1. Transitions of Care in the Training Environment: ACGME Standards Bradley F. Marple, MD Professor and Vice-Chair Otolaryngology Associate Dean Graduate Medical Ed Designated Institutional Official University of Texas Southwestern Medical Center

2. ACGME Highlights Its Standards on Resident Duty Hours - May 2001 Work hour limits introduced in 2003 with intent to: Decrease fatigue resident safety safety and effectiveness of patient care “The ACGME believes that it is ill advised to "carve out" a section of this environment - resident duty hours - in a way that does not consider the other elements essential to the quality of the educational process. There is a significant potential for an unanticipated impact that may be detrimental to high quality education and safe and effective patient care. “ http://www.acgme.org/acwebsite/resinfo/ri_osharesp.asp

3. Objective ACGME implemented duty hours to mitigate fatigue-related risk Goal was to determine impact upon work hours, sleep, and safety Methods Prospective cohort study during implementation of duty hours 3 pediatric programs Reported MVCs, occupational exposures, med errors, educational experience, depression, and burn-out 220 residents reported 6007 daily reports of work hours and sleep 16,158 medication orders

6. Conclusions No change in Work hours Sleep Depression Resident injuries Educational ratings Improvements Resident burn-out Worsened Medication errors

7. CPR VI.B Transitions of Care VI.B.1 – Programs must design clinical assignments to minimize the number of transitions in patient care

8. Transitions of care Continuity of care constitutes an important aspect of quality Continuity of care is challenged Teaching environment Multiple specialties Modalities of care Transitions Providers Provider teams Units Impact of ACGME duty hours on transitions Before 2003 - single transfer of care After 2003 – 2 or more physicians 2-3 times per day. Riebschleger M, Philibert I. 2011ACGME Duty Hour Standards

9. Transitions of care Each transition of care creates and opportunity for information to be lost or distorted Handoffs are a major contributing factor in trainee- related malpractice cases Malpractice more frequent when trainees are involved in care as compared to attending-only cases (19% vs 13%, p-0.02) Scoglietti VC, et al. Am Surg. 2010;76(7):682-686. Arora V, et al. J Gen Intern Med. 2007;22(12):1751-1755 Singh H et al. Arch Intern Med. 2007;167(19):2030-2036

10. CPR VI.B Transitions of Care VI.B.2 – Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety

11. More unintended consequences Impact of increased limits on duty hours More hand-overs Increased “Cross-cover” (defined as outside the primary care team) Increased likelihood for unplanned changes in care Asynchronous handoffs Fewer person to person interactions Creates need for Structure Process Education

12. Impact upon Patient Safety Patients with potentially preventable AEs were more likely to be covered by a physician from another team (cross-cover) at the time of the event (OR 3.5;P=0.01) Peterson LA et al. “Academia and Clinic: Does Housestaff Discontinuity of Care Increase the Risk for Preventable Adverse Events?” Ann Int Med 1994;121:866-872. A member of the primary team was in the hospital for only 47% of the hospitalization Horwitz LI et al. “Transfers of patient care between house staff on internal medicine wards: a national survey” Arch Intern Med 2006;166(11);1173-7.

13. Impact of Transition on Patient Safety MGH Residents 59% reported “problematic handoffs” caused harm to one or more patients on most recent clinical rotation 12% reported cases of “major” harm 31% reported quality of handoffs as “fair or poor” Handoffs were rarely quiet Handoffs were frequently interrupted Led to “handoff-safety education program” for housestaff intended to improve safety and effectiveness of handoffs Kitch BT et al. Jt Comm J Qual Patient Saf. 2008;34(10):563-570.

14. 2006 Joint Commission TJC data revealed that communication is identified in 65-70% of root cause analyses TJC formalized a “standardized approach to hand-off communications” in 2006, which included: Interactive communications Up-to-date and accurate information Limited interruptions A process for verification An opportunity to review relevant historical data Adamski P. Nurs Manage. 2007;38:10-12. AHRQ. “Patient Safety Primer: Handoffs and Signoffs.” http://psnet.ahrq.gov/primer.asp?primerID=9 Arora V, et al. Jt Comm J Qual Patent Saf. 2006;31(11):646-655

15. CPR VI.B Transitions of Care VI.B.3 – Programs must ensure that residents are competent in communicating with team members in the hand-over process. ACGME 2011 Common Program Requirements. www.acgme.org

16. Impact of Communication on Patient Safety Audiotaped handoffs for 8 IM housestaff teams and compared written handoff forms Median duration was 35 seconds per patient Only 50% of verbal and 38% of written handoffs included comments on current clinical condition 59% included no questions from recipient 22% contained omissions of mischaracterizations on data Horwitz LI et al. Qual Saf Health Care. 2009;18(4):248-255.

17. Impact of Communication on Patient Safety Chang V et al. Pediatrics 2010;125(3):491-496 60% of handoffs did not include the “most important piece of information” despite post-call intern thinking it had 60% disagreement in on-call vs. post-call decision rationale. McSweeny ME et al. Clin Pediatr. 2011;50:57-63 Only 19% reported that written sign-outs reflected actual current clinical information and management plans.

18. Conclusions Changes in the work environment have increased the need to focus upon various aspects of transition of care ACGME 2011 CPR focus upon three major areas Decreasing numbers of handoffs Creation of standardized handoffs Accurate communication Potential solutions Redundancy of systems Education Evaluation of the transitions process Focused supevision Feedback Skills-based examinations