Resident Handoff Research Articles

Factors That Correlate With the Decision to Delay Extubation After Multilevel Prone Spine Surgery

Multilevel spinal decompressions and fusions often require long anesthetic and operative times, which may result in airway edema and prolonged postoperative intubation. Delayed extubation can lead to bronchopulmonary infections and other complications. This study analyzed which factors correlated with the decision to delay extubation after multilevel spine surgery. We reviewed the records of 289 patients who underwent multilevel spine surgery lasting ≥8 hours in the prone position from 2006 to 2012. Variables hypothesized to affect the decision of the anesthesiologist to delay extubation at the end of the surgery were collected. These included preoperative factors (age, sex, ASA class, history of obstructive sleep apnea, BMI, previous spine surgery, current cervical surgery, anterior in addition to posterior spine surgery, emergency surgery) and intraoperative factors (difficult intubation, number of surgical levels, case time, estimated blood loss, fluid and blood administration, attending handoff and resident handoff, and case end time). We also compared the incidence of pulmonary postoperative complications between patients extubated at the end of the case to patients who had a delayed extubation. A total of 126 patients (44%) were kept intubated after multilevel spine surgery. Multiple linear regression analysis showed factors that correlated with prolonged intubation which included age, ASA class, procedure duration, extent of surgery, total crystalloid volume administered, total blood volume administered, and the case end time. Patients who had a delayed extubation had a 3-fold higher rate of postoperative pneumonia. Our study found that age, ASA class, procedure duration, extent of surgery, and total crystalloid and blood volume administered correlate with the decision to delay extubation in multilevel prone spine surgery. It also finds that the time the case ends is an independent variable that correlates with the decision not to extubate at the end of a long multilevel spinal surgery. The incidence of postoperative pneumonia is higher in patients who had a delayed extubation after surgery.

Are Attendings Different?. Intensivists Explain Their Handoff Ideals, Perceptions, and Practices

What is known about physician handoffs is almost entirely limited to resident practice, but attending physicians ultimately determine care plans and goals of care. This study sought to understand what is unique about attending intensivist handoffs, to identify perceptions of the ideal content and format of intensive care unit (ICU) attending handoffs, and to understand how ideal and reported practices are aligned in the delivery of care. Intensivists in active practice in U.S. adult academic ICUs were purposively sampled and interviewed over 9 months in 2011 to 2012. Thirty attendings from 15 institutions in nine U.S. states were interviewed. Subjects' specialties included anesthesiology, emergency medicine, internal medicine, and surgery. The "perfect handoff" was described as succinct, included verbal plus written communication, and took place in person. Respondents believed that the attending handoff should be less detailed than resident handoffs. Most attendings participated in handoffs at the end of each ICU rotation (n = 26). Standardized handoff practice was rare (n = 1). Media used for handoffs included combinations of telephone conversations (n = 25), in-person communications (n = 11), e-mail (n = 9), or text message (n = 2). Handoff duration varied from 10 to 120 minutes for 5 to 42 patients. Five of 30 respondents had undergone formal training in how to conduct handoffs. A national sample of academic intensivists identified common ideal attributes of attending handoffs, yet their reported handoff practices varied widely. Ideal handoff practices may form the basis of future interventions to improve communication between intensivists.

Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of Resident Handoff Bundle: Starmer A, Sectish, T, Simon D, et al. JAMA 2013;310:2262–70.

Handoffs between outgoing teams to oncoming teams can lead to medical errors through miscommunication. This study sought to determine if a handoff bundle reduces adverse events and medical errors among hospitalized patients. The prospective intervention study included 1255 admissions on two inpatient units at a children's hospital. A resident handoff bundle was compared to preintervention data. The bundle included standardized communication, handoff training, a verbal mnemonic, and a new team-based structure plus a computerized handoff tool in one of the hospital units.

Structured, Standardized Resident Handoffs Reduce Medical Errors and Adverse Events

Resident work hours were reduced to eliminate fatigue and improve patient safety, but this practice has increased the frequency of patient handoffs and

Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle

Handoff miscommunications are a leading cause of medical errors. Studies comprehensively assessing handoff improvement programs are lacking. To determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow. Prospective intervention study of 1255 patient admissions (642 before and 613 after the intervention) involving 84 resident physicians (42 before and 42 after the intervention) from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Children's Hospital. Resident handoff bundle, consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced. The primary outcomes were the rates of medical errors and preventable adverse events measured by daily systematic surveillance. The secondary outcomes were omissions in the printed handoff document and resident time-motion activity. Medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3-40.3) to 18.3 per 100 admissions (95% CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95% CI, 1.7-4.8) to 1.5 (95% CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention (8.3%; 95% CI 7.1%-9.8%) vs 10.6% (95% CI, 9.2%-12.2%; P = .03). The average duration of verbal handoffs per patient did not change. Verbal handoffs were more likely to occur in a quiet location (33.3%; 95% CI, 14.5%-52.2% vs 67.9%; 95% CI, 50.6%-85.2%; P = .03) and private location (50.0%; 95% CI, 30%-70% vs 85.7%; 95% CI, 72.8%-98.7%; P = .007) after the intervention. Implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children. Improvements in verbal and written handoff processes occurred, and resident workflow did not change adversely.

Comparative evaluation of the content and structure of communication using two handoff tools: Implications for patient safety

PurposeHandoffs vary in their structure and content, raising concerns regarding standardization. We conducted a comparative evaluation of the nature and patterns of communication on 2 functionally similar but conceptually different handoff tools: Subjective, Objective, Assessment and Plan, based on a patient problem-based format, and Handoff Intervention Tool (HAND-IT), based on a body system-based format. MethodA nonrandomized pre-post prospective intervention study supported by audio recordings and observations of 82 resident handoffs was conducted in a medical intensive care unit. Qualitative analysis was complemented with exploratory sequential pattern analysis techniques to capture the characteristics and types of communication events (CEs) and breakdowns. ResultsUse of HAND-IT led to fewer communication breakdowns (F1,80 = 45.66: P < .0001), greater number of CEs (t40 = 4.56; P < .001), with more ideal CEs than Subjective, Objective, Assessment and Plan (t40 = 9.27; P < .001). In addition, the use of HAND-IT was characterized by more request-response CE transitions. ConclusionThe HAND-IT's body system-based structure afforded physicians the ability to better organize and comprehend patient information and led to an interactive and streamlined communication, with limited external input. Our results also emphasize the importance of information organization using a medical knowledge hierarchical format for fostering effective communication.

I-PASS Handoff Curriculum: Computer Module

Abstract The I-PASS Computer Module provides a unique platform for asynchronous, individualized learning of key elements of the I-PASS curriculum. It features embedded knowledge questions which pro...

A Survey of Handoff Practices in Emergency Medicine

This study aimed to assess practices in emergency department (ED) handoffs as perceived by emergency medicine (EM) residency program directors and other senior-level faculty and to determine if there are deficits in resident handoff training. This cross-sectional survey study was guided by the Kern model for medical curriculum development. A 12-member Council of Emergency Medicine Residency Directors (CORD) Transitions in Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to the CORD listserv. There were 147 responses to the anonymous survey, which were collected using an online tool. At least 41% of the 158 American College of Graduate Medical Education EM residency programs were represented. More than half (56.6%) of responding EM physicians reported that their ED did not use a standardized handoff. There also exists a dearth of formal handoff training and handoff proficiency assessments for EM residents.

PACT project: standardized resident handoff implementation improves handoff quality

PACT project: standardized resident handoff implementation improves handoff quality

Results of an Enhanced Clinic Handoff and Resident Education on Resident Patient Ownership and Patient Safety

Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff. In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes. Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P<.01), more verbal handoffs (80% versus 38%, P<.01), more patients aware of the handoff (100% versus 74%, P=.01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P=.03), and more ownership of patients before the first visit (56% versus 26%, P=.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P<.01), and more tests were followed up appropriately (67% versus 46%, P=.02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P=.06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P=.06). Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.

Assessment and standardization of resident handoff practices: PACT project

BackgroundAccreditation Council for Graduate Medical Education duty hour guidelines have resulted in increased patient care transfers. Although structured hand-over processes are required in the guidelines, how to implement these processes is not defined. The purpose of this study is to investigate current handoff methods at our center in order to develop an effective structured handoff process. Materials and methodsThis is a prospective study conducted at two hospitals with large in-house patient censuses. Resident focus groups were used to define current practices and future directions. Based on this input, we developed a direct observation handoff analysis tool to study time spent in handoffs, content, quality, and number of interruptions. ResultsTrained medical students observed 86 handoffs. Survey response rates among junior and senior residents were 63% and 54%, respectively. Average daily patient census was 36 ± 10 patients with an average handoff time of 12 ± 9 min. There were 1.5 ± 1.8 interruptions per handoff. The majority of handoffs were unstructured. Based on information they were given in the handoff, junior residents had a 58% rate of incompletion of the assigned tasks and 54% incidence of being unable to answer a key patient status question. ConclusionsCurrent handoffs are primarily unstructured, with significant deficits. Determination of key elements of an effective handoff coupled with evaluation of existing deficiencies in our program is essential in developing an institution-specific method for effective handoffs. We propose utilization of the mnemonic PACT (Priority, Admissions, Changes, Task) to standardize handoff communication.

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

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

What Do Patients Think About Year-End Resident Continuity Clinic Handoffs?: A Qualitative Study

Although Internal Medicine year-end resident clinic handoffs affect numerous patients, little research has described patients' perspectives of the experience. To describe patients' perceptions of positive and negative experiences pertaining to the year-end clinic handoff; to rate patient satisfaction with aspects of the clinic handoff and identify whether or not patients could name their new physicians. Qualitative study design using semi-structured interviews. High-risk patients who underwent a year-end clinic handoff in July 2011. Three months post-handoff, telephone interviews were conducted with patients to elicit their perceptions of positive and negative experiences. An initial coding classification was developed and applied to transcripts. Patients were also asked to name their primary care physician (PCP) and rate their satisfaction with the handoff. In all, 103 telephone interviews were completed. Patient experiences regarding clinic handoffs were categorized into four themes: (1) doctor-patient relationships (i.e. difficulty building rapport); (2) clinic logistics (i.e. difficulty rescheduling appointments); (3) process of the care transition (i.e. patient unaware transition occurred); and (4) patient safety-related issues (i.e. missed tests). Only 59 % of patients could correctly name their new PCP. Patients who reported that they were informed of the clinic transition by letter or by telephone call from their new PCP were more likely to correctly name them (65 % vs. 32 % p = 0.007), report that their new doctor assumed care for them immediately (81 % [68/84] vs. 53 % [10/19], p = 0.009) and report satisfaction with communication between their old and new doctors (80 % [67/84] vs. 58 % [11/19], p = 0.04). Patients reported positive experiences such as learning more about their new physician through personal sharing, which helped them build rapport. Patients who reported being aware of the medical education mission of the clinic tended to be more understanding of the handoff process. Patients face unique challenges during year-end clinic handoffs and provide insights into areas of improvement for a patient-centered handoff.

Assessment of Current Handoff Practices and Development of a Standardized Resident Handoff: PACT Project

Assessment of Current Handoff Practices and Development of a Standardized Resident Handoff: PACT Project

Intern Workload and Discontinuity of Care on 30-Day Readmission

Intern Workload and Discontinuity of Care on 30-Day Readmission

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Introduction: Every time a patient changes their level of care, the health care team must handoff essential information. Failure to adequately complete this process can lead to patient harm. While current research has focused on resident handoffs the critical care team is multi-professional (MP). There is less research on the multi-professional handoff. We developed a MP committee to assess our current hand off system for patients admitted directly from the OR to the SICU. Hypothesis: The goal of this study was to determine if a MP handoff would improve staff perception of handoff quality and Pt care. Methods: In 2012 we empowered a MP team of attendings in anesthesiology and critical care, nurse anesthetist, ICU nurses and fellows, and respiratory therapist to evaluate our current handoff process on direct admits from the OR to the ICU. A new process was developed to make the handoff MP. This includes a standardized report process and written communication checklist. A 10 item handoff survey on a 4 point Likert scale was developed. Of the 10 items, four had objective measures, three evaluated process, and 2 communications, the 10th item was an overall rating. Compliance and perceptions of the handoff process before and after establishing the MP handoff was compared. Responses before and after were tested using Mann Whitney U with significance set at 0.05. Results: There were 124 pre-survey and 93 post-survey responses. The average increase was 0.31 (range 0.01-0.51). There was an overall improvement and in 3 objective (30 & 5 min notice, resident presence on arrival), 2 process (Clear role defined & tine for questions), and 2 communication (adequate phone & in-person report given) measures (p < 0.05). Increased, improvements in pt stability and having a clear transition were NS. CRNAs and RN were more likely to report improvements then MDs or RTs. All team members thought the care was improved with a MP handoff. Conclusions: A structured MP handoff improves information exchange and process of care on direct admits from the OR to ICU. The checklist improves the ability to monitor the performance of the MP team and subjectively improved patient care. A future prospective evaluation of patient outcomes is warranted.

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 ...

I-pass, a mnemonic to standardize verbal handoffs.

The first cohort of IIPE projects from 2009 are beginning to realize some early successes. We bring you this article in the spirit of sharing what works and what doesn't. The lesson about the importance of context is critical in adopting and adapting innovations to your own learning environment. —Carol Carraccio, MD, MA Section Editor New duty hours standards have increased the frequency of transitions in care or handoffs for resident physicians. Because miscommunications are a leading cause of adverse events in hospitals, optimizing the handoff process is essential for patient safety. The I-PASS Study aims to determine the effectiveness of implementing a “resident handoff bundle” to standardize inpatient transitions in care and decrease medical errors in 10 pediatric institutions.1 The resident handoff bundle includes 3 major elements: team training by using focused TeamSTEPPS communication strategies,2 implementation of a standardized template for the written or printed computerized handoff document, and introduction of several evidence-based verbal handoff processes, which are referred to by using a novel verbal mnemonic. This multisite collaborative education and research project was launched with the support of the Initiative for Innovation in Pediatric Education (IIPE) and the Pediatric Research in Inpatient Settings (PRIS) network. The title I-PASS is an acronym that not only denotes the title and purpose of our research study—IIPE-PRIS Accelerating Safe Sign-outs—but also serves as the verbal mnemonic for the standardized handoff itself. Individual elements of the I-PASS mnemonic will be defined in this article. Mnemonics are memory aids. Effective mnemonics are catchy, symbolic, parsimonious, utilitarian, and may conjure up a visual image linked to a process or subject. In this report, we emphasize the importance of structured communication strategies to enhance patient safety, review literature pertinent to the handoff process, including the use of verbal mnemonics, and describe the creation of … Address correspondence to Amy J. Starmer, MD, MPH, Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health and Science University, Mail code: CDRCP, 707 SW Gaines St, Portland, OR 97239-2998. E-mail: starmer{at}ohsu.edu

Resident Handoffs: Appreciating Them as a Critical Competency

Resident Handoffs: Appreciating Them as a Critical Competency