TRANSITIONS OF CARE: HOSPITAL HANDOFFS...Defining the Problem: Patient Handovers 1. Transitions of...

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TRANSITIONS OF CARE: HOSPITAL HANDOFFS Intern Orientation

Transcript of TRANSITIONS OF CARE: HOSPITAL HANDOFFS...Defining the Problem: Patient Handovers 1. Transitions of...

Page 1: TRANSITIONS OF CARE: HOSPITAL HANDOFFS...Defining the Problem: Patient Handovers 1. Transitions of Care o Change in patient location, or provider, or both o ER, ICU, discharge, shift

TRANSITIONS OF CARE:

HOSPITAL HANDOFFS

Intern Orientation

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Avoiding the Overnight Handover

Fumble

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Objectives

After today, you will be able to:

• Understand the importance of communication around

care transitions

• Identify what patient information should be

communicated at handover

• Know what to include in the “sign-out” sheet

• Communicate the essential elements of a nightly

handover using a standardized format

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Outline

9:00-9:45 Presentation

• Define care transitions and handovers

• Overnight handovers

10:00 Break into small groups

10:00-11:30 Transitions Workshops

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Defining the Problem: Patient Handovers

1. Transitions of Care

o Change in patient location, or provider, or both

o ER, ICU, discharge, shift change, service change

2. Handovers or Handoff

o The exchange of information and transfer of

responsibility that occurs during a transition of care

Arora AM, Manjarrez E, Dressler DD, et al. J Hosp Med 2009

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Question

How many times is an average inpatient

transitioned during a 5 day hospitalization?

A. 5

B. 10

C. 15

D. 25

E. None of the above

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Question

How many times is an average inpatient

transitioned during a 5 day hospitalization?

A. 5

B. 10

C. 15

D. 25

E. None of the above

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What the patient experiences

Average inpatient is transitioned 15 times in a 5 day

hospital stay

Patients can be seen by three different physicians in

the first 24 hours of care

All of this equates to discontinuity and opportunities

for medical errors to occur

Vidyarthi et al. JHM. 2006Philibert I. QualSaf Health Care. 2009

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Post-Call Intern 1

Post-Call Intern 2

Short-Call Intern 4

Short-Call Intern 3

Pre-Call Intern 5

Pre-Call Intern 6

Long-Call Intern 2Long-Call Intern 1 Long-Call Resident

Before 7PM: 1) Handover written signouts

2) Verbal on sick pts

Available by pager until 8PM

Written handover before 7PM

NF XC Resident

At 7PM: 1) Handover Written signouts

(interns 1-6)

2) Verbal signout

(supervised by resident)

Non-Long Call Wards Residents

7PM-8PM:Telephone verbal signout

1

3

2

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Frightening Handover Facts

of sentinel events reported to the Joint Commission had communication errors as a contributing factor

of residents report adverse events related to poor handovers; 15% of these were life threatening

is the cost of preventable medical errors

60-80%

30%

$17

billion

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http://www.jointcommission.org/Sentinel_Event_Statistics/

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The Uncertain Clinician

A study of the sign-out process noted that “the most

important information about a patient was not

successfully communicated 60% of the time”

73% of pediatrics residents surveyed noted

uncertainty regarding care plans due to incomplete

verbal hand-offs

Only 19% of written sign-outs were accurate with

respect to patient information and care plans

Improving physician hand-offs. Sarita Warrier, MD. http://www.rimed.org/medhealthri/2011-

11/2011-11-344.pdf

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Worried Patients

Fletcher et al cited that 28% of patients reported

concerns about how often hand offs of care

occurred

In this same study patients’ “worries about

“fatigue/discontinuity” were significantly associated

with trust in and satisfaction with the health care

provider

Fletcher KE, Wiest FC, Halasyamani L, et al. How Do Hospitalized Patients

Feel About Resident Work Hours, Fatigue, and Discontinuity of Care? J

Gen Intern Med. 2007;23(5):623–8.

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Question

When extrapolated to all US hospitals

approximately how many deaths are attributable to

medical error?

A.10,000-40,000

B. 40,000-90,000

C. 90,000-130,000

D. 130,000-170,000

E. None of the above

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Question

When extrapolated to all US hospitals

approximately how many deaths are attributable to

medical error?

A.10,000-40,000

B. 40,000-90,000

C. 90,000-130,000

D. 130,000-170,000

E. None of the above

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Institute of Medicine

“To Err is Human”

~55% of adverse events in hospitalized patients can be attributed to errors.

When extrapolated to all US hospitals, this represents 44,000 – 98,000 deaths / year caused by medical errors – exceeding deaths by motor vehicle accidents or breast cancer. Medical errors are the 8th leading cause of death.

Total national costs are estimated between $17 and $29 billion (1996 dollars)

http://books.nap.edu/openbook.php?record_id=9728

http://books.nap.edu/openbook.php?record_id=9728
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Ramping up the Research…

Flemming et al., Int J Med Inf, 2013; http://dx.doi.org/10.1016/j.ijmedinf.2013.03.004

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The Goal of the Handover

Provide information about patient’s current

condition, care, and treatment

Anticipate changes in current health status

Provide rationale for interventions

“Information presented during hand-off must be

accurate in order to meet patient safety goals.”

Joint Commission 2009.

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Optimal Handovers – Society of

Hospital Medicine

• Decide on a handoff plan

• Train new users on the plan

• Include verbal exchange of information

• Include a “handoff tool”

Arora et al., JHM 2009; 4: 443-440

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http://vimeo.com/12349347

Handovers in the Hospital

http://vimeo.com/12349347
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Barriers to Effective Communication during

Patient Handovers

o Interruptions

o Erroneous information becomes “fact”

o Omission of information

o Human Element

o Technology

o Time constraints

o Lack of training

Philibert I. QualSaf Health Care. 2009Patterson ES. J Qual Healthcare 2004

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Don’t Forget the Big Stuff…

Arch Intern Med. 2008;168(16):1755-1760.

doi:10.1001/archinte.168.16.1755

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Components of a Strong Handover

1. Structured

Communication

S2AIF-IR

Both users know what

to expect

2. Dialogue not

Monologue

3. Close the Loop

Chu et al., JHM 2010; 5: 344-348.

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SAIF-IR

S: SICKEST FIRST

“This is my sickest patient. This is Mr. C, he is a 70

year-old male located in 5J step-down unit. He was

admitted today through the Emergency Room for

decompensated heart failure. He has been

evaluated by the MICU resident and they are

aware of him.”

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SAIF-IR

S: SUMMARY STATEMENT

1-3 sentences

“He has an EF of 10% and p/w respiratory distress

and confusion. He required BiPAP in the Emergency

Department and is now on a dobutamine drip

through a central line that we put in. Cardiology is

on board.”

Basics:

1. 1-3 sentences

2. Why is he here and what do

you think is going on?

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SAIF-IR

A: ACTIVE ISSUES

“He’s doing a little better, with improved

respiratory status and urine output. He’s currently on

5L of O2 through a nasal cannula and is breathing

in the low 20s.

“Also, just a heads up that this patient

is still a bit confused although that’s

improving too. He knows where he is

but is not sure why he’s here.”

Basics:

What happened today that I

should be aware of?

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SAIF-IR

I: IF-THEN CONTINGENCY PLANNING

F: FOLLOW UP ACTIVITIES

“He has a troponin leak with last troponin of 0.10. He has a third set pending tonight at 10pm if you could follow-up on that.

If-then scenario: If it is increasing, repeat an EKG, make sure that he is chest pain free, and start a heparin drip and continue to cycle his enzymes.

If he has chest pain, cardiology needs to be notified as well as the CCU.”

Basics:

1. Are there any lab or radiology

findings that I should be aware

of?

2. What do I need to do

overnight? If-Then Scenarios!

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SAIF-IR

I: IF-THEN CONTINGENCY PLANNING

F: FOLLOW UP ACTIVITIES

“He’s still confused but re-directable and has a

sitter in the room. If he gets worse, I’d check a blood

gas and another EKG. If those look OK, you can try

low-dose Haldol.”

“He is full code so if his respiratory status worsens

and doesn’t improve with BiPAP, he can be

intubated.”

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SAIF-IR

I: INTERACTIVE QUESTIONING

Correct or clarify any information given by the off-

going provider

R: READ BACKS

Confirm follow-up activity or contingency plans

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What about the Sign-Out Receiver?

Now is NOT the time to multi-task

Active Listening!

Clarify tasks

Ask questions

Close the loop in the morning

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To Recap…

SAIF-IR

Sickest first, Summary statement

Active issues

If-then contingency planning

Follow up activities

Interactive questioning

Read-back

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https://vimeo.com/99182377

Handovers in the Hospital

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Final Nightly Handover Thoughts

Anticipation is Key!

o Figure out which patients deserve a more thorough verbal signout

o Anticipate possible overnight scenarios or recurring problems

Avoid general tasks such as “Check CBC”

o Give specific task and complete with an if-then statement

Keep the dialogue open

Avoid a multi-tasking scenario

Page 34: TRANSITIONS OF CARE: HOSPITAL HANDOFFS...Defining the Problem: Patient Handovers 1. Transitions of Care o Change in patient location, or provider, or both o ER, ICU, discharge, shift

Objectives

After today, you will be able to:

• Understand the importance of communication around

care transitions

• Identify what patient information should be

communicated at handover

• Know what to include in the “sign-out” sheet

• Communicate the essential elements of a nightly

handover using a standardized format

Page 35: TRANSITIONS OF CARE: HOSPITAL HANDOFFS...Defining the Problem: Patient Handovers 1. Transitions of Care o Change in patient location, or provider, or both o ER, ICU, discharge, shift

Transitions of Care Committee

Larry Beer, MD*

Joanna Bonsall, MD, PhD

Dan Dressler, MD*

Erin Lundberg, MD

Amy Miller, MD

Christopher O’Donnell

Ugochi Ohuabunwa, MD

Melissa Stevens, MD

Anna Von, MD

Christina Payne, MD*

Manuel Eskildsen, MD*

Page 36: TRANSITIONS OF CARE: HOSPITAL HANDOFFS...Defining the Problem: Patient Handovers 1. Transitions of Care o Change in patient location, or provider, or both o ER, ICU, discharge, shift

And Finally…

Questions?


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