Evaluation of Sign Out and Handoffs Alexander M. Djuricich, MD David Miller, MD Christine Todd, MD APDIM Chief Residents Workshop April, 2009 Objectives Review the current literature on handoff evaluation See results of a practice handoff performed by you during this workshop Describe the real and perceived barriers to systematically evaluate the handoff process Work in small groups to develop one method of handoff evaluation that can be implemented in your home institution
Agenda Intro 10 minutes Short exercise to demonstrate Handoff 5 minutes Review literature 10 minutes Djuricich Handoff Definition 10 minutes Miller OSCE 10 minutes Todd Small group Exercise 20 minutes Direct observation of Handoff Djuricich ICU Handoff Miller OSCE Evaluation Todd Large group final discussion 20 min Evaluation 5 minutes What literature already exists? Touch on a few articles Please see written bibliography for larger list of articles (not all-inclusive)
Arora Jt Comm J Qual 2006 Model for Adoption of a Standardized Handoff Process (create process map) Content (create standardized checklist) Implementation (garner leadership and resident buy-in) Monitoring (ensure protocol is in place and identify barriers) Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf 2006;32(11):646-655. 655. Chu Acad Med 2009 Attendings supervised intern handoffs First 3 months: interns had little confidence in their handoff abilities After the program, perceptions improved 85% felt supervision was useful or extremely useful 51% felt lecture on handoffs was useful Chu ED, Reid M, et al. A structured handoff program for interns. Acad Med 2009;84:347-52.
Chu Acad Med 2009 SAIF-IR IR Summary statement Active issues If-then contigency planning Follow-up activities Interactive questioning Read backs Chu ED, Reid M, et al. A structured handoff program for interns. Acad Med 2009;84:347-52. Vidyarthi, Arora. J Hosp Med 2006 Reviews discontinuity from handoffs Parallel system: aviation industry Checklist for elements of safe handout ANTICipate Administrative data New Information Tasks Illness Contingency Planning Vidyarthi, AR, et al. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med 2006;1:257-266. 266.
Vidyarthi, Arora. J Hosp Med 2006 Checklist for verbal communication during signout Who should participate What content needs to be verbal Where should sign-out occur? When is the optimal time? How should verbal communication be performed? Vidyarthi, AR, et al. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med 2006;1:257-266. 266. Borowitz Qual Saf Health Care 2008 Survey to pediatrics residents post-call Important information is not transmitted Educators should analyze missed opportunities Borowitz SM, Waggoner-Fountain LA, et al. Adequacy of information transmitted at resident ent signout (inhospital handover of care): a prospective survey. Qual Saf Health Care 2008;17:6-10. 10.
Horwitz LA. Arch Intern Med 2008 Reviewed specific sign-outs via audiotape Determined patient care consequences from inadequate handoffs Omission of key info during sign-out can have important consequences for patients and health providers Horwitz LA, et al. Consequences of inadequate sign-outsfor patient care Arch Intern Med 2008;168:1755-60. 60. Solet. Acad Med 2005 Describe parallel process in aviation Barriers Physical setting Social setting Language barriers Medium of communication List of essential elements for successful handoffs Solet DJ, et al. Lost in translation: challenges and opportunities in physician-to to-physician communication during patient handoffs. Acad Med 2005;80:1094-1099. 1099.
Horwitz LI. JGIM 2007 Formal written curriculum teaching residents sign-out skills Oral sign-out skills curriculum was brief, structured, and well received by participants. Horwitz LI, et al. Development and implementation of an oral sign-out skills curriculum JGIM 2007; 22(10):1470-4. 4. Kitch BT. JCJQPS 2009 Survey of medical and surgical housestaff on harm from handoffs 59% reported harm from handoff from last clinical rotation 12% said harm was major 37% said interruptions occur during handoff Kitch BT, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Pt Safety 2008;34:563 563-70d.
Reisenberg LA, Am J Med Qual 2009 Mnemonics for handoffs AIDET, ANTIC, CUBAN, DeMIST, GRRR, HANDOFFS, I PASS the BATON, PEDIATRIC, SBAR, SHARED, and many others Reisenberg LA, et al. Systematic review of handoffs mnemonic literature. Am J Med Qual 2009; epub ahead of print, Mar 2009 Other articles Several other articles (old and new) on this topic See attached bibliography for article references
OSHE Farnan, J, U of Chicago Presented at Midwest SGIM, 2008 Objective Structured Handoff Evaluation Done with 4 th year students at U of C
APDIM Handoff Eval slides Christine Todd, MD SIUSOM Handoff RULES 10 residents have been selected. You are numbered, from 1 to 10. I will sign a patient out to resident #1 in the hallway. This will be a verbal sign out only. Resident #1 will then get Resident #2, go out into the hallway, and transfer care. No notes are allowed, and you can t t ask questions. And so on. Once Resident #10 has gotten the sign out, he or she will come back and tell us what they know about the patient.
What I signed out... Ms. Adamsky is a 68 year old female who presented to us with syncope. She was hemoccult positive and her HB kept dropping so GI saw her and scoped her. She had an ulcer and was positive for H pylori. She s s on ampicillin and clarithromycin and an omeprazole drip. We are transfusing her. She will have labs at 6 pm so if her hemoglobin is less than 10 give her a transfusion again because she has a cardiac problem. She might need lasix, too. She is very confused, and she keeps trying to get out of bed at night. She is in room 604. Her son is very worried about her and he might call you. She is a DNR. Evaluation of Handoff The handoff itself Could it have been better? Are residents taught a specific format to follow? The handoff process Could it have been better? What are the best practices for the handoff process?
Best Practices Transfer of Care IN PERSON (supervised?) No Distractions Updated Tool Organized Format (SBAR) Specific instructions with readback Anticipate Issues Advanced Directives Efficient (under a minute?) SBAR Situation Background Assessment Recommendation Didactic, Teamwork Retreat, Consistent across services (Physician and Other), Daily Feedback.
Handoff OSCE Part One (Pt s s room) Your co-intern admitted a woman last night with community acquired pneumonia. He had to go home sick, though, so you need to look at the chart and see the patient. Part Two (Resident s s Lounge) You have clinic this afternoon, so after you have seen the patient, sign her out to the intern covering you. The Hidden Agenda Part One This patient has very little evidence to support the diagnosis of pneumonia. Instead, she probably has a PE. Part Two The resident in the lounge taking sign outs is paying no attention whatsoever.
Evaluation Tool Did they establish a good environment? Did they use SBAR? Did they update the Info Card? Did they get a read back? We rated residents who didn t demonstrate at least 3 of these as poor. poor. A very interesting result... Residents who recognized that the patient had a PE uniformly gave a good signout. None of the residents who gave poor sign outs recognized that the patient had been misdiagnosed.
The Moral of the Evaluation Story Residents who struggle with one competency (communication, in the case of the handoff) struggle in others (medical knowledge/patient care in the case of the diagnosis). A small amount of evaluation/observation can open up a world of ways to help a resident improve.
Handoffs David E. Miller, M.S., M.D. Indiana University School of Medicine Associate Program Director, Medicine Residency Assistant Professor of Clinical Medicine Division of Pulmonary, Allergy, Occupational and Critical Care MedicineM HANDOFF: The transfer of role and responsibility from one person to another in a physical or mental process.
Shift Changeover: A Different Perspective 25% of Errors in Air Route Traffic Control Centers and Terminal Radar Facilities occur within 15 minutes after change-over. (Della Rocco et al, FAA, NITS #199990310-004, 004, 1999) 1988 Piper Alpha Oil Rig Disaster (167 men died, $3.4 bil) 1991 Contintal Express Flight 2574 (14 dead)
NASA-MARS Rover-Best Practice Recs Capture problems, hypothesis and Sufficient Schedule Overlap intent rather than just a list of Sufficient Time and distraction-free issues space To Do list Face-to to-face Handover Policy Time allocation to prepare Handover Training handover material Handover Monitoring Necessary Information Sources Equal available to incoming worker responsibility of both incoming and outgoing parties Time and resources for the Cultivation development of handover support of culture: mistakes are materials expected Good Catch. Longer/More Written support material developed Detailed Handoffs in with input of users crisis mode. Schedule Trialing of written materials with staggering continuity opportunity to make adjustment Searchable Computer databases to help Blank fields in handover materials with handover workload for unusual occurences Seen as not only error-prone, but as Demands inclusion of relevant an opportunity information ascertained by worker input Adapted From Parke et al, Proceedings of the International Association for Advancement of Space Safety Conference. ESA, NASA, JAXA, Nice France, October 2005 Handoffs In Medicine Increased Number of Handoffs 15 handoffs per patient per five day hospitalization and greater then 300 handoffs per intern in a one month period. The increased number of handoffs in our health care system has not been limited to resident teaching hospitals. The escalating prevalence of hospitalists (doctors who work exclusively in the hospital setting) 1 and their movement towards shift work contributes to the production of handoffs. Additionally, as primary care providers leave the inpatient arena, the handoffs from hospitalists to the primary care physicians becomes ever important. Vidyarthi, AR.., MD, et al. Journal of Hospital Medicine 2006; 1:257 266. Gandhi, TK. Ann Intern Med. 2005;142:352 358
Fumbles 44,000-98,000 patients die in US hospitals annually due to injuries as a result of error. (Institute of Medicine, 2000) Communication (HANDOFFS) has been identified as the leading cause of medical errors (25-67%). (Wilson et al, Med Jnl of Australia, 1995)
Even More Transitions of care: To outpatient setting To NH setting To OR/Procedures (IR) Nursing handoffs happen several times a day Computer/ Equipment Malfunction Environment Interruptions/ Ongoing Workload of On Call MD Potential Failures No designated meeting place; interruptions; workload Interruptions; Workload Omission of Information Updatgion of Infromation not a top priority Communication Text Page: Sign Out is on the wall Culture Sign Out Not A Priority: I ve Gotta Go Text Page to On Call MD: Sign Out is on the wall Omissions; failure to verbally communicate/ empasize important issues Nothing to Do
Handoff: Pitfalls Potential for Disaster Missing Data Incorrect Data Ineffective communication Time Space Interruptions Unfamiliarity the the tertiary handof Monologues versus conversations What s s Important? Failure to close the loop Do medical handoffs convey how sick a patient is? Level of experience of Handoff recipient Voltage Drop. Potential Barriers Physical Setting PRIVATE Quiet Light Desk/Table Hierarchy Language Barriers Medium of Communication Direct v. Indirect Time and convenience issues Quality of HO is proprotional to time spent preparing and delivering it. Varies by service being covered. Only 8% of medical schools teach handoff skills (Solet et al, Gen Int Med, 2004)
Taxonomy of a Hand-Off Inefffective Sign-Out Content Omissions Meds/treatments Tests/Consults Medical Problems Active Anticipated Baseline Status Code Status Rationale of primary team Good Sign-Out Written Sign Out Patient Content Code Status Anticipated problems Baseline exam Pending tests or consults Overall features Legible Relevant Accurate Up to date Verbal Sign-out Failure-prone communication Anticipate processes Pertinent Lack of vis-à-vis communication Vis-à-vis Double Sign Out Thorough Can t t read the thing Dialogue Adapted from Meltzer DO et al, QualSaf Health Care 2005; 14: 401 407
Handoffs: Opportunities Can a Handoff be GOOD for patient care? Responsibility/Accountability Handoffs should occur with the goal to move the patient though their care plan, not put the care plan on hold until Monday. Avoid Voltage Drop! Provide a structured, regular forum in which to carefully and concisely review pertinent events of hospitalization.
Essential Elements for Successful Handoffs Each physician team should be assigned a distinctive name and color. List all staff names, team members and pager numbers Complete patient identification (full name, age, sex, race, location, Social Security number or hospital number), date of admission, and a location. Add a one-or or-two-sentence assessment of the patient s presentation. Include an active problem list plus a pertinent past medical history. List all active medications. List allergies. Supply information on venous instrumentation and access, status of access, and any actions to be taken if access changes. Include the Patient's code status Pertinent laboratory data List your concerns for the next 18-24 hours and a recommended course of action. Consider listing the long term plans, as family may visit in the evening during off-hours to discuss the issue with covering housestaff. Discuss any psychosocial concerns that may influence therapeutic choices. Safe and Effective Written Sign- out - ANTICipate Administrative data Name, age, sex, mr#, room#, family contact, primary inpatient team and attending New information (clinical update) Chief complaint, HPI, diagnosis, current base line List of medications Recent procedures and significant events Tasks (what needs to be done) If / then statements To do list and what action to take for new information Illness Is the patient sick? Contingency planning / Code status What may go wrong and what to do about it What has or has not worked Difficult family or psychosocial situations Code status
SIGNOUT Sick or DNR Identifying data Name, age, gender, diagnosis General hospital Course New events of the day Overall health status / clinical condition Upcoming possibilities with plan, rational Tasks to be completed with plan? Any Questions
Small Group Discussion Direct observation ICU Handoff OSCE Djuricich Miller Todd What can you take back to your own institution? Group discussion Please tell us what you think you can use to evaluate handoffs in your residency
Evaluation Please complete your evaluations of this workshop Thank you!! Alex Djuricich Dave Miller Christine Todd Indiana University Indiana University Southern Illinois Univ