesiology learners, including junior residents, medical students, and student nurse anesthetists. The simulation centered upon an anesthesiology resident taking care of an ICU patient and handing that patient off to another anesthesiology provider, who took the patient to the OR. We charged learners with reviewing the patient's history and hospital course and giving a complete handoff. We evaluated learners on the completeness and quality of the handoff, as well as on their performance during the session.

RESULTS

Twenty-seven learners participated in this handoff simulation. The participants reported that the simulation improved their understanding of the anesthetic implications of medical conditions and gave them a better understanding of the essential elements of a handoff. Learners also indicated that the debriefing portion of the simulation was effective in filling some of their medical knowledge gaps and improving their handoff skills.

DISCUSSION

This simulation was found to be an effective educational experience for our CA-1 and CA-3 residents, medical students, and student nurse anesthetists. Feedback was positive from all learners. As a result, this simulation will be implemented in the early learning curriculum for all of our CA-1 residents.

Resident-Physician Preferences for Electronic Handoff Note Content: Implications for Implementation of a System-Wide Electronic Health Record-Integrated Handoff Tool

Increasing attention is paid to the Handoff Process and EHR- integrated tools to enhance the Handoff Process and aid in creating Handoff Notes are becoming more prevalent. In this study, we attempted to determine the ideal content of the Handoff Note based on the preferences of the resident physicians for whom the tool was being constructed. This commenced with an initial semi-structured interview and culminated in a large-scale survey. Overall, 315 resident physicians completed the survey. Plan of Care, Illness Severity, and Patient Summary were the most important content elements to resident physicians. The importance and trustworthiness of other content elements, as well as their preferred display and level of granularity within the Handoff Note, varied considerably. Subjective assessment by a colleague of a patient's hospital course and plan of care, rather than any single piece of objective data, are preferred as ideal content for Handoff Note composition by resident physicians.

I-PASS Mentored Implementation Handoff Curriculum: Implementation Guide and Resources

Introduction

Communication failures during shift-to-shift handoffs of patient care have been identified as a leading cause of adverse events in health care institutions. The I-PASS Handoff Program is a comprehensive handoff program that has been shown to decrease rates of medical errors and adverse events. As part of the spread and adaptation of this program, a comprehensive implementation guide was created to assist individuals in the implementation process.

Methods

The I-PASS Mentored Implementation Guide grew out of materials created for the original I-PASS Study, Society of Hospital Medicine (SHM) mentored implementation programs, and the experience of members of the I-PASS Study Group. The guide provides a comprehensive framework of all elements required to implement the large-scale I-PASS Handoff Program and contains detailed information on generating institutional support, training activities, a campaign, measuring impact, and sustaining the program.

Results

Thirty-two sites across North America utilized the guide as part of the SHM program. The guide served as a main reference for 477 hours of mentoring phone calls between site leads and their mentors. Postprogram surveys from wave 2 sites revealed that 85% (N = 34) of respondents felt the quality of the guide was very good/excellent. Site leads noted that they referenced the guide most often during the early part of the program and that they referenced the sections on the curriculum and handoff observations most often.

Discussion

The I-PASS Mentored Implementation Guide is an essential resource for those looking to implement the large-scale I-PASS Handoff Program at their institution.

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Use of Simulation to Improve Cardiopulmonary Resuscitation Performance and Code Team Communication for Pediatric Residents

INTRODUCTION

Cardiorespiratory events are infrequent in pediatric teaching hospitals but can lead to significant morbidity and mortality. Clear communication within the response team prevents delays in action and allows all team members to contribute to providing optimum management. This resource was developed to simulate high-acuity and low-frequency events for pediatric residents. The scenario options are recurrent supraventricular tachycardia, prolonged QT syndrome, myocarditis, and respiratory syncytial virus bronchiolitis.

METHODS

The simulation is best performed in a simulation center with audio- and video-recording capabilities but could also be performed in situ in the pediatric intensive care unit or emergency room. Necessary personnel include a simulation technician and two instructors. A code cart, mock medications, and defibrillator with hands-free pads appropriate for the mannequin are necessary supplies. Critical actions include initial survey and intervention, rhythm recognition, cardiopulmonary resuscitation (CPR), use of defibrillator, and administration of anti-arrhythmic medications when needed. At the conclusion of the scenario, a formal debriefing with learners using structured feedback is performed.

RESULTS

These cases have been used with groups of pediatric or emergency medicine residents approximately 16 times over the past 3 years. Learners have reported that participation increased their confidence and comfort with management of cardiorespiratory events and that communication technique practice improved their teamwork and sign-out skills. Rhythm recognition and CPR performance scores during the simulation scenarios improved, with subjective improvement during actual cardiorespiratory events.

DISCUSSION

This resource advances learner knowledge of Pediatric Advanced Life Support algorithms and teamwork communication and identifies learner knowledge and management deficits.

Electronic Health Records in Prehospital Care

Documentation is an essential part and duty in all clinical settings. "ELGA" (short for "Elektronische Gesundheitsakte") is the Austrian Electronic Health Record and aims to support the process of clinical decision-making. However the use case of integrating ELGA to an out-of-hospital setting is not defined yet. This work explores the special requirements in prehospital care. The aim of research is to identify needed information and processes at the emergency scene to establish appropriate decisions about diagnosis, treatments and transport. Moreover the mentioned use case should be discussed by mapping available data fields in ELGA to the required data at scene. To satisfy the research goal an exploratory research using field work and expert interviews was done as well as a systematic analysis of findings. The results were analyzed with a thematic analysis approach and structured as flow charts, to illustrate the process, and as an Entity-Relationship-Model, to show the required data at scene mapped to available data fields in ELGA. It was possible to show that ELGA is suitable to serve several use cases in prehospital care.

Assessing Provider-Generated Free-Text Quality in EHR-Integrated Handoff Notes

Handoff notes are increasingly integrated within electronic health record (EHR) systems and often contain data automatically generated from the EHR and free-text narratives. We examined the quality of data entered by providers in the free-text portion of our institutional EHR handoff tool. Overall, 65% of handoff notes contained at least one error (average 1.7 errors per note). Most errors were omissions in information around patient plan/management or assessment/diagnosis rather than entry of false data. Factors associated with increased error rate were increasing hospital day number; weekend note; medical (vs. surgical) service team; and authorship by a medical student, first or fourth year resident physician, or attending physician. Our findings suggest that errors are common in handoff notes, and while these errors are not completely false data, they may provide individuals caring for patients an inaccurate understanding of patient status.

Patient Handovers - Cognitively Demanding: Does the Handover EHR Meet This Challenge?

Patient handovers are crucial to warrant continuity of care and patient safety. The handoverEHR is an instrument that allows users to depict the main features of a clinical case in cognitive maps. We were interested whether this tool had an effect on the task load. A cross-over study with 30 nursing students was therefore conducted. Mental demand showed a statistical trend to be lower in cognitive map handovers than in the other handover types.

Entrustable Professional Activity 10: Recognizing the Acutely Ill Patient-A Delirium Simulated Case for Students in Emergency Medicine

INTRODUCTION

This simulation case was designed to evaluate the ability of third- and fourth-year emergency medicine clerkship students and acting interns to perform the tasks outlined in the Association of American Medical College's Core Entrustable Professional Activity 10, to "recognize a patient requiring urgent or emergent care and initiate evaluation and management." The overarching goal is to assess medical students' ability to recognize and take steps to stabilize a sick patient.

METHODS

In this case, students encounter a physician, simulated with a high-fidelity manikin, who has suddenly become confused. Students are expected to recognize that he is acutely ill, call for help, and begin the initial steps of resuscitation. Bedside testing reveals hypoglycemia, which students are expected to treat. Further examination, history gathering, and diagnostic tests reveal that the patient is suffering from gram-negative sepsis. Students are evaluated on their ability to recognize signs of serious illness, call for appropriate help, perform critical assessment and treatment tasks, communicate their findings to an attending physician, and determine the appropriate patient disposition. Outcomes are measured using critical action checklists.

RESULTS

Initial trials of this case demonstrated its feasibility. All 13 students who have participated in this session have identified all five critical actions.

DISCUSSION

In later iterations, the number of roles was streamlined in order to reduce how many personnel were required. As a result of the very high critical-actions success rates of the first two groups of students tested, our case-specific checklist was revised with the goal of improving its discriminatory power.

Team-Based Simulation for Medical Student Handoff Education

INTRODUCTION

Good handoffs require teamwork, clear communication, a cognitively safe environment, and a good understanding of the patient's medical needs. Complex tertiary care training institutions require multiple handoffs over a patient's time in the hospital. Medical students need better handoff education. We designed a handoff training exercise using a simulated patient care environment for students to practice and observe multiple handoffs over time.

METHODS

An initial large-group didactic session provides direct instruction on handoffs. In small groups, students are subsequently assigned roles as individual physicians in a chain of providers during a simulated patient hospitalization over several days, with an additional student as an observer. Blinded to any prior discussion, student physicians sequentially give and receive handoffs about the patient from a previous physician as their simulated hospital course evolves. The observer shares his or her insights, and a large-group structured debriefing exercise follows.

RESULTS

In both 2015 and 2016, we implemented this session with a cohort of 30 fourth-year medical students. Most recently we implemented this with chief residents, and a group of 20 third-year pediatric clerkship students. We reviewed a selection of the discussion guides and found reporters/ observers noted that participants stated the primary problem 95% of the time (19 of 20 handoffs), the patient acuity 90% of the time (18 of 20 handoffs), and a clear contingency plan 85% of the time (17 of 20 handoffs).

DISCUSSION

We found students initially to be preoccupied with making correct clinical decisions instead of giving effective handoffs, and consequently we clarified details and adjusted clinical information to be more transparent. Results suggest the session achieves our goals of using a structured handoff method to communicate higher-level information and debrief effectively with peers. We envision this activity to be applicable to teaching handoffs to residents, nurses, and other health care professionals, as well as possibly in diverse clinical environments or in collaboration with outpatient providers.

Impact of electronic reminders on venous thromboprophylaxis after admissions and transfers

OBJECTIVE

Clinical decision support has the potential to improve prevention of venous thromboembolism (VTE). The purpose of this prospective study was to analyze the effect of electronic reminders on thromboprophylaxis rates in wards to which patients were admitted and transferred. The latter was of particular interest since patient handoffs are considered to be critical safety issues.

METHODS

The trial involved two study periods in the six departments of a university hospital, three of which were randomly assigned to the intervention group displaying reminders during the second period. At 6 h after admission or transfer, the algorithm checked for prophylaxis orders within 0-30 h of the patient's arrival, increasing the specificity of the displayed reminders.

RESULTS

The significant impact of the reminders could be seen by prophylaxis orders placed 6-24 h after admission (increasing from 8.6% (223/2579) to 12% (307/2555); p<0.0001) and transfer (increasing from 2.4% (39/1616) to 3.7% (63/1682); p=0.034). In admission wards, the rate of thromboprophylaxis increased from 62.4% to 67.7% (p<0.0001), and in transfer wards it increased from 80.2% to 84.3% (p=0.0022). Overall, the rate of prophylaxis significantly increased in the intervention group from 69.2% to 74.3% (p<0.0001). No significant changes were observed in the control group. Postponing prophylaxis checks to 6 h after admissions and transfers reduced the number of reminders by 62% and thereby minimized the risk of alert fatigue.

CONCLUSIONS

The reminders improved awareness of VTE prevention in both admission and transfer wards. This approach may contribute to better quality of care and safer patient handoffs.