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- 1. Free Ebooks for All courses By: ebooks.edhole.com
- 2. Handoffs National Pediatric Nighttime Curriculum Written by Shilpa Patel and Lauren Destino Stanford University ebooks.edhole.com
- 3. Case 1 The handoff from your fellow intern: “Your first patient is Will, a 4 yo with asthma, probably going home tomorrow, so nothing to do. Is still on a little oxygen, but try to wean it overnight so he can actually go home, ok?” ebooks.edhole.com
- 4. Case 1 Are you ok with this information? Do you think you have all you need to take care of this patient overnight? What can you do to improve this communication? What if the nurse calls you and states Will is needing more oxygen? ebooks.edhole.com
- 5. Case 2 The handoff from your fellow senior: “The sickest patient is Mackenzie. She is a 3 yo ex-preemie with CP, developmental delay, chronic lung disease who is here with pneumonia. She just came up from the ED and her main issue is respiratory distress. She is on continuous albuterol at 15mg/hr, IV clinda and ceftriaxone and IVF. I would look at her right after sign out since if she gets a lot worse, the PICU may need to be consulted.” ebooks.edhole.com
- 6. Case 2 Are you ok with this information? Do you think you have all you need to take care of this patient overnight? What can you do to improve this communication? What will you discuss with the intern? What would you do if you get a page about this patient in the middle of the hand off? ebooks.edhole.com
- 7. Objectives To recognize effective vs. ineffective handoffs To identify the components of an effective handoff To understand the importance of communication to patient care ebooks.edhole.com
- 8. Why Should We Care? Institute of Medicine estimates up to 100,000 patients die in U.S. hospitals annually due to errors in their care. Failures in communication a leading cause of adverse events in healthcare. Issues around communication, continuity of care, or care planning cited as root cause in >80% of reported sentinel events. Australian review of 28 hospitals found communication errors associated with twice as many deaths as clinical inadequacy. ebooks.edhole.com Coverage by a second team of residents one of strongest predictors of adverse outcome
- 9. Sentinel Events Unanticipated event that results in death or serious physical or psychological injury to a patient and is not related to the natural course of the patient’s illness ebooks.edhole.com
- 10. Why Now? More turnover of patients and personnel: Increase in rate of transfers and discharges12 by 40% since duty hour changes made New duty hours: average of 15 handovers during a 5-day hospitalization Each intern involved in >300 handovers in average month-long rotation13 Healthcare more specialized:12 Greater number of clinicians providing narrow focus of care Specialized units designed for specific diseases, procedures, phases of illness may mean loss of big clinical picture Increase in rate of discontinuity13 Changes in the resident schedule structure to reduce fatigue Cultural change in healthcare delivery that utilizes schedules with shifts Many points of transitions, transfers of responsibility (MD to MD, RN to RN) ebooks.edhole.com
- 11. What do we know about communication? A recent handoff study supports literature on the psychology of miscommunication: Speakers systematically overestimate how well their message is understood by listeners Speakers also assume that the listener has all the same knowledge that they do (gets worse the better you know someone) ebooks.edhole.com
- 12. The Handoff Players Sender Receiver ebooks.edhole.com
- 13. What Works: a look at other high risk industries 3,4 Face to face: verbal, interactive questioning in safe environment Limit interruptions: so can go through handover systematically Sender provides updated printed summary Opportunities for both receiver and sender to introduce topics Information relayed in structured format: decreases omissions ebooks.edhole.com
- 14. What Works: a look at other high risk industries 3,4 Specific contingency plans Read back: insures info received correctly Checklist: avoids content omissions Delay transfer of responsibility when concerned about patient status Unambiguous transfer of responsibility: wards know who to call Receiver scans historical data either right before or right after the handoff ebooks.edhole.com
- 15. Components of Ideal Handoff Brief one liner about the patient including: How sick is the patient? Significant past medical history Reason for admission CURRENT condition, recent interventions, active problems ebooks.edhole.com
- 16. Components of Ideal Handoff Systematic approach to communicating needed information. Use one consistently so receiver knows what to expect. --Systems --IPASS the BATON --SIGNOUT --SBAR --SAFE-IR --Problems Contingency planning – i.e. anticipated problems, results, procedures and what to do about them: BE SPECIFIC “Read back” to verify a shared mental model ebooks.edhole.com
- 17. Two Way Street to a Shared Mental Picture Sender Paints picture Relevant items Specific directions with rationale Check receiver understanding Receiver Listens Ask questions Use system to remember important items Read back ebooks.edhole.com
- 18. Back to Case 1 Identification: Will is a 4 yo with mild persistent asthma on hospital day #2 for an asthma exacerbation, triggered by URI. He is improving and no longer very sick and should go home tomorrow if he can be weaned off oxygen overnight. ebooks.edhole.com
- 19. Back to Case 1 Problems Asthma: He was on continuous albuterol at 10mg/kg on admit but now weaned to 4 puffs MDI every 4 hours. He has wheezing before treatments but no retractions, flaring or work of breathing. He is on day 2 of oral steroids and on Flovent twice a day. Nutrition: He has an IV and required a bolus on admit. He is now eating and drinking well. Hypoxia: Will has needed 0.5-2L by nasal cannula and is currently down to 0.25 L with sats >95%. Infectious Disease: Will has been afebrile and his current exacerbation is thought to be due to a viral process. He is in isolation given his runny nose and ebookcso.eudghh.ole.com
- 20. Back to Case 1 Contingency Planning: If Will has an increasing oxygen requirement try increasing albuterol frequency to every 3 hours If he is febrile, recheck his lung exam to assure no focal signs concerning for a developing pneumonia Wean the oxygen as the goal is discharge tomorrow If his IV falls out there is no need to replace it Readback: Receiver repeats important information ebooks.edhole.com
- 21. Practice a handoff Please practice signing out the patient on the following slide using the ideal sign-out components in a pre-determined standard order The details are intentionally disorganized One person should observe the sign-out and give feedback One person should give the sign-out One person should receive the sign-out (ask questions and read back). ebooks.edhole.com
- 22. Practice handing off this patient • JS is a 7 yo girl with known asthma who was admitted to the PICU 2 days ago. • In the PICU she was on heliox, continuous albuterol and a terbutaline drip for one day. The terbutaline has been off for 15 hours, the heliox off for 24 hours. • She is currently on 6 puffs every 2 hours, a 2 Liter O2 requirement, IV methylprednisolone at 4 mg/kg/day. • She is also on maintenance IVF for continued poor po intake. • She came to the floor this morning and was doing well until around 3 pm when the intern was called to evaluate for increasing O2 requirement. On assessment, she seemed to be aerating less on the right when compared to the left; a CXR was done but is not yet up. She was restarted on continuous albuterol at 5 mg/kg/hr. The plan is to get a gas if things continue to worsen. • Also a pulmonary consult was obtained for multiple recent admissions, and for poor compliance. If they have recommendations, it is okay to follow through with them unless they seem excessive, in which case, they should be discussed with the attending. If CXR shows consolidation, antibiotics should be started. If there is concern for a pneumothorax on the CXR, talk to the senior resident and consider PICU consult for thoracentesis. • She should be kept NPO due to her worsening clinical status. But if the CXR is normal and she is improving from a respiratory point of view, consider restarting diet. • Currently on exam, her RR=35, she is on 10L face mask, and she is retracting and wheezing everywhere except on the right side, where there are diminished breath sounds. She can speak in 3 word sentences, which is a decline from this morning. However, she is still alert and responsive. This afternoon at 1300, she had a fever to 38.4 C; she had been ebooks.edhole.com afebrile at home.
- 23. Take Home Points Giving sign out: Be specific, concise and deliver the information in a standardized format. Receiving sign-out: Summarize what you were told and ask questions as needed; listen actively by anticipating potential issues. “Read back” the most salient points of the sign-out. Communication Poor communication can lead to errors, near misses and adverse events Good communication can improve quality and safety of patient care It ebooks. eisd hboeles.tc onmot to assume knowledge
- 24. Selected References Chang VY, Arora VM, Lev-Air S, D’Arcy M, Keysar B. Interns overestimate the effectiveness of their hand-off communication. Pediatrics 2010;125(3):491-496. Arora VM, Johnson JK, Meltzer DO and Humphrey HJ. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care 2008; 17:11-14. Patterson ES, Roth EM, Woods DD, Chow R and Gomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Intl J Qual Health Care 2004;16(2):125- 132 ebooks.edhole.com
- 25. Bibliography 1. Arora V, Johnson J: A model for building a standardized hand-off protocol. J Qual Patient Safety 32(11), 646-655, Nov 2006. 2. Sidlow R, Katz-Sidlow RJ: Using a computerized sign-out system to improve physician-nurse communication. J Qual Patient Safety 32: 32-36, Jan 2006. 3. Patterson ES, et al: Handoff strategies in settings with high consequences for failure: lessons for health care operations. Intl J Qual Health Care 16(2): 125-132, 2004. 4. Arora V, Johnson J et al: Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 14:401-407, Dec 2005. 5. Streitenberger K, Breen-Reid K, Harris C: Handoffs in care - can we make them safer? Pediatr Clin N Am 53:1185- 1195, 2006. 6. Solet DJ, Norvell JM, et al: Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med 80:1094-1099, 2005. 7. Williams RG, et al: Surgeon information transfer and communication. Ann Surg 245(2): 159-169, 2007. 8. Frank G, Lawless ST, Steinberg TH: Improving physician communication through an automated, integrated sign-out system. J Healthcare Info Mgmt 19(4):68-74, 2005. 9. VanEaton EG, et al: A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. Surgery 136(1):5-13, 2004. 10. Haig, KM, et al: SBAR: a shared mental model for improving communication between clinicians. J Qual Patient Safety 32(3): 167-175, March 2006. 11. Bernstein JA, Imler DL, Longhurst CA: Physicians report improved workflow after integration of sign-out notes into the electronic medical record. Submitted for publication, transcript provided by Dr. Longhurst. 12. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043) http://www.ahrq.gov/qual/nurseshdbk/ ebooks.edhole.com
- 26. Bibliography continued 13. Vidyarthi, AF, Arora, V, Schnipper JL Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. Journal of Hospital Medicine 2006; 1:257-266. 14. Peterson LA, Brennan TA, O’Neill AC Does housestaff discontinuity of care increase the risk for preventable adverse events. Ann Intern Med. 1994; 121:866- 872. 15. Mukherjee S A precarious exchange. NEJM 2004; 351:1822-1824. 16. Chang VY, Arora VM, Lev-Air S, D’Arcy M, Keysar B. Interns overestimate the effectiveness of their hand-off communication. 2010;125(3):491-496. ebooks.edhole.com
Editor's Notes
- Take some time to read this handoff, given to you by a fellow intern, who is leaving for the evening.
- How would you rate this handoff? This handoff is actually inadequate. A danger in hand off communication is that the receiver doesn’t think critically about the information being given, assuming that the sender will give all the pertinent information. Studies show that the more familiar the sender and receiver are with each other, the more potential for missed information. 2. Think about whether you have all the information you need: there are many things that could happen with this patient that you may not be able to predict at the time of the hand off. However, with each illness there should be some important pieces of information that are communicated. For instance, for a patient with asthma it is good to know: The current respiratory status with recent exam and exact amount of oxygen the patient is on The current medications and their frequency or method of delivery – for instance, is the patient on albuterol nebs or MDIs? Are the steroids oral or IV? Is the patient on inhaled corticosteroids? If the patient did not follow a typical hospital course, what has gone wrong in the past and what helped. It is also important to note any historical data that further describe baseline status (e.g. is the patient an ex-preemie or have they had previous PICU stays for asthma exacerbations?) e. It is also always good to know if the patient has IV access and what the plan should be if that IV falls out or if there are any psychosocial issues and who to call if there are questions or concerns. What can be done to improve the communication? The sender can provide the additional information just mentioned above. The receiver should also ask questions and summarize the salient information he or she heard. If there is time before the hand off occurs, it is also very useful to review any documentation that may be readily available. These concepts are discussed ahead in the didactic. 4. The final question brings out the critical piece of contingency planning – what to do if something does not go as planned. Maybe the patient needed more oxygen in the past at various times and improved with decreased time between respiratory treatments – this is the type of thing that should be communicated in the hand off. There are many other reasons why the patient could need more oxygen and one should think about these reasons in addition to the ones potentially communicated in the handoff. Contingency planning saves time and allows the covering physician to provide better patient-specific care without having to “figure it out” from scratch.
- Take some time to read this second case about a patient whom a fellow senior is signing out to you before she leaves for clinic.
- How would you rate this handoff? One positive is that it starts out with a helpful piece of information – “this is your sickest patient” and thus sets the stage for the communication. However, as with the first example there is lack of information: current respiratory status (Retracting? Tachypneic? Alert?); what was done in the ED?; potential contingency plans (Repeat CXR if worsens? Go up on albuterol? Add O2 to reduce work of breathing? Though the potential need for the PICU is mentioned, there are several things that could be tried prior to calling the PICU). Do you think you have all the information you need to take good care of this patient overnight? Again, the receiver should get a little more information. Has Mackenzie ever been sick like this before and what worked or didn’t work? Who should be called if she worsens – you could imagine that a patient that is complex may have subspecialty services involved in his or her care. You were told she was on IVF but why (was she made NPO because of her respiratory distress is severe or is she on IVF because she is dehydrated? It is unclear from the information given to you). Problems often arise when one assumes something that may or may not be true. What can be done to improve the communication? The same concepts discussed in Case 1 apply here as well. In addition, with this patient – “the sickest” – it is often helpful for the receiver and sender of the hand off to visualize the patient together. Some terms used to describe patients can be vague and/or residents with different levels of training may interpret and communicate physical findings differently. Visualizing the patient together assures that everyone is on the same page and the receiver can clarify what they heard during the hand off. As a supervising resident you would want to be sure to communicate your concerns to your intern: let the intern know when you want to be notified about the patient and set up a specific plan for re-evaluating the patient throughout the evening. Your level of supervision may change depending on the intern’s level of training and knowledge but with any ill patient it is better to be more involved. And it is always better to be specific about expectations for re-evaluation, rather than assume the intern has the same level of concern that you do. And lastly, how would you handle an interruption during the hand off? Though interruptions can be bothersome and may derail a handoff that is going well, some interruptions may actually contribute important facts or updates to the handoff itself. If the page has more information (such as a text page), it can be helpful to triage it appropriately (for example, “mom has arrived and wants an update” versus “Mackenzie now working harder to breath”). Without that information, it is best to interrupt the hand off or delegate tasks to other available care providers if possible.
- This first bullet is data from the article, To Err is Human, and thus is already a decade old. Despite an increased focus on quality improvement after this information came out, there is no real evidence to say that this number has decreased. The other bullets are taken from various articles in the literature and are cited at the end of this presentation.
- A sentinel event is an …. As described in this table, communication is clearly the main contributor to sentinel events. As hand offs are all about communication, they are a very vulnerable piece of the medical care we provide. Thus it is important to: Be aware of the problems with hand offs Be aware of what elements help hand offs go more smoothly Continue to work on this piece of communication just as one may work on his or her presentations at rounds Provide ongoing feedback to each other regarding the quality of the hand off and any near misses, errors or adverse events where the hand off may have been a contributing factor.
- The first piece of information is from the original duty hour change (80 hour work week, 30 hour max shifts). It does not take into account the more recent changes which will potentially lead to even more hand offs. One must also consider the handoffs that occur at all other times and with other care providers. Any time a patient goes somewhere for a procedure, transfers units, nursing changes, attending on service changes there is a hand off.
- This slide refers to the study performed by Chang et al in Pediatrics 2010. Though it focused on interns, the psychology of miscommunication likely holds true for all care providers.
- In any hand off there is a sender: the person giving the information; and a receiver: the person receiving the information. The sender is typically post call or the day time resident who is leaving for the evening and the receiver is typically on call or the night time resident. This is a well-known Gary Larson cartoon that depicts the psychology of miscommunication - speakers/senders overestimate how well their message is understood and also overestimate the amount of knowledge the receiver has.
- Examination of other high-risk industries that are successful at handovers, such as the aerospace, railway and nuclear industries, tell us that the following things contribute to effective hand offs…
- Continuation of the listed started on previous slide
- So, how might you hand off patients better? The next 2 slides review the components of an ideal handoff: A brief one liner about the patient sets the stage as well as communicates whether the patient is sick or not sick and why they are still hospitalized.
- There are various systematic approaches to providing this type of information. Handoff mnemonics allow the receiver to know what to expect and may prevent omissions if the sender gives the information in the same way every time. Some examples of mnemonics are: IPASS the BATON – Introduce yourself, Patient introduction, Assessment, Situation, Safety concerns, Background, Actions, Timing, Ownership, Next SIGNOUT – Sick or DNR, Identify Data, General Hosp Course, New events, Overall health status, Upcoming possibilities with plan and rationale, Tasks to complete with plan and rationale SBAR – Situation, Background, Assessment, Recommendation It is very important to talk about anticipated problems – what might go wrong and what to do about it as well as what has gone wrong in the past and what has worked. For example, stating, “if the patient is fluid overloaded, give lasix” is not nearly as helpful as stating “if patient is >500 cc positive at midnight, give 0.5mg/kg of IV lasix and check the fluid status every 6 hours”. Read back of the salient points confirms that the receiver and the sender are on the same page: they have a shared mental model of the patient.
- This slide depicts the goal of the handoff: that both the sender and the receiver of the handoff have a shared mental picture of the how best to care for the patient. For the sender: You want to be sure you are specific and that you are creating the picture of the patient that you want the receiver to see. Make sure that the receiver understood your communication correctly by listening carefully during the read back. For receiver: You should listen actively and concentrate on the information you are receiving. Asking questions ensures you understand directions and learn. Read back the salient points confirming that everyone is on the same page. It is all too often true that the sender thinks they communicated something clearly and what the receiver heard was actually something different -- this is why READ BACK is one of the most important steps to an effective hand over.
- Here is another pass at the handoff about our first patient – this handoff continues on subsequent slides.
- Case 1 handoff revisted continued…
- Case 1 handoff revisted continued…
- The presenter may want to print the slide with the patient information on it to hand out to the residents for this part of the module. It is recommended that the presenter familiarize themselves with the information on this slide prior to giving the module and organize it themselves into a good hand off format.