4/4/2012. Sign Out Competence: Easier Said Than Done. Hypothesis: Introduction. Our Program

Transcription

1 Introduction Information sign out is essential to patient care Sign Out Competence: Easier Said Than Done Sarah A Rawstron M.B.,B.S., Sajad Khazal M.B.,Ch.B., Cynthia Katz M.D. Duty hour restrictions (more shift work) highlighted the importance of this skill Hand off is a Joint Commission 2006 National Patient Safety Goal 2011 ACGME Common Program Requirements Include Transitions of Care 2011 ACGME Common Program Requirements Transitions of Care Programs must design clinical assignments to minimize the number of transitions in patient care Sponsoring institutions and programs must ensure and monitor effective, structured hand-over process to facilitate both continuity of care and patient safety Programs must ensure that residents are competent in communicating with team members in the hand-over process The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and residents currently responsible for each patient s care Our Program Medium size- 12 residents each year (36 total) Community hospital in Brooklyn One inpatient floor 18 beds Day Team: 2 day interns, 1 PL3 Night Team: 1) 1 night intern (6 nights in a row), 2) overnight PL2 (PICU + floor) 3) overnight PL3 (24 hr call) cover PICU and floor Day shift 7 am to 6 pm (previously 5) Changing the sign out process at TBHC (First Attempt ) New PD tried to change sign out from computerized printed data base to individual sign out sheets Intermittent follow up Residents not using sheets Residents kept trying to make computer sheets work, but data inaccurate (old, wrong), inconsistent system depending on team FAILURE Changing the sign out process at TBHC (Second Attempt 2007) New APD fresh from residency New ideas Enthusiastic Start study Collect Data Institute changes Hypothesis: More regular observation of process should change behavior 1

2 Sign Out Project data 2007 Observations of afternoon sign out by PD or APD Observation tool No feedback Data reviewed Recommended changes 96 observations Interns not signing out Seniors doing all sign out Interns not actively (not writing, asking questions) Basic information (IVF, meds) missing Anticipated problems and plans inadequate Rounding in conference room- patients seen by evening team later- but often very late Sign Out Project (10/2007-9/2008) 1) Introduction of new intern sign out sheets (paper template, write in data) 2) Interns designated to sign out 3) Sign out near bedside. 4) New team introduce themselves to all patients Results Intermittent direct observations (approx 1-2/month) with feedback immediately at the end of the observation Results results summary (n = 96) (n = 137) Diet 44 (46%) 76 (55%) IVFs 45 (47%) 67 (49%) Access 18 (19%) 46 (34%) Meds 65 (68%) 93 (68%) Plan 36 (37%) 89 (65%) Jr. signed out 31 (32%) 136 (99%) 2

3 Sign Out Project (8/2009-9/2011) Monthly orientation to new inpatient team on how to sign out importance of using sign out sheets for sign out essential information to sign out optional information to sign out overnight plan anticipated problems Intermittent direct observations (approx 1-2/month) with immediate feedback Sign out item Results (96 (137 (204 Vital signs 117 (57%) Diet 44 (46%) 76 (55%) 91 (45%) IV Fluid 45 (47%) 67 (49%) 114 (56%) IV access 18 (19%) 46 (34%) 76 (37%) Medications 65 (68%) 93 (68%) 154 (75%) Plan 36 (37%) 89 (65%) 153 (75%) Intern sign out 31 (32%) 136 (99%) 177 (87%) Intern actively 92 (67%) 96 (47%) New team introduced to patient 93 (68%) 196 (96%) Phase 3 (9/2011 to present) Sustained improvement Intern sign out Team introduces to patients Room for improvement diet IV access IV site Meds plans 1) Sign out sheet modified with * to indicate essential sign out information 2) Morning sign out observations by 4th year chief in addition to intermittent evening sign out observations Results Sign out item (96 (137 (204 Phase 3 (93 observations Vital signs 117 (57%) 81 (87%) Diet 44 (46%) 76 (55%) 91 (45%) 61 (61%) IV Fluid 45 (47%) 67 (49%) 114 (56%) 68 (73%) IV access 18 (19%) 46 (34%) 76 (37%) 46 (49%) Medications 65 (68%) 93 (68%) 154 (75%) 75 (81%) Plan 36 (37%) 89 (65%) 153 (75%) 83 (89%) Intern sign out 31 (32%) 136 (99%) 177 (87%) 86 (92%) Intern actively New team introduced to patient 92 (67%) 96 (47%) 60 (65%) 93 (68%) 196 (96%) 93 (100%) 3

4 Summary of Project % Sign out items < 80% at phase 3 Diet IV fluid iv access intern actively sign out items Phase 3 Although sign out items still < 90% for all items, observers note significant improvement Intern sign out more systematic Sign out sheets used most of the time Less prompting from seniors required as less information missed Sign out more efficient over time Final thoughts on changing a culture Changing a culture from the outside (by faculty) is difficult Changing a culture takes significant time Senior residents do not always reinforce changes (?Just like faculty?) Hypothesis and challenges More frequent observations during the same month did not consistently result in a significant change (phase 1 results) New duty hours for PL1 (shifts) makes it difficult for faculty observers to watch sign out Surprising that monthly education, observations and repeated feedback did not result in more rapid and sustained improvements New Change Providing results of sign out observation to individual residents with summary score Summary: Curriculum for Sign out Introduction during June orientation Monthly orientation for floor team (10 minutes) Use of modified sign out paper sheets Direct observation (using observation tool) with immediate feedback Observation tool modified for individual competency evaluation documentation 4

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