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Applying Crew Resource
Management to Safe Transitions
in Patient Care
2008 NPSF Annual Patient Safety Congress
Nashville, ...
The Josie King Story

2
Clinical Vignette

3
Teamwork

4
What are the characteristics of a
TEAM?

5
Communication

6
If information flow is the
currency of medical practice,
why is so little attention paid
to communication
effectiveness in...
Communication Skills

In medical school and nursing
school, the focus is on
successful communication
with the patient.
8
Communication failure
is a leading source of
adverse events in healthcare.
Evidence from Surgery, Medicine, Emergency Medi...
10
Root Cause Analyses (RCA)
Database*
• ~70% to 80% of RCAs cited
COMMUNICATION FAILURE as, at
least one of the root causes/...
Collaboration & Teamwork in ICU =
Lower Morbidity & Mortality +
Increased RN Retention
Evidence from ICUs
• Knaus – 5030 I...
Institute of Medicine* (2000):
“…establish team training programs
for personnel in critical care areas
using proven method...
Communication
Definition: The exchange of thoughts,
messages, or information.*
A dynamic process between people:
• Sender ...
Faculty Role Play

15
Was our communication
successful?

16
Successful Communication
• Many communication improvements
focus on improving accuracy and
availability of content, e.g. C...
Communication Context
•
•
•
•
•
•
•
•
•

Culture
Gender
Language barriers
Differing mental models
Professions and discipli...
Assertive Statements
Direct and clearly communicated statements that
facilitate patient advocacy in decision-making.

• No...
Words to Avoid
• “You” - blame/shame, elicits defenses
• “Should” – judgmental, value statement
• Hyperbole – “never,” “al...
Words to Use
• “The” statements (policy) – stick to the
facts
– Avoiding conflating person with behavior
– Attack the prob...
CRM Communication
Techniques

22
Call Out
• Communicate to all what you see and
know
• If you “feel the pinch” that trouble is
brewing, communicate that to...
Step Back
• “Pause in the Action” – can be dramatic
• Reassess a situation that doesn’t appear to be
working
• Challenge a...
Clear Communication
• Read Back
– Write down what you heard
– Read back what you wrote
– Confirm with the sender
• Repeat ...
Dynamic Skepticism
• Attitude of constantly questioning and evaluating
the patient care environment
– Avoid trusting what ...
Assume Nothing!
Communicate what you
see and know!

27
Safe Transitions in Patient Care
Responsibility

28
Some Conspicuous Types of Handoffs
(formality
• Shift Changes and temporality varies widely)

– Physicians
– Nurses

• Int...
Why are Goodor unknown clinical information
Handoffs Important?
• Provide access to new
• Increase efficiency/flow
– Preve...
What Should be in a Good Handoff?
•
•
•
•
•
•
•
•
•
•
•
•

Team Identifiers - Staff names, phone numbers, covering staff
c...
2007 (and 2008) Joint Commission
National Patient Safety Goal
• (2) Improve the effectiveness of communication
among careg...
RCAs and Handoffs

• Most RCAs cite communications as a
contributing factor
• Handoffs are situations where communications...
Top 10 Topics of VA RCAs
Delay in Treatment/Diagnosis/Surgery

1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)

Falls (close to 50% of ...
Developing a Standardized Approach
to Hand-off Communications
• A standardized approach should identify :– The “hand-off” ...
Examples
• Flowcharts for two standardized kinds
of shift-change handoffs for nurses
– Had more pre-existing standardizati...
HANDOFF PROCESS WITH IN-PERSON TRANSFER OF PATIENT INFORMATION
Midnight (AM) to Morning (AM) Shift Change (7:30 – 8:00 am)...
HANDOFF PROCESS WITH TAPE RECORDED PATIENT INFORMATION
Midnight (AM) to Morning (AM) Shift Change (7:30 – 8:00 am)

Night ...
Options for nurses: In the event that a question remains or occurs
after getting a shift report by tape, face-to-face, or ...
Shift Handoff Tool (Short) History
Created by Indianapolis (Roudebush) VAMC with inputs from pilot
testers at the followin...
Create Link To
HANDOFF TOOL in
CPRS Tool Bar

41
42
These fields can be specified
by site/department – i.e. HPI

Time limits to ensure
fields are updated

43
HPI

Covering
Physician

Problem List

To Do List
Pending Workup

44
Patient and Team Identifiers from CPRS which can be site specified.
i.e.) Full SSN vs. last four / DOB / Sex / Age
i.e.) D...
CODE status from CPRS

Allergies
from CPRS

Active medications from CPRS

46
Typically 3-5 patients
per printed page -depends mostly on meds

47
Team list name/
Sign-out provider info

Entire Team name / titles /
contact numbers

Identifiers / CPRS retrieved fields
M...
Time and date sign-out created

Page numbers
i.e.) 2 of 3

49
Shift Handoff Tool
• Uniform and Easy to Learn
– Not another software training requirement

• Legible, and standardized ab...
Results from Research Project
• Selected findings from surveys and abstracted
ad hoc (pre) and software-based (post) tools...
Take Home Points
• Good information in a Handoff Tool
does not replace the medical
record/chart
• Faster Handoffs (i.e., l...
Special Thanks to:
Richard J. Sowinski, Chief of Application Development,
Roudebush VAMC, MSCS, BSEE
Charlet Lynn Cottee, ...
What are the elements of a safe
patient hand-off?

54
Patient Hand-Offs: SBAR

55
SBAR
Clearly communicates the critical elements
of a case to another clinician:
Situation
What is the problem?

Background...
SBAR
• Melds MD and RN cultures
– RN: holistic focus; background important; paints a
complete picture of the patient
– MD:...
SBAR Film 5:
MD-to-MD Hand-Off
Hospitalist-to-PCP

58
Debrief SBAR Film 5
MD-to-MD Hand-Off
Hospitalist-to-PCP

59
NCPS SBAR Hand-Off Guide
RN-to-RN or MD-to-MD Patient Transfer

S
Situation

Situation: What is the situation with this pa...
SBAR Film 7
MD-to-MD Medical Resident
Sign Out

61
Debrief SBAR Film 7
MD-to-MD Medical Resident
Sign-out

62
NCPS SBAR Hand-Off Guide
RN-to-RN or MD-to-MD Change of Shift

Situation: What is the situation with this patient?

S

Pat...
SBAR Film 3
RN-to-MD Change in Patient
Condition

64
Debrief SBAR Film 3
RN-to-MD Change in Patient
Condition

65
NCPS SBAR Hand-Off Guide
RN-to-MD Change in Patient Condition

S
Situation

Situation: What is the situation you are calli...
SBAR Film 9
RN-to-RRT Patient Hand-Off

67
Debrief SBAR Film 9
RN-to-RRT Patient Hand-off

68
Is Organizing Change Like
Herding Cats?

69
“If you want to go quickly, go alone.
If you want to go far, go together.”
African Proverb

70
Thank You
edward.dunn@va.gov

71
72
Extra Slides

73
Code Scenario
Film

74
Debriefing
• Facilitator
• Team-based discussion
• Review of a shared experience:
– What went well?
– What didn’t go well?...
Code Team Debriefing
Film

76
Debrief Code Scenario Debriefing
Film

77
CARDIAC ARREST (CODE 4000)
DEBRIEFING GUIDE
Review Elements of a Good Code
 Did all members of the Code Team arrive at th...
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Crew Resource Management Slides - including Handoffs - from 2008 National Patient Safety Foundation Meeting - With Dr. Edward Dunn

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Presentation on Crew Resource Management and Team Training in the Department of Veterans Affairs. Dr. Dunn did most of the presentation, and I covered the handoffs portion. (Afterward someone from NPSF told me that this was the highest-rated breakout session at the conference.) One related video is on Youtube at: https://www.youtube.com/watch?v=aYZx1l8rkXA . A story on the software tool we developed for handoffs is at this website, see pages 12-13. http://www.va.gov/opa/publications/vanguard/09janfebVG.pdf
An article on the tool in the Joint Commission Journal is on-line at: http://www.ingentaconnect.com/content/jcaho/jcjqs/2010/00000036/00000002/art00003 Sorry it's not a full-text freebie. If you would like a pdf copy of it you can email me at neldridge202@yahoo.com.

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Crew Resource Management Slides - including Handoffs - from 2008 National Patient Safety Foundation Meeting - With Dr. Edward Dunn

  1. 1. Applying Crew Resource Management to Safe Transitions in Patient Care 2008 NPSF Annual Patient Safety Congress Nashville, TN May 16, 2008 Edward J. Dunn, MD, MPH Noel Eldridge, MS VA National Center for Patient Safety 1
  2. 2. The Josie King Story 2
  3. 3. Clinical Vignette 3
  4. 4. Teamwork 4
  5. 5. What are the characteristics of a TEAM? 5
  6. 6. Communication 6
  7. 7. If information flow is the currency of medical practice, why is so little attention paid to communication effectiveness in medical training and education? 7
  8. 8. Communication Skills In medical school and nursing school, the focus is on successful communication with the patient. 8
  9. 9. Communication failure is a leading source of adverse events in healthcare. Evidence from Surgery, Medicine, Emergency Medicine • Gawande – 43% of adverse events are due to communication failures between two or more clinicians – Complications (2002) – Better (2007) • Risser* – 54 tort claims from ED due to “teamwork failure” – Med Teams Research Consortium • Sutcliffe – interviewed 26 med residents…communication failure cited in 70 adverse events 9
  10. 10. 10
  11. 11. Root Cause Analyses (RCA) Database* • ~70% to 80% of RCAs cited COMMUNICATION FAILURE as, at least one of the root causes/contributing factors for an adverse event or close call report. *VA NCPS Database, January 18, 2008 Total Individual + Aggregate RCAs (1999-2008) = 13,774 11
  12. 12. Collaboration & Teamwork in ICU = Lower Morbidity & Mortality + Increased RN Retention Evidence from ICUs • Knaus – 5030 ICU pts in 13 hospitals – M&M risk improved with collaboration • Baggs – 286 consecutive Med ICU pts transferred – M&M risk decreased from 16% to 5% • Shortell – 17440 pts from 42 ICU – Teamwork across disciplines improved outcomes & RN retention • Pronovost – Daily briefings in ICU with RNs and Residents – Improved quality of care 12
  13. 13. Institute of Medicine* (2000): “…establish team training programs for personnel in critical care areas using proven methods such as the crew resource management training techniques employed in aviation.” Corrigan J, Kohn LT, Donaldson MS. To Err Is Human. Washington, DC: National Academy Press; 1999. 13
  14. 14. Communication Definition: The exchange of thoughts, messages, or information.* A dynamic process between people: • Sender (talks/writes/signals) & Receiver (listens/reads/signals) • Roles alternate back & forth •Verbal vs. non-verbal Feedback: • Sending a message is not sufficient • Was it received…understood? * The American Heritage Dictionary, 4th edition, Houghton Mifflin Company (2001): 179. 14
  15. 15. Faculty Role Play 15
  16. 16. Was our communication successful? 16
  17. 17. Successful Communication • Many communication improvements focus on improving accuracy and availability of content, e.g. CPOE, CPRS, “Hand-Off” templates • Poor communication results from context. Context is vulnerable to culture, gender, education, experience, time pressure, stress, mood, etc. 17
  18. 18. Communication Context • • • • • • • • • Culture Gender Language barriers Differing mental models Professions and disciplines Power gradient (hierarchy) Differing information needs Temperament and personality Outside interference and distractions 18
  19. 19. Assertive Statements Direct and clearly communicated statements that facilitate patient advocacy in decision-making. • Not a license to be rude • Use “I” statements, rather than “You” statements • “I” statements describe your experience rather than another’s shortcomings • Give people options 19
  20. 20. Words to Avoid • “You” - blame/shame, elicits defenses • “Should” – judgmental, value statement • Hyperbole – “never,” “always,” “nothing,” “everything” – Not fact – Not credible – Inflates correctable problem into impossible challenge 20
  21. 21. Words to Use • “The” statements (policy) – stick to the facts – Avoiding conflating person with behavior – Attack the problem, not the person • “We” statements – shared responsibility and shared interests – Invoke common principle, accepted standard 21
  22. 22. CRM Communication Techniques 22
  23. 23. Call Out • Communicate to all what you see and know • If you “feel the pinch” that trouble is brewing, communicate that to everyone • If you keep it to yourself, the patient may suffer Examples from COPD film? Code Scenario film? 23
  24. 24. Step Back • “Pause in the Action” – can be dramatic • Reassess a situation that doesn’t appear to be working • Challenge all previous assumptions • Protects against fixation on prior assumptions that are not supported by accruing evidence “Fixation Error:” Persisting in a planned action despite incoming data that contradicts previous assumptions. Wakefield continuing to attempt intubation when the patient might do well with mask ventilation. 24
  25. 25. Clear Communication • Read Back – Write down what you heard – Read back what you wrote – Confirm with the sender • Repeat Back – Reflect back what you hear – Confirm with sender 25
  26. 26. Dynamic Skepticism • Attitude of constantly questioning and evaluating the patient care environment – Avoid trusting what appears to be obvious – Do not assume! – Seek facts – Verification is NOT a mistrust of others – Questioning and verifying is safe practice 26
  27. 27. Assume Nothing! Communicate what you see and know! 27
  28. 28. Safe Transitions in Patient Care Responsibility 28
  29. 29. Some Conspicuous Types of Handoffs (formality • Shift Changes and temporality varies widely) – Physicians – Nurses • Intrafacility (within facilities) – ICU to Med/Surg and vice versa, etc. • Interfacility (between facilities) • Short-term – Med/Surg to radiology, etc. – Lunch or bathroom break (for caregiver) 29
  30. 30. Why are Goodor unknown clinical information Handoffs Important? • Provide access to new • Increase efficiency/flow – Prevent pointless re-tests – Decrease length of stay • Key issue for across all levels of healthcare – Nursing shortage; therefore, temporary staff – Resident 80-hour workweek means more handoffs – Various medical specialties have their own issues • ICU, Surgeons, et al. • Reduce likelihood of adverse events… – or substandard care based on misinformation or lack of information 30
  31. 31. What Should be in a Good Handoff? • • • • • • • • • • • • Team Identifiers - Staff names, phone numbers, covering staff contact info, distinctive team name/color Appropriate patient identifier - 2 forms of identification 1-2 sentence of patient presentation Active problem list - pertinent past medical history Medications – all active listed Allergies Access - Venous / Arterial Access and what to do if changes Code status Pertinent labs Concerns over next 18-24 hours and what to do in those situations (problem vs. system based) Long term plans / family questions that could arise if indicated Psychological concerns Ref: Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs, Academic Medicine, Dec 2005 31
  32. 32. 2007 (and 2008) Joint Commission National Patient Safety Goal • (2) Improve the effectiveness of communication among caregivers – Requirement 2e– implement a standardized approach to “hand-off” communications, including an opportunity to ask and respond to questions – Rationale – the primary objective of a “hand-off” is to provide accurate information about a patient’s care, treatment and services, current condition and any recent or anticipated changes. The information communicated during a hand off must be accurate in order to meet patient safety goals 32
  33. 33. RCAs and Handoffs • Most RCAs cite communications as a contributing factor • Handoffs are situations where communications lapses can be especially hazardous • Full disclosure: we haven’t specifically searched for handoffs cited as the cause of specific adverse events – Speculation: more likely to be seen as a “contributing factor” than a stand-alone “cause” 33
  34. 34. Top 10 Topics of VA RCAs Delay in Treatment/Diagnosis/Surgery 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) Falls (close to 50% of VA reports, but only ~12% of VA RCAs) Delay in Treatment/ Diagnosis/ Surgery High Alert Adverse Drug Events Death Other Than Suicide Misidentification Missing Patient Outpatient Suicide Hospital Acquired Infection Communication about Abnormal Result Medical Device Incorrect Surgery 34
  35. 35. Developing a Standardized Approach to Hand-off Communications • A standardized approach should identify :– The “hand-off” situations that it applies to – Who is, or should be, involved in the communication – What information should be communicated • Diagnoses and current condition of the patient • Recent changes in condition or treatment • Anticipated changes in condition or treatment • What to watch for in the next interval of care – Opportunities to ask and respond to questions – When to use certain techniques (repeat-back; SBAR) – What print or electronic information should be available 35
  36. 36. Examples • Flowcharts for two standardized kinds of shift-change handoffs for nurses – Had more pre-existing standardization • Shift Handoff Tool software developed for physicians – Had less pre-existing standardization 36
  37. 37. HANDOFF PROCESS WITH IN-PERSON TRANSFER OF PATIENT INFORMATION Midnight (AM) to Morning (AM) Shift Change (7:30 – 8:00 am) Night Staff Nurse prepares tape recorded report for late AM Staff Nurse Night Staff Nurse briefs AM Charge Nurse on critical / urgent patient care issues. YES Is AM Staff Nurse LATE or ABSENT? NO AM Staff Nurse goes to report room AM Staff Nurse review patient assignment list. AM Charge Nurse addresses urgent patient care issues identified by Night Staff Nurse. AM Staff Nurse locates respective Night Staff Nurse (s) to get verbal report on prospective patients on his / her assignment listing. AM Charge Nurse gives AM Staff Nurse verbal report of patient care topics. Night Staff Nurse and AM Staff Nurses conducts walking (bedside) rounds for all patients assigned to the respective AM Staff Nurse and provides summary information on patient status and needs schedules. AM Staff Nurse listens to tape recorded reports. AM Charge Nurse clarifies /answers all questions from AM Staff Nurse regarding patient care topics. AM Staff Nurse review end of shift report list of all active patients on the ward. HandOff complete for All Active Patients Night Staff Nurse clarifies / answer all questions from AM Staff Nurse regarding patient care topics. Note: Morning and Evening Shift Change is the same as above
  38. 38. HANDOFF PROCESS WITH TAPE RECORDED PATIENT INFORMATION Midnight (AM) to Morning (AM) Shift Change (7:30 – 8:00 am) Night Staff Nurses prepares tape recorded reports for AM Staff Is AM Staff Nurse LATE or ABSENT? AM Staff Nurses goes to report room NO YES Review end of shift report. AM Staff review patient assignment list. Review patient assignment list. AM Staff Nurse listens to tape recorded reports. AM Staff Review end of shift report list of all active patients on the ward. AM Charge Nurse and Staff Nurses listen to tape recorded reports. AM Charge Nurse clarifies /answers all questions from AM Staff Nurse regarding patient care topics. AM Charge Nurse conduct walking (bedside) rounds with Night Charge Nurse to discuss patient care topics before he/she leaves. HandOff complete for All Active Patients Note: Morning and Evening Shift Change is the same as above AM Staff Nurse may leave room to discuss patient care topics with Night Staff nurses before he /she leaves. 38
  39. 39. Options for nurses: In the event that a question remains or occurs after getting a shift report by tape, face-to-face, or in a text (paper or electronic) version, the following options may be available: 1) Ask face-to-face to the nurse from previous shift if he or she hasn’t left yet and is still present in the unit. 2) Ask a nurse whose schedule is crossing the shift change (e.g., on a 12 hour shift, staggered overlapping shift, or doing overtime into the new shift). 3) Ask the charge nurse that received a separate report from the previous shift’s charge nurse. 4) Ask another member of the staff if the question is within their areas of expertise to answer, for example: – Ask the resident or attending physician that is responsible for the patient, either in-person or by pager/mobile phone. – Ask ancillary staff on duty, for example, a respiratory therapist or phlebotomist, if the question is within their scope of knowledge. 5) Read the recent progress notes, nursing notes, or other information in the patient’s medical record. 6) Telephone the nurse from the previous shift, calling their home or mobile phone number. (A list of all the mobile and home phone numbers for all the nurses on the unit would have to be readily available when needed for official use if this method is recommended by the organization.) 7) Some questions may be appropriate to ask the patient, depending on the nurse’s assessment of the patient’s ability to answer accurately, e.g., questions about what the patient ate, if the patient was visited by a specialist that had been scheduled, etc. 39
  40. 40. Shift Handoff Tool (Short) History Created by Indianapolis (Roudebush) VAMC with inputs from pilot testers at the following VAMCs: Washington, DC; Iowa City; Des Moines; Ann Arbor; Loma Linda; Dallas; White River Junction December 2005: • Paper published in Academic Medicine by Indianapolis VAMC: Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs, Academic Medicine, Dec 2005 January 2006: • New JCAHO Patient Safety Goal to standardize Handoffs goes into effect, software from Indianapolis reviewed… September 2006: • Meeting in Washington, DC to establish consensus requirements July 2007: • Tool installed & being tested and/or used at 12 facilities. • Selected for upgrade to “Class 1” software – Helpdesk support, etc. April/May 2008 (planned): • Made available to VA System (150+) hospitals 40
  41. 41. Create Link To HANDOFF TOOL in CPRS Tool Bar 41
  42. 42. 42
  43. 43. These fields can be specified by site/department – i.e. HPI Time limits to ensure fields are updated 43
  44. 44. HPI Covering Physician Problem List To Do List Pending Workup 44
  45. 45. Patient and Team Identifiers from CPRS which can be site specified. i.e.) Full SSN vs. last four / DOB / Sex / Age i.e.) Date of admission / Length of stay / Admitting diagnosis i.e.) Room location / Assigned team, attending, outpatient provider 45
  46. 46. CODE status from CPRS Allergies from CPRS Active medications from CPRS 46
  47. 47. Typically 3-5 patients per printed page -depends mostly on meds 47
  48. 48. Team list name/ Sign-out provider info Entire Team name / titles / contact numbers Identifiers / CPRS retrieved fields Modifiable fields 48
  49. 49. Time and date sign-out created Page numbers i.e.) 2 of 3 49
  50. 50. Shift Handoff Tool • Uniform and Easy to Learn – Not another software training requirement • Legible, and standardized abbreviations in text pulled from CPRS (VA’s EMR) • Forces updates to predetermined fields – Minimizes obsolete data or information • Site/service customizable (within limits) • Time saving (in preparing report for recipient) 50
  51. 51. Results from Research Project • Selected findings from surveys and abstracted ad hoc (pre) and software-based (post) tools – – – – Less Time Typing Same Time Talking Perception of improving safety among users Perception of having received more complete information among users – Key information measured as always or almost always present in software-based tool • Medications • Allergy info • Demographics and Room number 51
  52. 52. Take Home Points • Good information in a Handoff Tool does not replace the medical record/chart • Faster Handoffs (i.e., less time talking face-to-face) is not the goal • Handoffs that foster real communication (text and verbal) is the goal • Need standardization/ consistency/ 52
  53. 53. Special Thanks to: Richard J. Sowinski, Chief of Application Development, Roudebush VAMC, MSCS, BSEE Charlet Lynn Cottee, Senior Developer, Roudebush VAMC, BSCS Divya Shroff, MD, Associate Chief of Staff – Informatics Washington DC VAMC Jaclyn Anderson, DO, VA Quality Scholar Iowa City VAMC Research Project Mentioned: Abstract at 2008 SGIM Conference THE PHYSICIAN-TO-PHYSICIAN HANDOFF: THE VETERANS AFFAIRS CAIRO PROJECT J.K. Anderson1; D. Shroff2; A. Curtis1; N. Eldridge3; K. Cannon1; R.M. Karnani1; T.E. Abrams1; P. Kaboli1. 1VA Iowa City Health Care System/University of Iowa, Iowa City, IA; 2Washington DC VA Healthcare System, Washington, DC; 3VA Central Office, Washington, DC. (Tracking ID # 190036) 53
  54. 54. What are the elements of a safe patient hand-off? 54
  55. 55. Patient Hand-Offs: SBAR 55
  56. 56. SBAR Clearly communicates the critical elements of a case to another clinician: Situation What is the problem? Background Brief background information Assessment What is your assessment of the patient? Recommendations What do you recommend? 56
  57. 57. SBAR • Melds MD and RN cultures – RN: holistic focus; background important; paints a complete picture of the patient – MD: time urgency; focus on specific problem; data • SBAR is a rule of language for communicating information, such as patient handoffs – RN-to-RN at change of shift/admission/transfer – MD-to-MD on call – RN-to-MD report of change in patient condition 57
  58. 58. SBAR Film 5: MD-to-MD Hand-Off Hospitalist-to-PCP 58
  59. 59. Debrief SBAR Film 5 MD-to-MD Hand-Off Hospitalist-to-PCP 59
  60. 60. NCPS SBAR Hand-Off Guide RN-to-RN or MD-to-MD Patient Transfer S Situation Situation: What is the situation with this patient? Patient Condition? Patient Name: ______________________ SSN: __________ DOB: _________ Admit Date: __________ Clinical Service: _________________ Attending MD: ________________ Resident MD: ________________ Admitting Diagnosis: _____________________ Procedure(s): ______________________________________ Brief Clinical Summary:______________________________________________________________________ ____________________________________________________________ Expected Time of Arrival: ______ B Background Background: What is relevant in this patient’s past medical history? 1. Relevant Past Med/Surg History: ___________________________________________________________ _________________________________________________________________________________________ 2. Medications: _____________________________________ Allergies: ____________________________ 3. Code Status: _____________________ Health Care Proxy: _____________________________________ 4. Family / Social Support: __________________________________________________________________ A Assessment R Recommendation Assessment: What is your assessment of this patient? 1. Nursing Assessment (choose relevant items only) BP ____/_____ HR ______ Resp. Rate _________ Temp _________ SaO2 ___________ Pain (1-10)_______ Cardiac: __________________________________________________________________________________ Respiratory: _______________________________________________________________________________ GI: ____________________________________________________________ Diet: _____________________ GU: ______________________________________________________________________________________ Musculoskeletal: ____________________________________ Fall Precautions: _________________________ Neuro: ____________________________________________________________________________________ Skin: ________________________________ Wound(s):_____________________________________________ Psychosocial: ______________________________________________________________________________ 2. Rx Concerns: ____________________________________________________________________________ 3. Lab / Imaging Data: _____________________________________________________________________ 4. Lines/Fluids:___________________________________ Tubes/Drains: ____________________________ Recommendations: What is the recommended plan of care? 1. Plan of Care: ____________________________________________________________________________ Lab/Imaging Tests: __________________________________________________________________________ Treatments/Procedures: _______________________________________________________________________ Consults: __________________________________________________________________________________ 60 2. To-Do List: _____________________________________________________________________________ 3. Red Flags: ______________________________________________________________________________
  61. 61. SBAR Film 7 MD-to-MD Medical Resident Sign Out 61
  62. 62. Debrief SBAR Film 7 MD-to-MD Medical Resident Sign-out 62
  63. 63. NCPS SBAR Hand-Off Guide RN-to-RN or MD-to-MD Change of Shift Situation: What is the situation with this patient? S Patient Condition? Patient Name: ______________________ SSN: __________ DOB: _________ Admit Date: ________ Clinical Service: _________________ Attending MD:________________ Resident MD:________________ Admitting Diagnosis: _____________________ Procedure(s): ____________________________________ Situation Brief Clinical Summary:___________________________________________________________________ _______________________________________________________________________________________ B Background: What is relevant in this patient’s past medical history? 1. Relevant Past Med/Surg History: ________________________________________________________ ________________________________________________________________________________ A Assessment Medications: ________________________________________ Allergies: ________________________ Code Status: __________________________ Health Care Proxy: _______________________________ 4. 1. 2. 3. Background Family/Social Support: _______________________________________________________________ Assessment: What is your assessment of this patient? 1. Nursing Assessment (choose relevant items only) BP _____/______ HR _______ Resp. Rate _________ Temp _________ SaO2 _______ Pain (1-10) _____ Cardiac: __________________________________________________________________________________ Respiratory: _______________________________________________________________________________ GI: ____________________________________________________________ Diet: _____________________ GU: ______________________________________________________________________________________ Musculoskeletal: ____________________________________ Fall Precautions: _________________________ Neuro: ____________________________________________________________________________________ Skin: ______________________________________ Wound(s):______________________________________ Psychosocial: ____________________________________________________________________________ 2. Rx Concerns: _______________________________________________________________________ 3. Lab/Imaging Data: _____________________________________________________________________ 4. Lines/Fluids:________________________________________ Tubes/Drains: ________________________ R Recommendation Recommendations: What is the recommended plan of care? 1. Plan of Care: ____________________________________________________________________________ ________________________________________________________________________________________ Lab/Imaging Tests: __________________________________________________________________________ Treatments/Procedures: _______________________________________________________________________ Consults: __________________________________________________________________________________ 2. To-Do List: _____________________________________________________________________________ 63 3. Red Flags: ______________________________________________________________________________
  64. 64. SBAR Film 3 RN-to-MD Change in Patient Condition 64
  65. 65. Debrief SBAR Film 3 RN-to-MD Change in Patient Condition 65
  66. 66. NCPS SBAR Hand-Off Guide RN-to-MD Change in Patient Condition S Situation Situation: What is the situation you are calling about? Relevant patient issues? I’m calling about… Patient Name: ______________________ SSN: __________ DOB: _________ Admit Date: __________ Clinical Service:___________________ Attending MD: ________________ Resident MD: ______________ Admitting Diagnosis: _________________________ Procedure(s): _________________________________ Problem(s) you are calling about: _____________________________________________________________ ______________________________________________________________________________________ B Background Background: What is relevant in this patient’s past medical history? 1. Relevant Past Med/Surg History: ________________________________________________________________________________________ ________________________________________________________________________________________ 2. Medications: __________________________________________ Allergies:_________________ 3. Code Status: ___________________ Health Care Proxy:__________________________________ 4. Family/Social Support: ___________________________________________________________ A Assessment Assessment: What is your assessment of this patient? 1. Nursing Assessment (choose relevant items only) BP ____/____ HR ______ Resp. Rate _______ Temp _________ SaO2 _________ Pain (1-10 scale)_______ Cardiac: __________________________________________________________________________________ Respiratory: _______________________________________________________________________________ GI: ___________________________________________________________ Diet: _____________________ GU: ______________________________________________________________________________________ Musculoskeletal: ____________________________________ Fall Precautions: _________________________ Neuro: ____________________________________________________________________________________ Skin: ____________________________________ Wound(s):________________________________________ Psychosocial: ______________________________________________________________________________ 2. Rx Concerns: _______________________________________________________________________ 3. Lab/Imaging Data: _____________________________________________________________________ 4. IV Lines/Fluids: _______________________________ Tubes/Drains: _____________________________ R Recommendation Recommendations: What should be done? I suggest …or…request that you: • See the patient for medical evaluation ASAP / STAT • Order tests, treatments, consultations: __________________________________________________ If a change in patient care is ordered: • To-Do List: ______________________________________________________________________ • Red Flags: _______________________________________________________________________ • Guidelines for follow-up call to physician: _______________________________________________ 66
  67. 67. SBAR Film 9 RN-to-RRT Patient Hand-Off 67
  68. 68. Debrief SBAR Film 9 RN-to-RRT Patient Hand-off 68
  69. 69. Is Organizing Change Like Herding Cats? 69
  70. 70. “If you want to go quickly, go alone. If you want to go far, go together.” African Proverb 70
  71. 71. Thank You edward.dunn@va.gov 71
  72. 72. 72
  73. 73. Extra Slides 73
  74. 74. Code Scenario Film 74
  75. 75. Debriefing • Facilitator • Team-based discussion • Review of a shared experience: – What went well? – What didn’t go well? – What lessons were learned? • Promotes situational learning 75
  76. 76. Code Team Debriefing Film 76
  77. 77. Debrief Code Scenario Debriefing Film 77
  78. 78. CARDIAC ARREST (CODE 4000) DEBRIEFING GUIDE Review Elements of a Good Code  Did all members of the Code Team arrive at the bedside quickly?  Was there an appropriate number of staff (or too many, few, etc)?  Did the Medical Consult identify him/herself quickly and clearly?  Were all necessary supplies/medications readily available/accessible?  Was the cardiac rhythm determined quickly?  Was the airway managed appropriately?  Was the airway established timely?  Was IV access established timely?  Were emotional issues handled effectively?  Were there futility issues?  Was there effective leadership? Poor = 1 (explain) Good = 3 Excellent 5 Physician Satisfaction: 1 2 3 4 5 Nurse Satisfaction: 1 2 3 4 5 Resp. Ther. Satisfaction: 1 2 3 4 5 Safety Breech:  Yes (explain)  No Unanticipated Events:  Yes (explain)  No Did the post-code debriefing detect a problem?  None  Minor (explain)  78 Major (explain)

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