Denise Campbell-Scherer, M.D. Ph.D Electronic Web Sign-out As an Interactive Tool to Improve Patient Safety Hobart Lee, M.D. Joel Heidelbaugh, M.D. Denise Campbell-Scherer, M.D. Ph.D

Signout (or Handoffs) Background Resident survey Computerized signout Future steps

Introduction Joint Commission on Accreditation of Healthcare Organizations (JCAHO) National Patient Safety Goals1 “[Implementation] of a standardized approach to ‘hand off’ communications, including an opportunity to ask and respond to questions.” New Institute of Medicine (IOM) work hour restrictions2 New IOM guidelines – Max 30 hour shift with 5 hour rest period or maximum 16 hours shift 1. National Patient Safety Goals 2006. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/ 2. IOM resident duty hour brief. http://www.iom.edu/CMS/3809/48553/60449.aspx

80 hour work week Hospital complications3 Patient safety or mortality4, 5 Preventable errors6 Resident’s perspectives: Improved signout reduces adverse events7 Poor signout contributes greatly to mistakes8 Hospital complications – increased hospital complications (hospital-acquired infection, adverse drug reaction, thrombotic events, respiratory failure, renal insufficiency, electrolyte abnormality) and delayed test ordering > 24 hours No change in patient safety or mortality (CHF, MI, PNA) 300,000 patients over 3 years in NY Non-primary team 2x as likely to commit preventable medical error Improved communication, procedural supervision, then improved signout MGH -- Poor signout causes more mistakes than working too many hours, carrying/admitting too many patients, inadequate supervision, or cross-covering too many patients 3. Laine C et al. The Impact of a Regulation Restricting Medical House Staff Working Hours on the Quality of Patient Care. JAMA 1993; 269(3): 374-378 4. Fletcher KE et al. Systematic Review: Effects of Resident Work Hours on Patient Safety. Ann Intern Med 2004; 141(11):851-7 5. Howard D. Do Regulations Limiting Resident’s Work Hours Affect Patient Mortality? J Gen Intern Med 2004; 19:1-7 6. Peterson LA. Does Housestaff Discontinuity of Care Increase the Risk for Preventable Adverse Events? Ann Intern Med 1994; 121(11):866-72 7. Sorkin, R et al. Attitudes About Patient Safety: A Survey of Physicians-In-Training. Amer J Medical Quality 2005; 20:70-7 8. Jagsi R et al. Residents Report on Adverse Events and Their Causes. Arch Intern Med 2005; 165:2607-13

Problems with Signout 92% medical schools have no formal education on signout9 IM residency programs:10 55% did not have both written & verbal signout 60% provided no lectures nor workshops on signout skills 57% information never transferred & 35% information inaccurately received11 A survey of emergency medicine residency program directors showed that 72% agreed that a standardized signout would improve communication and reduce medical error, yet 90% had no uniform written policy regarding signout and approximately 75% did not have any formal didactic training 9. Solet DJ. Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs. Acad Med 2005; 80(12):1094-9 10. Horwitz LI et al. Transfers of Patient Care Between House Staff on Internal Medicine Wards. Arch Intern Med 2006; 166:1173-7 11. Greenberg CC et al. Patterns of Communication Breakdowns Resulting In Injury to Surgical Patients. J Am Coll Surg 2007; 204: 533-40

How Structured Signout Helps 35% reduction in miscommunication12 Improved completeness of data and better care was delivered13 Non-primary team adverse error risk no longer statistically significant after computerized signout intervention14 Review of 444 surgical malpractice cases 12. Greenberg CC et al. Patterns of Communication Breakdowns Resulting In Injury to Surgical Patients. J Am Coll Surg 2007; 204: 533-40 13. Lee, LH et al. Utility of a Standardized Sign-Out Card for New Medical Interns. J Gen Intern Med 1996; 11:753-5 14. Petersen LA et al. Using a Computerized Sign-Out Program to Improve Continuity of Inpatient Care and Prevent Adverse Events. J Qual Improvement 1998; 24(2):77-87

U of M Family Medicine Resident Survey Have you received formal training or education (i.e. lectures, seminars) about how to sign-out patients during shift changes? Answer Options Response Percent Response Count No 87.0% 20 Yes -- as a medical student 0.0% Yes -- as a resident 13.0% 3 Yes -- as both a medical student and a resident   answered question 23 skipped question

U of M Family Medicine Resident Survey In the last 6 months, how often have you experienced each of the following while on Chelsea Family Medicine Inpatient Service? (Please rate all 8 items. If not sure, please give your best estimate.) Answer Options Every day or almost every day Once a week Once every 2 weeks Once a month Less than once a month Never Response Count Avoidable Admission 2 8 1 21 Medication Reaction 4 6 Prolonged Length of Stay 10 Mortality 5 Outpatient Complication 3 Medication Error 9 Adverse Outcome of Care Procedural Complication   answered question skipped question

U of M Family Medicine Resident Survey How often do you receive the following information during signout? Answer Options Very frequently Frequently Somewhat frequently infrequently Very infrequently Never Rating Average Response Count ID: patient's name, CPI #, room #, primary care doctor 8 2 7 3 1 2.428571 21 Code Status 6 9 4 2.142857 Chief Complaint 12 5 1.714286 Brief HPI 1.619048 Hospital Course (including relevant physical exam, labs, imaging) 2.095238 Active Problem List 11 Current Medications 3.428571 Allergies 3.476191 Contingency Plans / Anticipated Problems 2.761905   answered question skipped question

U of M Family Medicine Resident Survey Compared to a traditional paper-based signout: Answer Options Strongly agree Agree Disagree Strongly disagree Neither agree nor disagree Rating Average Response Count Using an electronic signout will make signout more efficient 9 8 1 4 2.26087 23 Electronic signout will result in the exchange of higher quality information 6 13 2 2.086957 Electronic signout will improve resident-to-resident communication 2.130435 Electronic signout will improve patient continuity of care 11 2.043478 Electronic signout will improve Night Seniors' adherance to patient care plans 1.956522   answered question skipped question

Web Signout Simulated Signout created through Google Documents Design tested with Focus group Transitioned to FileMaker and secure database

Simulated Signout

Simulated Signout

Simulated Signout

Focus Group Data Four residents (3 PGY-1 and 1 PGY-2) General Impressions Content Usability Potential Difficulties General Impressions: Easy to use, functional, templated questions better than free text, beneficial to have access at home Content: Appropriate amount of information Usability: Easy to enter new patient information Potential Difficulties: ? Increased time to prepare signout, ? transfer of excessive information

Limitations & Future Steps Web publishing vs. HIPAA compliance Pilot test at community hospital Repeat survey for post-intervention data

Thank You Dr. Joel Heidelbaugh Dr. Denise Campbell-Scherer Department of Family Medicine, University of Michigan

Questions?