Improving Sign-Outs in Hospital Medicine

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Improving Sign-Outs in Hospital Medicine Arpana R. Vidyarthi, MD Assistant Professor of Medicine Division of Hospital Medicine Director of Quality, Division of Hospital Medicine Director, Patient Safety and Quality Programs University of California, San Francisco Care Transitions: Landscape of Medicine Today Provider change Inpatient: shifts, cross-cover, change of service Outpatient: coverage, referrals Patient change Geographic: level of care, location Needs: change of service, consultant Both Admission to and discharge from the hospital Care Transitions Result in Handoffs Handoff: The transfer of patient care responsibility from one practitioner to another Sign-out: The process mechanism to manage that transfer Vidyarthi AR, et al. J Hosp Med. 2006;1:257-266. 1

Case Presentation: Edith 12 AM 1 AM 2 AM 3 AM 4 AM 5 AM 6 AM 7 AM 8 AM Shortness of breath ED ED MD Sent for CXR and labs Shift change ED MD 2 Admitted Overnight Hospitalist Settled in ward ED=emergency department; CXR=chest X-ray. medicine ward Day Hospitalist Case Presentation: Day 1 10 AM 2 PM 6 PM 10 PM 2 AM 6 AM 10 AM 2 PM 6 PM Decompensates Edith stable Transfer to MD To clinic- Cross-coverage Return from clinic Cross-coverage ends Overnight MD Edith stable Day MD =intensive care unit. Case Presentation: Day 2 10 AM 2 PM 6 PM 10 PM 2 AM 6 AM 10 AM 2 PM 6 PM Shortness of breath/ intubated Overnight MD Intubated and stable Day MD Extubated transfer to ward Hospitalist =intensive care unit. 2

The First 48 Hours of Edith s Stay. Total providers in charge of care: 9 Total sign-outs: 10 Hospitalist Do you remember me, Edith? I m the doctor taking care of you. Edith: Uh.no? Hospitalist to self: Poor Edith she s suffered a change in mental status. Why So Many Handoffs? We change with the times! Physicians Hospitalists Group practices Cross-coverage Nurses Shortage: Shift stretches Temporary nurses Residents: decreased duty hours UCSF Medicine Service 15 handoffs per patient for a 5- day stay 300 handoffs per month for each intern Nationally >8,000 training programs >100,000 trainees 2 >6 million patients 1 UCSF Medical Center: 4000 handoffs daily, 1.5 million handoffs a year Information Transfer and Harm Inpatient-outpatient 1 Medication errors Care follow-through Inpatient transition systems 2-4 Necessary care dropped Unnecessary treatments Resident discontinuity Delayed test ordering 5 Increased in-hospital complications 5 Increased medication errors 6 Presumed increase in length of stay 6 Preventable adverse events 7 1. Forster AJ, et al. Ann Intern Med. 2003;138:161-167; 2. Rogers SO, et al. Surgery. 2006;140(1):25-33; 3. Kachalia A, et al. Ann Emerg Med. 2007;49(2):196-205; 4. Coleman EA, et al. Arch Intern Med. 2006;166:1822-1828; 5. Laine C, et al. JAMA. 1993;269:374-378. 6. Gottlieb DJ, et al. Arch Intern Med. 1991;151:2065-2070. 7. Petersen LA, et al. Ann Intern Med. 1994;121:866-872. 3

Medical Errors: Studies of Closed Malpractice Claims Contributing factors to a missed or delayed diagnosis or surgical error Ambulatory claims: 20% improper handoffs 1 ED: 24% inadequate handoff 2 Surgical claims: 24% communication breakdown 3 1. Gandhi TK, et al. Ann Intern Med. 2006;145:488-496; 2. Kachalia A, et al. Ann Emerg Med. 2007;49(2):196-205; 3. Rogers SO, et al. Surgery. 2006;140(1):25-33. Communication Failures Lead to Errors Handoffs are a form of communication Failures in communication are the most common root cause of sentinel events reported to the Joint Commission Sentinel Event Statistics. Available at: http://www.jcaho.org. Joint Commission Patient Safety Goal 2e Implement a standardized approach to handoff communications, including an opportunity to ask and respond to questions Expectations Interactive communications: opportunity for questions Minimum content: up-to-date information Interruptions are limited Process for verification: read-back Opportunity to review prior care Allocation of time for handoffs 4

Best Practice Guidelines Content Clear patient identification Pertinent background information Major clinical problems Current condition Up-to-date data Anticipated problems Necessary psychosocial information Process Interactive questioning Methods for verification Minimize disruptions What Does This Look Like Written Sign-out format Chart Specified sign out computerization Verbal Sign-out Face:face Telephone VM Change Management: Creating Sustainable Improvements Establish a sense of urgency Joint Commission Form a powerful building coalition Stakeholders/unofficial leaders Create a vision Communicate that vision Countless committees Empower others to act on that vision Plan for and create short term wins Early converters Consolidate improvements and produce more change Institutionalize new approaches Policies and role modeling Kotter, Leading Change, Harvard Business Review 5

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