Patient Hand-offs: A Medical Education Perspective

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Patient Hand-offs A Medical Education
Perspective

The greatest problem with communication is the
illusion that it has been accomplished.

George Bernard Shaw
Ingrid Philibert, PhD, MBA, Sr. VP, Field
Activities, ACGME
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Why is the Hand-off of Interest?
Sentinel Event Unanticipated event that results
in death or serious physical or psychological
injury to a patient and is not related to the
natural course of the patients illness
3
Why is the Hand-off of Interest?(2)

• Across several studies communication problems
  implicated in 60 to 75 of all errors and adverse
  events
• Communication problems as source of errors, more
  prominent in teaching settings, larger number of
  factors implicated in each event (supervision,
  hand-off, team care)1
• Miscommunication incidence per ICU patient 1002
• Adverse effects of being cared for by
  cross-covering physician3
• Consequence Reduction in errors from reduced
  hours may be offset by increased errors from
  inadequate exchange of information during the
  patient hand-off
• 1 Singh et al., Arch Intern Med, 2007
• 2 Mistry, K et al., University of North
  Carolina, ACGME Conference 2006
• 3 Petersen, LA et al. Ann Intern Med, 1994

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Technology and Strategies from High-Reliability
Industries

• Use of electronic tools improved the hand-off
  process1
• Use of sign-out forms may reduce preventable
  adverse events2
• End of shift transfers from high-reliability
  industries may offer helpful models for the
  patient hand-off3
• Combining hospital IT data with resident-entered
  details could be a powerful tool to improve
  hand-offs4
• Yet no practical strategies to date to connect
  these learnings to every-day teaching of
  residents
• 1Parker J, et al. JAMIA. 2000 7(5) 453-61
• 2Petersen LA, et al. JCJQI. 1998 24(2) 77-87
• 3 Patterson E, et al. Int Journ Qual Hlth Care
  2004, 16 125-132.
• 4 Van Eaton, E et al. Surgery 2004 136(1) 14-5

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2006-08 Hand-off Study Summary Findings

• Hand-off is a clinical as well as a communication
  task
• Strategies from high-reliability industries are
  adapted to the mobile, fluid nature of residents
  work and the focus on multiple patients with
  differing needs for attention and care
• Results affirmed the importance of the
  interactive verbal transfer of information
• Time constraints, working patterns and
  interpersonal factors such as trust influenced
  the hand-off
• Use of short cuts focus on plans and
  contingencies (suggests most of the information
  in current hand-off summaries is not used)
• Use of technology to support transfer both
  helpful and problematic

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Summary Findings (2)

• Verbal hand-offs increasingly foregone in some
  settings, replaced with hand-off by phone,
  outgoing leaves electronic note or paper, option
  to page for questions rarely used
• Current technology to support hand-offs not
  adapted to filling in for the loss off
  interactive exchange of information (there are
  open web-based approaches)
• After duty hour limits Almost everything signed
  out. Two exceptions in 2006, largely eroded by
  2010 staff consults, communicating with families
• Read-back not used, not effective. Instead,
  more subtle cueing in conversations to highlight
  important data
• Critical role of others with extensive knowledge
  of the patient in recovering information lost in
  the hand-off
• Negative effect of cross-cover (replicates
  Petersen et al. 1994) short shifts not
  associated with appreciable loss of continuity

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Summary Findings Resident Learning Process

• The Intern Everything in the hand-off is
  important, but I cannot remember it all or use it
  all in patient care.
• The Mid-level Resident Nothing in the hand-off
  is important, I get my information from a fresh
  look at the patient (the Consult Effect).
• The Senior Resident The information from the
  outgoing resident AND the patient are important.
  I look for the comments in the hand-off to
  determined who needs special vigilance. Both
  cues are important for sick patients.
• Effect of level of training pronounced from 1st
  to 2nd year, negligible after (handoff is
  learned somewhere in the first year)
• At more advanced levels information is evaluated
  based on the whether it comes from a trusted
  source (assessment based on prior interactions)

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Odds of Errors under Different Shift Patterns,
Other Factors
Odds Ratio 95 CI P Value
In-House Call .35 .195-.630 .000
Cross Cover only 4.42 1.99-9.87 .001
Call and Cross Cover 6.20 3.106-12.390 .000
Any Shift with Cross Cover 4.77 2.416-9.407 .000
AY Quarter 1 1.607 .812-3.183 .186
ICU .22 .087-.558 .001
Incoming Low Rating of Quality of Hand-off 2.432 1.201-4.931 .018
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Consequences of Hand-off Surprises and Errors

• Very Common
• Not knowing critical information, resulting in
  feeling unhelpful and loss of credibility with
  care team or family
• Not knowing patient well and having to look up
  information when the patient is deteriorating
• Quite Frequently mentioned
• Omission of or delay in tests, therapeutic
  interventions or discharge (To do list errors
  of omission)
• Duplication of tests and therapies resulting in
  waste of time and resources (To do list errors
  of commission)
• Rare but Concerning
• Failure to Rescue (failing to noticing a
  patient is deteriorating)
• Wrong intervention for the patient (e.g., wrong
  treatment or medication due to outdated or
  erroneous information, coding patient who is DNR)

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State of Affairs in 2011

• Teaching of hand-offs is episodic, sporadic and
  not connected to clinical work and teaching ,
  despite sincere, well-meaning efforts to
  interpret and follow the new ACGME Standards on
  Transitions in Care
• More hand-off teaching and improvement work in
  specialties with inpatient based approaches, to
  address end of shift hand-offs
• Other transitions in care (hand-off from OR to
  ICU or unit, inter-unit, etc.) not as well
  addressed
• ACGME standards seek to address all transitions
  in care
• Faculty may not be the ideal teachers in many
  specialties (lack of training, and a perspective
  of I do not need to hand-off, I am available to
  my patient 24/7)
• Added value of near-peer teaching from a
  pedagogical perspective

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Proposed Solution Embedding Hand-off in Clinical
Teaching

• A structured approach to educate residents on
  hand-offs via a curricular blueprint
• Activities to learn and improve hand-offs are
  progressive from internship to the end of
  resident and continue into the work of clinical
  faculty
• View of hand-off as entrustable professional
  activity (EPA)
• Supervision of hand-offs (direct or indirect, by
  more senior residents) until an entrustment
  decision is made based on an assessment of
  performance
• A milestone perspective would expect
  entrustment of common hand-offs in the specialty
  to occur by end of the first year
• This embeds teaching of the hand of the hand-off
  in the process by which other clinical skills are
  taught
• Bottom Line Innovation in handoff education and
  improvement in hospital systems to support the
  hand-off are necessary components to adapt to an
  increasingly complex hospital environment

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Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold)
Patient Care Medical Knowledge IP Comm. Skills Profession-alism PBLI SBP
Educational Lecture / Web Tutorial with Post-Test Interns X X X X
Handoff Video with Formal Debriefing and Self-assessment Interns X X X
Use of "iSoBAR" Handoff Checklist with Formative Feedback Interns X X X X
Personalized Handoff Instruction and Formative Feedback from Senior Residents or Faculty Interns X X X X X X
Handoff OSHE with Debriefing and Formative Feedback Interns X X X X X X
Direct Supervision and Formative Feedback on Handoffs by Senior Resident or Faculty (until the hand-off is delegated as Entrustable Professional Activity) Interns X X X X X X
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Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold)
Patient Care Medical Knowledge IP Comm. Skills Profession-alism PBLI SBP
Resident-Led Morning Report with Feedback Junior/ Senior Residents X X X X
Train the Trainer Session for Supervising Intern Hand-offs Jr/Sr Residents X X X X
Quality audits and feedback of written or computerized hand-off notes(with Feedback), Jr/Sr Residents, Faculty X X
Adapt Handoff tools and forms to local setting using process Jr/Sr Residents, Faculty X X X X X X
Develop local formative and summative evaluation tools, potentially using existing models Jr/Sr Residents, Faculty X X X X X X