TEACHING RESIDENTS EFFECTIVE TRANSITIONS OF CARE: ADMISSION TO DISCHARGE TOC Task Force Emory University School of Medicine APDIM Workshop April 13, 2011 TIMELINE & RESOURCES 10 Minutes: Setting the Stage for Handovers 40 50 Minutes: Small group breakout sessions 20 Minutes: Emory s approach to Handover curriculum development 10 minutes: Questions Resources Transitions Pocket Card Transitions DVD (Slides, Handover videos)
WHEN YOU LEAVE THIS WORKSHOP YOU WILL BE ABLE TO: 1. Utilize resources needed for a structured Transitions of Care (TOC) curriculum for your program 2. Anticipate potential challenges to curriculum development within your institution 3. Begin to design a TOC curriculum u framework for your residency program TRANSITIONS OFCARE TASK FORCE: WHO ARE WE? o Emory University School of Medicine o 4 Hospitals; 8 Members o Vision: Standardize best practice to improve transitions of care (TOC) across the Department of Medicine. o Charge: Develop and implement a sustainable, ti effective curriculum to educate trainees & faculty on transitions of care best practice in the Department of Medicine.
THECARETRANSITIONS TASK FORCE Manuel Eskildsen: Chair Medical Director of Long Term Care, Wesley Woods Hospital Christina Payne: Co Chair Emory University Hospital Joanna Bonsall Emory University Hospital Midtown Eva Rimler Grady Memorial Hospital Amy Miller Veterans Affairs Hospital Jason Stein Emory University Hospital Dan Dressler: Associate Program Director Emory University Hospital THENUTS AND BOLTS: QUESTIONS TO ASK YOURSELF BEFORE STARTING: 1. How many people will I need? o o o How many hospitals at your institution? Program size Will you need a project manager? 2. What are aligning/competing interests? 3. What type of curriculum works best for my learners? 4. Baseline Needs Assessment
THE NUTS AND BOLTS: EMORY S INFRASTRUCTURE o Program size: 180 residents 4 hospitals o TOC Task Force: 1 2 representatives for each hospital Project Manager o Aligning and Competing Interests Hospital Drivers Trainee Drivers THE NUTS AND BOLTS: AN APPROACH TO CURRICULUMDESIGN Curriculum Design 1. Goals: What are the goals and objectives for our intervention? How will we determine our focus? 2. Environment: How will the institutional environment impact our goal? 3. Implementation: What concrete steps will we take to implement our content? 4. Results: How will we perform resident assessment, measure results, and curriculum evaluation?
THE NUTS AND BOLTS: EMORY S APPROACH TO CURRICULUMDESIGN Curriculum Design Goals Over one year, trainees will demonstrate handover competence using best practice guidelines Environment 4 hospitals; Competing/Aligning Interests differ based on location Implementation Attitudes Skills Knowledge Results Assessment of trainees Evaluation of methods DEFINING THEPROBLEM: PATIENT HANDOVERS Terminology: Transitions of Care Change in patient location, or provider, or both. Handovers or Handoff The exchange of information and transfer of responsibility that occurs during a transition of care Arora AM, Manjarrez E, Dressler DD, et al. Hospitalist handoffs. 2009
ACGME REQUIREMENTS FOR RESIDENTS 2003 Program Requirements Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. 2011 Program Requirements Ensure and monitor effective, structured handover processes to facilitate both continuity of care and patient safety. Ensure that residents are competent tin communication with team members in the handover process. CURRENT PRACTICES: WHAT ARE WE UP AGAINST? o Handovers not standardized or structured o Multiple l physician i providers = Diffusion i of responsibility o Cross coverage associated with Discontinuity of care plans Incomplete transmission of patient information Errors in judgment tby covering physicians i Vidyarthi et al. JHM. 2006 Petersen LA. Ann Intern Med. 1994
BARRIERS TO EFFECTIVE COMMUNICATION DURING PATIENT HANDOVERS o Interruptions o Erroneous information becomes fact o Omission of information o Human Element o Technology o Time constraints o Lack of training Philibert I. QualSaf Health Care. 2009 Patterson ES. J Qual Healthcare 2004 WHAT S THE EVIDENCE? Governing Bodies of Medicine and Handovers Institute t of Medicine Mdii The moment where patient errors are most likely to occur Joint Commission Ensure that healthcare organizations implement a standardized approach to handover communication Incorporate training on effective hand over communication into the educational curricula and continuing professional development for health care professionals. http://www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/ps Solution3.pdf
BEST PRACTICEGUIDELINES o Two way verbal exchange o Face to Face o Minimum data set Usually in form of mnemonic o Written support o Noise and distraction control o Clear policy guidance Clark C. Leading Clinical Handover Improvement. Journal of Patient Safety March 2011 SMALL GROUP BREAKOUT SESSION: CURRICULUM DEVELOPMENT CHOOSE YOUR HANDOVER
GOAL: WHAT OUTCOME DO WE WANT TO ACHIEVE? THINGS TO CONSIDER WHEN APPROACHING YOUR GOAL: What are we trying to accomplish with our curriculum? This may be based on your needs assessment What factors may change your approach? Best Practice Resident requirements Scope Initial Approach Measurable, realistic, time specific goal What measurable end points do we expect?
SMALLGROUP: GOALS AND OBJECTIVES Goal: A statement that describes in broad terms what the learner will gain from the instruction Example: The goal of this curriculum is to educate residents about the importance of handovers and incorporate the current recommended best practice into daily handovers. Objective: A statement that describes what the learner is expected to achieve or perform in measurable outcomes Example: The learner will prepare discharge summaries that contain the essential elements of the patient s stay in the hospital. ENVIRONMENT: WHAT ARE THE ANTICIPATED ENVIRONMENTAL CHALLENGES?
WHAT CHALLENGES CAN I ANTICIPATE? Awareness Current thandover practices Buy in? Scope of the problem Manpower Sustainability Other programs within my institution? Teaching a good handover? Resource availability IMPLEMENTATION AND RESULTS: HOW DO I BEGIN IMPLEMENTATION?
IMPLEMENTATION AND RESULTS ASK: Attitudes, Skills, Knowledge Teaching T the Handover Address the Barriers Continuous assessment of learners Feedback OSCE Modeling/Role Play Pre/Post Tests Evaluation of curriculum methods THE NUTS AND BOLTS: AN APPROACH TO CURRICULUMDESIGN Curriculum Design 1. Goals: What are the goals and objectives for our intervention? 2. Environment: How will the institutional environment impact our goal? 3. Implementation: What concrete steps will we take to implement our content? 4. Results: How will we perform resident assessment and measure our results?
MAKING A COMPLEX PROBLEM SIMPLE Admission Discharge Handover Nightly Handover ICU Handover Admitter Handover OVERNIGHT HANDOVERS Goal Environment Implementation: Attitudes Skills Knowledge Results: Assessment of Trainees Evaluation
NIGHTLY HANDOVER: GOAL What were we trying to accomplish? The goal of this portion of the curriculum is to educate residents about the importance of nightly handovers and incorporate the current recommended best practice into the nightly handover What are the objectives? Trainees explain the importance of Care Transitions within residency throughcontinuing core lecture series [ATTITUDE] Trainees will perform standardized nightly handovers using institution provided minimum data set [SKILL] Trainees will describe structured communication using the mnemonic 2 HANDOVER [KNOWLEDGE] NIGHTLY HANDOVER: ENVIRONMENT What challenges did we face within our environment at Emory? 1. Resident time constraints 2. Resident attitudes Everybody s Chillin I left the signout for you by the computer. NTD. 3. Variable practices at each hospital within our institutioni i 4. Attending physician culture change and buy in 5. Manpower to evaluate handovers real time
NIGHTLY HANDOVER: IMPLEMENTATION Address Best Practice Minimum Data Set Structured communication Attitudes Conferences Videos Pocket Card Skills 2 HANDOVER Intern Orientation: Role Play Knowledge NIGHTLY HANDOVER: RESULTS Evaluation of nightly handover Peer Evaluation of resident competence of nightly ihtl handover communication at morning report (VA hospital) Limited resources have made evaluation of the nightly handover portion of our curriculum difficult
MAKING A COMPLEX PROBLEM SIMPLE Admission Discharge Handover Nightly Handover ICU Handover Admitter Handover DISCHARGE HANDOVERS Goal Environment Implementation: Attitudes Skills Knowledge Results: Assessment of Trainees Evaluation
DISCHARGE HANDOVER: GOAL What were we trying to accomplish? The goal of this portion of the curriculum is to educate residents about the importance of discharge handovers and incorporate the current recommended best practice into the discharge handover What are the objectives? Trainees will explain the importance of discharge handovers through lecture series [ATTITUDE] Using examples of good and bad discharge summaries, the learner will prepare discharge summaries that contain essential elements of the patient s hospital stay [SKILL] Residents will receive monthly feedback on discharge summary performance using pre formed metric [KNOWLEDGE] DISCHARGE HANDOVER: ENVIRONMENT What challenges did we face within our environment at Emory? 1. Changes to resident training + changes to practice 2. Disparate practice standards at different institutions 3. Moving from limited pilots to broader interventions at different institutions
DISCHARGE HANDOVER: IMPLEMENTATION Address Best Practice Attitudes Conferences Pocket Card Skills Resident assessment and feedback Knowledge Intern assessment of discharge handover using pre and post test at orientation DISCHARGE HANDOVER: RESULTS Evaluation of discharge handover 1. Satisfaction surveys of residents and interns 2. Evaluation of quality discharge summaries 3. Surveys measuring residents confidence in performing discharge tasks
MOVING FORWARD WITH HANDOVERS 1. Realize that one size does not fit all. 2. Be ready to address the challenges within your institution. 3. Embrace collaboration with other programs. QUESTIONS?
1. Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. Hospitalist handoffs: A systematic review and task force recommendations. Journal of Hospital Medicine 2009; 4: 433 440. 2. Institute of Medicine consensus report. To err is human: building a safer health system. 1999. Accessed at: http://iom.edu/reports/1999/to Err is Human Building A Safer Health System.aspx (accessed July 27, 2010). 3. Joint Commission. FAQs for the 2008 national patient safety goals. 2008. 4. Lerner, B. A case that shook medicine. Washington Post, 11/28/2006. 5.. Vidyarthi et al. Managing discontinuity in academic medical centers. JHM 2006; 1: 257 266. 6. Petersen LA. Does discontinuity of care increase adverse events? Ann Intern Med 1994 Dec 1; 121(11): 866 72 7. Philibert I. Use of strategies from high reliability organizations. QualSaf Health Care. 2009; 18; 261 266. 8. Patterson ES, Roth EM. Handoff strategies in settings with high consequences for failure. Journal for Quality in Health Care 2004;16:2. 9. Patterson ES, Wears RL. Patient Handoffs: Standardized and reliable measurement tools remain elusive. JtComm J Qual Patient Saf. 2010 Feb;36(2):52 61. 10. Riesenberg, LA, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, Padmore JS, Karpovich KP. Residents and Attending Physicians Handoffs: A systematic review of the literature. Academic Medicine 2009; 84: 1775 1786. 11. Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Annals of Internal Medicine. 2004;140:533 536. 12. Kripalani S, LeFevre F, Phillips C, Williams M, Basaviah P, Baker D. Deficits in communication and information transfer between hospital based and primary care physicians. JAMA. 2007;297:831 841. 13. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee for service program. N Engl J Med. Apr 2 2009;360(14):1418 1428. 14. Clark C, Persaud DD. Leading clinical handover improvement: A change strategy to implement best practices in the acute care setting. J Patient Saf. 2011. 7; 1: 11 18. WOULD YOU LIKE TO WATCH MORE HANDOVER VIDEOS? HTTP://VIMEO.COM/CHANNELS/EMORYCARETRANSI TIONS TROUBLE VIEWING THE VIDEO? EMAIL: CBPAYNE@EMORY.EDU
Good Discharge Summary Example Transitions of Care Curriculum Emory Department of Medicine Patient Identifier: Joe Patient Date of admission: 6/2/2010 Date of discharge: 6/12/2010 Primary care provider: Dr. Joe Smith, at 404 686 2222 Attending of Record: Dr. I. Medicine Chief complaint / reason for admission: Shortness of breath Diagnoses: 1) Ischemic cardiomyopathy with acute decompensated heart failure, EF 35%, new diagnosis. 2) Coronary artery disease, s/p catheterization and PCI to mid LAD 3) Pseudomonas urinary tract infection, treated this admission 4) Acute kidney injury, creatinine 1.7 upon discharge 5) COPD, not on home oxygen 6) Diabetes Type 2, insulin dependent. A1C 7.5 7) Hypertension 8) Allergies: Lisinopril (cough) Hospital course by problem list: Brief HPI: Mr. Brown is a 58 year old male who presented to the ER complaining of 2 weeks of exertional shortness of breath, symmetrical leg swelling, paroxysmal noctural dyspnea, and orthopnea. Patient denied fevers or chest pain. Initial exam was pertinent for patient being afebrile, hypotensive with MAP of 65 and hypoxic with oxygen saturation of 92% on 3L. Additionally, he was noted to be volume overloaded with elevated JVP to 20cm, S3 gallop, congestive hepatomegaly, and cool extremities with 3 + pitting edema to the mid thigh. 1. Newly diagnosed ICM. For his new onset heart failure the patient was ruled out for acute coronary syndrome with stable troponin of 0.10 and EKG showing only nonspecific S T changes in the anterolateral leads. Initial BNP was 2200 with pulmonary edema on chest X ray. On admission, he was diuresed with Lasix with resulting hypotension and worsening respiratory status and the patient was transferred to the MICU for BIPAP and initiation of neseritide and dobutamine per cardiology recommendations. An echocardiogram showed an EF of 35% and regional wall motion abnormalities. His respiratory status and acute kidney injury improved with afterload reduction and diuresis and the patient was transferred to the floor for titration of his heart failure medications. Once stable, he was taken for heart catheterization which showed 70% mid LAD lesion which was intervened with drugeluting stent. At discharge the patient was ambulating the hallway without symptoms and was counseled in regards to his new diagnosis of heart failure and the importance of remaining compliant with his plavix. 2. COPD. He briefly treated with prednisone upon admission in case of exacerbation, however this was discontinued and his COPD remained stable while here. 3. Urinary tract infection. Three days prior to discharge, he developed fevers. Urine cultures grew Pseudomonas with negative blood cultures at discharge. The patient was transitioned from zosyn to oral Rev 7/29/10 Page 1 of 2
levaquin and will complete a 10 day course of antibiotics as an outpatient. He will be notified if his blood cultures turn positive after discharge. 4. Acute kidney injury. Admission creatinine was 2.6 with evidence of pre renal azotemia. His renal function improved with afterload reduction and dieresis with discharge creatinine of 1.7 5. Diabetes. His metformin was stopped on admission. His blood glucose was initially uncontrolled in the intensive care unit, requiring an insulin drip. He was transitioned to subcutaneous insulin upon transfer to the floor. His blood glucose remained well controlled after this. His metformin can be resumed by his primary care provider if appropriate. He was seen in consultation by the diabetic educator. Disposition at discharge: He was discharged to his home in good condition. He is full code. Discharge medications: New medications this admission: 1) Lasix 80 mg by mouth daily 2) Metoprolol XL 25 mg by mouth daily 3) Plavix 75 mg by mouth daily 4) Levaquin 500 mg by mouth every 48 hours, stop date 6/14/2010 5) Hydralazine 25 mg by mouth t.i.d. 6) Imdur 30 mg by mouth daily Previously prescribed medications to be continued upon discharge: 7) Aspirin 325 mg by mouth daily 8) Lantus 60 units subcutaneously q.h.s.; note new dose 9) Aspart 20 units subcutaneously q.a.c. 10) Valsartan 40 mg by mouth daily 11) Aspirin 325 mg by mouth daily 12) Combivent inhaler, two puffs by mouth every four hours as needed. 13) Advair 250/50, 1 dose inhaled twice daily. Medications to be stopped: 1) Metformin 2) Hydrochlorothiazide Discharge instructions: He was seen by the heart failure NP prior to discharge and provided with diet information, diuretic information, and was instructed to weigh himself daily. Tests pending at time of discharge: 1. ANA, SPEP/UPEP were sent as initial workup for new CHF. The results of these will need to be addressed by his PCP. Follow up appointments: 1. Primary care provider on 6/27/2010 at 1:30pm. 2. New cardiologist, Dr. Joseph Johnson, on 6/30/2010 at 2:45 pm. Office phone number is 404 686 1000. Rev 7/29/10 Page 2 of 2