Hand-Off Residents’ Perspective Celia M. Divino, MD Department of Surgery The Mount Sinai Medical School New York October 14, 2008

Hand off not Drop off

1.Hand-off as a requirement for NPSG 2.Contributing Factors to Hand-off failures 3.Challenges for residents and training programs 4.Standardized Hand-off Protocols

Root Causes of Sentinel Events All Categories The Mount Sinai Hospital

Communication (lack of) is the leading cause of sentinel events: The Mount Sinai Hospital

National Patient Safety Goal #2: Improve Effectiveness of Communication Among Caregivers Requirement 2E Implement a standardize approach to hand-off communications, including an opportunity to ask and respond to questions.

Definitions Hand-Off: the transfer of responsibility and/or information about a patient from one caregiver to another. Caregiver: any clinician, professional, or credentialed staff who provides direct patient care, treatment or service: –Nurse: RN, APN and LPN –Provider: Attending, fellow, house staff, PA –Therapist: OT/PT, respiratory therapist –Technician: radiologist –Consultant

Situations for Hand-Off Nurse –Change of shift –Coverage during (lunch) break –Change in patient status: serious or deteriorating –Nurse to Provider - MD, APN, PA Provider –Provider to nurse –Temporary or complete transfer responsibility of providers ED to floor / Anesthesiologist to PACU Medicine service to Neurology service –Primary provider to Radiologist / Specialist –On-call / weekend / vacation coverage

More Situations for Hand-Off Transport (with attention to isolation status) –Ambulance to ED –ED to any service unit (radiology) or inpatient unit –Dialysis, cardiac cath lab –Pre-op to OR to post-op to unit Reporting Critical Results (NPSG 2A) –Laboratory / Radiology / Diagnostic results Reporting special patient condition/situation –Diabetic, Insulin delayed until after test is completed –Hold procedure until (lab test) result received Transfer –to another hospital, nursing home, home health

Good Patient Care

Communication Related Incidents Decreased surgeon familiarity with patients Distorted or inhibited communication Blurred boundaries of responsibility Diverted surgeon attention * Williams et al, Ann Surg, 2007.

80-Hour Work Week?

Consequences 15 hand-offs /patient in a 5 day hospitalization Delayed test ordering Increased adverse events Medication errors Longer length of stay

Team Based Approach to Patient Care Non-Physician Extenders Shift Work Resident Perception of responsibility

Challenges Work Flow Patterns Increased Multitasking Shift Changes Multispecialty Care

Ownership of Patients Definition of Roles Empowerment Standardized Hand-off Protocol

Hand off Protocol R edundancy R ead Back R espond to questions R educe communication links R estrict interruptions

The Joint Commission’s Elements for Effective Communication 1.Interactive with opportunity for questioning between giver and receiver. 2. Up to date information regarding patient’s condition including recent or anticipated changes. 3. Verify: Read back or read-back techniques. 4. Receiver is able to review relevant patient historical data. 5. Minimal interruptions.

Tools for Hand Off UW Cores U of Washington web-based computerized rounding and signout system U of Chicago Microsoft Word document Johns Hopkins Hospital 10-Point Guideline Brigham & Women’s Hospital Computerized sign-out The Mount Sinai Hospital Verbal and written SBAR

S B A R

At Mount Sinai we use SBAR as the standard format for Hand-Off SBAR is an acronym –S: Situation –B: Background –A: Assessment “your professional opinion” –R: Recommendation SBAR provides the framework for the communication. The content is patient specific. Empowerment tool.

S B A R Situation: (introduction to situation) –I am ____ (name) from____ (unit / area) –The patient is_____ (name / DOB) –I am concerned because _____ Background: (patient’s background) –The patient’s VS are____ –Mental status is____ –Pt received xyz medication and is not responding Assessment: (caregiver’s assessment) –I think the problem is____ –I am not sure but the patient is deteriorating Recommendation: (Caregiver’s recommendation) –I recommend you see the patient right away –I request you order x med / test

Apply SBAR Nurse: Dr. Allen. This is Ms. Jones from 11 W. I’m calling about Sam Smith, your 45 yo with hx of pancreatic cancer. (S) He was stable but suddenly has SOB - HR 120; R 28. (B) I think he might have thrown a pulmonary embolus. (A) I request you order blood gases and come see him. (R) Dr. Allen to his colleague. Hey, I got to go. This sounds serious. And to Ms. Jones: Sorry about that. Seems like a good call. Yes, get O 2 Sat, if <90 start a facemask with and FL0 2 of 5 L and draw the blood gases. I’ll come right up. Nurse: Thanks. I heard you say…. Yes, I will start O 2 now. What’s next….? Elements / Criteria: Current Ask/Respond Clarify/Verify Anticipate Change Succinct

Residents: Know what to really expect! What does SBAR mean? –S__ B__ A__ R__ (similar to admitting note with ….) –OK, it really is the framework for how I communicate Ok, what does it really mean? –That a nurse can say she/he thinks VS indicate possible CVS and that I need to order … and get to the floor immediately. –That if I don’t respond, the nurse can/will/should kick it up to the PGY 2, or Fellow and/or Attending. I better respond but I can also ask for clarification. –That surgery can be held if the critical test result is outside limits and puts patient at risk. And if I get the patient I better make sure I have what I need from the previous provider. –That it’s not just a good idea to communicate, it’s a requirement. –That it’s not as easy as I thought – but that with practice I’m won’t be so nervous. –That I don’t need to write more just more effectively so the next guy knows what she’s doing.

TOOLS TO HELP YOU MOUNT SINAI developed a generic notepad print shop ED & Amb care customized their own. ▲ TJC Required elements

Sign-Out

National Patient Safety Goal SBAR to Improve Effective Communication for Hand-Off S Situation – Describe I am concerned because… B Background – Current status..… Pt VS / mental status is… A Assessment – Opinion I think the problem is...… R Recommend / Request I recommend you………. √ Succinct √ Ask-Respond √ Clarify Verify√ Anticipate change √ Minimal interruption NPSG / SBAR card Attach to ID badge NPSGs on reverse side And now 16 SBAR

p4: SBAR does not substitute for other professional responsibilities and policies. Mount Sinai Policy A2-404

Common Questions Is Hand-off and SBAR only for nursesNO –Hand-off/SBAR applies to all caregivers Do I need to keep the note pad: NO –But make sure there is a confidentiality statement on the top Do I need to document I used SBAR: NO –But it does not replace writing chart notes Do I need to give the pts life history: NO –But you need to communicate information that is relevant, pertinent. Be succinct and with minimal interruption.