Transcript Simple Standardized Patient Hand

Simple Standardized
Patient Hand-Off System
that Increases Accuracy
and Completeness
Jeffrey D. Wayne, MD, Rajesh Tyagi, PhD,
Gilles Reinhardt, PhD, Deborah Rooney, MS,
Gregory Makoul, PhD, Sunil Chopra, PhD,
Debra A. DaRosa, PhD
The Challenge
• 80 hour work week
• Transfers of care are increasingly frequent
• Few residency programs have care systems
in place to accommodate this change
Horowitz. LI et al., Arch Intern Med, 2006
Handoffs: Objectives
• “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
handoff must be accurate in order to meet
patient safety goals”
The Joint Commission, 2008 National Patient Safety Goals
The New Surgical Residency
•
•
•
•
Apprenticeships
Small Teams
Night Float
Short call
DaRosa, DA and Bell RH, Surgery, 2004
Patient Safety
• Poor communication between physicians
• Handoff issues
– Little formal instruction
– Need for standardization
Greenberg CC et al, JACS, 2007
Rogers, SO et al, Surgery, 2006
Borowitz SM et al, Qual Saf Health Care, 2008
Solet DJ et al, Acad Med, 2005
Purpose/ Research Questions
• What were baseline perceptions of residents regarding
quality of handoffs?
• To what extent were nurses clear as to the exact time
patient care was transferred between day and night
residents?
• What is the effect of a standardized hand off instrument
on perceptions of completeness, accuracy, efficiency,
and appropriateness of task delegation?
• Does resident experience and type of rotation (ICU vs.
non-ICU) on handoff completeness, accuracy,
efficiency, and appropriateness of task delegation?
Methods: Baseline Description
• Direct observation
– Efficiency and operations team
• Method
• Quality and form of written documentation
• 12 Services
• Focus group
– Residents, nurses, administrators, surgeons
• Electronic Survey
• Phone Survey (Baseline/ Post-intervention)
Baseline Observation
Handoff without interaction:
•
Endocrine
•
Breast
•
General Surgery 1
•
General Surgery 2
Handoff with face-to-face encounter:
•
Vascular
•
Trauma
•
Transplant
•
Cardiothoracic
Handoff with phone or face-to-face encounter:
Depends on
a) complexity of patient care
b) resident preference
•
Surgical Oncology
•
Colorectal 1
•
Colorectal 2
•
Gastrointestinal surgery
ICU handoffs are always face-to-face, takes full one hour and residents discuss each
patient
Baseline Observation
Handoff: Face-to-face
1.
Vascular
2.
Trauma
3.
Transplant
4.
Cardio Thoracic
New residents
Sign-In
Attending
dictates,
resident takes
hand notes
Resources:
Attending,
Resident
Outgoing
Resident’s Final
Update
Resources: Outgoing
resident, shared file
Take Notes &
Update
spreadsheets
during shift
Resources:
Resident,
spreadsheet
Outgoing
resident
prints
sheets
Resources:
Resident,
printer
Sheets waiting at
the table
Incoming
receives
critical
updates
Resources:
Incoming/
outgoing
residents,
spreadsheets
Information
exchange
about key
patients
Resources:
Incoming/Outg
oing residents
Incoming resident
begins shift
Hand Off Evaluation Form
Efficiency:
Approximately how much of your time was spent updating the “hand off” sheet?
____ Minutes
Accuracy:
To what extent were there any inaccuracies of information on the “hand off” sheet that you received or gave out?
□
None
□ Few (1-3 inaccuracies) □ Some (4-6 inaccuracies) □ Many (7+ inaccuracies)
Completeness:
To what extent was there any incomplete information on the “hand off” sheet that you received or gave out?
□ None □ Few (1-3 occurrences) □ Some (4-6 occurrences) □ Many (7+ occurrences)
Responsibility:
In the past 24 hours, on a scale from 1 to 5 with 1 being unclear and 5 being very clear, how clear was the exact time the resident handing off to
you officially transferred patient responsibility to you?
1 Unclear
2
3 Somewhat clear
4
5 Very Clear
Approximately how may tasks were you expected to do that should have been taken care of in a previous shift?
□ None □ Few (1-3 tasks) □ Some (4-6 tasks) □ Many 7+ tasks
“Hand-off” Dissemination:
□ Sheet dropped off □ Discussed over phone □ Face-to-face discussion
Name of Rotation:
I am on:
□ Night Float □ Day Team
Notes/Comments:
Day of Week/Date:
Time:
Results : On line survey
Please indicate your level of agreement with the following statements. (1= Strongly Disagree and 7=Strongly Agree)
Question
Mean score and
Standard Deviation (St
Dev)
It is important that the column headings on the hand off excel spreadsheets are
uniform across different services.
Mean: 4.00 ST dev:
1.041
During the handoff process, the most clinically relevant patient information is displayed
on the spreadsheet.
Mean: 5.46, St Dev: 0.957
During the handoff process, the on call attending is accurately identified for each
clinical service.
Mean: 3.75 , ST Dev: 2.04
The current hand off spreadsheets provide accurate patient information.
Mean: 4.7, St Dev: 1.02
Hand off spreadsheets are updated accurately on at least a daily basis.
Mean: 5.29, St Dev: 0.93
The spreadsheet makes it easy to identify tasks to be performed over the shift.
Mean: 5.29, St Dev: 1.136
During the handoff process, the exact time of the transfer of responsibility from
outgoing to incoming resident is clear.
Mean: 4.62, St Dev: 1.65
During the handoff process, the exact time of the transfer of responsibility from
outgoing to incoming resident is clear to other patient care providers (i.e. PA’s, nurses,
etc).
Mean: 3.33, St Dev: 1.46
Current spreadsheets identify critical patient care issues that have occurred over the
last 24 hour period.
Mean: 4.33, St Dev: 1.28
The resident library provides a convenient location and environment for an efficient
handoff process.
Mean: 5.83, St Dev: 1.14
I am satisfied with the quality of the existing handoff process.
Mean: 5.0, St Dev: 0.91
Results : On line survey
It is important to know which elements of the Hand Off process are important from your perspective. Please
rate each of the below elements.
(1= Strongly Disagree and 7=Strongly Agree)
Question
Mean score and
Standard Deviation (St
Dev)
The consistency of information provided in hand off spreadsheets across different
services.
Mean: 4.19 St Dev: 1.18
The relevancy of pertinent patient information displayed on the spreadsheet.
Mean 6.04, St Dev: 0.73
The exact time of the transfer when one resident assumes patient responsibilities from
the departing resident .
Mean: 4.29, St Dev: 1.13
Accurate information on the spreadsheet.
Mean: 6.5, ST Dev: 0.57
Up-to-date information on the spreadsheet.
Mean: 6.5, St Dev: 0.64
Identifying tasks to be performed over the shift using the spreadsheet.
Mean: 6.45, St Dev: 0.7
A clear transfer of responsibility from outgoing to incoming resident, so both residents
know the exact time when the incoming resident assumes primary responsibility for the
patients being “handed off.”
Mean: 5.04, St Dev: 1.24
A clear transfer of responsibility from outgoing to incoming resident so that other health
care providers (nurses, PA’s, attendings, etc) know the exact time when the incoming
resident assumes primary responsibility for the patients being “handed off.”
Mean: 5.12, St Dev: 1.09
Accurately pinpointing critical patient care issues or changes on the hand off
spreadsheet that have occurred over the last 24 hour period.
Mean: 6.12, St Dev: 1.20
Estimate the number of patients in the past 3 months for which any of the above issues with the handoff process
caused you concern with regards to patient care.
0 (12.5%), 1-3 (50%), 4-6 (29.17%), and 7 or more (8.33%)
Standardized Hand off Instrument
Room Attending
XY
YZ
ZA
AB
BC
CD
Name/MR # Age
On duty
Attending
Fellow/Resident
WayneJeffrey(53471)
BilimoriaKarl(58609)
Admit/OR
Admit/Diagn PMHx/Code
Allergies
Date
osis
Status
Post-Op Day
31-Jul-05
967
25-Jul-05
972
01-Aug-05
966
05-Aug-05
962
8/7/2005 23:04
Meds
8/7/2005 23:17
DVT/GI
Drain/Tubes Vital/Labs/Test/
Sign-out To Do
PROPH IVF Diets /Lines
Cultures
Accuracy
3
*p = 0.003
2.5
2
1.5
Baseline
Post-intervention
1
0.5
0
To what extent were there any inaccuracies of information on the “hand off” sheet that you received or gave out?
Accuracy
3
2.5
p=NS
p=0.006
2
Baseline
Post-intervention
1.5
1
0.5
0
ICU
non-ICU
Completeness
3.5
3
*p= 0.015
2.5
2
1.5
Baseline
Post-intervention
1
0.5
0
To what extent was there any incomplete information on the “hand off” sheet that you received or gave out?
Completeness
4
3.5
P=0.005
3
2.5
Baseline
Post-intervention
2
1.5
1
0.5
0
ICU
Non-ICU
Responsibility
*p = 0.07
5
4.5
*p =0.005
4
3.5
3
Baseline
Post-intervention
2.5
2
1.5
1
0.5
0
Night Float
Day Shift
In the past 24 hours, on a scale from 1 to 5 with 1 being unclear and 5 being very clear,
how clear was the exact time the resident handing off to you officially transferred patient responsibility
to you?
Responsibility
5
4.9
4.8
4.7
Baseline
Post-intervention
4.6
4.5
4.4
4.3
4.2
ICU
Non-ICU
Responsibility
1
0.9
0.8
* p<0.05
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Baseline
Post-intervention
# of tasks
Approximately how may tasks were you expected to do
that should have been taken care of in a previous shift?
Regression analysis
• Resident experience (in months) is not a
significant factor in the perceived
improvements
• ICU rotations have some impact on tow of
the outcome measures:
– Completeness of information
– Clarity if time of responsibility transfer
Other High Risk Settings
• NASA
• Airline Industry
• Nuclear Power plants
– Handoff skills are practiced repetitively to
optimize precision and anticipate errors
– Reduce complexity
– Reveal hidden events and activities
– Focus attention
Patterson ES, Ann Surg, 2007
Patterson ES et al, Int J Qual Health Care, 2004
Stevens, DP, Qual Saf Health Care, 2008
Other Strategies
• Computerized Resident Sign-out System
• PDA’s
• Competency-based approach
– Required verbal communication
– Professionalism
• “Shared Responsibility”
Van Eaton, EG et al, Surgery 2004
Van Eaton, EG et al, JACS, 2005
Park J, et al, JSE, 2007
Arora VM et al, Qual Saf Health Care, 2008
Limitations of Study
• Single Institution
• Outcome measures based on perception data
– Review of medical records
Ideal (?) handoff process
Test
results
Patient info
History
Medication
Central
Insurance
Billing
Staff
Schedules
Resident
continuously
updated via
(handheld) device
Future Directions
• Focused training on handoffs
– Importance
– Process
• Sample Medical records
– Better define accuracy and completeness