Morning report 6/28/13: Handoffs

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Morning report 6/28/13: Handoffs

  1. 1. Improving signout skills JHU/Sinai Hospital Morning report 6/28/13
  2. 2. Goals Review common pitfalls during signout Learn to create and update a written signout Learn how to execute a verbal handoff
  3. 3. Sender oranizes & updates handoff information Specific verbal exchange between sender and receiver Pre-handoff Arrival Dialogue Post-handoff •Lack of time, poor time management, fatigue or work prevent updating •Lack of clinical judgement •Vague language •No set location or time •Not able to contact sender or receiver •Competing obligations •Handoff not a priority over other tasks Sender could: •Provide disorganized info •Use vague language •Fail to provide clinical impression, anticipatory guidance, plan or rationale Receiver could: •Not listen •Misunderstand •Not clarify (ask) •Forget key tasks or information •Not document actions taken •Act on plan without taking new information into account •Not invest in the care of patient
  4. 4. Two-way street Handoffs are dialogues Sender must paint a picture Receiver must see it, understand it, act on it, and, ultimately, communicate it to someone else.
  5. 5. Core components of handoffs Verbal communication in person or over the phone Written communication sign-out Transfer of professional responsibility
  6. 6. Constructing a written sign-out Abstracted from H&P Information that may become important in a critical situation code status, i.v. access, PCP, family info admission diagnosis, date, team All patients, even those being d/c’d that day Avoid vague language tomorrow/today/yesterday…
  7. 7. 9 Ds iDentitiy / Doctor / DNR? Diagnosis and Disease Diet Drugs Daily progress Directions: if/then, to-do
  8. 8. iDentitiy Room number remember to update it Patient name Age, gender Medical record number
  9. 9. Diagnosis and Disease Same column Diagnosis first Reason for admission and/or The main problem that is being worked up Then the disease (co-morbidities) CHF exacerbation CAD, HTN, DM, asthma
  10. 10. Drugs Sometimes difficult to list all, but you can use abbreviations highlight the important ones (antibiotics, narcotics, anticoagulants…) with a * … * If you copy/paste from Rounds Report, have to spend some time removing cruft
  11. 11. Diet Many calls about NPO status Especially in patients going to surgery/procedures the next day
  12. 12. Daily progress/Plan Things that explain patient’s *current* condition, progress, interventions, problems, plans e.g. On Lasix 40 mg IV q12h, net –ve 1.5L/24hr, improving; echo: EF 30%; continuing diuresis, cardiology to evaluate
  13. 13. Directions Items To Do: only important things that need to be addressed or require follow up, with special instructions for further plans and rationale—avoid “check BMP” If/then: anticipatory guidance for what may happen, short and clear
  14. 14. Updating written sign-out Update daily: Drugs Directions Nearly 1/3 of signouts discrepant with chart: 80% with at least 1 omission 40% with one comission
  15. 15. CoPaGA syndrome Copy/Paste Gone Amok Repeated copying and pasting text from H&Ps and progress notes into singout Crowds out useful information by gluts of useless data Zombie-like propagation of inaccuracies
  16. 16. Information overload Overreliance on signouts for your own work Signouts become unnecessarily long shadow chart Often becomes a personal tracker of information But remember, your covering intern needs it simple
  17. 17. Verbal handoffs Speakers systematically overestimate how well their messages are understood by listeners Egocentric heuristic—senders assume that receiver has all the same knowledge that they do Worsens the better you know someone
  18. 18. Biases in signout The most important piece of information was not communicated 60% of the time, despite the sender believing it had been Did not agree on the rationales provided for 60% of items Some things more likely to be remembered: ToDo (65%), If/then (69%), more likely than knowledge items (35%)
  19. 19. What can senders do? Relevant items that will be Remembered focus on the sickest patient first daily progress direction: to-do and if/then items Directions with Rationale avoid ambiguity: “check CBC” without giving a reason why and what to do with results Check for Receiver understanding
  20. 20. What can receivers do? Actively listen stay focused, limit interruptions taking notes can enhance memory Ask questions to ensure you understand dirctions Use a system to keep track of to-do items Readback
  21. 21. Example 1 A nurse calls because the patient wants to know if they can eat. Signout says “Patient is NPO for surgery tomorrow” Always give dates Avoid use of today/tomorrow/yesterday What procedure? How important?
  22. 22. Example 2 Your signout says “Check BMP at 8pm” The patient has a sodium of 124. What are you supposed to do with abnormalities? What is the baseline? What are you looking for?
  23. 23. Example 3 The patient you are covering is being evaluated for SBO. The surgeon comes by after being in the OR and asks you what the patient’s coags are. You say: “I’m sorry, but that’s not my patient”. Handoffs are more than just a transfer of content, but also a transfer of personal responsibility. Every patient is your patient.

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