Spotlight Case September 2006

1. Spotlight Case September 2006 Triple Handoff

2. Source and Credits • This presentation is based on the September 2006 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available through the Web site • Commentary by: Arpana Vidyarthi, MD, UCSF School of Medicine • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Appreciate the prevalence of handoffs and signout-related errors • Understand the key elements of a safe and effective written and verbal signout • List Kotter’s 8 steps to leading change

4. Case: Triple Handoff An 83-year-old man with a history of COPD, GERD, and paroxysmal atrial fibrillation with sick sinus syndrome is admitted to the Cardiology Service for initiation of dofetilide and placement of a permanent pacemaker. The patient underwent placement of the pacemaker via the left subclavian vein at 2:30 p.m. A routine post-op single view radiograph was taken and showed no pneumothorax.

5. Case: Triple Handoff The patient was sent to the recovery unit for overnight monitoring. At 5:00 p.m. the patient stated he was short of breath and requested his COPD inhaler. He also complained of new left-sided back pain. The nurse found that his pulse oxygenation had dropped from 95% to 88%. Supplemental oxygen was started and the nurse asked the covering physician to see the patient.

6. Case: Triple Handoff The patient was on the nurse practitioner (NP) non-housestaff service; the on-call intern covers after the NPs leave for the day. The intern, who had never met the patient, found him already feeling better with improved oxygenation on supplemental oxygen. The nurse suggested a stat x-ray in light of the recent surgery. The intern agreed, and a portable x-ray was done within 30 minutes. An hour later, the nurse wondered about the x-ray so he asked the covering intern if he had seen it.

7. Case: Triple Handoff The covering intern stated that he was signing out the x-ray to the night float resident, who was coming on duty at 8:00 p.m. Meanwhile, the patient continued to feel well, except for mild back pain. The nurse gave the patient acetaminophen as prescribed and continued to monitor his heart rate and respirations.

8. Case: Triple Handoff At 10:00 p.m. the nurse asked the night float resident about the x-ray. The night float had been busy with an emergency but promised to look at the x-ray and advise the nurse of any problem. Finally at midnight, the nurse signed out to night shift, mentioning the patient's symptoms and noting that the night float had not called with any bad news.

9. Signout • Definition: mechanism by which patient care responsibility and patient information is transferred from one practitioner to another • All care providers, including RNs, NPs, and MDs, must sign out patients • Housestaff duty-hour restrictions have increased the number of handoffs Vidyarthi A, et al. J Hosp Med. 2006;1:257-266.University HealthSystem Consortium; May 2006.

10. Signout: Numbers • After duty-hours restrictions, signouts increased by 40% • Average number of times a resident signs out per month: 300 • Estimated total number of signouts per day (including all health care providers) in large academic hospital: 4,000 • Estimated total number of signouts per year in a hospital: 1.6 million HCUPnet, Healthcare Cost and Utilization Project.

11. JCAHO Takes on Handoffs • JCAHO National Patient Safety Goal 2E: • All health care providers must “implement a standardized approach to handoff communications including an opportunity to ask and respond to questions” Joint Commission on Accreditation of Healthcare Organizations. 2006.

12. JCAHO Takes on Handoffs • Components of JCAHO National Patient Safety Goal 2E • Include interactive communications • Up-to-date and accurate information • Limited interruptions • A process for verification • Opportunity to review relevant historical data Joint Commission on Accreditation of Healthcare Organizations. 2006.

13. Case (cont.): Triple Handoff The next morning, the radiologist read the x-ray performed at 4:00 p.m. and notified the NP that it showed a large left pneumothorax. Cardiothoracic surgery service was consulted and a chest tube was placed at 2:30 p.m., nearly 23 hours after the x-ray was performed.The patient ultimately recovered.

14. Signout Errors • Important information lost due to handoffs causing diagnosis and treatment delay and a potentially significant error • Most signout errors are “content omissions” in which critical information is not communicated • Omission errors occur at a rate of 1/100 • Many caught before harm reaches patient Arora V, et al. Qual Saf Health Care. 2005;14:401-407.Nolan TW. BMJ. 2000;320:771-773.

15. Signout: Making It Safe • Standardize or structure the signout • Include both written and verbal signout to optimize information transfer • “ANTICipate”: • Administrative data • New information • Tasks • Illness • Contingency plans Vidyarthi A, et al. J Hosp Med. 2006;1:257-266.See Notes for complete references.

16. Signout: Making It Safe • Accurate administrative information • New information—brief history and diagnosis, updated medications and problem list, current baseline status and recent procedures, significant events • Tasks—“to-do” list • Illness—primary provider’s subjective assessment of the severity of illness • Contingency planning—statements that assist cross-coverage in managing anticipated problems

17. ANTICipate

18. Written Signout • Computerized template • MS Word, Filemaker Pro, MS Excel • Systems depend on user for accurate data entry • Wide variability of content accuracy has been noted • Linking signout to hospital electronic medical record (EMR) may decrease chances of inaccurate data Olsen C, et al. Poster presented at: The Society of Hospital Medicine Annual Meeting; May 2006.

19. Computerized Written Signout: “Synopsis”* • Can import data from the EMR, including administrative information, laboratory results, medications, allergies, and code status • Shown to improve resident efficiency and quality of signout and to reduce the risk of signout-related medical injuries * System used at UCSF Medical Center Van Eaton EG, et al. J Am Coll Surg. 2005;200:538-534.Petersen LA, et al. Jt Comm J Qual Improv. 1998;24:77-87.

20. Synopsis: UCSF Medical Center Signout System

21. Verbal Signout • Tailor to the receiver • Conduct in a quiet, distraction-free place at a designated time • Provide access to up-to date information • Use structured format • Require receiver to repeat back or “read back” tasks Leonard M, et al. Qual Saf Health Care. 2004;13(suppl 1):i85-i90.Barenfanger J, et al. Am J Clin Pathol. 2004;121:801-803.

22. Case: Triple Handoff The team subsequently learned that the night float resident had mistakenly examined the radiograph done immediately post-operatively, rather than the chest x-ray done at 4:00 p.m., and therefore did not see the film with the large pneumothorax.

23. X-ray of Pneumothorax

24. Kotter's 8-Step Approach to Leading Change • Establish urgency • Form a powerful guiding coalition • Create a vision • Communicate the vision • Empower others to act on the vision • Plan for short-term wins • Consolidate improvements, creating more change • Institutionalize new approach Kotter JP. Harv Bus Rev. March 1995.

25. The UCSF Experience • Establish urgency • Residents needs and JCAHO patient safety goal • Form a powerful guiding coalition • Information Technology (IT), Medical Center, and Graduate Medical Education (GME) leadership • Create a vision • A sign-out system that could grow with our new EMR making resident work more efficient and the sign-out process safer for patients • Communicate the vision • Presented to leadership at numerous committee meetings

26. The UCSF Experience • Empower others to act on the vision • Engaged the medical center IT and GME leadership to help core group of “champions” move forward in development of Synopsis • Plan for short term wins • Designed a “rounds report” linked to Synopsis facilitating information consolidation and tracking increasing resident workflow efficiency • Consolidate improvements, creating more change • Synopsis spread organically once residents saw its capacity on one of the pilot units • Institutionalize new approach • Policies passed at the GME and Medical Center level

27. The UCSF Experience • Results • More than 50% of the patients at 600-bed acute care hospital cared for with the assistance of Synopsis signout system

28. Take-Home Points • Signouts and discontinuity are an inevitable part of today’s hospital systems • Patients are at risk for errors due to discontinuity and signouts • Structured sign-out systems, including verbal and written standards, can assist in improving the effectiveness of the sign-out process • A change framework can be an effective strategy to implementing safe and effective sign-out systems