Handoff Communication

1. HandoffCommunication Katie Gielissen, MD IM Associate Clerkship Director

2. What is a handoff (sign out)? • Transfer of: • Information • Authority • Responsibility • Occurs during transitions in care: • Shift changes • End of service block • Unit transfers • Discharges

3. Have you had the chance to perform a handoff? • How many of you have seen a handoff performed in real clinical settings? • How many of you have performed a handoff in real clinical settings? • How many of you have gotten feedback on the handoff you performed?

4. Objectives • Discuss the importance of high-quality handoff communication as part of patient care (and why you should learn it as a medical student). • Learn about and practice a technique for performing handoffs while on your internal medicine rotation(s). • Introduce a method to get feedback on your handoffs.

5. Objectives • Discuss the importance of high-quality handoff communication as part of patient care (and why you should learn it as a medical student). • Learn about and practice a technique for performing handoffs while on your internal medicine rotation(s). • Introduce a method to get feedback on your handoffs.

6. Why is communication important in healthcare? Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type.

7. Communication events by trainees • Landmark study of IM Residents in 1994 • 3146 patients admitted over 4 months • 124 adverse events, 44% preventable • Patients with adverse events were more likely than controls to be covered by a physician from another team at the time of event (Odds Ratio 6.1!) Multiple studies have demonstrated transitions of care are the most unsafe time for patients! Petersen LA. Annals of Internal Medicine. 1994; 121(11):886-872.

8. Handoff Curricula in Med Schools • 121/143 members of Clerkship Directors in Internal Medicine were surveyed in 2014 • 15% reported structured handoff curriculum during the IM clerkship • 37% reported handoff curriculum during IM Sub-I’s • 66% stated 3rd year med student did not perform handoffs • 93% stated 4th year Sub-I’s did perform handoffs Liston, BW. HJ Gen Intern Med. 2014 May; 29(5): 765-769.

9. Interns’ Perceptions on Their Preparedness Ryan MS. Medical Science Educator. 2016. 26(3), 463-473. Provide an oral presentation Give or receive a patient handover

10. When are Trainees Exposed to Handoffs? T TTTTTT E EE EEEEE EE EEEEEEEEEEEEEEEEEEEEE EPA 6: Oral Presentation A A A Ryan MS. Medical Science Educator, 2016. 26(3), 463-473. T E EE EEEEEEEEEEEEEEEEEEEEE EPA 8: Give a Handover T = Teaching E = Experience A = Assessment MS1 MS2 MS3 MS4 PGY1 PGY2 PGY3 

11. Key Points • Effective handoffs are essential to safe patient care • Medical students are asked to perform handoffs during their Sub-Is without sufficient training • Many recent graduates feel unprepared to perform handoffs as they transition to internship

12. Objectives continued • Discuss the importance of high-quality handoff communication as part of patient care (and why you should learn it as a medical student). • Learn about and practice a technique for performing handoffs while on your internal medicine rotation(s). • Introduce a method to get feedback on your handoffs.

13. I-PASS Technique

14. Video Reflection • As you watch the video, jot down what you observe. • How could the handoff been performed more safely and effectively?

15. Key Components of Handoffs • Effective Handoffs: • Ensure transfer of accurate information • Facilitate transfer of responsibility • Two components to effective handoffs: Verbal Handoffs: Are structured Employ close-loop communication Printed Handoffs Provide more detail Integrate with verbal handoffs

16. I-PASS Handoff Technique

17. The I-PASS Mnemonic • I  Illness Severity • Stable, “Watcher,” Unstable • P  Patient Summary • Summary statement; events leading to admission; hospital course; ongoing assessment; plan • A  Action List • To-do list; timeline and ownership • S  Situation Awareness & Contingency Planning • Know what’s going on; plan for what might happen • S  Synthesis by Receiver • Receiver summarizes what s/he heard; asks questions; restates key action items Starmer, A.J. Pediatrics. 129.2 (2012): 201-204.

18. The I-PASS Mnemonic I Illness Severity P Patient Summary A Action List S Situation Awareness S Synthesis by Receiver Starmer, A.J. Pediatrics. 129.2 (2012): 201-204.

19. The I-PASS Mnemonic I Illness Severity P Patient Summary AAction List SSituation Awareness SSynthesis by Receiver Starmer, A.J. Pediatrics. 129.2 (2012): 201-204.

20. Why should we flag illness severity? • Focuses attention appropriately to sickest patients first • Helps develop a shared understanding of pt status • Clearly stating code status with illness severity can also help to frame the patient

21. Illness severity: a continuum • Watcher: any clinical “gut feeling” that a patient is at risk of deterioration or “close to the edge” • On the medicine units you might hear the term “sick” or “not sick”

22. Sample Dialogue

23. The I-PASS Mnemonic I Illness Severity P Patient Summary A Action List S Situation Awareness S Synthesis by Receiver Starmer, A.J. Pediatrics. 129.2 (2012): 201-204.

24. Patient Summary – Why is this important? • Succinct description of the ‘big picture’ • Reason(s) for admission • Events leading to admission • Hospital course • Overarching plan(s) • Communicates concerns and nuances • Anticipates expected course

25. Sections of Patient Summary • Summary Statement • Events leading up to admission • Hospital course • Ongoing assessment • Plan

26. Summary Statement • Events leading up to admission • Hospital course • Ongoing assessment • Plan Summary Statement • “One-liner” • Contains only critical identifying information • Name • Age • Gender • Pertinent PMHx • Reason for admission “Mr. S is a 73yo M with PMHx of HFpEF and COPD who presented with hypoxia thought to be due to RLL community-acquired pneumonia.”

27. Summary Statement • Events leading up to admission • Hospital course • Ongoing assessment • Plan Events Leading to Admission • Describes the way the patient presented • Includes ONLY essential history and exam findings • Can be truncated when high level of diagnostic certainty is attained • Should be revised every day as new information comes in “Mr. Smith is a 74yo man with PMHx of COPD who presented with RLL community acquired pneumonia.” “Mr. Smith is a 74yo man with PMHx of COPD who presented with fever, SOB, and cough for 3 days, found to have hypoxia and RLL crackles.”

28. Summary Statement • Events leading up to admission • Hospital course • Ongoing assessment • Plan Hospital Course • List key events and updates • Highlights special considerations • Family/social issues • Nursing concerns • Relevant chronic medical conditions

29. Summary Statement • Events leading up to admission • Hospital course • Ongoing assessment • Plan Ongoing Assessment • Provides diagnostic reasoning • Ex: “We chose do diurese today because…” • Offers differential diagnosis and assessment • Ex: for a patient with presumed CAP who is not improving, you may mention a concern for antibiotic resistance or developing empyema with an overnight plan to consider imaging or changing antibiotics

30. Summary Statement • Events leading up to admission • Hospital course • Ongoing assessment • Plan Plan • Mention specific plans for certain problems ONLY if relevant to overnight work • AVOID to-do lists from the day shift • If no specific plan required for a problem, it is likely you don’t need to mention or include it

31. Sample Dialogue

32. The I-PASS Mnemonic I Illness Severity P Patient Summary A Action List S Situation Awareness S Synthesis by Receiver Starmer, A.J. Pediatrics. 129.2 (2012): 201-204.

33. Action List • To-do list • Includes specific elements: • Timeline • Clearly assigned responsibility • Indication of what ‘completion’ means • Actions to be taken • If no action items anticipated, clearly state “nothing to do”

34. Example Action List

35. Sample Dialogue

36. The I-PASS Mnemonic I Illness Severity P Patient Summary A Action List S Situation Awareness & Contingency Planning SSynthesis by Receiver Starmer, A.J. Pediatrics. 129.2 (2012): 201-204.

37. Situation Awareness • “Know what’s going on with your patient” • Status of patient’s disease process (improving, worsening, etc) • Team member’s role in this patient’s care • Environmental factors

38. Contingency Planning • Critical for patient safety • Problem solving before things go wrong • IF/THEN statements • Provides the receiver with specific instructions for what might go wrong

39. Effective Contingency Planning • Articulate what might go wrong • Define the plan • List interventions that have/have not worked • Ex: “If he desats, we found repositioning him in the bed is really helpful” • Identify resources and chain of command • Ex: “Here is Dr. Richards’ phone number.”

40. Sample Dialogue

41. The I-PASS Mnemonic I Illness Severity P Patient Summary A Action List S Situation Awareness & Contingency Planning SSynthesis by Receiver Starmer, A.J. Pediatrics. 129.2 (2012): 201-204.

42. Synthesis by Receiver • Provides brief re-statement of essential information in a cogent summary • Demonstrates information is received and how it was understood • Opportunity for receiver to: • Clarify elements of handoff • Ensure there is a clear understanding • Have an active role in the handoff process It is NOT a restating of the entire verbal handoff!

43. Sample Dialogue

44. The I-PASS Mnemonic I Illness Severity P Patient Summary A Action List S Situation Awareness & Contingency Planning S Synthesis by Receiver Starmer, A.J. Pediatrics. 129.2 (2012): 201-204.

45. Handoff Exercise Use IPASS technique to perform a verbal handoff with a partner

46. Handoff Exercise • Break into groups of two • Practice the I-PASS technique, each taking a turn as the handoff giver and receiver • One person acts as Participant A, one person as Participant B • Follow directions on your handout • Debrief and give one another feedback using the QR code on the back of your card

47. Getting evaluations while on rotation • Ask and intern or resident if you can perform handoff(s) on your patient(s), then ask if they can directly observe you and provide feedback. • Have your resident fill out the feedback form using the QR code on your card • These assessments are NOT required and will NOT be counted towards your grade! • Let us know if this method works for you… we want to find ways for you to get meaningful practice!