Improving The Clinical Improving The Clinical HandoffHandoff

Jenny Han, MD � Anna Lukowski, MD � Peter Watson, MD

Goals and ObjectivesGoals and Objectives1. “Handoff” Overview

2. Understand Key Components of an Effective Standardized Handoff (I-SWITCH)

3. Discuss the Handoff Environment and Communication Techniques

4. Evaluate Handoff Effectiveness

Definition of a Clinical Definition of a Clinical “Handoff”“Handoff”

A clinical handoff is the temporary transfer of care and responsibility from the primary (outgoing) physician to the covering (oncoming) physician

Clinical “Handoffs”Clinical “Handoffs” Multiple physicians take care of one

patient: Primary intern →on-call intern →night

float resident →back to primary intern

Verbal and written handoffs are the main ways to relay vital information about the patient and their anticipated needs

Study Goals and ObjectivesStudy Goals and Objectives This PowerPoint presentation is part of

an ongoing educational intervention in handoff training during this academic year

Our goal is to develop a handoff training process that will lead to improved educational outcomes and translate into better clinical practice

Handoffs and Patient Handoffs and Patient SafetySafety

Transfers of care have been associated with adverse clinical outcomes

Improving handoffs is an national patient safety goal

Most sentinel events are caused by communication breakdown

Handoffs and Resident Handoffs and Resident EducationEducation

Increased handoffs with reduced work hours

Many training programs do not have standardized handoff training programs

Discussion: What do you Discussion: What do you think is important in a think is important in a

handoff?handoff?

What items in the handoff do you think are important?

Key Components of an Key Components of an Effective Clinical HandoffEffective Clinical Handoff

Clarity about the patient’s current condition, including severity of illness

Anticipating changes in patient condition with specific interventions

Proposed Handoff Proposed Handoff Template:Template: I-SWITCHI-SWITCH

I: Identifiers Name/ Record Number/Location

S: Severity of illness W: Working problem list I: Intervention on anticipated problems T: Tests and consults pending C: Code Status H: History pertinent to immediate

problems

IdentifiersIdentifiers Ensure that all are clear:

Patient name Medical Record Number Location (Room, Unit) Primary team responsible for care

of patient Responsible physician while on-call

Severity Severity of illnessof illness Stratify patients by severity of illness:

Severe, Moderate, Mild

Severely ill patients: Prioritize first, they may require

closer monitoring or potentially intensive care transfer

Bedside handoff Involve senior resident

How do I determine illness How do I determine illness severity?severity?

Recent changes in vital signs Signs of end organ failure:

Abnormal mental status Decreased urine output

Evaluate for SIRS criteria Leukocytosis/leukopenia Tachypnea/hypocapnea Tachycardia Fever/hypothermia

How do I determine illness How do I determine illness severity?severity?

Other high risk groups: Sepsis patients Respiratory decompensation Severe congestive heart failure Severe hepatic failure Intestinal hemorrhage Severe electrolyte disturbances

Working Working ProblemsProblems What are the active medical

problems being addressed during the current admission?

The most recent assessment and plan from the H&P or progress note can serve as a guide

Intervention Intervention on on anticipatedanticipated problemsproblems

Most important component of handoff: to be able to anticipate potential problems and potential solutions

Challenge yourself to use an analytical approach to predict what problems may arise in your patients on the next shift

AnticipationAnticipation as Part of the as Part of the Hand-OffHand-Off

What is the worst thing that could practicably go wrong?

Recurrent problems that have occurred with this patient so far during the admission?

Potential common problems putting patient at risk?

Intervention Intervention of anticipated of anticipated problemsproblems

Avoid general/non-specific statements “nothing to do or check” (NTD or

NTC), check labs, check results of CT

General statements or ambiguous tasks (“check labs”) do not help covering resident prioritize response to an event

Intervention Intervention of anticipated of anticipated problemsproblems

Use IF… THEN statements: CT abdomen to rule out mass

lesion causing obstruction IF obstruction seen, THEN make NPO and call Surgery

Renal Failure IF K above 6.0, THEN check EKG, give kayexelate, amp D50, Insulin 10units

Tests Tests and Consultations and Consultations PendingPending

Make clear what pertinent labs/consultations need to be checked and how to act on them if anticipated abnormalities are noted: Avoid things like “Check CBC”

Instead write… Check platelet count… IF less than 15, THEN transfuse 6 units platelets

CodeCode Status Status Code status should be addressed and

documented on all patients

Code discussions with family while the patient begins to decompensate are not optimal, nor fair to the patient or family

HistoryHistory Only a concise pertinent

history is important to support the problem list

The handoff is never meant to duplicate the medical record−keep history to a minimum

Discussion: What do you Discussion: What do you think is important in a think is important in a

handoff?handoff? What about the effect of

environment?

What types of communication are important?

Handoff EnvironmentHandoff Environment Interruptions are common, but

can be barriers to a clear and accurate handoff

Take the time to go to a quiet place and be uninterrupted (office, call room, lounge)

Handoff is a Two-Way Handoff is a Two-Way TransferTransfer

The person receiving the handoff is expected to ask pertinent questions to clarify any unanswered questions

Clear accurate information needs to be handed off as well as received back the next morning (“closing the loop”)

Discussion: Current Handoff Discussion: Current Handoff TemplateTemplate

What is the effectiveness of our current electronic template?

Knowing what you now know about the key elements of a handoff…what would you do differently about the use of this template?

Current Handoff Current Handoff TemplateTemplate

I-SWITCHI-SWITCH

Identifiers

History

Tests/Consults

Working Problem

List

Intervention On AnticipatedProblems

No Clear Place for Severity?

Code Status

Handoff Example #1Handoff Example #1

Discussion: Handoff Discussion: Handoff Evaluation #1Evaluation #1

How effective was this handoff (written/verbal)? Why?

What elements were missing from this handoff?

Other observations?

What would you suggest be done differently to create a more effective handoff in this case?

Handoff Example #2Handoff Example #2

Take Home PointsTake Home Points Remember the Key Components

of an Effective Standardized Handoff (I-SWITCH)

Anticipation (IF… THEN) as Part of the Handoff is Crucial

Effective Two-Way Communication that is Clear and Accurate (Verbal and Written)