Care Handoffs Research Articles

Closing the Gap: A Needs Assessment of Medical Students and Handoff Training

Closing the Gap: A Needs Assessment of Medical Students and Handoff Training

IMOUTA: A proposal for patient care handoffs

An increased frequency of patient handoffs has occurred as a result of the new resident work-hour restrictions that have recently been instituted. Inadequate handoff of patient care has been associated with adverse patient events due to residents being unprepared for events that happen during cross cover periods. The objective of our study was to develop and test the effectiveness of a patient handoff method in an otolaryngology residency program. Single-blinded controlled clinical trial. A standardized, anonymous questionnaire was developed that scored on-call residents' understanding of their patients' diagnoses, hospital courses, active concerns, and treatment plans. For the first 45 days, residents used their traditional handoff. This handoff was prepared by the residents, relaying relevant patient information without any structured format. For the next 45 days, the residents followed the acronym of IMOUTA for handoffs. This mnemonic was developed to help residents identify data (I), medical course (M), outcomes possible tonight (OU), responsibilities to do tonight (T), and opportunity to ask questions and give morning feedback in the AM (A). The questionnaires were then compared at the end of the study. The residents who used the IMOUTA acronym scored significantly higher on their perceived knowledge of patients diagnoses (P = 0.001), hospital courses (P <0.001), active concerns (P <0.001), and treatment plans (P <0.001). Residents felt significantly better prepared for call duties when using the IMOUTA acronym. This standardized system of patient handoff may also be valuable to other residency programs.

Flow disruptions in trauma care handoffs

BackgroundEffective handoffs of care are critical for maintaining patient safety and avoiding communication problems. Using the flow disruption observation technique, we examined transitions of care along the trauma pathway. We hypothesized that more transitions would lead to more disruptions, and that different pathways would have different numbers of disruptions. MethodsWe trained observers to identify flow disruptions, and then followed 181 patients from arrival in the emergency department (ED) to the completion of care using a specially formatted PC tablet. We mapped each patient’s journey and recorded and classified flow disruptions during transition periods into seven categories. ResultsMapping the transitions of care shows that approximately four of five patients were assessed in the ED, transferred to imaging for further diagnostics, and then returned to the ED. There was a mean of 2.2 ± 0.09 transitions per patient, a mean of 0.66 ± 0.15 flow disruptions per patient, and 0.31 ± 0.07 flow disruptions per transition. Most of these (53%) were related to coordination problems. Although disruptions did not rise with more transitions, patients who went directly to the operating room or needed direct admission to intensive care unit were significantly more likely (P=0.0028) to experience flow disruptions than those who took other, less expedited pathways. ConclusionsTransitions in trauma care are vulnerable to systems problems and human errors. Coordination problems predominate as the cause. Sicker, time-pressured, and more at-risk patients are more likely to experience problems. Safety practices used in motor racing and other industries might be applied to address these problems.

Flow Disruptions in Trauma Care Handoffs

Effective handoffs of care are frequently cited as critical for maintaining safety and avoiding communication problems. Using the flow disruption observation technique, we sought to examine transitions of care along the trauma pathway. Our hypothesis was that an increase in hand-offs in trauma care is associated with an increase in flow disruptions and a decrease in efficiency.

Developing a Better Understanding of Handoffs

In today's health care environment, patients encounter various health care providers during their experience. Along the continuum of care, these health care providers are engaging in handoffs of patient care. Each handoff is fraught with potential errors, such as the loss of essential information, which could lead to adverse events, delays in treatment and diagnosis, ordering of repeat tests, longer hospitalization, and increased costs. Clearly, poor communications can lead to errors. Communication failure is often cited as a cause in sentinel events.

An Intervention to Improve Ambulatory Care Handoffs at the End of Residency

The medical literature shows evidence of numerous initiatives to improve inpatient physician handoffs. In contrast, handoffs of ambulatory patients to incoming interns or junior residents at the end of residency are an area of potential concern that has been overlooked. To examine handoffs of high-risk ambulatory patients by outgoing residents to junior colleagues and to compare current practice to a standard handoff process. We hypothesized the intervention would lead to increases in the number and quality of ambulatory care handoffs. Fourteen graduating internal medicine and combined internal medicine-pediatrics residents who practiced at an academic continuity clinic were randomized to an intervention or a control group. E-mail instructions were sent asking the intervention group to write a handoff note using the clinic's electronic medical record system. The e-mail included a detailed outline of information to incorporate and highlight features of the electronic medical record that would facilitate the process. The handoff notes of the intervention and control group were independently evaluated and scored for quality using a predetermined point system. Six of the 7 residents (86%) in the intervention group completed 19 handoff notes; none of the residents in the control group completed handoff notes. Most of the handoffs provided a brief paragraph or 2 of background information on the patient and then focused on issues needing short-term follow-up during the coming months. The standardized handoff process implemented via simple e-mail instructions increased the number of outpatient handoffs at the completion of residency. Further study with a larger number of residents, identification and removal of barriers to the handoff process, and correlation of handoffs to clinical outcomes are key next steps.

Investigating the scope of resident patient care handoffs within neurosurgery.

IntroductionHandoffs are defined as verbal and written communications during patient care transitions. With the passage of recent ACMGE work hour rules further limiting the hours interns can spend in the hospital, many fear that more handoffs will occur, putting patient safety at risk. The issue of handoffs has not been studied in the neurosurgical literature.MethodsA validated, 20-question online-survey was sent to neurosurgical residents in all 98 accredited U.S. neurosurgery programs. Survey results were analyzed using tabulations.Results449 surveys were completed yielding a 56% response rate. 63% of neurosurgical residents surveyed had not received formal instruction in what constitutes an effective handoff; 24% believe there is high to moderate variability among their co-residents in terms of the quality of the handoff provided; 55% experience three or more interruptions during handoffs on average. 90% of neurosurgical residents surveyed say that handoff most often occurs in a quiet, private area and 56% report a high level of comfort for knowing the potential acute, critical issues affecting a patient when receiving a handoff.ConclusionsThere needs to be more focused education devoted to learning effective patient-care handoffs in neurosurgical training programs. Increasingly, handing off a patient adequately and safely is becoming a required skill of residency.

An Interactive Workshop to Increase Resident Readiness to Perform Patient Hand-offs

OPEN ACCESSJuly 3, 2012An Interactive Workshop to Increase Resident Readiness to Perform Patient Hand-offs Michael Aylward, MD Michael Aylward, MD University of Minnesota Medical School Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.9189 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail Abstract Introduction: Patient handoffs are an increasingly common aspect of patient care. Residents perform a significant number of patient handoffs, often with little training or oversight. Therefore, we created this resident handoff workshop, which is inexpensive, is easy to administer, and requires minimal materials. Methods: The workshop consists of a handoff script, didactic PowerPoint slides, a case presentation, a handoff video, and an instructor's guide. The workshop takes 90 minutes to implement. It has traditionally been run during intern orientation for all medicine and medicine-pediatric residents at the University of Minnesota Medical School. Results: The workshop has been used over the past 3 years. We have shown a 26% improvement in overall readiness to perform a handoff. A follow-up survey 3–6 months after the workshop indicated that over 90% of interns had incorporated an aspect of what they learned in the workshop into their handoffs. Discussion: The workshop is simple to run, is inexpensive and short, and can be easily deployed during resident orientation. Residents perform a significant number of patient care handoffs in teaching hospitals, where complexity and acuity are high. Because preventable adverse events are directly proportional to house staff discontinuity, it is imperative to find ways to improve residents' handoff skills. Educational Objectives By the end of this workshop, learners will be able to: Discuss the importance of handoffs and potential sources of error during the handoff process.Determine how to convey information in an efficient and effective manor.Observe a handoff and deconstruct what was done well and what was done poorly.Practice a handoff in a role-play setting. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Case Presentation.doc Hand-off Video - Quicktime Version.mov Hand-off Video - Windows Version.wmv Hand-off Workshop Script.pdf Hand-off Workshop Slides.ppt Instructor's Guide for Hand-off Workshop.pdf Long Call Packet.pdf Night Float Packet.pdf Primary Team Packet.pdf To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. CitationAylward M. An Interactive Workshop to Increase Resident Readiness to Perform Patient Hand-offs. MedEdPORTAL. 2012;8:9189. https://doi.org/10.15766/mep_2374-8265.9189 Copyright & Permissions© 2012 Aylward. This is an open-access article distributed under the terms of the Creative Commons Attribution license.KeywordsHand-offWorkshop Disclosures None to report. Funding/Support None to report. Loading ...

Implementing Faculty Evaluation of Written Sign-Out

Purpose: Recently the Accreditation Council for Graduate Medical Education mandated decreased shift duration for intern physicians to no more than 16 hours. Such work-hour restrictions are likely to increase patient care hand-offs. It is well accepted that sign-out (i.e., hand-off) processes are error prone and lack standardization. Moreover, many residency programs do not evaluate sign-out. We designed and tested whether a sign-out evaluation process could be implemented to improve written sign-out. Method: Based on observed sign-out deficiencies at our institution we adapted a simple curriculum incorporating the SIGNOUT mnemonic, which we paired with weekly faculty member evaluation and feedback on sign-out using a structured sign-out evaluation tool. Later in the week, written sign-out was independently scored by 2-blinded senior resident reviewers who compared the inclusion of sign-out content, organization, and readability. Results: Compared to baseline data in 128 written sign-outs, the pairing of a 1-page curriculum with weekly faculty member evaluation of written sign-out improved the inclusion of advanced directives from 38% to 69% (p < .001) and anticipatory guidance from a mean score of 1.8 (SD = 1.2) to 2.3 (SD = 1.5) on a 5-point scale ( p = .01) in 177 written sign-outs. Readability and organization were unchanged. Conclusions: A simple curriculum paired with structured faculty evaluation and feedback can improve some parameters of sign-out. Structured evaluative sign-out tools may be useful to improve and teach sign-out skills.

Use of an Appreciative Inquiry Approach to Improve Resident Sign-Out in an Era of Multiple Shift Changes

Resident duty hour restrictions have resulted in more frequent patient care handoffs, increasing the need for improved quality of residents' sign-out process. To characterize resident sign-out process and identify effective strategies for quality improvement. Mixed methods analysis of resident sign-out, including a survey of resident views, prospective observation and characterization of 64 consecutive sign-out sessions, and an appreciative-inquiry approach for quality improvement. Internal medicine residents (n = 89). An appreciative inquiry process identified five exemplar residents and their peers' effective sign-out strategies. Surveys were analyzed and observations of sign-out sessions were characterized for duration and content. Common effective strategies were identified from the five exemplar residents using an appreciative inquiry approach. The survey identified wide variations in the methodology of sign-out. Few residents reported that laboratory tests (13%) or medications (16%) were frequently accurate. The duration of observed sign-outs averaged 134 ±73s per patient for the day shift (6p.m.) sign-out compared with 59 ± 41s for the subsequent night shift (8p.m.) sign-out for the same patients (p = 0.0002). Active problems (89% vs 98%, p = 0.013), treatment plans (52% vs 73%, p = 0.004), and laboratory test results (56% vs 80%, p = 0.002) were discussed less commonly during night compared with day sign-out. The five residents voted best at sign-out (mean vote 11 ± 1.6 vs 1.7 ± 2.3) identified strategies for sign-out: (1) discussing acutely ill patients first, (2) minimizing discussion on straightforward patients, (3) limiting plans to active issues, (4) using a systematic approach, and (5) limiting error-prone chart duplication. Resident views toward sign-out are diverse, and accuracy of written records may be limited. Consecutive sign-outs are associated with degradation of information. An appreciative-inquiry approach capitalizing on exemplar residents was effective at creating standards for sign-out.

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses’ handoffs on medical and surgical units: Insights from interviews and observations

Patient care handoffs are cognitively intense activities, especially on medical and surgical units where nurses synthesize information across an average of four to five patients every shift. The objective of this study was to examine handoffs and nurses' use of computerized patient summary reports in an electronic health record after computerized provider order entry (CPOE) was installed. We observed and audio taped 93 patient handoffs on 25 occasions on 5 acute care units in 2 different facilities sharing a vendor's electronic health record. We found that the computerized patient summary report and the electronic health record were minimally used during the handoff and that the existing patient summary reports did not provide adequate cognitive support for nurses. The patient summary reports were incomplete, rigid and did not offer "at a glance" information, or help nurses encode information. We make recommendations about a redesign of patient summary reports and technology to support the cognitive needs of nurses during handoffs at the change of shift.

The July Effect: Fertile Ground for Systems Improvement

In this issue, Young and colleagues' systematic review suggests that housestaff changeover is associated with some adverse outcomes. The editorialists discuss these findings and argue that efficien...

Nurses’ Information Management and Use of Electronic Tools During Acute Care Handoffs

Little evidence is available about nurses' use of electronic tools during handoffs. This qualitative study explored information management and use of electronic tools during nursing handoffs. The sample included 93 handoffs by 26 nurses on 5 medical/surgical units in 2 western hospitals with a robust electronic health record (EHR). Data collection included audiotaping handoffs, semi-structured interviews, observations, and fieldnotes. The dataset was inductively coded into 33 categories and 5 themes: good nurse expectations for handoffs, paper forms are best, information at a glance, only pertinent information please, and information tools that work. Two-thirds of the nurses abandoned use of the leadership-endorsed electronic handoff form, preferring personal paper forms. The findings suggest effective electronic solutions will require extensive contextually-based information, information integrated across EHR modules and portable, electronic support throughout shifts. This is a call to action for leaders and informaticists as they select and design future electronic tools.

Quality Improvement Methods for Medical Handoffs

Objectives: We describe the application of fundamental quality improvement methods to medical handoffs in order to improve resident learning and clinical training.Methods: We select six pervasive quality improvement methods that each highlight a particular aspect of overall process improvement. The six methods are the 7-S Framework, Plan-Do-Check-Act, DefineMeasure-Analyze-Improve-Control, Lean, Root Cause Analysis, and the Prioritization Matrix.Results: We describe how each method can be used to improve the efficiency and effectiveness of a patient care handoff. Examples are provided throughout to help depict each method in the handoff context. Our exposition is written so as to introduce the methods to a practitioner charged with improving a medical handoff, or a medical educator providing a course on healthcare process improvement.Conclusions: The medical field recognizes the importance of studying other disciplines in order to optimize key processes in medicine. We present six quality improvement methods not universally acknowledged in the medical field that are particularly applicable to improving medical handoffs. By contextualizing these methods into the medical handoff, we show both how to improve the overall process and emphasize the value in implementing concepts from other disciplines as part of the residency training curriculum.

Residents, Training Directors Get New Duty-Hour Rules

Residents, Training Directors Get New Duty-Hour Rules

Model development for EHR interdisciplinary information exchange of ICU common goals

PurposeEffective interdisciplinary exchange of patient information is an essential component of safe, efficient, and patient-centered care in the intensive care unit (ICU). Frequent handoffs of patient care, high acuity of patient illness, and the increasing amount of available data complicate information exchange. Verbal communication can be affected by interruptions and time limitations. To supplement verbal communication, many ICUs rely on documentation in electronic health records (EHRs) to reduce errors of omission and information loss. The purpose of this study was to develop a model of EHR interdisciplinary information exchange of ICU common goals. MethodsThe theoretical frameworks of distributed cognition and the clinical communication space were integrated and a previously published categorization of verbal information exchange was used. 59.5h of interdisciplinary rounds in a neurovascular ICU were observed and five interviews and one focus group with ICU nurses and physicians were conducted. ResultsCurrent documentation tools in the ICU were not sufficient to capture the nurses’ and physicians’ collaborative decision-making and verbal communication of goal-directed actions and interactions. Clinicians perceived the EHR to be inefficient for information retrieval, leading to a further reliance on verbal information exchange. ConclusionThe model suggests that EHRs should support: (1) information tools for the explicit documentation of goals, interventions, and assessments with synthesized and summarized information outputs of events and updates; and (2) messaging tools that support collaborative decision-making and patient safety double checks that currently occur between nurses and physicians in the absence of EHR support.

Say What You Mean to Say

Say What You Mean to Say

Effectiveness of a course designed to teach handoffs to medical students

Handoffs of patient care are increasingly common and are known to contribute to medical errors. A significant number, if not the large majority, of first-year Internal Medicine residents have not received formal education pertaining to handoffs during medical school. To develop a program designed to teach handoffs to medical students entering their fourth year of training. University of Colorado Denver School of Medicine. Our Handoff Selective was first offered in April 2007 as part of a 2-week Integrated Clinician's Course conducted once yearly between the third and fourth years of medical school. The Selective consisted of a didactic session in which communication theory and elements were discussed and a practicum in which students used faculty-developed case scenarios to practice both giving and receiving handoffs. Sixty (the maximum number of spots available) out of 150 students participated in the course, although many more students chose the course than spots available. Prior to taking the Selective, medical students' confidence in performing handoffs was poor, but it improved after the course (P < 0.001); 92% of students felt the Handoff Selective was "useful" or "extremely useful." While both components of the course were thought to be useful to the large majority of students, the practicum portion was thought to be more useful (P < 0.001). Formal education on handoffs is well received by medical students and improves their self-perceived understanding and performance of handoffs.

Nursing Handoffs: A Systematic Review of the Literature

Handoffs of patient care from one nurse to another are an integral part of nursing practice; but there is abundant evidence that poor communication and variable procedures result in inadequate handoffs. We sought to conduct a systematic review of articles that focused on nursing handoffs, conduct a qualitative review of barriers to and strategies for effective handoffs, and identify features of structured handoffs that have been effective. We conducted a systematic review of English-language articles, published between January 1, 1987, and August 4, 2008, that focused on nursing handoffs in the United States. The search strategy yielded 2,649 articles. After title review, 460 of these were obtained for further review by trained abstractors. Ninety-five articles met the inclusion criteria; of these, 55 (58%) were published between January 1, 2006 and August 4, 2008. Content analysis yielded identification of barriers to effective handoffs in eight major categories and strategies for effective handoffs in seven major categories. Twenty articles involved research on nursing handoffs. Quality assessment scores for the research studies ranged from 2 to 12 (possible range, 1 to 16). The majority of the research studies on nursing handoffs (17 studies; 85%) received quality scores at or below 8 and only three achieved scores above 10. Ten (50%) of the studies included measures of handoff effectiveness. Despite the well-known negative consequences of inadequate nursing handoffs, very little research has been done to identify best practices. There is remarkable consistency in the anecdotally suggested strategies; but there is a paucity of evidence to support them. We call for high-quality studies of handoff outcomes that focus on systems factors, human performance, and the effectiveness of structured protocols and interventions.

Encouraging patients and family caregivers to assert a more active role during care hand-offs: The Care Transitions Intervention™

What is the model: During a 4-week program, patients with complex care needs and family caregivers receive specific tools and work with a ‘Transitions Coach,’ to learn self-management skills that will ensure their needs are met during the transition from hospital to home. This is a low-cost, low-intensity intervention comprised of a home visit and three phone calls. What makes this model unique: In contrast to traditional case management approaches, the Care Transitions Intervention is a selfmanagement model. The Care Transitions Program has modeled national Medicare data sets to demonstrate the frequency with which older adults making care transitions across settings will experience another transition in the near future. In other words, for most of these individuals, there will be a ‘next time’. Using qualitative techniques, the Care Transitions Program worked with older adults to identify the key self-management skills needed to assert a more active role in their care. Next, a Transition Coach was introduced to help impart these skills and help the individual and the family caregiver become more confident in this new role. Although critics are quick to point out that this is only applicable to highly educated or motivated patients, our studies have shown that most patients and family caregivers are able to become engaged and do considerably more for themselves. In essence, the model involves making an investment in helping patients and family caregivers become more comfortable and competent in participating in their care during care transitions. Five months after the Transition Coach signed off, these patients continued to remain out of the hospital demonstrating a sustained effect from coaching. The intervention focuses on four conceptual domains referred to as pillars: 1. Medication self-management 2. Use of a dynamic patient-centered record, the personal health record 3. Timely primary care/specialty care follow-up 4. Knowledge of red flags that indicate a worsening in their condition and how to respond What are the key findings: Patients who received this program were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five months after the end of the one-month intervention. Thus, rather than simply managing post-hospital care in a reactive manner, imparting self-management skills pays dividends long after the program ends. Anticipated net cost savings for a typical coach panel of 350 chronically ill adults with an initial hospitalization over 12 months is USD$ 295,594. Patients who received this program were also more likely to achieve self-identified personal goals around symptom management and functional recovery. To date more than 160 organizations have adopted the care transitions intervention. Project sponsors: The John A. Hartford Foundation and The Robert Wood Johnson Foundation Where Can I Learn More?: Please visit www.caretransitions.org or email: Eric.Coleman@ucdenver.edu