Improving The Clinical Handoff Jenny Han, MD    Anna Lukowski, MD    Peter Watson, MD
Goals and Objectives <ul><li>“Handoff” Overview </li></ul><ul><li>Understand Key Components of an Effective Standardized H...
Definition of a Clinical “Handoff” <ul><li>A  clinical handoff  is the temporary transfer of care and responsibility from ...
Clinical “Handoffs” <ul><li>Multiple physicians take care of one patient: </li></ul><ul><ul><li>Primary intern  -> on-call...
Study Goals and Objectives <ul><li>This PowerPoint presentation is part of an ongoing educational intervention in handoff ...
Handoffs and Patient Safety <ul><li>Transfers of care have been associated with adverse clinical outcomes </li></ul><ul><l...
Handoffs and Resident Education <ul><li>Increased handoffs with reduced work hours </li></ul><ul><li>Many training program...
Discussion: What do you think is important in a handoff? <ul><li>What items in the handoff do you think are important? </l...
Key Components of an  Effective Clinical Handoff <ul><li>Clarity about the patient’s current condition, including severity...
Proposed Handoff Template:   I-SWITCH <ul><li>I :  Identifiers  Name/ Record Number/Location </li></ul><ul><li>S :  Severi...
Identifiers <ul><li>Ensure that all are clear: </li></ul><ul><ul><li>Patient name </li></ul></ul><ul><ul><li>Medical Recor...
Severity  of illness <ul><li>Stratify patients by severity of illness: </li></ul><ul><ul><li>Severe, Moderate, Mild </li><...
How do I determine illness severity? <ul><li>Recent changes in vital signs </li></ul><ul><li>Signs of end organ failure: <...
How do I determine illness severity? <ul><li>Other high risk groups: </li></ul><ul><ul><li>Sepsis patients </li></ul></ul>...
Working  Problems <ul><li>What are the active medical problems being addressed during the current admission? </li></ul><ul...
Intervention  on  anticipated  problems <ul><li>Most important component of handoff: to be able to anticipate potential pr...
Anticipation  as Part of the Hand-Off <ul><li>What is the worst thing that could practicably go wrong? </li></ul><ul><li>R...
Intervention  of anticipated problems <ul><li>Avoid general/non-specific statements </li></ul><ul><ul><li>“nothing to do o...
Intervention  of anticipated problems <ul><li>Use IF… THEN statements:   </li></ul><ul><ul><li>CT abdomen to rule out mass...
Tests  and Consultations Pending <ul><li>Make clear what pertinent labs/consultations  need  to be checked and how to act ...
Code  Status <ul><li>Code status should be addressed and documented on  all  patients </li></ul><ul><li>Code discussions w...
History <ul><li>Only a concise  pertinent history  is important to support the problem list </li></ul><ul><li>The handoff ...
Discussion: What do you think is important in a handoff? <ul><li>What about the effect of environment? </li></ul><ul><li>W...
Handoff Environment <ul><li>Interruptions are common, but can be barriers to a clear and accurate handoff </li></ul><ul><l...
Handoff is a Two-Way Transfer <ul><li>The person receiving the handoff is expected to ask pertinent questions to clarify a...
Discussion: Current Handoff Template <ul><li>What is the effectiveness of our current electronic template? </li></ul><ul><...
Current Handoff Template I-SWITCH Identifiers History Tests/Consults Working  Problem List Intervention  On Anticipated Pr...
Handoff Example #1
Discussion: Handoff Evaluation #1 <ul><li>How effective was this handoff (written/verbal)? Why? </li></ul><ul><li>What ele...
Handoff Example #2
Take Home Points <ul><li>Remember the Key Components of an Effective Standardized Handoff  </li></ul><ul><li>( I-SWITCH ) ...
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ISWITCH

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ISWITCH

  1. 1. Improving The Clinical Handoff Jenny Han, MD  Anna Lukowski, MD  Peter Watson, MD
  2. 2. Goals and Objectives <ul><li>“Handoff” Overview </li></ul><ul><li>Understand Key Components of an Effective Standardized Handoff ( I-SWITCH ) </li></ul><ul><li>Discuss the Handoff Environment and Communication Techniques </li></ul><ul><li>Evaluate Handoff Effectiveness </li></ul>
  3. 3. Definition of a Clinical “Handoff” <ul><li>A clinical handoff is the temporary transfer of care and responsibility from the primary (outgoing) physician to the covering (oncoming) physician </li></ul>
  4. 4. Clinical “Handoffs” <ul><li>Multiple physicians take care of one patient: </li></ul><ul><ul><li>Primary intern -> on-call intern -> night float resident -> back to primary intern </li></ul></ul><ul><li>Verbal and written handoffs are the main ways to relay vital information about the patient and their anticipated needs </li></ul>
  5. 5. Study Goals and Objectives <ul><li>This PowerPoint presentation is part of an ongoing educational intervention in handoff training during this academic year </li></ul><ul><li>Our goal is to develop a handoff training process that will lead to improved educational outcomes and translate into better clinical practice </li></ul>
  6. 6. Handoffs and Patient Safety <ul><li>Transfers of care have been associated with adverse clinical outcomes </li></ul><ul><li>Improving handoffs is an national patient safety goal </li></ul><ul><li>Most sentinel events are caused by communication breakdown </li></ul>
  7. 7. Handoffs and Resident Education <ul><li>Increased handoffs with reduced work hours </li></ul><ul><li>Many training programs do not have standardized handoff training programs </li></ul>
  8. 8. Discussion: What do you think is important in a handoff? <ul><li>What items in the handoff do you think are important? </li></ul>
  9. 9. Key Components of an Effective Clinical Handoff <ul><li>Clarity about the patient’s current condition, including severity of illness </li></ul><ul><li>Anticipating changes in patient condition with specific interventions </li></ul>
  10. 10. Proposed Handoff Template: I-SWITCH <ul><li>I : Identifiers Name/ Record Number/Location </li></ul><ul><li>S : Severity of illness </li></ul><ul><li>W : Working problem list </li></ul><ul><li>I : Intervention on anticipated problems </li></ul><ul><li>T : Tests and consults pending </li></ul><ul><li>C : Code Status </li></ul><ul><li>H : History pertinent to immediate problems </li></ul>
  11. 11. Identifiers <ul><li>Ensure that all are clear: </li></ul><ul><ul><li>Patient name </li></ul></ul><ul><ul><li>Medical Record Number </li></ul></ul><ul><ul><li>Location (Room, Unit) </li></ul></ul><ul><ul><li>Primary team responsible for care of patient </li></ul></ul><ul><ul><li>Responsible physician while on-call </li></ul></ul>
  12. 12. Severity of illness <ul><li>Stratify patients by severity of illness: </li></ul><ul><ul><li>Severe, Moderate, Mild </li></ul></ul><ul><li>Severely ill patients: </li></ul><ul><ul><li>Prioritize first, they may require closer monitoring or potentially intensive care transfer </li></ul></ul><ul><ul><li>Bedside handoff </li></ul></ul><ul><ul><li>Involve senior resident </li></ul></ul>
  13. 13. How do I determine illness severity? <ul><li>Recent changes in vital signs </li></ul><ul><li>Signs of end organ failure: </li></ul><ul><ul><li>Abnormal mental status </li></ul></ul><ul><ul><li>Decreased urine output </li></ul></ul><ul><li>Evaluate for SIRS criteria </li></ul><ul><ul><li>Leukocytosis/leukopenia </li></ul></ul><ul><ul><li>Tachypnea/hypocapnea </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Fever/hypothermia </li></ul></ul>
  14. 14. How do I determine illness severity? <ul><li>Other high risk groups: </li></ul><ul><ul><li>Sepsis patients </li></ul></ul><ul><ul><li>Respiratory decompensation </li></ul></ul><ul><ul><li>Severe congestive heart failure </li></ul></ul><ul><ul><li>Severe hepatic failure </li></ul></ul><ul><ul><li>Intestinal hemorrhage </li></ul></ul><ul><ul><li>Severe electrolyte disturbances </li></ul></ul>
  15. 15. Working Problems <ul><li>What are the active medical problems being addressed during the current admission? </li></ul><ul><li>The most recent assessment and plan from the H & P or progress note can serve as a guide </li></ul>
  16. 16. Intervention on anticipated problems <ul><li>Most important component of handoff: to be able to anticipate potential problems and potential solutions </li></ul><ul><li>Challenge yourself to use an analytical approach to predict what problems may arise in your patients on the next shift </li></ul>
  17. 17. Anticipation as Part of the Hand-Off <ul><li>What is the worst thing that could practicably go wrong? </li></ul><ul><li>Recurrent problems that have occurred with this patient so far during the admission? </li></ul><ul><li>Potential common problems putting patient at risk? </li></ul>
  18. 18. Intervention of anticipated problems <ul><li>Avoid general/non-specific statements </li></ul><ul><ul><li>“nothing to do or check” (NTD or NTC), check labs, check results of CT </li></ul></ul><ul><ul><li>General statements or ambiguous tasks (“check labs”) do not help covering resident prioritize response to an event </li></ul></ul>
  19. 19. Intervention of anticipated problems <ul><li>Use IF… THEN statements: </li></ul><ul><ul><li>CT abdomen to rule out mass lesion causing obstruction  IF obstruction seen, THEN make NPO and call Surgery </li></ul></ul><ul><ul><li>Renal Failure  IF K above 6.0, THEN check EKG, give kayexelate, amp D50, Insulin 10units </li></ul></ul>
  20. 20. Tests and Consultations Pending <ul><li>Make clear what pertinent labs/consultations need to be checked and how to act on them if anticipated abnormalities are noted: </li></ul><ul><ul><li>Avoid things like “Check CBC” </li></ul></ul><ul><ul><li>Instead write… Check platelet count… IF less than 15, THEN transfuse 6 units platelets </li></ul></ul>
  21. 21. Code Status <ul><li>Code status should be addressed and documented on all patients </li></ul><ul><li>Code discussions with family while the patient begins to decompensate are not optimal, nor fair to the patient or family </li></ul>
  22. 22. History <ul><li>Only a concise pertinent history is important to support the problem list </li></ul><ul><li>The handoff is never meant to duplicate the medical record−keep history to a minimum </li></ul>
  23. 23. Discussion: What do you think is important in a handoff? <ul><li>What about the effect of environment? </li></ul><ul><li>What types of communication are important? </li></ul>
  24. 24. Handoff Environment <ul><li>Interruptions are common, but can be barriers to a clear and accurate handoff </li></ul><ul><li>Take the time to go to a quiet place and be uninterrupted (office, call room, lounge) </li></ul>
  25. 25. Handoff is a Two-Way Transfer <ul><li>The person receiving the handoff is expected to ask pertinent questions to clarify any unanswered questions </li></ul><ul><li>Clear accurate information needs to be handed off as well as received back the next morning (“closing the loop”) </li></ul>
  26. 26. Discussion: Current Handoff Template <ul><li>What is the effectiveness of our current electronic template? </li></ul><ul><li>Knowing what you now know about the key elements of a handoff…what would you do differently about the use of this template? </li></ul>
  27. 27. Current Handoff Template I-SWITCH Identifiers History Tests/Consults Working Problem List Intervention On Anticipated Problems No Clear Place for Severity? Code Status
  28. 28. Handoff Example #1
  29. 29. Discussion: Handoff Evaluation #1 <ul><li>How effective was this handoff (written/verbal)? Why? </li></ul><ul><li>What elements were missing from this handoff? </li></ul><ul><li>Other observations? </li></ul><ul><li>What would you suggest be done differently to create a more effective handoff in this case? </li></ul>
  30. 30. Handoff Example #2
  31. 31. Take Home Points <ul><li>Remember the Key Components of an Effective Standardized Handoff </li></ul><ul><li>( I-SWITCH ) </li></ul><ul><li>Anticipation ( IF… THEN ) as Part of the Handoff is Crucial </li></ul><ul><li>Effective Two-Way Communication that is Clear and Accurate </li></ul><ul><li>(Verbal and Written) </li></ul>

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