In Search of Common Ground in Handoff Documentation in an Intensive Care Unit
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1 In Search of Common Ground in Handoff Documentation in an Intensive Care Unit Sarah A. Collins, RN, PhD 1 ; Lena Mamykina, PhD 2 ; Desmond Jordan, MD 2,3 ; Dan M. Stein, MD, PhD 2 ; Alisabeth Shine MA 2 ; Paul Reyfman, BS 2 ; David Kaufman, PhD 2 1 Partners Healthcare Systems 2 Columbia University, New York, NY 3 New York Presbyterian Hospital, New York, NY 1
2 Introduction Handoff Frequent Multiple points for potential communication break-down Multiple disciplines Purpose of the handoff To establish common ground Conversations Shared handoff documentation tools Dayton, E, Henriksen, K. Communication failure: basic components, contributing factors, and the call for structure. Joint Commission Journal of Quality and Patient Safety 2007; 33:34-47 Horwitz, LI, Moin, T, Krumholz, HM, et al. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Quality & Safety in Health Care 2009; 18:
3 Handoff in critical care Problem Intra-disciplinary process but critical information flow spans Multiple disciplines and handoff documentation tools/artifacts (Benham-Hutchins, 2010) Information complexity increases potential for communication breakdown and errors Proposed solutions within literature Standardization Unclear definition for handoff Computer-based tools to support collaborative work Should embed functionalities and infrastructure of paper they replaced (Xiao, 2005) Standards based 3
4 Aim To understand the structure, functionality, and content of nurses and physicians ICU handoff artifacts to inform development of standards-based EHR handoff tools 4
5 Interdisciplinary Handoff Information Coding (IHIC) framework IHIC coding framework Systematic Review of 36 nurse and physician handoff studies 95 handoff information elements categorized in lists: Interdisciplinary (46%) Nursing (36%) Physician (18%) Continuity of Care Document (CCD) standard Covered 80% of elements Remaining 20% - we developed Hospital Handoff Sections Collins, SA, Stein, DM, Vawdrey, DK, et al. Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: A systematic review. Journal of Biomedical Informatics
6 IHIC Code Examples CCD Section Nurse only data Physician only data Interdisciplinary data Functional Neurological status Physical exam findings Patient's condition Status Cardiovascular status Baseline status Plan of care trent Respiratory status Specialty specific key Gastrointestinal status physiologic parameters Skin integrity (e.g., critical care Activities of Daily Living measurements, sepsis status, APACHE risk scale) 6
7 Setting Methods 21 bed Cardiothoracic Intensive Care Unit (CTICU) Large urban medical center Used EHR for clinical documentation, not for handoff Data Collection Observations Handoff artifacts used by nurses, resident physicians and physician assistants (PAs) Purposive sampling maximize variability by patient type/clinical status Data Analysis - two-steps Artifact analysis (Nemeth 2005; Nemeth 2004; Hutchins 1995) Structure and function Semantic coding using IHIC Inter-coder reliability with physician informatician (30% of artifacts) 7
8 Results Observed a total of 9 changes of shifts 22 artifacts collected 6 nurse admission Kardex 8 nurse personal handoff sheets 8 resident/pa handoff print-outs 8
9 Nurse Kardex 9
10 Nurse Personal Handoff Sheet 10
11 Resident/PA Handoff Print-out 11
12 Results: Artifact Structure and Functionality Highly structured Predefined structure and norms for organizing data Functionality Consistent use for nurses and residents/pas Main cognitive adjuncts Discarded after shift Used to copy data into EHR Summarization significant events Highlighted temporal information 12
13 Artifact Content IHIC coding 827 data elements on 22 artifacts 52 unique IHIC codes 92% (757/827 ) elements were interdisciplinary Inter-coder reliability 83% Nurse Kardexes 309 elements => 301 interdisciplinary and 8 nursing Nurse personal sheets 261 elements => 204 interdisciplinary and 57 nursing Resident/PA print-outs 257 elements => 252 interdisciplinary and 5 physician 13
14 Interdisciplinary Elements consistently Present in Physician and Nurse Artifacts Antibiotics Intravenous infusions Lines and invasive devices Significant events during last shift/overnight Specialty specific key physiologic parameters/interventions Clinicians involved in case Hospital course/summary/current history Past medical/surgical history Patient age Patient name Patient sex Patient's hospital MRN Plan Reason for admission/transfer Tasks/To-dos Test/procedure results 14
15 CCD sections 70% (573/827) elements Mapping to CCD Hospital Handoff sections developed for IHIC framework 30%(254/827) elements Admission demographics Hospital course Past medical/surgical history Consultations Fluid Balance Education Updates Anticoagulation status 15
16 Discussion Paper-based handoff artifacts Non-technical, yet sophisticated and structured system Physical location of data was important High degree of interdisciplinary content IHIC coding confirmed mapping to discipline specific lists Coordinate work beyond tasks Annotations => critical thinking (Gurman, 1998; MacKay, 1999) Nurses circled and annotated electrolyte and blood glucose values 1. Acknowledgment of the critical value 2. Unambiguous statement = medication given for that particular critical value 3. Captured the temporal nuances of patient data e.g. Potassium over-dosing errors 16
17 Discussion Handoff and interdiciplinary communication highly variable (Dayton, 2007) Common paper structures may be leveraged to better ensure continuity of care and coordination Computer-based tools Further organize and coordinate work beyond paper-based system Structured narrative Patient-centered Role of paper-printouts and mobile devices 17
18 Limitations 1 setting CTICU Further work is needed to determine the generalizability 18
19 Conclusions Management of handoff content Leveraged for patient-centered care Customized for specialty settings Structured narrative (Johnson, 2008) Transitions of care standards from other settings Ongoing work Validate IHIC coding in other settings Multidisciplinary rounds Mapping to HL7vMR 19
20 Follow-up study: Multidisciplinary Rounds Standards-Based Observational Tool 20
21 Acknowledgements Thank you to CTICU clinicians who participated in this study James S McDonnell Foundation (JSMF) for Cognitive Complexity and Error in Critical Care, PI: Vimla L. Patel, (Grant No ) Dr. Collins was supported by the National Library of Medicine (T15 LM ) 21
22 Thank you! Questions? 22
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