Simple Standardized Patient Hand-Off System that Increases Accuracy and Completeness

1. Simple Standardized Patient Hand-Off System that Increases Accuracy and Completeness Jeffrey D. Wayne, MD, Rajesh Tyagi, PhD, Gilles Reinhardt, PhD, Deborah Rooney, MS, Gregory Makoul, PhD, Sunil Chopra, PhD, Debra A. DaRosa, PhD

2. The Challenge • 80 hour work week • Transfers of care are increasingly frequent • Few residency programs have care systems in place to accommodate this change Horowitz. LI et al., Arch Intern Med, 2006

3. Handoffs: Objectives • “to provide accurate information about a patient’s care, treatment and services, current condition and any recent or anticipated changes” • “the information communicated during a handoff must be accurate in order to meet patient safety goals” The Joint Commission, 2008 National Patient Safety Goals

4. The New Surgical Residency • Apprenticeships • Small Teams • Night Float • Short call DaRosa, DA and Bell RH, Surgery, 2004

5. Patient Safety • Poor communication between physicians • Handoff issues • Little formal instruction • Need for standardization Greenberg CC et al, JACS, 2007 Rogers, SO et al, Surgery, 2006 Borowitz SM et al, Qual Saf Health Care, 2008 Solet DJ et al, Acad Med, 2005

6. Purpose/ Research Questions • What were baseline perceptions of residents regarding quality of handoffs? • To what extent were nurses clear as to the exact time patient care was transferred between day and night residents? • What is the effect of a standardized hand off instrument on perceptions of completeness, accuracy, efficiency, and appropriateness of task delegation? • Does resident experience and type of rotation (ICU vs. non-ICU) on handoff completeness, accuracy, efficiency, and appropriateness of task delegation?

7. Methods: Baseline Description • Direct observation • Efficiency and operations team • Method • Quality and form of written documentation • 12 Services • Focus group • Residents, nurses, administrators, surgeons • Electronic Survey • Phone Survey (Baseline/ Post-intervention)

8. Baseline Observation • Handoff without interaction: • Endocrine • Breast • General Surgery 1 • General Surgery 2 • Handoff with face-to-face encounter: • Vascular • Trauma • Transplant • Cardiothoracic • Handoff with phone or face-to-face encounter: • Depends on • a) complexity of patient care • b) resident preference • Surgical Oncology • Colorectal 1 • Colorectal 2 • Gastrointestinal surgery • ICU handoffs are always face-to-face, takes full one hour and residents discuss each patient

9. Handoff: Face-to-face • Vascular • Trauma • Transplant • Cardio Thoracic New residents Sign-In Take Notes & Update spreadsheets during shift Resources: Resident, spreadsheet Attending dictates, resident takes hand notes Resources: Attending, Resident Outgoing resident prints sheets Resources: Resident, printer Outgoing Resident’s Final Update Resources: Outgoing resident, shared file Sheets waiting at the table Incoming receives critical updates Resources: Incoming/ outgoing residents, spreadsheets Information exchange about key patientsResources: Incoming/Outgoing residents Incoming resident begins shift Baseline Observation

11. Results : On line survey Please indicate your level of agreement with the following statements. (1= Strongly Disagree and 7=Strongly Agree)

12. Results : On line survey It is important to know which elements of the Hand Off process are important from your perspective. Please rate each of the below elements. (1= Strongly Disagree and 7=Strongly Agree) Estimate the number of patients in the past 3 months for which any of the above issues with the handoff process caused you concern with regards to patient care. 0 (12.5%), 1-3 (50%), 4-6 (29.17%), and 7 or more (8.33%)

13. Standardized Hand off Instrument

14. Accuracy *p = 0.003 To what extent were there any inaccuracies of information on the “hand off” sheet that you received or gave out?

15. Accuracy p=NS p=0.006

16. Completeness *p= 0.015 To what extent was there any incomplete information on the “hand off” sheet that you received or gave out?

17. Completeness P=0.005

18. Responsibility *p = 0.07 *p =0.005 In the past 24 hours, on a scale from 1 to 5 with 1 being unclear and 5 being very clear, how clear was the exact time the resident handing off to you officially transferred patient responsibility to you?

19. Responsibility

20. Responsibility * p<0.05 Approximately how may tasks were you expected to do that should have been taken care of in a previous shift?

21. Regression analysis • Resident experience (in months) is not a significant factor in the perceived improvements • ICU rotations have some impact on tow of the outcome measures: • Completeness of information • Clarity if time of responsibility transfer

22. Other High Risk Settings • NASA • Airline Industry • Nuclear Power plants • Handoff skills are practiced repetitively to optimize precision and anticipate errors • Reduce complexity • Reveal hidden events and activities • Focus attention Patterson ES, Ann Surg, 2007 Patterson ES et al, Int J Qual Health Care, 2004 Stevens, DP, Qual Saf Health Care, 2008

23. Other Strategies • Computerized Resident Sign-out System • PDA’s • Competency-based approach • Required verbal communication • Professionalism • “Shared Responsibility” Van Eaton, EG et al, Surgery 2004 Van Eaton, EG et al, JACS, 2005 Park J, et al, JSE, 2007 Arora VM et al, Qual Saf Health Care, 2008

24. Limitations of Study • Single Institution • Outcome measures based on perception data • Review of medical records

25. Ideal (?) handoff process Test results Patient info History Resident continuously updated via (handheld) device Medication Central Insurance Billing Staff Schedules

26. Future Directions • Focused training on handoffs • Importance • Process • Sample Medical records • Better define accuracy and completeness