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Hand-Off Residents’ Perspective
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Transcript of Hand-Off Residents’ Perspective
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Hand-OffResidents’ Perspective
Celia M. Divino, MDDepartment of Surgery
The Mount Sinai Medical SchoolNew York
October 14, 2008
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Hand off not Drop off
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1. Hand-off as a requirement for NPSG
2. Contributing Factors to Hand-off failures
3. Challenges for residents and training programs
4. Standardized Hand-off Protocols
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Root Causes of Sentinel EventsAll Categories - 2007
The Mount Sinai Hospital
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Communication (lack of) is the leading cause of sentinel events:
The Mount Sinai HospitalThe Mount Sinai Hospital
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National Patient Safety Goal #2: Improve Effectiveness of
Communication Among Caregivers
Requirement 2E
Implement a standardize approach
to hand-off communications,
including an opportunity to
ask and respond to questions.
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Definitions
Hand-Off: the transfer of responsibility and/or information about a patient from one caregiver to another.
Caregiver: any clinician, professional, or credentialed staff who provides direct patient care, treatment or service:– Nurse: RN, APN and LPN – Provider: Attending, fellow, house staff, PA– Therapist: OT/PT, respiratory therapist – Technician: radiologist– Consultant
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Situations for Hand-Off
Nurse– Change of shift– Coverage during (lunch) break– Change in patient status: serious or deteriorating– Nurse to Provider - MD, APN, PA
Provider – Provider to nurse– Temporary or complete transfer responsibility of
providers • ED to floor / Anesthesiologist to PACU• Medicine service to Neurology service
– Primary provider to Radiologist / Specialist– On-call / weekend / vacation coverage
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More Situations for Hand-Off
Transport (with attention to isolation status)– Ambulance to ED– ED to any service unit (radiology) or inpatient unit– Dialysis, cardiac cath lab– Pre-op to OR to post-op to unit
Reporting Critical Results (NPSG 2A)– Laboratory / Radiology / Diagnostic results
Reporting special patient condition/situation– Diabetic, Insulin delayed until after test is completed– Hold procedure until (lab test) result received
Transfer– to another hospital, nursing home, home health
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Good Patient Care
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Communication Related Incidents
Decreased surgeon familiarity with patients
Distorted or inhibited communication
Blurred boundaries of responsibility
Diverted surgeon attention
*Williams et al, Ann Surg, 2007.
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80-Hour Work Week?
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Consequences
15 hand-offs /patient in a 5 day hospitalization
Delayed test ordering
Increased adverse events
Medication errors
Longer length of stay
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• Team Based Approach to Patient Care
Non-Physician Extenders
• Shift Work
• Resident Perception of responsibility
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Challenges
• Work Flow Patterns
• Increased Multitasking
• Shift Changes
• Multispecialty Care
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• Ownership of Patients
• Definition of Roles
• Empowerment
• Standardized Hand-off Protocol
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Hand off Protocol
R edundancy
R ead Back
R espond to questions
R educe communication links
R estrict interruptions
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The Joint Commission’s Elementsfor Effective Communication
1. Interactive with opportunity for questioning between giver and receiver.
2. Up to date information regarding patient’s condition including recent or anticipated changes.
3. Verify: Read back or read-back techniques.
4. Receiver is able to review relevant patient historical data.
5. Minimal interruptions.
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Tools for Hand Off
UW Cores
U of Washington web-based computerized rounding and signout system
U of Chicago Microsoft Word document
Johns Hopkins Hospital
10-Point Guideline
Brigham & Women’s Hospital Computerized sign-out
The Mount Sinai Hospital Verbal and written SBAR
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S B A R
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At Mount Sinai we use SBAR as the standard format for Hand-Off
• SBAR is an acronym – S: Situation– B: Background – A: Assessment “your professional opinion”– R: Recommendation
• SBAR provides the framework for the communication.
• The content is patient specific.• Empowerment tool.
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S B A R
• Situation: (introduction to situation)
– I am ____ (name) from____ (unit / area) – The patient is_____ (name / DOB) – I am concerned because _____
• Background: (patient’s background)
– The patient’s VS are____– Mental status is____– Pt received xyz medication and is not responding
• Assessment: (caregiver’s assessment) – I think the problem is____– I am not sure but the patient is deteriorating
• Recommendation: (Caregiver’s recommendation)
– I recommend you see the patient right away– I request you order x med / test
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Apply SBARNurse:
Dr. Allen. This is Ms. Jones from 11 W. I’m calling about Sam Smith, your 45 yo with hx of pancreatic cancer. (S)
He was stable but suddenly has SOB - HR 120; R 28. (B) I think he might have thrown a pulmonary embolus. (A) I request you order blood gases and come see him. (R)
Dr. Allen to his colleague. Hey, I got to go. This sounds serious. And to Ms. Jones: Sorry about that. Seems like a good call. Yes, get O2 Sat,
if <90 start a facemask with and FL02 of 5 L and draw the blood gases. I’ll come right up.
Nurse: Thanks. I heard you say…. Yes, I will start O2 now. What’s next….? Elements / Criteria: Current Ask/Respond Clarify/Verify Anticipate Change Succinct
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Residents: Know what to really expect!
• What does SBAR mean? – S__ B__ A__ R__ (similar to admitting note with ….) – OK, it really is the framework for how I communicate
• Ok, what does it really mean?– That a nurse can say she/he thinks VS indicate possible CVS and
that I need to order … and get to the floor immediately.– That if I don’t respond, the nurse can/will/should kick it up to the
PGY 2, or Fellow and/or Attending. I better respond but I can also ask for clarification.
– That surgery can be held if the critical test result is outside limits and puts patient at risk. And if I get the patient I better make sure I have what I need from the previous provider.
– That it’s not just a good idea to communicate, it’s a requirement.– That it’s not as easy as I thought – but that with practice I’m won’t
be so nervous.– That I don’t need to write more just more effectively so the next guy
knows what she’s doing.
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TOOLS TO HELP YOU
MOUNT SINAI developed a
generic notepad
print shopED & Amb care
customized their own.
▲
TJCRequired elements
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Sign-Out
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National Patient Safety GoalSBAR to Improve Effective Communication for Hand-OffS Situation – Describe I am concerned because…B Background – Current status..…Pt VS / mental status is… A Assessment – Opinion I think the problem is...…R Recommend / RequestI recommend you………. √ Succinct √ Ask-Respond √ Clarify Verify√ Anticipate change√ Minimal interruption
NPSG / SBAR card Attach to ID badge
NPSGson reverse side
1237891315
And now 16
SBAR
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p4: SBAR does not substitute
for other professional
responsibilities and policies.
Mount Sinai Policy A2-404
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Common Questions
• Is Hand-off and SBAR only for nurses NO– Hand-off/SBAR applies to all caregivers
• Do I need to keep the note pad: NO– But make sure there is a confidentiality statement
on the top
• Do I need to document I used SBAR: NO – But it does not replace writing chart notes
• Do I need to give the pts life history: NO – But you need to communicate information that is
relevant, pertinent. Be succinct and with minimal interruption.
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