The Sign-out Success workshop: A handoff workshop for physicians in training

Transcription

1 Leonard Feldman, M.D., Assistant Professor, Departments of Medicine and Pediatrics, Associate Director, Osler Medical Training Program The Sign-out Success workshop: A handoff workshop for physicians in training

2 Disclosures No Relevant Disclosures

3 Acknowledgements Created by: Hanan Aboumatar, M.D., M.P.H., Education & Research Associate. Center for Innovation in Quality Patient Care, School of Medicine, Johns Hopkins University A big thank you for our SOS Workshop Team Michael Fradley, MD Maulik Majmudar, MD Hansie Mathelier, MD Channing Paller, MD Jay Parkinson, MD, MPH Kevin Woods, MD and all our interns who sat through the pilot implementation of this workshop. Thank you to Ms. Mavis Knox and Dr. Peter Greene for their valuable contribution and support towards development of the computerized sign-out tool.

4 Workshop Objectives By the end of this workshop participants will be able to: 1. Describe system-based strategies for safegaurding transitions of care from miscommunication threats 2. Teach a structured verbal and written communication approach for delivering sign-outs 3. Conduct SOS workshop for their interns and residents 4. Describe two evaluation strategies to follow up on sign-out training implementation

5 Workshop Outline Session 1 Session 2 Introductions and Objectives 8:30-8:40 12:15-12:30 Opening Exercise 8:40-9:00 12:30-12:50 SOS strategy & videoclip 9:00-9:30 12:50-1:20 Implementation & evaluation of sign-out training 9:30-10:00 1:20-1:45

6 Why have sign-out training? Shorten the learning curve Address discontinuity of care and increased opportunities for miscommunication ACGME competencies Systems based practice Communication Meet requirement for standardized hand-offs by Joint Commission Doing things systematically is all of the rage

7 Opening Exercise Introduce yourself to your partner Review your case, sign-out to your partner. Listen to their sign-out After both of you have signed out, evaluate the sign-out you received using provided tool. Do not share your evaluation individually. Will discuss as a group. 15 minutes for the exercise

8 For new interns Case Scenario: 4:00 AM You were paged at 4:00 AM shortly after you went for a nap: Mr. smith is complaining of SOB. Please come now. Jane Walden RN x You pull your sign-out and it says that Mr. Smith is a 65 yr old male with severe COPD (FEV1 1.0 lit) who came in with a flare and had his nebulizer treatments spaced today. He has no history of cardiac disease and is full code. You answer Jane that you re on your way. Meanwhile you ask her to check vitals, and administer a nebulizer treatment

9 How did Mr. Smith s sign-out help you?

10 Sign-out Transfer of information & patient care responsibility during transitions of care Alternative names: Hand-over, sign-out, signoff, change of shift, giving report. How does a good sign-out help you? save the physician on-call time avoid unnecessary work/anxiety improve patient care.

11 Joint Commission s Communication-related Goals National Patient Safety Goals Improve the effectiveness of communication among caregivers : Read-Back // Handoff Accurately and completely reconcile medications and other treatments across the continuum of care: Address specifically during handoff Encourage the active involvement of patients and their families in the patient s care, as a patient safety strategy

12 JC Communication-related Goals Interactive Up-to-date Recent or anticipated changes Verification or read-back Limit interruptions

13 JHACO Website. Sentinel Events Statistics

14 PSN Review Reviewed 143 PSN events Nature of missing information: An action12 Patient assessment10 Patient background 54 Ownership of required action16 Patient misidentification 5 Safety precautions e.g. fall risk 26 Treatment urgency/ timing issues 20

15 ED Medical Reco Laboratory Operator Radiology Other Diagnostic services Other Supportive services

16 Hand-Off/ Sign-out challenges Communications skills vary among individuals Listening skills vary among individuals High stress situations can affect our capability to process or articulate information Potential for information overload A standardize approach can help!

17 What make s for good communication during sign-out? Face to face sign-out is best Need a verbal & written component. Limit interruptions ( interferes with information transfer). Receiver of sign-out should have opportunity to review info/ data & ask questions Receiver needs to summarize & prioritize received information, esp. To do tasks, via teachback method.

18 Sign-out Key Points Select quiet location- avoid high traffic areas Sign-out templates and computerized sign-outs are better than handwritten ones. Avoid double hand-offs Adjust length and depth of review depending on oncoming resident knowledge about patient and type of transition in care ( e.g. transfer sign-out vs. overnight cross-coverage) Sign-out represents a dual opportunity for error & error detection (fresh set of eyes- Patterson)

19 WHAT INFORMATION IS CRUCIAL FOR A GOOD SIGN-OUT?

20 Taxonomy of Sign-Out Quality- from Arora,et al.,2005 Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. Dec 2005;14(6):

21 Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate signout for patient care. Arch Intern Med. Sep ;168(16):

22 Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. Jul 2006;1(4):

23 Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. Jul 2006;1(4):

24 SHM Proposed Process Verbal exchange standards (4 I s) Interruptions are limited Interactive process is used Ill patients given priority Insight given to receiver on what to expect or do Content exchange standards (3A s) Administrative data up-to-date Anticipated events emphasized Action items highlighted (i.e. To-do)

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26 Sign-out Demonstration Video clip

27 Breakout Sessions Verbal & written sign-out practice Interactive, small group sessions Resident facilitators Role play conducting sign-outs on provided cases

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30 Dow, John MD, SIGN-OUT

31 Closing Exercise & Debriefing

32 Evaluation

33 % Answering' strongly agree' on questions Q1-Q7, on Opening and Closing Sign Out Exercise (N=38) % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Q1 Q2 Q3 Q4 Q5 Q6 Q7 opening closing Q1: I felt confident that I knew the plan of care for each patient Q2: I knew what patients, or tasks, I needed to attend to first Q3: I received information about potential problems that might arise during my call period Q4: I received guidance on what to do if particular problems arise during my call period Q5: I was told (either verbally or written) what has or has not worked in the past for certain problems Q6: I got full information on things that I need to follow up on (for example, important pending information on labs or consultant recommendations) Q7: In general, the overall quality of the sign out was excellent

34 Question 6 responses: Opening vs. Closing Exercise 5 4 Response score Q6- Opening Exercise Q6- Closing Exercise 35 Wilcoxon Signed Rank Test p=0.000

35 Post then Pre Survey Question Before After Q1 I am confident that I can effectively sign out my patients to others on my team Q2 I can deliver a clear and organized verbal sign out Q3 I know the four basic steps for sign out Q4 I can prepare a complete written sign out Q5 I am confident that I can clearly communicate the discharge instructions to my patients Q6 I know how to prepare my COPD patients to take care of their medical condition upon discharge Q7 I know how to prepare my CHF patients to take care of their medical condition upon discharge Q8 I know how to ensure that my patients understood my discharge instructions Q9 I am confident of my ability to use the Teach Back communication method Q10 I m aware of the problem of health literacy and how it can impact patient care Q11 The sign out approach I learned today can improve my patients safety 100% 4.9 Q12 The discharge approach I learned today can improve my patients safety 100% 4.8 Q13 I plan to use the sign out approach I learned today as I sign out to my colleagues 100% 4.97 Q14 I plan to use the Teach back method I learned today to ensure that my patients understood my instructions. 94% 4.8

36 Post then Pre Survey Average rating on 1-5 Likert scale Before After 0 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 1= Disagree strongly 2= Disagree slightly 3= Neutral 4= Agree slightly 5= Agree strongly All differences were found to be statistically significant (p<0.05)

37 Implementation Pointers Train incoming interns as early as possible Involved junior & senior residents in the training helps resident education and prepares them to provide focused feedback on sign-outs to interns. - helps buy in for sign-out strategy & tools. Adopt one standard written sign-out tool that all can use instead of multiple versions/templates avoid handwritten formats - best if tool doesn t require duplicative work, can be updated, and automatically populates active meds ( collaboration with IT is needed for this) Place workplace reminders of SOS strategy to prompt memory & set group expectations.

38 Post workshop follow up Two interns signing out with Sign-out poster in background. Nov, 07.

39 Follow-up Evaluation

40 Evaluation Pointers Periodic direct observations of intern sign-outs by junior &/or senior residents is best - Opportunity for practice based learning via focused feedback - Sign-out checklist provided Alternative: Follow up surveys of workshop participants - satisfaction with sign-outs - implementation of written tool and verbal strategy.

41 Three months later: Workshop participants f/u survey: Response rate 61 % ( ) "The sign out approach I learned can improve the safety of patients whom I take care of ". Neutral 8% " I had positive experiences applying the principles taught in this workshop. " Neutral 13% 4% Slightly agree 38% Strongly agree 54% Slightly agree 30% Strongly agree 53% " Having my computerized sign out available has helped me in presenting my patients during sign out. " Slightly disagree Neutral 4% 13% Slightly agree 21% Strongly agree 62% " The computerized sign out saves me time " Slightly agree 33% Neutral 24% Strongly agree 43%

42 Participants comments Question: Please comment on your experience as you ve applied the four steps for sign-out communication: 14 responded. Two said can t recall steps Working to find private quiet time during sign-out is not easy, but as a result of resident assistance we were able to make time in our busy schedules to make a concise complete sign-out. I think putting the principles into practice has been VERY good for patient care. The challenge comes when we really want to leave and so we might skip one of the steps or at least not do it justice.

43 Other Comments I am more aware of problems that might arise overnight. The training was very helpful in learning good sign-out techniques. sign-outs are longer but more complete. It was useful to think about what other interns need to know.

44 2-month Follow-up Survey ( ) Response Rate: 29 of 39 (74%) Question Mean Std % Agree Patients on my firm are discharged safely Patients on my firm know what the follow up plan is upon their discharge (e.g. follow up appointments or tests) Patients on my firm understand how to take their medications appropriately before their discharge I provide adequate instruction to help my congestive heart failure patients manage their condition My knowledge about health literacy impacts how I talk to/teach my patients I am applying the 'Teach Back ' method when I prepare patients for discharge I am applying the Teach Back method correctly I am following the sign out four steps when I sign out The discharge approach taught in the workshop has improved the safety of my patients The sign out approach taught in this workshop has improved the safety of my patients The transitions workshop was a good use of my time Have you used or applied any of the concept/tools taught in the workshop? Yes No 10 36

45 Lessons Learned The structured sign-out approach helped both senders and receivers and was perceived as helpful for improving patient safety Senior residents involvement was educational for them, well accepted by learners, and helped long term implementation of taught concepts/tools. For written tool development: Prepopulating form with meds, etc.. is safer & reduce time; computer response time is very important for user satisfaction; specialty customization of forms is a must; inclusion in permanent medical record is controversial.

46 Group Discussion Do you think sign-out training would be useful in your program? What level trainees? Is it useful for junior residents? senior residents? How about attendings? Describe 3-5 next steps to provide training in your program : - Whom to collaborate with to decide on training? - Who can be the training team? - What written tools are available? Do they need to be updated? Are meds automatically updated? Should IT personnel be involved? - When to offer training? To whom?

47 References: 1. Borowitz SM, Waggoner-Fountain LA, Bass EJ, Sledd RM. Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey. Qual Saf Health Care. Feb 2008;17(1): Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. Dec 2005;14(6): Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. Sep ;168(16): Horwitz LI, Moin T, Green ML. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med. Oct 2007;22(10): Kemp BA, Moyer PR. Equivalent therapy at lower cost. The oral penicillins. Jama. May ;228(8): Nabors C, Peterson SJ, Lee WN, et al. Experience with faculty supervision of an electronic resident sign-out system. Am J Med. Apr;123(4): Farnan JM, Paro JA, Rodriguez RM, et al. Hand-off education and evaluation: piloting the observed simulated hand-off experience (OSHE). J Gen Intern Med. Feb;25(2): Foster PN, Sidhu R, Gadhia DA, DeMusis M. Leveraging computerized sign-out to increase error reporting and addressing patient safety in graduate medical education. J Gen Intern Med. Apr 2008;23(4): Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. Jul 2006;1(4): Arora V, Kao J, Lovinger D, Seiden SC, Meltzer D. Medication discrepancies in resident sign-outs and their potential to harm. J Gen Intern Med. Dec 2007;22(12): Wayne JD, Tyagi R, Reinhardt G, et al. Simple standardized patient handoff system that increases accuracy and completeness. J Surg Educ. Nov-Dec 2008;65(6): Salerno SM, Arnett MV, Domanski JP. Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward. Teach Learn Med. Apr-Jun 2009;21(2): Chu ES, Reid M, Schulz T, et al. A structured handoff program for interns. Acad Med. Mar 2009;84(3): Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. Jul 2009;4(6): Gakhar B, Spencer AL. Using Direct Observation, Formal Evaluation, and an Interactive Curriculum to Improve the Sign-Out Practices of Internal Medicine Interns. Acad Med. Apr Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of signout among internal medicine house staff. Qual Saf Health Care. Aug 2009;18(4):

48 Sign-Out Workshop 9-noon Opening exercise: 15 minutes Sign-out essentials and video: 25 minutes Concurrent break-out sessions Verbal sign-out: 35 minutes Written sign-out: 35 minutes Top ten things I wish I knew: 20 min Closing exercise and debrief: 25 min

49 Top Ten Things I Wish I Knew Please do not hesitate to call your back up whenever you are concerned about your patient s safety or when you have a reason to question the patient care plan Chest pain Somnolence/ Delta MS SOB Afib with RVR Hypoglycemia Hyperglycemia Hypertension / Hypertensive urgency Fever Hypotension GI symptoms N/V/D Muscular or Joint Pain

50 Transitions workshop Post workshop Survey Rate your level of agreement on the statements below using the provided 1-5 scale. Think what your response would have been before you participated in this course and enter under the BEFORE column, then rate your current level of agreement and enter under the AFTER column. 1= Disagree strongly 2= Disagree slightly 3= Neutral 4= Agree slightly 5= Agree strongly Level of agreement BEFORE attending this course Level of agreement AFTER attending this course I am confident that I can effectively sign out my patients to others on my team I can deliver a clear and organized verbal sign out I know the four basic steps for sign out I can prepare a complete written sign out I am confident that I can clearly communicate the discharge instructions to my patients I know how to prepare my COPD patients to take care of their medical condition upon discharge. I know how to prepare my CHF patients to take care of their medical condition upon discharge. I know how to ensure that my patients understood my discharge instructions. I am confident of my ability to use the Teach Back communication method I m aware of the problem of health literacy and how it can impact patient care. The sign out approach I learned today can improve my patients safety The discharge approach I learned today can improve my patients safety I plan to use the sign out approach I learned today as I sign out to my colleagues I plan to use the Teach back method I learned today to ensure that my patients understood my instructions

51 Top Ten Things I Wish I Knew Please do not hesitate to call your back up whenever you are concerned about your patient s safety or when you have a reason to question the patient care plan Chest pain Assess patient and vital signs: o Physical exam, JVP, fluid status (check I/Os) Order EKG, cardiac enzymes, CXR, consider urine tox Look at signout for underlying PMHx, reason for admission: o URGENT: ACS vs PE vs dissection vs PTX Diagnosis of exclusion: GERD, musculoskeletal, bogus chest pain Somnolence/ Delta MS Evaluate pt and vital signs: check dexi, pulse ox, ABG, medication list, EKG If unresponsive: consider STAT head CT Therapeutic trial of narcan ( mg IV), if not sure of etiology Order urine tox; check BMP for electrolyte abnormalities; consider hepatic or uremic encephalopathy Consider seizures consider other etiologies and EKG before trial of ativan! SOB DDx: PE, aspiration pneumia, COPD or asthma exacerbation, MI, fluid overload, mucus plugging Examine patient and vital signs Check CXR, pulse ox, ABG, and EKG Communicate with nurses about your action plan to avoid further pages If patient not improving, consider transfer to stepdown unit (MPC or CCP), consider NIPPV, and MICU consult (if deemed appropriate) Always confirm CODE STATUS at signout!!! Afib with RVR Are they symptomatic? o Examine patient and vital signs o Look at EKG is it really Afib with RVR? If hypotensive and symptomatic o consider synchronized cardioversion If stable BP o consider metoprolol or diltiazem IV push and then start gtt; also consider amiodarone IV load and gtt Consider anti-coagulation Order cardiac enzymes Try and determine etiology: hypovolemia, infection, PE, thyroid disease, or cardiac Also, look at Osler Guide for more details Hypoglycemia Repeat dexi with a different machine and order STAT glucose (green top to critical care lab) If symptomatic: give ½ - 1 AMP D50 If patient lost IV access, consider glucagon IM and/or sugar under tongue Look at orders on POE: HOLD standing insulin orders Consider etiology: infection, overdose, renal failure (decr clearance), etc. etc. Make sure you have good access! Hyperglycemia Repeat dexi/send to stat lab if very high (>400), consider BMP to eval for anion gap Give an extra dose of SQ insulin Created by Michael Fradley, Maulik Majmudar, Hansie Mathalier

52 Evaluate med list see if pt on steroids, etc. Adjust SSI accordingly; consider increasing standing /baseline insulin dose Hypertension / Hypertensive urgency Establish baseline per bedside flowchart Consider redosing meds (for ex: one hour early) Try oral meds first: o Nifedipine XL PO 30 mg or 60 mg STAT o Hydralazine PO ONLY 10 mg or 20 mg o Captopril PO 12.5 mg Don t drop it precipitously risk for STROKE! STOP IV fluids, if patient only continuous fluids! If symptomatic with headache or delta MS: head CT If oral agents fail consider IV agents such as: o Labetolol 20 mg IV push and then 2 6 mg/min IV gtt, or o Metoprolol 5 mg IV push (if not bradycardic), or o Nicardipine 5-15 mg/hr IV gtt Look at OSLER GUIDE for more detailed info. Fever Most of the times, reflex response should be: o CXR, blood cultures x 2 sets, urinalysis (+/- urine culture); consider sputum culture as well If blood cultures drawn within the last 12 hours OK not to repeat them Tylenol (not prn u want to know if they are consistently spiking) Think outside the box: not always infectious etiology Hypotension Are they symptomatic? What s the underlying etiology? o Sepsis, CHF, Pulm HTN, hypovolemia, PE, MI, iatrogenic (drugs), or GI bleed Closely examine the DRUG list and ask nurse/look at MAR about meds in the past six hours Physical examination to evaluate for warm, well perfused vs. cold and decreased peripheral pulses o EXAMINE the patient and communicate with the patient to establish mental status Check bedside flowcharts to establish baseline Fluid challenge BOLUS (500 cc to 1L) If hypotension persists: o Send off an ABO or make sure there s an active one available; check PT/PTT o Consider cultures, cardiac enzymes, antibiotics, change in meds o Establish response to fluid bolus, and consider MORE ACCESS GI symptoms N/V/D Nausea/ Vomiting: o Phenergan 12.5 mg IV (start slow higher doses can cause hallucinations, etc); other alternatives: ondesetran /dolasetron or compazine o For pts with pulm HTN N/V portends poor prognosis and impending doom evaluate patient and assess fluid status and diurese as needed Constipation: o Try oral route first dulcolax, miralax, Mg citrate, etc. Then, go to enemas Diarrhea: o Make sure order culture for C. diff/fecal leuks, if negative then consider loperamide o Replete losses with IV fluids, if copious. o Replete electrolytes as necessary Created by Michael Fradley, Maulik Majmudar, Hansie Mathalier

53 Muscular or Joint Pain Tylox, Ultram, NSAID s, Oxycodone, Morphine, Dilaudid (last resort) If colicky (nephrolithiasis) ketoralac works well Many pts on dilaudid but, some are drug-seeking; use your own judgement re: prescribing narcotics for pain Created by Michael Fradley, Maulik Majmudar, Hansie Mathalier

54 Sign out Checklist Please use the following checklist to guide you in providing specific feedback on sign outs. Use one per each patient that is verbally signed out: Written sign out provided Yes No Brief admission history Yes No Active problems Yes No Baseline Status Yes No Recent Events Yes No Current Meds Yes No Allergies Yes No Code Status Yes No Pending results to check Yes No To Do List reviewed Yes No Anticipated Problems Yes No Past solutions for anticipated problems Yes No Location of sign out Designated Room Hallway Other Interruptions Yes No Interruption Type Pager Telephone Outside Person Sign out receiver had opportunity to ask questions Yes No Clear and Relevant Yes No Center for Innovation in Quality Patient Care, Johns Hopkins Medicine, 2007

55 Opening Exercise Sign Out Feedback Tool At the end of this sign-out: Strongly disagree Slightly disagree Neutral Slightly agree Strongly agree I felt confident that I knew the plan of care for each patient I knew what patients, or tasks, I needed to attend to first I received information about potential problems that might arise during my call period I received guidance on what to do if particular problems arise during my call period I was told (either verbally or written) what has or has not worked in the past for certain problems I got full information on things that I need to follow up on (for example, important pending information on labs or consultant recommendations) In general, the overall quality of the sign out was excellent Center for Innovation in Quality Patient Care, Johns Hopkins Medicine, 2007

56 Closing Exercise Sign Out Feedback Tool At the end of this sign-out: Strongly disagree Slightly disagree Neutral Slightly agree Strongly agree I felt confident that I knew the plan of care for each patient I knew what patients, or tasks, I needed to attend to first I received information about potential problems that might arise during my call period I received guidance on what to do if particular problems arise during my call period I was told (either verbally or written) what has or has not worked in the past for certain problems I got full information on things that I need to follow up on (for example, important pending information on labs or consultant recommendations) In general, the overall quality of the sign out was excellent Center for Innovation in Quality Patient Care, Johns Hopkins Medicine, 2007