Presented at the George Washington University 1st GME Retreat. Includes overview of handoff function and content, pitfalls for handoffs, and strategies for safe and effective communication during handoffs, and how to use process improvement techniques to make handoffs safer. Handout includes handoff menu of educational tools to be used by faculty teaching.

1. Making the Most of Patient Handoffs: Critical for Patient Safety & Learning Vineet Arora, MD, MAPP Assoc Director, Internal Medicine Residency Asst Dean, Pritzker School of Medicine University of Chicago The George Washington University Medical Center April 16, 2010

4. Hand-off Theatre

5. What did you observe? What went well in this scenario? Observations Facilitators Other Environmental (e.g., distractions and obstacles interfering with completing proper hand-off procedure) Communication (e.g., vague terms, incomplete information, lack of verification, etc.) Cultural (e.g., not prioritizing hand-offs, following proper procedures, unprofessional behavior, etc.) Observations/Thoughts Barriers

9. What types of handoffs come to mind when you think about handoffs?

16. How can we improve handoffs? Understanding the good, bad & ugly… University of Chicago Experience

21. Differential Diagnosis of Uncertainty Farnan, et al. QSHC. 2008 Beresford E. The Hastings Center Report 1991 Patients’ treatment preferences Transfer of patient from floor to ICU Performing of a lumbar puncture Example Learn during handoff Lack of personal relationship with patient Personal uncertainty Seek supervision Difficulty applying abstract criteria to concrete situations Conceptual uncertainty Seek supervision Absence of or inadequate scientific data; limitations of fund of knowledge Technical uncertainty Strategy Definition Domain

23. Fatigue vs Uncertainty: Task Matters n=300 incoming interns at 3 Midwestern institutions

24. Improving Handoffs: Handoffs as a Form of Communication “ who says what to whom in what channel with what effect” Harold Dwight Lasswell

27. Hand-off as a Form of Communication “ When you move from right to left, you lose richness, such as physical proximity and the conscious and subconscious clues. You also lose the ability to communicate through techniques other than words such as gestures and facial expressions. The ability to change vocal inflection and timing to emphasize what you mean is also lost…Finally, the ability to answer questions in real time, are important because questions provide insight into how well the information is being understood by the listener.” – Alistair Cockburn

31. Now..Let’s put our communication skills to the test The Paper Tear Exercise

42. A Sample Hand-off Process (Internal Medicine)

44. Advanced Process Mapping: Identifying Barriers

47. Debriefing

50. Neurology Hand-Off Transfer of professional responsibility Verbal hand-off

52. Pediatric Post-Call Hand-Off “ closed-loop” communication

53. Anesthesia Resident to PACU Nurse Hand-Off Clear delineation of roles/responsibility Back-up Behavior

54. Mercy Hospital Sign Out Evening Handoff to Night Float

55. Mercy Hospital Sign in Morning Handoff from Night Float

56. Resorts to operator, pill bottles, or Google to get PCP contact info

57. PCP “pieces together” what happens from available labs & studies “ It’s like a detective” PCP finds out via active surfing of roster, or coaches patient to call PCP if they go to hospital, or home health fax “ Maybe smoke signals”

58. Redesigning the Process… Engage frontline staff in redesign of process…

59. Teaching Handoffs: A Competency Based Approach Communication Professionalism Arora, et al. QSHC 2008. 2/3 of IM programs report some type of teaching on handoffs (APDIM Survey, 2008)

61. Horwitz et al, JGIM. 2007 “ SIGNOUT?” Sample verbal sign-out S Sick or DNR? OK, this is our sickest patient, and he’s full code. I Identifying data (one liner) Mr. Jones is a 77-year-old gentleman with a right middle lobe pneumonia. G General hospital course He came in a week ago hypoxic and hypotensive but improved rapidly with IV levofloxacin. N New events of day Today he spiked to 39.5°C and white count bumped from 8 to 14. Portable chest x-ray was improved from admission, we sent blood and urine cultures. U/A was negative but his IV site looked red so we started vanco. O Overall health status Right now he is satting 98% on 2 L NC and is afebrile. U Upcoming possibilities with plan and rationale If he becomes persistently febrile or starts to drops his pressures start normal saline at 125 cc/h and have a low threshold for calling the ICU to take a look at him because possible sepsis. T Tasks to complete overnight with plan, rationale I’d like you to look in on him around midnight and make sure his vitals and exam are unchanged. I don’t expect any blood culture results back tonight so there is no need to follow those up. ? Any questions? Any questions?

63. Is the checklist the holy grail?

67. SBAR Arora, Johnson, Jt Comm J Qual Patient Saf. Schilling, eds. 2009

68. Some Case Examples… Based on real signouts…

69. 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?

70. 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?

71. A patient you are covering is being evaluated for small bowel obstruction. The attending surgeon comes by after being in the OR and asks you what the patient’s coags are. You say, I’m sorry but that is not my patient. Handoffs are more than just a transfer of content, but also a transfer of professional responsibility Every patient is your patient

72. Evaluation of Handoff Skills Simulation Peer Evaluation ½ of IM programs are evaluating handoffs (APDIM Survey, 2008)

80. Jeanne Farnan, MD, MHPE U Chicago Julie Johnson, MSPH, PhD U New South Wales, AU Holly Humphrey, MD U Chicago Boaz Keysar, PhD U Chicago Monica Lypson, MD U Michigan Sam Seiden, MD Stanford Leora Horwitz, MD, MS Yale Arpana Vidyarthi, MD UCSF David Meltzer, MD, PhD U Chicago Julia Kao, MD Northwestern Vivian Chang, MD UCLA Keiki Hinami, MD Northwestern John Paro, MS4 U Chicago

81. Vineet Arora varora@uchicago.edu Questions or Ideas? For copies of our papers or tools: [email_address] For our videos: “ MergeLab” on YouTube http://www.youtube.com/mergelab