Communication and Handoffs
Division of General Internal Medicine and Geriatrics Hospital Medicine Rev. 2015 Goals and Objectives Define clinical handoffs Recognize the importance of effective handoffs Understand key components of an effective standardized handoff Clinical handoff A clinical handoff is the temporary transfer of care and responsibility from the primary physician to the covering physician Verbal Written IOM report 2000 To Err is Human Preventable adverse events are a major cause of death Medical errors are really expensive Patient safety should be a priority Improving handoffs is a national patient safety goal Handoffs and Patient Safety Sentinel events commonly results from communication breakdown – 65 % of the time 92% of communication errors occur during verbal communication between 1 transmitter and 1 receiver Errors commonly result from omission of content or lack of direct discussion Ideal handoff components Face to face interaction for verbal communication Considered gold standard although studies on benefit are conflicting Updated written or computerized information (use actual dates) Clarity about the patient’s current condition, including severity of illness Anticipating changes in patient condition with specific interventions Minimal interruptions Structured format (time, place) Summary of Themes from “White Papers” Need for training Ensure adequate time for handoff Reduce interruptions Keep information updated in template or technology solution Facilitate interactive questioning Focus on ill patients Delineate actions to be taken 2011 ACGME Duty Hour Restrictions Interns no longer allowed to do 24 hour call Intern shifts limited to 16 hours Unintended consequences Increase in self-reported medical errors 130-200% increase in number of handoffs Sen et al. Effects of the 2011 Duty Hour Reforms on Interns and Their Patients. JAMA Intern Med 2013. Current Status of Handoffs in Residency Programs ACGME requires residency programs to be competent in handoffs Transitions of care is one component assessed in CLER (Clinical Learning Environment Report) visit with goal of increasing emphasis on patient safety Most programs have dedicated handoff curriculum Written templates Face-face discussion Opportunities to ask questions Home Institution • AHRQ housestaff patient safety survey found handoffs and communications the lowest ranking area of safety Disagree / Neutral/ Agree Things “fall between the crack” when transferring patients from one unit to another Important patient care information is often lost during shift changes Problems often occur in the exchange of information across hospital units Shift changes are problematic for patients in this hospital MUSC Handoffs iCATCH GME-wide intern orientation Focus on quality and safety Observed verbal handoffs (OSHE) Orientation survey data Only 23 % of incoming interns had formal training on handoffs Improvements: Extract key points from a large medical record Convey pertinent info effectively Allen et al, Acad Med Oct 14 Proposed Medical Student EPA Give or receive a patient handover to transition care responsibility Functions for transmitter of information • Conduct handover communication that minimizes known threats to transitions of care (e.g., by ensuring you engage the listener, avoiding distractions). • Document—and update—an electronic handover tool. • Follow a structured handover template for verbal communication. • Provide succinct verbal communication that conveys, at a minimum, illness severity, situation awareness, action planning, and contingency planning. • Elicit feedback about the most recent handover communication when assuming primary responsibility of the patients. • Demonstrate respect for patient privacy and confidentiality. AAMC 2014 Proposed Medical Student EPA Functions for receiver of information • Provide feedback to transmitter to ensure informational needs are met. • Ask clarifying questions. • Repeat back to ensure closed-loop communication. • Ensure that the health care team (including patient/family) knows that the transition of responsibility has occurred. • Assume full responsibility for required care during one’s entire care encounter. • Demonstrate respect for patient privacy and confidentiality. AAMC 2014 I-Pass Handoff Bundle Prospective study 2014; >10,000 patients I-PASS I- Illness Severity P-Patient Summary A-Action Items S- Situation Awareness and Contingency Planning S- Synthesis by Receiver Bundle Standard format for written and oral handoffs Resident physician training and practice Faculty development and direct observation with feedback Active surveillance for medical errors – collaborative cross-checking Sustainability campaign for culture change Decreased medical errors and preventable errors without increased time Starmer et al; NEJM 2014 Key Messages Good handoffs Use standardized formats Interactive Focus on ill patients Provide anticipatory guidance May reduce sentinel events / improve patient safety References Allen S, Caton C, Cluver J, Mainous A, Clyburn B. Targeting improvements in patient safety at a large academic center: an institutional handoff curriculum for graduate medical education. Acad Med 2014; 89(10):1366. Arora V, Johnson J, et al. Communication failures in patient sign-out and suggestions for improvement: A critical incident analysis. Qual Saf Health Care 2005; 14 (6):401 Arora VM, Manjarrex E, et al. Hospitalist handoffs: A systematic review and task force recommendations. J Hosp Med 2009; 4(7):433 Greenberg CC, Regenbogen SE, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2007; 204(4):533 Joint Commission Sentinel Event Database Starmer A, Spector N, Srivastava D, et al. Changes in medical errors after implementation of a handoff program. N Eng J Med 2014; 371(19): 1803. Revision History Original Version: Cathryn Caton, MD 2013 Revised 4/9/2015: Ashley Duckett, MD
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