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, 2007 Rogers, SO et al, Surgery, 2006 Borowitz SM et al, Qual Saf Health Care, 2008 Solet 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 care b) 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 shift Resources: Resident, spreadsheet Outgoing Resident’s Final Update Resources: Outgoing resident, shared file New residents Sign-In Handoff: Face-to-face 1.Vascular 2.Trauma 3.Transplant 4.Cardio Thoracic Incoming receives critical updates Resources: Incoming/ outgoing residents, spreadsheets Information exchange about key patients Resources: Incoming/Outg oing residents Incoming resident begins shift Baseline Observation

Hand Off Evaluation Form Efficiency: 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 survey Please indicate your level of agreement with the following statements. (1= Strongly Disagree and 7=Strongly Agree) QuestionMean 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: During the handoff process, the most clinically relevant patient information is displayed on the spreadsheet. Mean: 5.46, St Dev: 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: 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) QuestionMean 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%)

Standardized Hand off Instrument

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

Accuracy p = NS p=0.006

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

Completeness P=0.005

Responsibility *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

* 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, 2007 Patterson ES et al, Int J Qual Health Care, 2004 Stevens, 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 2004 Van Eaton, EG et al, JACS, 2005 Park J, et al, JSE, 2007 Arora 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 info History Insurance Billing Staff Schedules Medication Test results Resident continuously updated via (handheld) device

Future Directions Focused training on handoffs –Importance –Process Sample Medical records –Better define accuracy and completeness