Docstoc

Simple Standardized Patient Hand-Off System that Increases

Document Sample
Simple Standardized Patient Hand-Off System that Increases Powered By Docstoc
					            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
             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
          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
The New Surgical Residency

•   Apprenticeships
•   Small Teams
•   Night Float
•   Short call



                      DaRosa, DA and Bell RH, Surgery, 2004
               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
      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?
   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)
                   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
                     Baseline Observation
                                                                                         Handoff: Face-to-face
                                                                                         1.  Vascular
                                                                                         2.  Trauma
                 New residents                                                           3.  Transplant
                    Sign-In                                                              4.  Cardio Thoracic

   Attending                         Take Notes &
   dictates,                            Update
resident takes                       spreadsheets
  hand notes                          during shift
  Resources:                          Resources:
   Attending,                          Resident,
    Resident                          spreadsheet




                                                     Outgoing
                  Outgoing                            resident
              Resident’s Final                         prints
                   Update                              sheets
                                                     Resources:            Sheets waiting at
             Resources: Outgoing
                                                      Resident,               the table
             resident, shared file
                                                       printer


                                                                    Incoming
                                                                                                 Information
                                                                     receives
                                                                                                  exchange
                                                                      critical
                                                                                                  about key      Incoming resident
                                                                     updates
                                                                                                   patients         begins shift
                                                                   Resources:
                                                                                                  Resources:
                                                                    Incoming/
                                                                                               Incoming/Outg
                                                                     outgoing
                                                                                                oing residents
                                                                    residents,
                                                                  spreadsheets
                                                   Hand Off Evaluation Form
Efficiency:
Approximately how much of your time was spent updating the “hand off” sheet?
   ____ Minutes
Accuracy:
To what extent were there any inaccuracies of information on the “hand off” sheet that you received or gave out?

  □    None     □ Few (1-3 inaccuracies) □ Some (4-6 inaccuracies) □ Many (7+ inaccuracies)
Completeness:
To what extent was there any incomplete information on the “hand off” sheet that you received or gave out?

   □ None □ Few (1-3 occurrences) □ Some (4-6 occurrences) □ Many (7+ occurrences)
Responsibility:
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?

1 Unclear        2          3 Somewhat clear        4         5 Very Clear
  Approximately how may tasks were you expected to do that should have been taken care of in a previous shift?

   □ None □ Few (1-3 tasks) □ Some (4-6 tasks) □ Many 7+ tasks
“Hand-off” Dissemination:

   □ Sheet dropped off □ Discussed over phone □ Face-to-face discussion
Name of Rotation:                                       Day of Week/Date:                              Time:
I am on:

   □ Night Float □ Day Team
Notes/Comments:
                 Results : On line survey
Please indicate your level of agreement with the following statements. (1= Strongly Disagree and 7=Strongly Agree)



         Question                                                                                     Mean score and
                                                                                                      Standard Deviation (St
                                                                                                      Dev)
         It is important that the column headings on the hand off excel spreadsheets are              Mean: 4.00 ST dev:
         uniform across different services.                                                           1.041
         During the handoff process, the most clinically relevant patient information is displayed    Mean: 5.46, St Dev: 0.957
         on the spreadsheet.
         During the handoff process, the on call attending is accurately identified for each          Mean: 3.75 , ST Dev: 2.04
         clinical service.
         The current hand off spreadsheets provide accurate patient information.                      Mean: 4.7, St Dev: 1.02
         Hand off spreadsheets are updated accurately on at least a daily basis.                      Mean: 5.29, St Dev: 0.93
         The spreadsheet makes it easy to identify tasks to be performed over the shift.              Mean: 5.29, St Dev: 1.136
         During the handoff process, the exact time of the transfer of responsibility from            Mean: 4.62, St Dev: 1.65
         outgoing to incoming resident is clear.
         During the handoff process, the exact time of the transfer of responsibility from            Mean: 3.33, St Dev: 1.46
         outgoing to incoming resident is clear to other patient care providers (i.e. PA’s, nurses,
         etc).
         Current spreadsheets identify critical patient care issues that have occurred over the       Mean: 4.33, St Dev: 1.28
         last 24 hour period.
         The resident library provides a convenient location and environment for an efficient         Mean: 5.83, St Dev: 1.14
         handoff process.
         I am satisfied with the quality of the existing handoff process.                             Mean: 5.0, St Dev: 0.91
                   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)
       Question                                                                                     Mean score and
                                                                                                    Standard Deviation (St
                                                                                                    Dev)
       The consistency of information provided in hand off spreadsheets across different            Mean: 4.19 St Dev: 1.18
       services.
       The relevancy of pertinent patient information displayed on the spreadsheet.                 Mean 6.04, St Dev: 0.73
       The exact time of the transfer when one resident assumes patient responsibilities from       Mean: 4.29, St Dev: 1.13
       the departing resident .
       Accurate information on the spreadsheet.                                                     Mean: 6.5, ST Dev: 0.57
       Up-to-date information on the spreadsheet.                                                   Mean: 6.5, St Dev: 0.64
       Identifying tasks to be performed over the shift using the spreadsheet.                      Mean: 6.45, St Dev: 0.7
       A clear transfer of responsibility from outgoing to incoming resident, so both residents     Mean: 5.04, St Dev: 1.24
       know the exact time when the incoming resident assumes primary responsibility for the
       patients being “handed off.”
       A clear transfer of responsibility from outgoing to incoming resident so that other health   Mean: 5.12, St Dev: 1.09
       care providers (nurses, PA’s, attendings, etc) know the exact time when the incoming
       resident assumes primary responsibility for the patients being “handed off.”
       Accurately pinpointing critical patient care issues or changes on the hand off               Mean: 6.12, St Dev: 1.20
       spreadsheet that have occurred over the last 24 hour period.

    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%)
       Standardized Hand off Instrument
                                              On duty
                                              Attending                              Fellow/Resident
                                                                                                                                            8/7/2005 23:04   8/7/2005 23:17
                                              Wayne-                                 Bilimoria-
                                              Jeffrey(53471)                         Karl(58609)
                                 Admit/OR                     Admit/Diagn PMHx/Code                           DVT/GI          Drain/Tubes Vital/Labs/Test/
Room Attending   Name/MR # Age   Date           Post-Op Day   osis        Status    Allergies          Meds   PROPH IVF Diets /Lines      Cultures         Sign-out To Do
XY                                    31-Jul-05           967
YZ                                    25-Jul-05           972
ZA                                   01-Aug-05            966
AB                                   05-Aug-05            962
BC
CD
                                         Accuracy

            3                                        *p = 0.003
         2.5

            2
                                                                                  Baseline
         1.5
                                                                                  Post-intervention

            1

         0.5

            0


To what extent were there any inaccuracies of information on the “hand off” sheet that you received or gave out?
                   Accuracy
 3

2.5         p=NS                p=0.006

 2

1.5                                       Baseline
                                          Post-intervention
 1

0.5

 0
      ICU             non-ICU
                                  Completeness

       3.5

          3                                     *p= 0.015

       2.5

          2                                                                    Baseline
                                                                               Post-intervention
       1.5

          1

       0.5

          0

To what extent was there any incomplete information on the “hand off” sheet that you received or gave out?
            Completeness
 4
3.5
 3                    P=0.005
2.5
 2                              Baseline
1.5                             Post-intervention

 1
0.5
 0
      ICU       Non-ICU
                                Responsibility
                                                        *p = 0.07
         5
      4.5                      *p =0.005
         4
      3.5
         3
      2.5                                                                       Baseline
         2                                                                      Post-intervention
      1.5
         1
      0.5
         0
                   Night Float                    Day Shift
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?
            Responsibility
 5
4.9
4.8
4.7
4.6                          Baseline
4.5                          Post-intervention

4.4
4.3
4.2
      ICU        Non-ICU
                  Responsibility

  1
0.9
0.8
                                   * p<0.05
0.7
0.6
0.5                                                              Baseline
0.4                                                              Post-intervention
0.3
0.2
0.1
  0
                      # of tasks
      Approximately how may tasks were you expected to do
      that should have been taken care of in a previous shift?
          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
         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
         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
         Limitations of Study
• Single Institution
• Outcome measures based on perception data
  – Review of medical records
     Ideal (?) handoff process


                           Test
                           results
Patient info
History



Medication                                Resident
                                        continuously
                Central                 updated via
                                     (handheld) device
  Insurance
  Billing        Staff
               Schedules
           Future Directions
• Focused training on handoffs
  – Importance
  – Process
• Sample Medical records
  – Better define accuracy and completeness

				
DOCUMENT INFO