Transcript File - Nicki Cliffer: Medical Informatics Capstone

Medical Informatics 402, Spring 2009
Group 2 Final Project
Leigh Moyer
Lincoln Farnum
Nicki Cliffer
Joint Commission’s 2007 National Patient Safety
Goal: Implement a standardized approach to
hand-offs.
(Sullivan, 2007)
 Hand-off – “The point at which the patient is
transferred, either physically to a different part
of the hospital, or administratively when a new
member of the care team takes responsibility.”
(Clancy, 2008)
 Why are hand-offs a cause for concern? They pose
a risk to the patient

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Interactive conversation between person
reporting off and person taking report
 Contain accurate and up-to-date information
 Receiving caregiver can read back, repeat back
and ask questions
 Adequate time should be allotted for the handoff and interruptions should be limited (Sandlin, 2007)

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Hand-off information includes at least:
 Current condition of the patient
 Recent changes in condition
 Pertinent history and physical results
 Test results
 Current vital signs
 Diagnosis
 Planned treatment
 Response to treatment already given
 Plans for future treatment
(Sandlin, 2007)
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Formats previously developed to organize hand-offs:
 SBAR


I PASS the BATON


Situation, History, Assessment, Recommendations,
Questions
5 Ps (V1)


Introduction, Patient, Assessment, Situation, Safety
Concerns, (the), Background, Actions
SHARQ


Situation, Background, Assessment, Recommendation
Patient, Plan, Purpose of plan, Problem, Precaution
5 Ps (V2)

Patient, Precautions, Plan of Care, Problems, Purpose
(Sandlin, 2007)
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Key Features
 Patient Identification Verification – Photo/ Bar
scan
 Patient information
 Current findings/list/details
 Problem list/ Current suggested disease list
 Preventive health/action verification
 Screen Tabs – Patient List, Patient Information,
Visit Information, Orders, Surgery, Results

Based on UCI Health Sciences SBAR Patient Report Guidelines:
Perioperative Services
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 Nursing
Unit on Hospital Floor – Shift change
 Nursing Unit on Hospital Floor to Pre-op
 Pre-op to Operating Room
 Operating Room to PACU/Critical
 PACU to Nursing Unit on Hospital Floor – Post
surgery
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Summary: Mrs. Sally Smith was
admitted to the hospital due to
the chief complaint of chest pain.
She will be observed and will
undergo a series of tests.
Currently Sally is in NW North
Room 204. The attending
physician is Dr. Jill Cohen, the
nurse in charge is RN Patricia
Appleman, and the cardiac
specialist is Dr. Bill Metzger.
Patient Name
Age
Sex
Chief
Complaint
Problem List
Rx
Sally A. Smith
43
Female
Chest Pain
Tobacco Usage
Coronary Disease
Chronic Angina
Levatol, 20mg daily
After crosscheck is complete, RN Appleman presses Acknowledge [Yes]
and the record is displayed.
*Patient history is updated with acknowledgement user, date and time.
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The screen
defaults to the
Visit History
tab.
RN Appleman
reviews the
patient history,
problem list,
medications,
and lab results.
She notes an
alert indicating
Tobacco Usage
that has not
been
addressed.
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X
Problem List: Tobacco Usage
RN Appleman clicks on
the alert to bring up the
acknowledgement data
screen and take action.
She reviews the tobacco
usage and gets details.
She then updates the
problem details and
marks the problem as
addressed.
RN Appleman ensures
the patient’s comfort,
and lets Dr. Cohen know
that the patient is ready
to be seen.
Tobacco Usage
ICD-9 305.1
Comments:
[P. Appleman, RN. 5/17/09 5:45pm] – Discussed dangers of smoking with
patient. Gave smoking cessation documentation and discussed programs
through hospital.
Ok
Cancel
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X
ABC Acute Care Diagnosis Assistance Tool
Dr. Cohen arrives
and launches the
Diagnosis Tool to get
a better idea of
what is going on
with Mrs. Smith.
Gender:
Duratio
n:
Femal
e
Chronic (> 4 weeks)
New Case
Findings
Age: 43y
Male
Current Findings List
Chest Pain, Crushing*
Cigarette Smoking
Angina Pectoris
The Problem List
and Chief complaint
are already
inputted into the DY
tool, along with
gender and age. Dr.
Cohen is prompted
to review the
problem list, chief
complaint, and
other data.
Chronic (> 4 weeks)
New Case Finding - Details
Female
Middle age (41 to 70 years)
Current Suggested Disease
List
++ Unstable angina pectoris
+ Prinzmetal variant angina
Aortic Valve stenosis
Espohagus, spasm
Bronchitis, chronic
Gastroesophageal reflux disease
Costochondritis
Save
Cancel
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Based the patient’s history, Dr.
Cohen believes unstable angina
pectoris is likely and orders an
echocardiogram.
Before Angioplasty
The echocardiogram results arrive
and Dr. Cohen is emailed. She
reviews the results and consults
with Dr. Metzger, the cardiac
specialist, who recommends a
coronary angiogram and possibly
angioplasty, if needed. These can
be done at the same time.
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 Dr.
Metzger and Dr. Cohen meet with the
patient and discuss the next steps.
 RN Appleman schedules the procedure for
the next day and documents the plan for the
patient’s food, water, and medication intake.
This is displayed on the patient information
tab.
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

The evening and
overnight
nursing staff
arrive and
review the
patient list for
their shifts.
The RN of the
day shift reports
on the patient.
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The night shift
nurse notes an
alert that Sally
is due for a
surgical test
tomorrow.
She is on
restricted diet,
and
medication.
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RN Appleman
returns in the
morning and
reviews the notes
on diet and
medication intake
from the night
before.
She begins the
transfer and SBAR
form for the move
to pre-op.
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





Nurse Reilly is prompted to
validate the patient’s name
and picture and asks the
patient to validate her
birthday
After crosscheck is complete,
Nurse Reilly presses
Acknowledge and the record
is displayed.
Patient history is updated
with acknowledgement user,
date and time.
Screen defaults to the Visit
History tab.
Nurse Reilly reviews the
problem list, medication list
and the SBAR form that was
filled out by Nurse
Appleman.
Nurse Reilly acknowledges
that this review is done.
Pre-Op
Sally Smith is moved from NW North Room 204 to pre-op room 5.
Attending: Dr. Jill Cohen
Transferring nurse: Patricia Appleman
Receiving nurse: Paul Reilly
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Nurse Reilly inserts the IV for medication.
 The anesthesiologist and nurse administer
Valium, Versed and morphine to relax the
patient and block pain.
 This is tracked on the flowsheet along with the
patient’s heart rate and blood pressure.
 The patient is ready for surgery.

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Nurse Reilly
transfers the
patient to
surgery and fills
out the correct
SBAR form.
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Nurse Roberts scans the patient’s barcode on her
bracelet to pull up the patient record on the
tablet PC assigned to the room.
 After crosscheck is complete, Nurse Roberts
presses Acknowledge and the record is displayed.
 Patient history is updated with
acknowledgement user, date and time.
 The screen defaults to the Visit History tab.

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Operating Room
Sally Smith is moved from pre-op room 5 to Surgery 1B
Procedural Doctor: Dr. Emile Sanchez
Transferring nurse: Paul Reilly
Receiving nurse: Scott Roberts






Nurse Roberts reviews the problem list, medication list and the
SBAR form that was filled out by Nurse Reilly.
Nurse Roberts calls Nurse Reilly to verify allergies.
Nurse Roberts acknowledges that this review is done.
Nurse Roberts accesses the Surgery tab which now appears based
on Patient Location.
Nurse Roberts ensures the heart rate and blood pressure
monitoring devices are hooked up to the patient and
communicating with the system.
Dr. Sanchez begins the procedure.
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Before Angioplasty




After Angioplasty
During the coronary angiogram, a small gap is seen in the
artery indicating there is a coronary blockage.
Dr. Sanchez takes a snapshot of the image and decides to
insert a stent via angioplasty.
After the stent is inserted, Dr. Sanchez repeats the
imaging test to validate that the angioplasty was a
success.
A clear artery is seen and Dr. Sanchez captures this image
as well.
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The procedure is
finished and Dr.
Sanchez
documents a
structured note
outlining the
procedure.
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Nurse Roberts
begins the
transfer to postop and fills out
the SBAR for the
op to post-op
transfer.
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Post-Op
Sally Smith is moved from Surgery 1B to Post-Op 4
Procedural Doctor: Dr. Emile Sanchez
Transferring nurse: Scott Roberts
Receiving nurse: Jessica Whitely

Nurse Whitely scans the patient’s barcode on her bracelet to pull up the
patient record on the tablet PC assigned to the room.


After crosscheck is complete, Nurse Whitely presses Acknowledge and the
record is displayed.






Nurse Whitely is prompted to validate the patient’s name and date of birth.
Patient history is updated with acknowledgement user, date and time.
Screen defaults to the Visit History tab
Nurse Whitely reviews the procedure info, problem list, medication list
and the SBAR form that was filled out by Nurse Roberts.
Nurse Whitely acknowledges that this review is done.
Nurse Whitely ensures the heart rate and blood pressure monitoring
devices are hooked up to the patient and communicating with the
system.
Patient Smith’s health is monitored as she comes off of anesthesia.
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When patient
Smith is awake
and stable,
Nurse Whitely
completes the
appropriate
SBAR form to
transfer to the
inpatient floor.
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Inpatient
Sally Smith is transferred from post op to NW North 410
Attending: Dr. Jill Cohen
RN: Patricia Appleman
Cardiac Specialist: Dr. Bill Metzger


RN Appleman scans the patient’s barcode on her bracelet to pull
up the patient record on the tablet PC assigned to the room.
RN Appleman is prompted to validate the patient’s name and
picture and asks the patient to validate her birthday.
After crosscheck is complete, RN Appleman presses Acknowledge and
the record is displayed.
 Patient history is updated with acknowledgement user, date and time.



After reviewing the SBAR form, RN Appleman calls Nurse Whitely
to verify the surgical procedure information.
Mrs. Smith is monitored until she is safe to be discharged.
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 Hospitals
- an inherently risky environment.
 Unless
the appropriate safety mechanisms are in place and
working as intended, unfortunate patient outcomes occur with
predictable regularity.
General Hospital, 59% of the house staff described that one or
more patients had been harmed during their most recent clinical
rotation due to faulty handoffs:
 31% of residents rated the quality of handoffs as only fair or
poor
 21%
reported that handoffs usually or always took place in a
quiet setting
 37%
reporting that one or more interruptions during the receipt
of handoff occurred either most of the time or always
 In
2005, the Joint Commission issued rules that required hospitals
to standardize their communication processes to reduce the risk
of errors related to patient transfers, known as “handoffs,” by
January 2006 – or risk losing their accreditation.
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 “We’ve
seen that approximately 70 percent of all serious
adverse events are related to breakdowns in
communication, typically at the point of handoff,” said Dr.
Richard Croteau, executive director for patient safety
initiatives for the commission.
 Sally Smith was moved between four different areas to
obtain a coronary angiogram and important information
about her case and care might have been lost at any one.
 Checklists can include a set of the most common and
problematic hand-off variables and they perform well to
ensure that those items listed are addressed in a
systematic fashion.
 A checklist of some kind almost seems mandatory to aid in
the reduction of handoff failures.
 The
tool just demonstrated is intended to facilitate safe
handoffs.
 Pertinent patient information is saved and displayed for
users at each stop - from the inpatient area to surgery and
back.
 Notes are embedded to allow viewing with mouseover
techniques
 Individual cells are highlighted when they contain notes
and are color-coded to describe the values relative to
normal or previous values.
 This tool is intended to take the place of numerous tabs
and worksheets, aggregating a wide variety of patient data
and making both its input and display more accessible and
easier to manage.
 This tool can serve as a prototype for patient data
aggregation and handoff management.
 Clancy, Carolyn, M. The Importance of Simulation: Preventing Hand-off
Mistakes. 2008. AORN Journal. 88(4): pp 625-627.
 Sandlin, Debbie. Improving Patient Safety by Implementing a Standardized and
Consistent Approach to Hand-off Communication. (2007) Journal of PeriAnesthesia
Nursing. 22(4): pp 289-292.
 Sullivan, Ellen E.. Hand-off Communication. (2007) Journal of PeriAnesthesia Nursing,
22 (4): pp275-279.
 UCI Health Sciences SBAR Patient Report Guidelines: Perioperative Services
 The Joint Commission Journal on Quality and Patient Safety; Handoffs Causing Harm:
A Survey of Medical and Surgical House Staff.
http://depts.washington.edu/respcare/public/hmc_files/journal_club/articles/2009
0406/Handoffs_causing_harm_a_survery_of_medical_and_surgical_house_staff.pdf
 Massachusetts Medical Society, Online Continuing Education; Reducing Errors Liability
in Patient Handoffs
http://www.massmed.org/Content/NavigationMenu2/ContinuingEducation
Events/NewCourses/ReducingErrorsLiabilityinPatientHandoffs1/PatientHandoffs/Patient_
Handoffs.htm
 http://www.mayoclinic.com/health/coronary-angiogram/MY00541
 http://www.medicinenet.com/coronary_angioplasty/page5.htm
 http://en.wikipedia.org/wiki/Angina_pectoris#Unstable_angina
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