Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out

The effect of information access cost and overconfidence bias on junior doctors’ pre-handover performance

This paper examined the effect of information access cost and overconfidence bias on doctors’ information retrieval strategies and performances during pre-handover. Sixteen medical residents participated in a simulated experiment, where they studied four patient cases and later on completed recall and recognition questions. The results showed that an increase in information access cost led to less information access attempts and poorer pre-handover performance. Further, there was an interaction between information access cost and overconfidence on pre-handover performance. When information access cost was high, overconfidence contributed to poor pre-handover performance.

Acute general surgery in Canada: a survey of current handover practices

BACKGROUND

Today's acute care surgery (ACS) service model requires multiple handovers to incoming attending surgeons and residents. Our objectives were to investigate current handover practices in Canadian hospitals that have an ACS service and assess the quality of handover practices in place.

METHODS

We administered an electronic survey among ACS residents in 6 Canadian general surgery programs.

RESULTS

Resident handover of patient care occurs frequently and often not under ideal circumstances. Most residents spend less than 5 minutes preparing handovers. Clinical uncertainty owing to inadequate handover is most likely to occur during overnight and weekend coverage. Almost one-third of surveyed residents rate the overall quality of the handovers they received as poor.

CONCLUSION

Handover skills must be taught in a systematic fashion. Improved resident communication will likely decrease loss of patient information and therefore improve ACS patient safety.

Using peers to assess handoffs: a pilot study

BACKGROUND

Handoffs among post-graduate year 1 (PGY1) trainees occur with high frequency. Peer assessment of handoff competence would add a new perspective on how well the handoff information helped them to provide optimal patient care.

OBJECTIVE

The goals of this study were to test the feasibility of the approach of an instrument for peer assessment of handoffs by meeting criteria of being able to use technology to capture evaluations in real time, exhibiting strong psychometric properties, and having high PGY1 satisfaction scores.

DESIGN

An iPad® application was built for a seven-item handoff instrument. Over a two-month period, post-call PGY1s completed assessments of three co-PGY1s from whom they received handoffs the prior evening.

PARTICIPANTS

Internal Medicine PGY1s at the University of Pennsylvania.

MAIN MEASURES

ANOVA was used to explore interperson score differences (validity). Generalizability analyses provided estimates of score precision (reproducibility). PGY1s completed satisfaction surveys about the process.

KEY RESULTS

Sixty-two PGY1s (100 %) participated in the study. 59 % of the targeted evaluations were completed. The major limitations were network connectivity and inability to find the post-call trainee. PGY1 scores on the single item of "overall competency" ranged from 4 to 9 with a mean of 7.31 (SD 1.09). Generalizability coefficients approached 0.60 for 10 evaluations per PGY1 for a single rotation and 12 evaluations per PGY1 across multiple rotations. The majority of PGY1s believed that they could adequately assess handoff competence and that the peer assessment process was valuable (70 and 77 %, respectively).

CONCLUSION

Psychometric properties of an instrument for peer assessment of handoffs are encouraging. Obtaining 10 or 12 evaluations per PGY1 allowed for reliable assessment of handoff skills. Peer evaluations of handoffs using mobile technology were feasible, and were well received by PGY1s.

Review of computerized physician handoff tools for improving the quality of patient care

BACKGROUND

Computerized physician handoff tools (CHTs) are designed to allow distributed access and synchronous archiving of patient information via Internet protocols. However, their impact on the quality of physician handoff, patient care, and physician work efficiency have not been extensively analyzed.

METHODS

We searched MEDLINE, PUBMED, EMBASE, CINAHL, the Cochrane database for systematic reviews, and the Cochrane central register for clinical trials, from January 1960 to December 2011. We selected all articles that reported randomized controlled trials, controlled clinical trials, controlled before-after studies, and quasi-experimental studies of the use of CHTs for physician handoff for hospitalized patients. Relevant studies were evaluated independently for their eligibility for inclusion by 2 individuals in a 2-stage process.

RESULTS

The literature search identified 1026 citations of which 6 satisfied the inclusion criteria. One study was a randomized controlled trial, whereas 5 were controlled before-after studies. Two studies showed that using CHTs reduced adverse events and missing patients. Three studies demonstrated improved overall quality of handoff after CHT implementation. One study suggested that CHTs could potentially enhance work efficiency and continuity of care during physician handoff. Conflicting impacts on consistency of handoff were found in 2 studies.

CONCLUSIONS

The evidence that CHTs improve physician handoff and quality of hospitalized patient care is limited. CHT may improve the efficiency of physician work, reduce adverse events, and increase the completeness of physician handoffs. However, further evaluation using rigorous study designs is needed.

Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program

BACKGROUND

Poor quality handoffs have been identified as a major patient safety issue. In residency programs, problematic handoffs may be an unintended consequence of duty-hour restrictions, and key data are frequently omitted from written handoffs because of the lack of standardization of content.

OBJECTIVE

Determine whether an intervention that facilitates face-to-face communication supported by an electronic template improves the quality and safety of handoffs.

DESIGN

Before-after trial.

PARTICIPANTS

Thirty-nine interns providing nighttime coverage over 132 intern shifts, representing ∼9,200 handoffs.

INTERVENTIONS

Two interventions were implemented serially-an alteration of the shift model to facilitate face-to-face verbal communication between the primary and nighttime covering physicians and an electronic template for the day-to-night handoff.

MEASUREMENTS

Overall satisfaction and handoff quality were measured using a survey tool administered at the end of each intern shift. Written handoff quality, specifically the documentation of key components, was also assessed before and after the template intervention by study investigators. Interns used the survey tool to report patient safety events related to poor quality handoffs, which were validated by study investigators.

RESULTS

In adjusted analyses comparing intern cohorts with similar levels of training, overall satisfaction with the new handoff processes improved significantly (p < 0.001) post intervention. Verbal handoff quality (4/10 measures) and written handoff quality (5/6 measures) also improved significantly. Study investigators also found significant improvement in documentation of key components in the written handoff. Interns reported significantly fewer reported data omissions (p = 0.001) and a non-significant reduction in near misses (p = 0.056), but no significant difference in adverse events (p = 0.41) post intervention.

CONCLUSIONS

Redesign of shift models common in residency programs to minimize the number of handoffs and facilitate face-to-face communication, along with implementation of electronic handoff templates, improves the quality of handoffs in a learning environment.

Participation and experience of third-year medical students in handoffs: time to sign out?

BACKGROUND

Although interns are expected to be competent in handoff communication, it is currently unclear what level of exposure, participation, and comfort medical students have with handoffs prior to graduation.

OBJECTIVE

The aim of this study is to characterize passive and active involvement of third-year medical students in the major components of the handoff process.

DESIGN

An anonymous voluntary retrospective cross-sectional survey administered in 2010.

PARTICIPANTS

Rising fourth-year students at two large urban private medical schools.

MAIN MEASURES

Participation and confidence in active and passive behaviors related to written signout and verbal handoffs during participants' third-year clerkships.

KEY RESULTS

Seventy percent of students (n = 204) responded. As third-year medical students, they reported frequent participation in handoffs, such as updating a written signout for a previously admitted patient (58 %). Students who reported frequent participation (at least weekly) in handoff tasks were more likely to report being confident in that task (e.g., giving verbal handoff 62 % vs. 19 %, p < 0.001). Students at one site that did not have a handoff policy for medical students reported greater participation, more confidence, and less desire for training. Nearly all students believed they had witnessed an error in written signout (98 %) and almost two-thirds witnessed an error due to verbal handoffs (64 %).

CONCLUSIONS

During their third year, many medical students are participating in handoffs, although reported rates differ across training environments. Medical schools should consider the appropriate level of competence for medical student participation in handoffs, and implement corresponding curricula and assessment tools to ensure that medical students are able to effectively conduct handoffs.

Answering questions on call: pediatric resident physicians' use of handoffs and other resources

BACKGROUND

Little is known in the literature about the types of questions being asked of on-call housestaff and the resources used to provide answers.

OBJECTIVE

To characterize questions being asked of pediatric interns on call and evaluate their use of written handoffs, verbal handoffs, and other resources.

DESIGN/METHODS

Prospective direct observational study.

SETTING

Inpatient wards at an academic tertiary care children's hospital.

PARTICIPANTS

Pediatric interns.

RESULTS

Trainees were asked 2.6 questions/hour (interquartile range: 1.4-4.7); most involved medications (28%), general care plans (27%), diagnostic tests/procedures (22%), diet/fluids (15%), and physical exams (9%). Interns reported using information provided in written or verbal handoffs to answer 32.6% questions (written 7.3%; verbal 25.3%). Other resources utilized included general medical knowledge, the medical record, and parental report. Questions pertaining to diet/fluids were associated with increased written handoff use (odds ratio [OR]: 3.64, 95% confidence interval [CI]: 1.51-8.76), whereas having worked more consecutive nights was associated with decreased written handoff use (OR: 0.29, 95% CI: 0.09-0.93). Questions regarding general care plans (OR: 2.07, 95% CI: 1.13-3.78), those asked by clinical staff (OR: 1.95, 95% CI: 1.04-3.66), and questions asked of patients with longer lengths of stay (OR: 1.97, 95% CI: 1.02-3.80) were predictive of verbal handoff use.

CONCLUSIONS

Pediatric housestaff face frequent questions during overnight shifts and frequently use information received during handoffs to provide answers. A better understanding of how handoffs and other resources are utilized by housestaff could inform future targeted initiatives to improve trainees' access to key information at night.

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety

PURPOSE

Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff.

METHOD

In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes.

RESULTS

Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P<.01), more verbal handoffs (80% versus 38%, P<.01), more patients aware of the handoff (100% versus 74%, P=.01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P=.03), and more ownership of patients before the first visit (56% versus 26%, P=.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P<.01), and more tests were followed up appropriately (67% versus 46%, P=.02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P=.06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P=.06).

CONCLUSIONS

Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.

Sustainability and effectiveness of a quality improvement project to improve handoffs to night float residents in an internal medicine residency program

BACKGROUND

Handoff is the process in which patient care is transitioned from one provider to another. In teaching hospitals, handoffs are frequent, and resident duty hour restrictions have increased the use of night float staff. To date, few studies have focused on long-term sustainability and effectiveness of a handoff quality improvement project.

OBJECTIVE

The objective of our resident-driven quality improvement project was to evaluate the effectiveness and sustainability of a standardized template for handoff quality in a community hospital internal medicine program.

METHODS

We used a multistep continuous quality improvement approach. Problems in the handoff process were identified through process mapping and anonymous needs assessment of the residents. A group of residents and faculty identified problems during biweekly discussions, created a standardized template, and adopted a new handoff process. We audited handoffs and surveyed residents at 3 and 9 months after implementation to assess effectiveness and sustainability.

RESULTS

Before the intervention, only 40% of residents reported regular morning handoff. Using the standardized template, statistically significant, sustained improvements were seen in morning handoff frequency (59% preintervention, 90% at 3 months, 89% at 9 months), along with decreases in unreported overnight events (84% preintervention, 58% at 3 months, 50% at 9 months) and uncertainty about decisions because of poor handoffs (72% preintervention, 49% at 3 months, 37% at 9 months). Statistically significant decreases in missed content (69%-46%) and copy-and-paste behavior (78%-38%) at 3 months were not sustained.

CONCLUSIONS

We demonstrated sustained improvements in unreported events and uncertainty caused by poor handoffs. Initial improvements in missed content and copy-and-paste behavior that were not sustained suggest a need for ongoing reinforcement and monitoring of handoff quality.

Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study

IMPORTANCE

In 2003, the first phase of duty hour requirements for US residency programs recommended by the Accreditation Council for Graduate Medical Education (ACGME) was implemented. Evidence suggests that this first phase of duty hour requirements resulted in a modest improvement in resident well-being and patient safety. To build on these initial changes, the ACGME recommended a new set of duty hour requirements that took effect in July 2011.

OBJECTIVE

To determine the effects of the 2011 duty hour reforms on first-year residents (interns) and their patients.

DESIGN

As part of the Intern Health Study, we conducted a longitudinal cohort study comparing interns serving before (2009 and 2010) and interns serving after (2011) the implementation of the new duty hour requirements.

SETTING

Fifty-one residency programs at 14 university and community-based GME institutions.

PARTICIPANTS

A total of 2323 medical interns.

MAIN OUTCOME MEASURES

Self-reported duty hours, hours of sleep, depressive symptoms, well-being, and medical errors at 3, 6, 9, and 12 months of the internship year.

RESULTS

Fifty-eight percent of invited interns chose to participate in the study. Reported duty hours decreased from an average of 67.0 hours per week before the new rules to 64.3 hours per week after the new rules were instituted (P < .001). Despite the decrease in duty hours, there were no significant changes in hours slept (6.8 → 7.0; P = .17), depressive symptoms (5.8 → 5.7; P = .55) or well-being score (48.5 → 48.4; P = .86) reported by interns. With the new duty hour rules, the percentage of interns who reported concern about making a serious medical error increased from 19.9% to 23.3% (P = .007).

CONCLUSIONS AND RELEVANCE

Although interns report working fewer hours under the new duty hour restrictions, this decrease has not been accompanied by an increase in hours of sleep or an improvement in depressive symptoms or well-being but has been accompanied by an unanticipated increase in self-reported medical errors.

Development of a handoff evaluation tool for shift-to-shift physician handoffs: the Handoff CEX

BACKGROUND

Increasing frequency of shift-to-shift handoffs coupled with regulatory requirements to evaluate handoff quality make a handoff evaluation tool necessary.

OBJECTIVE

To develop a handoff evaluation tool.

DESIGN

Tool development.

SETTING

Two academic medical centers.

SUBJECTS

Nurse practitioners, medicine housestaff, and hospitalist attendings.

INTERVENTION

Concurrent peer and external evaluations of shift-to-shift handoffs.

MEASUREMENTS

The Handoff CEX (clinical evaluation exercise) consists of 6 subdomains and 1 overall assessment, each scored from 1 to 9, where 1 to 3 is unsatisfactory and 7 to 9 is superior. We assessed range of scores, performance among subgroups, internal consistency, and agreement among types of raters.

RESULTS

We conducted 675 evaluations of 97 unique individuals during 149 handoff sessions. Scores ranged from unsatisfactory to superior in each domain. The highest rated domain for handoff providers was professionalism (median: 8; interquartile range [IQR]: 7-9); the lowest was content (median: 7; IQR: 6-8). Scores at the 2 institutions were similar, and scores did not differ significantly by training level. Spearman correlation coefficients among the CEX subdomains for provider scores ranged from 0.71 to 0.86, except for setting (0.39-0.40). Third-party external evaluators consistently gave lower marks for the same handoff than peer evaluators did. Weighted kappa scores for provider evaluations comparing external evaluators to peers ranged from 0.28 (95% confidence interval [CI]: 0.01, 0.56) for setting to 0.59 (95% CI: 0.38, 0.80) for organization.

CONCLUSIONS

This handoff evaluation tool was easily used by trainees and attendings, had high internal consistency, and performed similarly across institutions. Because peers consistently provided higher scores than external evaluators, this tool may be most appropriate for external evaluation.

Implementing peer evaluation of handoffs: associations with experience and workload

BACKGROUND

Although peer evaluation can be used to evaluate in-hospital handoffs, few studies have described using this strategy.

OBJECTIVE

Our objective was to assess feasibility of an online peer handoff evaluation and characterize performance over time among medical interns.

DESIGN

The design was a prospective cohort study.

PATIENTS

Subjects were medical interns from residency program rotating at 2 teaching hospitals.

MEASUREMENTS

Measurements were performance on an end-of-rotation evaluation of giving and receiving handoffs.

RESULTS

From July 2009 to March 2010, 31 interns completed 60% (172/288) of peer evaluations. Ratings were high across domains (mean, 8.3-8.6). In multivariate regression controlling for evaluator and evaluatee, statistically significant improvements over time were observed for 4 items compared to the first 3 months of the year: 1) communication skills (season 2, +0.34 [95% confidence interval (CI), 0.08-0.60], P = 0.009); 2) listening behavior (season 2, +0.29 [95% CI, 0.04-0.55], P = 0.025); 3) accepting professional responsibility (season 3, +0.37 [95% CI, 0.08-0.65], P = 0.012); and 4) accessing the system (season 2, +0.21 [95% CI, 0.03-0.39], P = 0.023). Ratings were also significantly lower when interns were postcall in written sign-out quality (8.21 vs 8.39, P = 0.008) and accepting feedback (8.25 vs 8.42, P = 0.006). Ratings from a community hospital rotation, with a lower census than the teaching hospital, were significantly higher for overall performance and 7 of 12 domains (P < 0.05 for all). Significant evaluator effects were observed.

CONCLUSIONS

Although there is evidence of leniency, peer evaluation of handoffs demonstrate increases over time and associations with workload such as postcall status. This suggests the importance of examining how workload impacts handoffs in the future.

Brief educational intervention improves content of intern handovers

BACKGROUND

The Accreditation Council for Graduate Medical Education requires residency programs to ensure safe patient handovers and to document resident competency in handover communication, yet there are few evidence-based curricula teaching resident handover skills.

OBJECTIVE

We assessed the immediate and sustained impact of a brief educational intervention on pediatrics intern handover skills.

METHODS

Interns at a freestanding children's hospital participated in an intervention that included a 1-hour educational workshop on components of high-quality handovers, as well as implementation of a standardized handover format. The format, SAFETIPS, includes patient information, current diagnosis and assessment, patient acuity, a focused plan, a baseline exam, a to-do list, anticipatory guidance, and potential pointers and pitfalls. Important communication behaviors, such as paraphrasing key information, were addressed. Quality of intern handovers was evaluated using a simulated encounter 2 weeks before, 2 weeks after, and 7 months after the workshop. Two trained, blinded, independent observers scored the videotaped encounters.

RESULTS

All 27 interns rotating at the Children's Hospital consented to participate in the study, and 20 attended the workshop. We included all participant data in the analysis, regardless of workshop attendance. Following the intervention, intern reporting of patient acuity improved from 13% to 92% (P < .001), and gains were maintained 7 months later. Rates of key communication behaviors, such as paraphrasing critical information, did not improve.

CONCLUSIONS

A brief educational workshop promoting standardized handovers improved the inclusion of essential information during intern handovers, and these improvements were sustained over time. The intervention did not improve key communication behaviors.

Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist

BACKGROUND

The increasing fragmentation of healthcare has resulted in more patient handoffs. Many professional groups, including the Accreditation Council on Graduate Medical Education and the Society of Hospital Medicine, have made recommendations for safe and effective handoffs. Despite the two-way nature of handoff communication, the focus of these efforts has largely been on the person giving information.

OBJECTIVE

To observe and characterise the listening behaviours of handoff receivers during hospitalist handoffs.

DESIGN

Prospective observational study of shift change and service change handoffs on a non-teaching hospitalist service at a single academic tertiary care institution.

MEASUREMENTS

The 'HEAR Checklist', a novel tool created based on review of effective listening behaviours, was used by third party observers to characterise active and passive listening behaviours and interruptions during handoffs.

RESULTS

In 48 handoffs (25 shift change, 23 service change), active listening behaviours (eg, read-back (17%), note-taking (23%) and reading own copy of the written signout (27%)) occurred less frequently than passive listening behaviours (eg, affirmatory statements (56%) nodding (50%) and eye contact (58%)) (p<0.01). Read-back occurred only eight times (17%). In 11 handoffs (23%) receivers took notes. Almost all (98%) handoffs were interrupted at least once, most often by side conversations, pagers going off, or clinicians arriving. Handoffs with more patients, such as service change, were associated with more interruptions (r=0.46, p<0.01).

CONCLUSIONS

Using the 'HEAR Checklist', we can characterise hospitalist handoff listening behaviours. While passive listening behaviours are common, active listening behaviours that promote memory retention are rare. Handoffs are often interrupted, most commonly by side conversations. Future handoff improvement efforts should focus on augmenting listening and minimising interruptions.

Supplementing cross-cover communication with the patient acuity rating

BACKGROUND

Patient hand-offs at physician shift changes have limited ability to convey the primary team's longitudinal insight. The Patient Acuity Rating (PAR) is a previously validated, 7-point scale that quantifies physician judgment of patient stability, where a higher score indicates a greater risk of clinical deterioration. Its impact on cross-covering physician understanding of patients is not known.

OBJECTIVE

To determine PAR contribution to sign-outs.

DESIGN

Cross-sectional survey.

SUBJECTS

Intern physicians at a university teaching hospital.

INTERVENTIONS

Subjects were surveyed using randomly chosen, de-identified patient sign-outs, previously assigned PAR scores by their primary teams. For each sign-out, subjects assigned a PAR score, then responded to hypothetical cross-cover scenarios before and after being informed of the primary team's PAR.

MAIN MEASURE

Changes in intern assessment of the scenario before and after being informed of the primary team's PAR were measured. In addition, responses between novice and experienced interns were compared.

KEY RESULTS

Between May and July 2008, 23 of 39 (59 %) experienced interns and 25 of 42 (60 %) novice interns responded to 480 patient scenarios from ten distinct sign-outs. The mean PAR score assigned by subjects was 4.2 ± 1.6 vs. 3.8 ± 1.8 by the primary teams (p < 0.001). After viewing the primary team's PAR score, interns changed their level of concern in 47.9 % of cases, their assessment of the importance of immediate bedside evaluation in 48.7 % of cases, and confidence in their assessment in 43.2 % of cases. For all three assessments, novice interns changed their responses more frequently than experienced interns (p = 0.03, 0.009, and <0.001, respectively). Overall interns reported the PAR score to be theoretically helpful in 70.8 % of the cases, but this was more pronounced in novice interns (81.2 % vs 59.6 %, p < 0.001).

CONCLUSIONS

The PAR adds valuable information to sign-outs that could impact cross-cover decision-making and potentially benefit patients. However, correct training in its use may be required to avoid unintended consequences.

Trial of shift scheduling with standardized sign-out to improve continuity of care in intensive care units

BACKGROUND

Since 2003, the Accreditation Council for Graduate Medical Education requires residency programs to restrict to 80 hrs/wk, averaged over 4 wks to improve patient safety. These restrictions force training programs with night call responsibilities to either maintain a traditional program with alternative night float schedules or adopt a "shift" model, both with increased handoffs.

OBJECTIVE

To assess whether a 65 hrs/wk shift-work schedule combined with structured sign-out curriculum is equivalent to a 65 hrs/wk traditional day coverage with night call schedule, as measured by multiple assessments.

DESIGN

Eight-month trial of shift-work schedule with structured sign-out curriculum (intervention) vs. traditional call schedule without curriculum (control) in alternating 1-2 month periods.

SETTING

A mixed medical-surgical intensive care unit at a tertiary care academic center.

SUBJECTS

Primary subjects: 19 fellows in a Multidisciplinary Critical Care Training Program; Secondary subjects: intensive care unit nurses and attending physicians, families of intensive care unit patients.

INTERVENTIONS

Implementation of shift-work schedule, combined with structured sign-out curriculum.

MEASUREMENTS

Workplace perception assessment through Continuity of Care Survey evaluation by faculty, fellows, and nurses through structured surveys; family assessment by the Critical Care Family Needs Index survey; clinical assessment through intensive care unit mortality, intensive care unit length of stay, and intensive care unit readmission within 48 hrs; and educational impact assessment by rate of fellow didactic lecture attendance.

MAIN RESULTS

There were no statistically significant differences in surveyed perceptions of continuity of care, intensive care unit mortality (8.5% vs. 6.0%, p = .20), lecture attendance (43% vs. 42%), or family satisfaction (Critical Care Family Needs Index score 24 vs. 22) between control and intervention periods. There was a significant decrease in intensive care unit length of stay (8.4 vs. 5.7 days, p = .04) with the shift model. Readmissions within 48 hrs were not different (3.6% vs. 4.9%, p = .39). Nurses preferred the intervention period (7% control vs. 73% intervention, n = 30, p = .00), and attending faculty preferred the intervention period and felt continuity of care was maintained (15% control vs. 54% intervention, n = 11, p = .15).

CONCLUSIONS

A shift-work schedule with structured sign-out curriculum is a viable alternative to traditional work schedules for the intensive care unit in training programs.

Effect of surgery resident change of shift on trauma resuscitations and outcomes

INTRODUCTION

The ability of surgery residents to provide continuity of care has come under scrutiny with work hour restrictions. The impact of the surgery resident sign-out period (6-8am and 6-8pm) on trauma outcomes remains unknown. We hypothesize that during shift change, resuscitation times are prolonged with worse outcomes.

METHODS

Records of patients treated at a university-based urban trauma center during 2008 and 2009 were reviewed. Patients were separated into a shift change group (6-8am and 6-8pm) and a control group of all other time periods and compared using ANOVA, chi square, and unpaired t-tests.

RESULTS

We reviewed the charts of 4361 consecutive trauma patients. There was no difference in gender, acuity, resuscitation times, Glasgow Coma Scale, revised trauma score, injury severity score (ISS), or probability of survival score between patients arriving during shift change compared to other times (p>0.2). There was no difference in total emergency department time for patients arriving during shift change (p = 0.07), even when stratified by ISS (ISS<15, p = 0.09; ISS>15, p = 0.2). Length of stay was increased for patients arriving during shift change compared to other times (5 vs 4 days, p<0.05). This was more pronounced for those with ISS>15 (16 vs 11 days, p = 0.03); however, there was no impact on intensive care unit length of stay, ventilator days, and mortality (p>0.3) regardless of ISS.

CONCLUSIONS

Trauma outcomes are generally unaffected by patient arrival during shift change when resident sign-outs occur. Although adaptations are being made to accommodate trauma patient arrival during these times, we need to continue paying close attention, especially to seriously injured patients, to ensure that there are no delays in care that may potentially affect patient outcomes.

Last chance to observe: assessing residency preparedness following the 4th-year subinternship

BACKGROUND

The subinternship is an integral part of the 4th year of medical school. There is little description of innovations aimed at assessing the preparedness and confidence of graduating students as they move on the next step in their training.

DESCRIPTION

An innovation including an Objective Structured Clinical Examination (OSCE) at the conclusion of the subinternship was designed. We focused on key themes of transitions of care, communication within the health care system, and communication with patients and providers.

EVALUATION

A pre- and postsurvey addressed student self-perceived skill, confidence, and overall perception of importance. Improvement (p<.05) was seen across all themes from pre- to postsurvey, with more favorable scores on the postsurvey.

CONCLUSIONS

A subinternship innovation including an OSCE was feasible and had a positive effect on student assessment, perception and confidence. As the landscape of medical education evolves, assessing students' preparedness for residency will become increasingly imperative.

Outcomes for resident-identified high-risk patients and resident perspectives of year-end continuity clinic handoffs

BACKGROUND

Many patients nationwide change their primary care physician (PCP) when internal medicine (IM) residents graduate. Few studies have examined this handoff.

OBJECTIVE

To assess patient outcomes and resident perspectives after the year-end continuity clinic handoff

DESIGN

Retrospective cohort

PARTICIPANTS

Patients who underwent a year-end clinic handoff in July 2010 and a comparison group of all other resident clinic patients from 2009-2011. PGY2 IM residents surveyed from 2010-2011.

MEASUREMENTS

Percent of high-risk patients after the clinic handoff scheduled for an appointment, who saw their assigned PCP, lost to follow-up, or had an acute visit (ED or hospitalization). Perceptions of PGY2 IM residents surveyed after receiving a clinic handoff.

RESULTS

Thirty graduating residents identified 258 high-risk patients. While nearly all patients (97 %) were scheduled, 29 % missed or cancelled their first new PCP visit. Only 44 % of patients saw the correct PCP and six months later, one-fifth were lost to follow-up. Patients not seen by a new PCP after the handoff were less likely to have appropriate follow-up for pending tests (0 % vs. 63 %, P<0.001). A higher mean no show rate (NSR) was observed among patients who missed their first new PCP visit (22 % vs. 16 % NSR, p<0.001) and those lost to follow-up (21 % vs. 17 % NSR, p=0.019). While 47 % of residents worried about missing important data during the handoff, 47 % reported that they do not perceive patients as "theirs" until they are seen by them in clinic.

CONCLUSIONS

While most patients were scheduled for appointments after a clinic handoff, many did not see the correct resident and one-fifth were lost to follow-up. Patients who miss appointments are especially at risk of poor clinic handoff outcomes. Future efforts should improve patient attendance to their first new PCP visit and increase PCP ownership.

Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships?

Long hours are an accepted component of resident education, yet data suggest they contribute to fatigue that may compromise patient safety. A systematic review confirms that limiting duty hours increases residents' hours of sleep and improves objective measures of alertness. Most studies of operative experience for surgical residents found no effect, and there is evidence of a limited positive effect on residents' mood. We find a mixed effect on patient safety, although problems with supervision, rather than the limits, may be responsible or contibute; evidence of reduced continuity of care and reduced continuity in residents' clinical education; and evidence that increased workload under the limits has a negative effect on patient and resident outcomes. We highlight specific areas for research and offer recommendations for national policy.

Investigating the scope of resident patient care handoffs within neurosurgery

INTRODUCTION

Handoffs are defined as verbal and written communications during patient care transitions. With the passage of recent ACMGE work hour rules further limiting the hours interns can spend in the hospital, many fear that more handoffs will occur, putting patient safety at risk. The issue of handoffs has not been studied in the neurosurgical literature.

METHODS

A validated, 20-question online-survey was sent to neurosurgical residents in all 98 accredited U.S. neurosurgery programs. Survey results were analyzed using tabulations.

RESULTS

449 surveys were completed yielding a 56% response rate. 63% of neurosurgical residents surveyed had not received formal instruction in what constitutes an effective handoff; 24% believe there is high to moderate variability among their co-residents in terms of the quality of the handoff provided; 55% experience three or more interruptions during handoffs on average. 90% of neurosurgical residents surveyed say that handoff most often occurs in a quiet, private area and 56% report a high level of comfort for knowing the potential acute, critical issues affecting a patient when receiving a handoff.

CONCLUSIONS

There needs to be more focused education devoted to learning effective patient-care handoffs in neurosurgical training programs. Increasingly, handing off a patient adequately and safely is becoming a required skill of residency.

Effects of education on interns' verbal and electronic handoff documentation skills

BACKGROUND

Improving handoff communications is a National Patient Safety Goal. Interns and residents are rarely taught how to safely handoff their patients. Our objective was to determine whether teaching safe handoff principles would improve handoff quality.

METHODS

Our study was conducted on the inpatient services at 2 teaching hospitals. In this single-institution, randomized controlled trial, internal medicine interns (N  =  44) and residents (N  =  24) participated in a 45-minute educational session on safe handoff communication skills. Residents received additional education on effective feedback practices and were asked to provide each intern with structured feedback. Quality of interns' electronic and verbal handoffs was measured by using a Handoff Evaluation Tool created by the authors. The frequency of handoff communication failures was also assessed through semistructured phone interviews of postcall interns.

RESULTS

Interns who received handoff education demonstrated superior verbal handoff skills than control interns (P < .001), while no difference was seen in electronic handoff skills. Communication failures related to code status (P < .001) and overnight tasks (P < .050) were less frequent in the intervention group.

CONCLUSIONS

Interns' electronic handoff documentation skills did not improve with the intervention. This may reflect greater difficulty in changing physicians' electronic documentation habits.

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements

With changes in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements related to transitions in care effective July 1, 2011, sponsoring institutions and training programs must develop a common structure for transitions in care as well as comprehensive curricula to teach and evaluate patient handoffs. In response to these changes, within the Duke University Health System, the resident-led Graduate Medical Education Patient Safety and Quality Council performed a focused review of the handoffs literature and developed a plan for comprehensive handoff education and evaluation for residents and fellows at Duke. The authors present the results of their focused review, concentrating on the three areas of new ACGME expectations--structure, education, and evaluation--and describe how their findings informed the broader initiative to comprehensively address transitions in care managed by residents and fellows. The process of developing both institution-level and program-level initiatives is reviewed, including the development of an interdisciplinary minimal data set for handoff core content, training and education programs, and an evaluation strategy. The authors believe the final plan fully addresses both Duke's internal goals and the revised ACGME Common Program Requirements and may serve as a model for other institutions to comprehensively address transitions in care and to incorporate resident and fellow leadership into a broad, health-system-level quality improvement initiative.

Narrative, written sign-outs and interns' and senior medical students' confidence: a randomized, controlled crossover trial

BACKGROUND

Failures of communication during the transfer of patient care errors.

METHODS

We created a new format for written sign-out material, based on aviation industry practice and cognitive psychology theory, designed to improve interns' and senior medical students' communication during transfers of patient care responsibility. We carried out a randomized, blinded, crossover trial, comparing a new, narrative, written sign-out report to a usual written sign-out. Thirty-two interns and fourth-year medical students rated their confidence across various clinical tasks and answered clinical questions regarding hypothetical patients presented to them in written, new, narrative sign-out compared with the customary format.

RESULTS

There was no statistical difference in confidence when interns and senior medical students received usual versus narrative sign-outs.

CONCLUSIONS

Although a limited measure suggested some improvement in competence, the narrative format did not improve participants' self-rated confidence during patient-care transfer.

Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes

BACKGROUND

Resident duty hour restrictions have resulted in more frequent patient care handoffs, increasing the need for improved quality of residents' sign-out process.

OBJECTIVE

To characterize resident sign-out process and identify effective strategies for quality improvement.

DESIGN

Mixed methods analysis of resident sign-out, including a survey of resident views, prospective observation and characterization of 64 consecutive sign-out sessions, and an appreciative-inquiry approach for quality improvement.

PARTICIPANTS

Internal medicine residents (n = 89).

INTERVENTIONS

An appreciative inquiry process identified five exemplar residents and their peers' effective sign-out strategies.

MAIN MEASURES

Surveys were analyzed and observations of sign-out sessions were characterized for duration and content. Common effective strategies were identified from the five exemplar residents using an appreciative inquiry approach.

KEY RESULTS

The survey identified wide variations in the methodology of sign-out. Few residents reported that laboratory tests (13%) or medications (16%) were frequently accurate. The duration of observed sign-outs averaged 134 ±73 s per patient for the day shift (6 p.m.) sign-out compared with 59 ± 41 s for the subsequent night shift (8 p.m.) sign-out for the same patients (p = 0.0002). Active problems (89% vs 98%, p = 0.013), treatment plans (52% vs 73%, p = 0.004), and laboratory test results (56% vs 80%, p = 0.002) were discussed less commonly during night compared with day sign-out. The five residents voted best at sign-out (mean vote 11 ± 1.6 vs 1.7 ± 2.3) identified strategies for sign-out: (1) discussing acutely ill patients first, (2) minimizing discussion on straightforward patients, (3) limiting plans to active issues, (4) using a systematic approach, and (5) limiting error-prone chart duplication.

CONCLUSIONS

Resident views toward sign-out are diverse, and accuracy of written records may be limited. Consecutive sign-outs are associated with degradation of information. An appreciative-inquiry approach capitalizing on exemplar residents was effective at creating standards for sign-out.

Handover patterns: an observational study of critical care physicians

BACKGROUND

Handover (or 'handoff') is the exchange of information between health professionals that accompanies the transfer of patient care. This process can result in adverse events. Handover 'best practices', with emphasis on standardization, have been widely promoted. However, these recommendations are based mostly on expert opinion and research on medical trainees. By examining handover communication of experienced physicians, we aim to inform future research, education and quality improvement. Thus, our objective is to describe handover communication patterns used by attending critical care physicians in an academic centre and to compare them with currently popular, standardized schemes for handover communication.

METHODS

Prospective, observational study using video recording in an academic intensive care unit in Ontario, Canada. Forty individual patient handovers were randomly selected out of 10 end-of-week handover sessions of attending physicians. Two coders independently reviewed handover transcripts documenting elements of three communication schemes: SBAR (Situation, Background, Assessment, Recommendations); SOAP (Subjective, Objective, Assessment, Plan); and a standard medical admission note. Frequency and extent of questions asked by incoming physicians were measured as well. Analysis consisted of descriptive statistics.

RESULTS

Mean (± standard deviation) duration of patient-specific handovers was 2 min 58 sec (± 57 sec). The majority of handovers' content consisted of recent and current patient status. The remainder included physicians' interpretations and advice. Questions posed by the incoming physicians accounted for 5.8% (± 3.9%) of the handovers' content. Elements of all three standardized communication schemes appeared repeatedly throughout the handover dialogs with no consistent pattern. For example, blocks of SOAP's Assessment appeared 5.2 (± 3.0) times in patient handovers; they followed Objective blocks in only 45.9% of the opportunities and preceded Plan in just 21.8%. Certain communication elements were occasionally absent. For example, SBAR's Recommendation and admission note information about the patient's Past Medical History were absent from 22 (55.0%) and 20 (50.0%), respectively, of patient handovers.

CONCLUSIONS

Clinical handover practice of faculty-level critical care physicians did not conform to any of the three predefined structuring schemes. Further research is needed to examine whether alternative approaches to handover communication can be identified and to identify features of high-quality handover communication.

The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department

Objectives

This study identifies best practice for shift handover and introduces a new tool used to hand over clinical and operational issues at the end of a shift in the emergency department (ED).

Methods

Literature review, semi-structured interviews and observations of handover were used to develop a standardised process for handover. Participants were ED middle grades, consultants and senior nurses. Interviews were used to identify agreed best practice and derive a tool to classify the information into relevant sections.

Results

Interviews identified a variety of perceived current deficits in handover including a lack of standardised practice and structure. Participants provided examples of poor handover that were thought to have led to adverse events; these included delay in investigations and treatment for patients who were handed over with brief or inaccurate information. There was wide variation in the understanding of the meaning and purpose of shift handover, and differences were apparent according to the level of experience of the middle grades interviewed. The experts' responses were used to reach a unifying ‘best practice’ for the content of handover. This was then grouped under ABCDE headings to develop the ABC of handover tool.

Conclusions

A simple tool was developed to provide the basis for medical shift handover, which includes clinical and operational information necessary for efficiency and organisation of the next shift. The ABC of handover classifies shift information to be handed over under the ABCDE headings, which are easy to remember and highly relevant to emergency medicine.

Restructuring an inpatient resident service to improve outcomes for residents, students, and patients

PURPOSE

This study assesses the effects of a resident teaching service restructuring on resident, student, and patient outcomes.

METHOD

Interventions included eliminating a "day float" admitting team, converting one-resident:one-intern teams to one-resident:two-intern teams, reducing patient caps from 11 to 7 patients per intern, and increasing pairing between resident teams and attendings. Resident end-of-rotation evaluations and time spent in categorized activities; student end-of-clerkship evaluations, patient logs, and subject exam scores; and hospital-collected patient outcome data were compared before (2007-2008) versus after (2008-2009) the changes.

RESULTS

Interns covered fewer patients per day post intervention (9.9 apiece to 6.3 apiece), whereas the total number of patients covered increased (2,501 to 2,916). Enjoyment of the rotation was higher post intervention for interns and senior residents. Residents' time in direct patient care activities and with interns increased post intervention, but residents spent less time with medical students. Students' ratings of several aspects of the clerkship were significantly higher in the postintervention year. Students evaluated more previously unevaluated patients post intervention (32.6% to 45.8%, P < .001), but subject exam scores were unchanged. The median length of stay decreased post intervention (5.0 to 4.0 days, P = .02), and fewer patients required ICU care (11.2% to 7.9%, P < .001). These differences persisted after adjusting for multiple covariates.

CONCLUSIONS

An intervention that reduced handoffs and intern patient census and that increased hospitalist pairing was associated with improved resident and student experiences, a favorable impact on patient outcomes, and probable cost savings.

An assessment of patient sign-outs conducted by University at Buffalo internal medicine residents

Internal medicine residents were surveyed regarding patient sign-outs at shift change. Data were used to design and implement interventions aimed at improving sign-out quality. This quasi-experimental project incorporated the Plan, Do, Study, Act methodology. Residents completed an anonymous electronic survey regarding experiences during sign-outs. Survey questions assessed structure, process, and outcome of sign-outs. Analysis of qualitative and quantitative data was performed; interventions were implemented based on survey findings. A total of 120 surveys (89% response) and 115 surveys (83% response) were completed by residents of 4 postgraduate years in response to the first (2008) and second (2009) survey requests, respectively. Approximately 79% of the respondents to the second survey indicated that postintervention sign-out systems were superior to preintervention systems. Results indicated improvement in specific areas of structure, process, and outcome. Survey-based modifications to existing sign-out systems effected measurable quality improvement in structure, process, and outcome.

A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers

BACKGROUND

Poor physician handoff can be a major contributor to suboptimal care and medical errors occurring in the hospital. Physician handoffs for intensive care unit (ICU)-to-ward patient transfer may face more communication hurdles. However, few studies have focused on physician handoffs in patient transfers from the ICU to the inpatient ward.

METHODS

We performed a hospitalized patient-based observational study in an urban, university-affiliated tertiary care center to assess physician handoff practices for ICU-to-ward patient transfer. One hundred twelve adult patients were enrolled. The stakeholders (sending physicians, receiving physicians, and patients/families) were interviewed to evaluate the quality of communication during these transfers. Data collected included the presence and effectiveness of communication, continuity of care, and overall satisfaction.

RESULTS

During the initial stage of patient transfers, 15.6% of the consulted receiving physicians verbally communicated with sending physicians; 26% of receiving physicians received verbal communication from sending physicians when patient transfers occurred. Poor communication during patient transfer resulted in 13 medical errors and 2 patients being transiently "lost" to medical care. Overall, the levels of satisfaction with communication (scored on a 10-point scale) for sending physicians, receiving physicians, and patients were 7.9±1.1, 8.1±1.0, and 7.9±1.7, respectively.

CONCLUSION

The overall levels of satisfaction with communication during ICU-to-ward patient transfer were reasonably high among the stakeholders. However, clear opportunities to improve the quality of physician communication exist in several areas, with potential benefits to quality of care and patient safety.

The revolving door of resident continuity practice: identifying gaps in transitions of care

BACKGROUND

It is well documented that transitions of care pose a risk to patient safety. Every year, graduating residents transfer their patient panels to incoming interns, yet in our practice we consistently find that approximately 50% of patients do not return for follow-up care within a year of their resident leaving.

OBJECTIVE

To examine the implications of this lapse of care with respect to chronic disease management, follow-up of abnormal test results, and adherence with routine health care maintenance.

DESIGN

Retrospective chart review

SUBJECTS

We studied a subset of patients cared for by 46 senior internal medicine residents who graduated in the spring of 2008. 300 patients had been identified as high priority requiring follow-up within a year. We examined the records of the 130 of these patients who did not return for care.

MAIN MEASURES

We tabulated unaddressed abnormal test results, missed health care screening opportunities and unmonitored chronic medical conditions. We also attempted to call these patients to identify barriers to follow-up.

KEY RESULTS

These patients had a total of 185 chronic medical conditions. They missed a total of 106 screening opportunities including mammogram (24), Pap smear (60) and colon cancer screening (22). Thirty-two abnormal pathology, imaging and laboratory test results were not followed-up as the graduating senior intended. Among a small sample of patients who were reached by phone, barriers to follow-up included a lack of knowledge about the need to see a physician, distance between home and our office, difficulties with insurance, and transportation.

CONCLUSIONS

This study demonstrates the high-risk nature of patient handoffs in the ambulatory setting when residents graduate. We discuss changes that might improve the panel transfer process.

Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer

BACKGROUND

Few studies have examined the safety risks of the annual outpatient clinic handoffthat occurs when residents either advance to a higher level of training or graduate ("year-end transfer"). A multifaceted intervention was designed and implemented to identify and improve followup of high-risk patients during academic year-end outpatient transfers in a psychiatry resident continuity clinic.

METHODS

Departing residents identified "acute" patients, who were scheduled on a priority basis for longer appointments during the first month after the transfer. In addition, standardized written and face-to-face sign-outs occurred, incoming clinicians contacted every patient in the first week, and specialized didactics were provided.

RESULTS

For the three intervention years combined, the odds ratio of hospitalization for acute patients compared to nonacute patients was 9.2 (95% confidence interval [CI]: 2.43, 34.7; p = .001). Compared to Year 1, the proportion of acute patients seen within 31 days in Years 2 and 3 increased by 32.2% (from 64.3% to 85.0%, p < .0001). The median time-to-first visit for acute patients decreased by 42% (from 24 days in Year 1 to 14 days in Year 3, p = .001). Finally, resident perception of the quality of the handoffim-proved in all areas compared to baseline, including resident-to-resident communication (2.8 to 3.0, p = .03), accuracy of caseload lists (2.8 to 4.1,p = .003), identification of high-risk patients (2.1 to 3.7, p < .0001), and usefulness of supervision during the transition (2.7 to 4.3, p < .0001).

CONCLUSIONS

Categorical designation by the outgoing clinicians effectively identified patients at higher risk for hospitalization during the transition. Relatively low-cost interventions may significantly improve patient safety and resident training in not only psychiatry, but also other disciplines and specialties.

Handover rounds in Irish hospitals

BACKGROUND

With the increasing complexities in medicine and the reduction in working hours, shift work patterns are emerging for hospital doctors and with them the possibility for discontinuity of patient care and negative outcomes for patient safety.

AIMS

The purpose of this study was to evaluate the prevalence, format and structure of formal handover rounds in Irish hospitals in four different specialties.

METHODS

A 26-item questionnaire was sent to 61 participants in 26 hospitals.

RESULTS

Just over a quarter of respondents (28%) reported formal handover rounds. Respondents from Obstetrics and Gynaecology were more likely to report handover rounds (80%). Prominent features of handover include frequent consultant (100%) and post-call staff (73%) attendance.

CONCLUSION

This study confirms that handover rounds are not universal in Irish hospitals. While this does not imply that patient safety is compromised, the need for effective and comprehensive handover is a critical aspect of patient care.

Resident sign-out and patient hand-offs: opportunities for improvement

BACKGROUND

Inpatient care is characterized by multiple transitions of patient care responsibilities. In most residency programs trainees manage transitions via verbal, written, or combined methods of communication termed "sign-out." Often sign-out occurs without standardization or supervision.

PURPOSE

The purpose was to assess daily sign-out with a goal of identifying aspects of this process most in need of improvement.

METHODS

This was a prospective, observational cohort study of interns' sign-out conducted by industrial engineering students. Daily sign-out was analyzed for inclusion of multiple criteria and scored on organization (on a scale of 0-4) based on how effectively written information was conveyed.

RESULTS

We observed 124 unique verbal and written sign-outs. We found that 99% of sign-outs included a general hospital course. Sign-outs were well organized with a mean of 3.1, though substantial variation was noted (SD = 0.8). Directions for anticipated patient events were included in only 42% of sign-outs. Do Not Resuscitate (DNR) or advanced directive discussions were reported in only 11% of sign-outs. Only 50% of successive daily sign-outs were updated.

CONCLUSIONS

We found variability in the content and organization of interns' sign-out, possibly reflecting a lack of instruction and supervision. Standardization of sign-out content, and education on good sign-out skills are increasingly important as patient hand-offs become more frequent.

Critical conversations: a call for a nonprocedural "time out"

BACKGROUND

Communication failures are an ongoing threat to patient safety. Procedural "time outs" were developed as a method to enhance communication and mitigate patient harm. Nonprocedural settings generate equal risks for communication failure, yet lack a similar communication tool or practice that can be applied, particularly with a patient-driven focus.

INNOVATION

Rapidly changing clinical states and care plans are common in the hospital setting, placing patients at risk for adverse events. Certain junctures allow for the highest potential of patient harm-at the time of admission, at a change in clinical condition, and at the time of discharge. Direct communication among healthcare providers at these junctures, which we have dubbed Critical Conversations, can provide an opportunity to clarify plans of care, address or anticipate concerns, and foster greater teamwork. Information exchanged during Critical Conversations includes a combination of checklist-type items and more open-ended questions but they ultimately create a structure and expectation for communication.

LESSONS LEARNED

Integration of Critical Conversations into practice requires provider education and buy-in, as well as expectations for them to occur. Monitoring adherence, capturing stories of success, and demonstrating effectiveness may enhance implementation and continuous improvement in the process.

CONCLUSIONS

Communication tools designed to reduce the likelihood of patient harm remain a focus of patient safety efforts. Critical Conversations are an innovative communication tool, intervention, and policy that potentially limits communication failures at critical junctures to ensure high quality and safe patient care.

Effect of 16-hour duty periods on patient care and resident education

OBJECTIVE

To measure the effect of duty periods no longer than 16 hours on patient care and resident education.

PATIENTS AND METHODS

As part of our Educational Innovations Project, we piloted a novel resident schedule for an inpatient service that eliminated shifts longer than 16 hours without increased staffing or decreased patient admissions on 2 gastroenterology services from August 29 to November 27, 2009. Patient care variables were obtained through medical record review. Resident well-being and educational variables were collected by weekly surveys, end of rotation evaluations, and an electronic card-swipe system.

RESULTS

Patient care metrics, including 30-day mortality, 30-day readmission rate, and length of stay, were unchanged for the 196 patient care episodes in the 5-week intervention month compared with the 274 episodes in the 8 weeks of control months. However, residents felt less prepared to manage cross-cover of patients (P = .006). There was a nonsignificant trend toward decreased perception of quality of education and balance of personal and professional life during the intervention month. Residents reported working fewer weekly hours overall during the intervention (64.3 vs 68.9 hours; P = .40), but they had significantly more episodes with fewer than 10 hours off between shifts (24 vs 2 episodes; P = .004).

CONCLUSION

Inpatient hospital services can be staffed with residents working shifts less than 16 hours without additional residents. However, cross-cover of care, quality of education, and time off between shifts may be adversely affected.

Patient handoffs: pediatric resident experiences and lessons learned

BACKGROUND

Within pediatrics, there is a paucity of data on pediatric resident handoff systems.

METHODS

Seventy-seven of 139 eligible pediatric housestaff participated in a cross-sectional survey that was distributed at an annual residency fall retreat in September 2007.

RESULTS

Seventy-three percent of the respondents noted uncertainty regarding patient care plans due to receipt of an incomplete verbal handoff. Nursing questions, phone, and page interruptions were noted barriers to giving an effective verbal sign-out. Personal fatigue was also reported to affect the accuracy of housestaff's written sign-outs more than verbal sign-outs (43% vs 23%, P = .026). Only 19% of the residents reported that written sign-outs were reflective of current patient information and care plans.

CONCLUSION

Written and verbal patient handoffs were perceived by pediatric housestaff to be important parts of patient care but often incomplete. New systems that provide a more protected handoff environment, reduce housestaff fatigue, and standardize the handoff procedure may be useful.

Template for success: using a resident-designed sign-out template in the handover of patient care

OBJECTIVE

Report our implementation of a standardized handover process in a general surgery residency program.

DESIGN

The standardized handover process, sign-out template, method of implementation, and continuous quality improvement process were designed by general surgery residents with support of faculty and senior hospital administration using standard work principles and business models of the Virginia Mason Production System and the Toyota Production System.

SETTING

Nonprofit, tertiary referral teaching hospital.

PARTICIPANTS

General surgery residents, residency faculty, patient care providers, and hospital administration.

RESULTS

After instruction in quality improvement initiatives, a team of general surgery residents designed a sign-out process using an electronic template and standard procedures. The initial implementation phase resulted in 73% compliance. Using resident-driven continuous quality improvement processes, real-time feedback enabled residents to modify and improve this process, eventually attaining 100% compliance and acceptance by residents.

CONCLUSIONS

The creation of a standardized template and protocol for patient handovers might eliminate communication failures. Encouraging residents to participate in this process can establish the groundwork for successful implementation of a standardized handover process. Integrating a continuous quality-improvement process into such an initiative can promote active participation of busy general surgery residents and lead to successful implementation of standard procedures.