Simple Standardized Patient Hand-Off System that Increases Accuracy

and Completeness

Jeffrey D. Wayne, MD, Rajesh Tyagi, PhD, Gilles Reinhardt, PhD, Deborah Rooney, MS,

Gregory Makoul, PhD, Sunil Chopra, PhD, Debra A. DaRosa, PhD

The Challenge

• 80 hour work week

• Transfers of care are increasingly frequent

• Few residency programs have care systems in place to accommodate this change

Horowitz. LI et al., Arch Intern Med, 2006

Handoffs: Objectives• “to provide accurate information about a

patient’s care, treatment and services, current condition and any recent or anticipated changes”

• “the information communicated during a handoff must be accurate in order to meet patient safety goals”

The Joint Commission, 2008 National Patient Safety Goals

The New Surgical Residency

• Apprenticeships

• Small Teams

• Night Float

• Short call

DaRosa, DA and Bell RH, Surgery, 2004

Patient Safety

• Poor communication between physicians

• Handoff issues– Little formal instruction– Need for standardization

Greenberg CC et al, JACS, 2007Rogers, SO et al, Surgery, 2006Borowitz SM et al, Qual Saf Health Care, 2008Solet DJ et al, Acad Med, 2005

Purpose/ Research Questions

• What were baseline perceptions of residents regarding quality of handoffs?

• To what extent were nurses clear as to the exact time patient care was transferred between day and night residents?

• What is the effect of a standardized hand off instrument on perceptions of completeness, accuracy, efficiency, and appropriateness of task delegation?

• Does resident experience and type of rotation (ICU vs. non-ICU) on handoff completeness, accuracy, efficiency, and appropriateness of task delegation?

Methods: Baseline Description

• Direct observation– Efficiency and operations team

• Method• Quality and form of written documentation• 12 Services

• Focus group– Residents, nurses, administrators, surgeons

• Electronic Survey• Phone Survey (Baseline/ Post-intervention)

Handoff without interaction:• Endocrine• Breast• General Surgery 1• General Surgery 2

Handoff with face-to-face encounter:• Vascular• Trauma• Transplant• Cardiothoracic

Handoff with phone or face-to-face encounter:Depends on

a) complexity of patient careb) resident preference

• Surgical Oncology• Colorectal 1• Colorectal 2• Gastrointestinal surgery

ICU handoffs are always face-to-face, takes full one hour and residents discuss each patient

Baseline Observation

Outgoing resident prints sheets

Resources: Resident,

printer

Sheets waiting at the table

Attending dictates,

resident takes hand notes Resources: Attending, Resident

Take Notes & Update

spreadsheets during shiftResources: Resident,

spreadsheet

Outgoing Resident’s Final

UpdateResources: Outgoing resident, shared file

New residents Sign-In

Handoff: Face-to-face1. Vascular2. Trauma3. Transplant4. Cardio Thoracic

Incoming receives critical

updatesResources: Incoming/ outgoing residents,

spreadsheets

Information exchange about key patients

Resources: Incoming/Outgoing residents

Incoming resident begins shift

Baseline Observation

Hand Off Evaluation FormEfficiency: Approximately how much of your time was spent updating the “hand off” sheet? ____ Minutes

Accuracy: To what extent were there any inaccuracies of information on the “hand off” sheet that you received or gave out?

□ None □ Few (1-3 inaccuracies) □ Some (4-6 inaccuracies) □ Many (7+ inaccuracies)

Completeness:To what extent was there any incomplete information on the “hand off” sheet that you received or gave out?

□ None □ Few (1-3 occurrences) □ Some (4-6 occurrences) □ Many (7+ occurrences)

Responsibility:In the past 24 hours, on a scale from 1 to 5 with 1 being unclear and 5 being very clear, how clear was the exact time the resident handing off to you officially transferred patient responsibility to you?

1 Unclear 2 3 Somewhat clear 4 5 Very Clear

Approximately how may tasks were you expected to do that should have been taken care of in a previous shift?

□ None □ Few (1-3 tasks) □ Some (4-6 tasks) □ Many 7+ tasks

“Hand-off” Dissemination:

□ Sheet dropped off □ Discussed over phone □ Face-to-face discussion

Name of Rotation: Day of Week/Date: Time:

I am on:

□ Night Float □ Day Team

Notes/Comments:

Results : On line surveyPlease indicate your level of agreement with the following statements. (1= Strongly Disagree and 7=Strongly Agree)

Question Mean score and Standard Deviation (St Dev)

It is important that the column headings on the hand off excel spreadsheets are uniform across different services.

Mean: 4.00 ST dev: 1.041

During the handoff process, the most clinically relevant patient information is displayed on the spreadsheet.

Mean: 5.46, St Dev: 0.957

During the handoff process, the on call attending is accurately identified for each clinical service.

Mean: 3.75 , ST Dev: 2.04

The current hand off spreadsheets provide accurate patient information. Mean: 4.7, St Dev: 1.02

Hand off spreadsheets are updated accurately on at least a daily basis. Mean: 5.29, St Dev: 0.93

The spreadsheet makes it easy to identify tasks to be performed over the shift. Mean: 5.29, St Dev: 1.136

During the handoff process, the exact time of the transfer of responsibility from outgoing to incoming resident is clear.

Mean: 4.62, St Dev: 1.65

During the handoff process, the exact time of the transfer of responsibility from outgoing to incoming resident is clear to other patient care providers (i.e. PA’s, nurses, etc).

Mean: 3.33, St Dev: 1.46

Current spreadsheets identify critical patient care issues that have occurred over the last 24 hour period.

Mean: 4.33, St Dev: 1.28

The resident library provides a convenient location and environment for an efficient handoff process.

Mean: 5.83, St Dev: 1.14

I am satisfied with the quality of the existing handoff process. Mean: 5.0, St Dev: 0.91

Results : On line survey

It is important to know which elements of the Hand Off process are important from your perspective. Please rate each of the below elements.

(1= Strongly Disagree and 7=Strongly Agree)

Question Mean score and Standard Deviation (St Dev)

The consistency of information provided in hand off spreadsheets across different services.

Mean: 4.19 St Dev: 1.18

The relevancy of pertinent patient information displayed on the spreadsheet. Mean 6.04, St Dev: 0.73

The exact time of the transfer when one resident assumes patient responsibilities from the departing resident .

Mean: 4.29, St Dev: 1.13

Accurate information on the spreadsheet. Mean: 6.5, ST Dev: 0.57

Up-to-date information on the spreadsheet. Mean: 6.5, St Dev: 0.64

Identifying tasks to be performed over the shift using the spreadsheet. Mean: 6.45, St Dev: 0.7

A clear transfer of responsibility from outgoing to incoming resident, so both residents know the exact time when the incoming resident assumes primary responsibility for the patients being “handed off.”

Mean: 5.04, St Dev: 1.24

A clear transfer of responsibility from outgoing to incoming resident so that other health care providers (nurses, PA’s, attendings, etc) know the exact time when the incoming resident assumes primary responsibility for the patients being “handed off.”

Mean: 5.12, St Dev: 1.09

Accurately pinpointing critical patient care issues or changes on the hand off spreadsheet that have occurred over the last 24 hour period.

Mean: 6.12, St Dev: 1.20

Estimate the number of patients in the past 3 months for which any of the above issues with the handoff process caused you concern with regards to patient care.

0 (12.5%), 1-3 (50%), 4-6 (29.17%), and 7 or more (8.33%)

On duty Attending Fellow/Resident

Wayne-Jeffrey(53471)

Bilimoria-Karl(58609)

8/7/2005 23:04 8/7/2005 23:17

Room Attending Name/MR # AgeAdmit/OR Date Post-Op Day

Admit/Diagnosis

PMHx/Code Status Allergies Meds

DVT/GI PROPH IVF Diets

Drain/Tubes/Lines

Vital/Labs/Test/Cultures Sign-out To Do

XY 31-Jul-05 967YZ 25-Jul-05 972ZA 01-Aug-05 966AB 05-Aug-05 962BCCD

Standardized Hand off Instrument

Accuracy

0

0.5

1

1.5

2

2.5

3

Baseline

Post-intervention

*p = 0.003

To what extent were there any inaccuracies of information on the “hand off” sheet that you received or gave out?

Accuracy

0

0.5

1

1.5

2

2.5

3

ICU non-ICU

BaselinePost-intervention

p=NS p=0.006

Completeness

0

0.5

1

1.5

2

2.5

3

3.5

Baseline

Post-intervention

*p= 0.015

To what extent was there any incomplete information on the “hand off” sheet that you received or gave out?

Completeness

0

0.5

1

1.5

2

2.5

3

3.5

4

ICU Non-ICU

BaselinePost-intervention

P=0.005

Responsibility

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Night Float Day Shift

Baseline

Post-intervention

*p =0.005

*p = 0.07

In the past 24 hours, on a scale from 1 to 5 with 1 being unclear and 5 being very clear, how clear was the exact time the resident handing off to you officially transferred patient responsibility to you?

Responsibility

4.2

4.3

4.4

4.5

4.6

4.7

4.8

4.9

5

ICU Non-ICU

BaselinePost-intervention

Responsibility

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

# of tasks

Baseline

Post-intervention

* p<0.05

Approximately how may tasks were you expected to do that should have been taken care of in a previous shift?

Regression analysis

• Resident experience (in months) is not a significant factor in the perceived improvements

• ICU rotations have some impact on tow of the outcome measures:– Completeness of information– Clarity if time of responsibility transfer

Other High Risk Settings

• NASA

• Airline Industry

• Nuclear Power plants– Handoff skills are practiced repetitively to

optimize precision and anticipate errors– Reduce complexity– Reveal hidden events and activities– Focus attention

Patterson ES, Ann Surg, 2007Patterson ES et al, Int J Qual Health Care, 2004Stevens, DP, Qual Saf Health Care, 2008

Other Strategies

• Computerized Resident Sign-out System• PDA’s• Competency-based approach

– Required verbal communication– Professionalism

• “Shared Responsibility”

Van Eaton, EG et al, Surgery 2004Van Eaton, EG et al, JACS, 2005Park J, et al, JSE, 2007Arora VM et al, Qual Saf Health Care, 2008

Limitations of Study

• Single Institution

• Outcome measures based on perception data– Review of medical records

Ideal (?) handoff process

Central

Patient infoHistory

InsuranceBilling Staff

Schedules

Medication

Testresults

Resident continuously updated via

(handheld) device

Future Directions

• Focused training on handoffs– Importance– Process

• Sample Medical records– Better define accuracy and completeness