Medical Informatics 402, Spring 2009

Group 2 Final ProjectLeigh Moyer

Lincoln Farnum

Nicki Cliffer

Joint Commission’s 2007 National Patient Safety Goal: Implement a standardized approach to hand-offs. (Sullivan, 2007)

Hand-off – “The point at which the patient is transferred, either physically to a different part of the hospital, or administratively when a new member of the care team takes responsibility.” (Clancy, 2008)

Why are hand-offs a cause for concern? They pose a risk to the patient

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Interactive conversation between person reporting off and person taking report

Contain accurate and up-to-date information

Receiving caregiver can read back, repeat back and ask questions

Adequate time should be allotted for the hand-off and interruptions should be limited (Sandlin, 2007)

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Hand-off information includes at least: Current condition of the patient Recent changes in condition Pertinent history and physical results Test results Current vital signs Diagnosis Planned treatment Response to treatment already given Plans for future treatment(Sandlin, 2007)

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Formats previously developed to organize hand-offs: SBAR

Situation, Background, Assessment, Recommendation I PASS the BATON

Introduction, Patient, Assessment, Situation, Safety Concerns, (the), Background, Actions

SHARQ Situation, History, Assessment, Recommendations,

Questions 5 Ps (V1)

Patient, Plan, Purpose of plan, Problem, Precaution 5 Ps (V2)

Patient, Precautions, Plan of Care, Problems, Purpose (Sandlin, 2007)

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Key Features Patient Identification Verification – Photo/ Bar

scan Patient information Current findings/list/details Problem list/ Current suggested disease list Preventive health/action verification Screen Tabs – Patient List, Patient

Information, Visit Information, Orders, Surgery, Results

Based on UCI Health Sciences SBAR Patient Report Guidelines: Perioperative Services

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Nursing Unit on Hospital Floor – Shift change

Nursing Unit on Hospital Floor to Pre-op Pre-op to Operating Room Operating Room to PACU/Critical PACU to Nursing Unit on Hospital Floor –

Post surgery

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Patient Name Sally A. SmithAge 43Sex FemaleChief Complaint

Chest Pain

Problem List Tobacco UsageCoronary DiseaseChronic Angina

Rx Levatol, 20mg daily

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Summary: Mrs. Sally Smith was admitted to the hospital due to the chief complaint of chest pain. She will be observed and will undergo a series of tests.

Currently Sally is in NW North Room 204. The attending physician is Dr. Jill Cohen, the nurse in charge is RN Patricia Appleman, and the cardiac specialist is Dr. Bill Metzger.

After crosscheck is complete, RN Appleman presses Acknowledge [Yes] and the record is displayed. *Patient history is updated with acknowledgement user, date and time.

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The screen defaults to the Visit History tab.

RN Appleman reviews the patient history, problem list, medications, and lab results.

She notes an alert indicating Tobacco Usage that has not been addressed.

Problem List: Tobacco Usage

CancelOk

Tobacco Usage ICD-9 305.1

[P. Appleman, RN. 5/17/09 5:45pm] – Discussed dangers of smoking with patient. Gave smoking cessation documentation and discussed programs through hospital.

Comments:

X

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RN Appleman clicks on the alert to bring up the acknowledgement data screen and take action.

She reviews the tobacco usage and gets details. She then updates the problem details and marks the problem as addressed.

RN Appleman ensures the patient’s comfort, and lets Dr. Cohen know that the patient is ready to be seen.   

Gender: Female

Male Age: 43y

Duration:

Chronic (> 4 weeks)

New Case Findings

ABC Acute Care Diagnosis Assistance Tool X

Current Findings List

New Case Finding - Details

Current Suggested Disease List

Chest Pain, Crushing*

Cigarette Smoking

Angina Pectoris

Chronic (> 4 weeks)

Female

Middle age (41 to 70 years)

++ Unstable angina pectoris+ Prinzmetal variant anginaAortic Valve stenosisEspohagus, spasmBronchitis, chronicGastroesophageal reflux diseaseCostochondritis

CancelSave

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Dr. Cohen arrives and launches the Diagnosis Tool to get a better idea of what is going on with Mrs. Smith.

The Problem List and Chief complaint are already inputted into the DY tool, along with gender and age. Dr. Cohen is prompted to review the problem list, chief complaint, and other data.

Before Angioplasty

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Based the patient’s history, Dr. Cohen believes unstable angina pectoris is likely and orders an echocardiogram.

The echocardiogram results arrive and Dr. Cohen is emailed. She reviews the results and consults with Dr. Metzger, the cardiac specialist, who recommends a coronary angiogram and possibly angioplasty, if needed. These can be done at the same time.

Dr. Metzger and Dr. Cohen meet with the patient and discuss the next steps.

RN Appleman schedules the procedure for the next day and documents the plan for the patient’s food, water, and medication intake. This is displayed on the patient information tab.

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The evening and overnight nursing staff arrive and review the patient list for their shifts.

The RN of the day shift reports on the patient.

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The night shift nurse notes an alert that Sally is due for a surgical test tomorrow. She is on restricted diet, and medication.

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RN Appleman returns in the morning and reviews the notes on diet and medication intake from the night before.

She begins the transfer and SBAR form for the move to pre-op. 

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Nurse Reilly is prompted to validate the patient’s name and picture and asks the patient to validate her birthday

After crosscheck is complete, Nurse Reilly presses Acknowledge and the record is displayed.

Patient history is updated with acknowledgement user, date and time.

Screen defaults to the Visit History tab.

Nurse Reilly reviews the problem list, medication list and the SBAR form that was filled out by Nurse Appleman.

Nurse Reilly acknowledges that this review is done.

Pre-OpSally Smith is moved from NW North Room 204 to pre-op room 5.Attending: Dr. Jill CohenTransferring nurse: Patricia ApplemanReceiving nurse: Paul Reilly

Nurse Reilly inserts the IV for medication. The anesthesiologist and nurse administer

Valium, Versed and morphine to relax the patient and block pain.

This is tracked on the flowsheet along with the patient’s heart rate and blood pressure.

The patient is ready for surgery.

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Nurse Reilly transfers the patient to surgery and fills out the correct SBAR form.

Nurse Roberts scans the patient’s barcode on her bracelet to pull up the patient record on the tablet PC assigned to the room.

After crosscheck is complete, Nurse Roberts presses Acknowledge and the record is displayed.

Patient history is updated with acknowledgement user, date and time.

The screen defaults to the Visit History tab.  20

Nurse Roberts reviews the problem list, medication list and the SBAR form that was filled out by Nurse Reilly.

Nurse Roberts calls Nurse Reilly to verify allergies. Nurse Roberts acknowledges that this review is done. Nurse Roberts accesses the Surgery tab which now

appears based on Patient Location. Nurse Roberts ensures the heart rate and blood pressure

monitoring devices are hooked up to the patient and communicating with the system.

Dr. Sanchez begins the procedure.

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Operating RoomSally Smith is moved from pre-op room 5 to Surgery 1BProcedural Doctor: Dr. Emile SanchezTransferring nurse: Paul ReillyReceiving nurse: Scott Roberts

During the coronary angiogram, a small gap is seen in the artery indicating there is a coronary blockage.

Dr. Sanchez takes a snapshot of the image and decides to insert a stent via angioplasty.  

 After the stent is inserted, Dr. Sanchez repeats the imaging test to validate that the angioplasty was a success.

A clear artery is seen and Dr. Sanchez captures this image as well.

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Before Angioplasty

After Angioplasty

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The procedure is finished and Dr. Sanchez documents a structured note outlining the procedure.

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Nurse Roberts begins the transfer to post-op and fills out the SBAR for the op to post-op transfer.

Nurse Whitely scans the patient’s barcode on her bracelet to pull up the patient record on the tablet PC assigned to the room. Nurse Whitely is prompted to validate the patient’s name and date of

birth. After crosscheck is complete, Nurse Whitely presses Acknowledge

and the record is displayed. Patient history is updated with acknowledgement user, date and time. Screen defaults to the Visit History tab

Nurse Whitely reviews the procedure info, problem list, medication list and the SBAR form that was filled out by Nurse Roberts.

Nurse Whitely acknowledges that this review is done. Nurse Whitely ensures the heart rate and blood pressure

monitoring devices are hooked up to the patient and communicating with the system.

Patient Smith’s health is monitored as she comes off of anesthesia.

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Post-Op

Sally Smith is moved from Surgery 1B to Post-Op 4

Procedural Doctor: Dr. Emile Sanchez

Transferring nurse: Scott Roberts

Receiving nurse: Jessica Whitely

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When patient Smith is awake and stable, Nurse Whitely completes the appropriate SBAR form to transfer to the inpatient floor.

RN Appleman scans the patient’s barcode on her bracelet to pull up the patient record on the tablet PC assigned to the room.

RN Appleman is prompted to validate the patient’s name and picture and asks the patient to validate her birthday. After crosscheck is complete, RN Appleman presses

Acknowledge and the record is displayed. Patient history is updated with acknowledgement user, date

and time. After reviewing the SBAR form, RN Appleman calls Nurse

Whitely to verify the surgical procedure information. Mrs. Smith is monitored until she is safe to be discharged.

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InpatientSally Smith is transferred from post op to NW North 410Attending: Dr. Jill CohenRN: Patricia ApplemanCardiac Specialist: Dr. Bill Metzger

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Hospitals - an inherently risky environment.

Unless the appropriate safety mechanisms are in place and working as intended, unfortunate patient outcomes occur with predictable regularity.

General Hospital, 59% of the house staff described that one or more patients had been harmed during their most recent clinical rotation due to faulty handoffs: 31% of residents rated the quality of handoffs as only fair or poor

21% reported that handoffs usually or always took place in a quiet setting

37% reporting that one or more interruptions during the receipt of handoff occurred either most of the time or always

In 2005, the Joint Commission issued rules that required hospitals to standardize their communication processes to reduce the risk of errors related to patient transfers, known as “handoffs,” by January 2006 – or risk losing their accreditation.

“We’ve seen that approximately 70 percent of all serious adverse events are related to breakdowns in communication, typically at the point of handoff,” said Dr. Richard Croteau, executive director for patient safety initiatives for the commission. Sally Smith was moved between four different areas to obtain a coronary angiogram and important information about her case and care might have been lost at any one. Checklists can include a set of the most common and problematic hand-off variables and they perform well to ensure that those items listed are addressed in a systematic fashion. A checklist of some kind almost seems mandatory to aid in the reduction of handoff failures.

The tool just demonstrated is intended to facilitate safe handoffs. Pertinent patient information is saved and displayed for users at each stop - from the inpatient area to surgery and back. Notes are embedded to allow viewing with mouseover techniques Individual cells are highlighted when they contain notes and are color-coded to describe the values relative to normal or previous values. This tool is intended to take the place of numerous tabs and worksheets, aggregating a wide variety of patient data and making both its input and display more accessible and easier to manage. This tool can serve as a prototype for patient data aggregation and handoff management.

Clancy, Carolyn, M. The Importance of Simulation: Preventing Hand-off

Mistakes. 2008. AORN Journal. 88(4): pp 625-627.

Sandlin, Debbie. Improving Patient Safety by Implementing a Standardized and Consistent Approach to Hand-off Communication. (2007) Journal of PeriAnesthesia Nursing. 22(4): pp 289-292.

Sullivan, Ellen E.. Hand-off Communication. (2007) Journal of PeriAnesthesia Nursing, 22 (4): pp275-279.

UCI Health Sciences SBAR Patient Report Guidelines: Perioperative Services

The Joint Commission Journal on Quality and Patient Safety; Handoffs Causing Harm: A Survey of Medical and Surgical House Staff. http://depts.washington.edu/respcare/public/hmc_files/journal_club/articles/20090406/Handoffs_causing_harm_a_survery_of_medical_and_surgical_house_staff.pdf

Massachusetts Medical Society, Online Continuing Education; Reducing Errors Liability in Patient Handoffs http://www.massmed.org/Content/NavigationMenu2/ContinuingEducation

Events/NewCourses/ReducingErrorsLiabilityinPatientHandoffs1/PatientHandoffs/Patient_Handoffs.htm

http://www.mayoclinic.com/health/coronary-angiogram/MY00541

http://www.medicinenet.com/coronary_angioplasty/page5.htm

http://en.wikipedia.org/wiki/Angina_pectoris#Unstable_angina

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