Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study

Development and Evaluation of I-PASS-to-PICU: A Standard Electronic Template to Improve Referral Communication for Interfacility Transfers to the Pediatric ICU

BACKGROUND

Miscommunication during interfacility handoffs to a higher level of care can harm critically ill children. Adapting evidence-based handoff interventions to interfacility referral communication may prevent adverse events. The objective of this project was to develop and evaluate a standard electronic referral template (I-PASS-to-PICU) to improve communication for interfacility pediatric ICU (PICU) transfers.

METHODS

I-PASS-to-PICU was iteratively developed in a single PICU. A core PICU stakeholder group collaboratively designed an electronic health record (EHR)-supported clinical note template by adapting elements from I-PASS, an evidence-based handoff program, to support information exchange between referring clinicians and receiving PICU physicians. I-PASS-to-PICU is a receiver-driven tool used by PICU physicians to guide verbal communication and electronic documentation during PICU transfer calls. The template underwent three cycles of iterative evaluation and redesign informed by individual and group interviews of multidisciplinary PICU staff, usability testing using simulated and actual referral calls, and debriefing with PICU physicians.

RESULTS

Individual and group interviews with 21 PICU staff members revealed that relevant, accurate, and concise information was needed for adequate admission preparedness. Time constraints and secondhand information transmission were identified as barriers. Usability testing with six receiving PICU physicians using simulated and actual calls revealed good usability on the validated System Usability Scale (SUS), with a mean score of 77.5 (standard deviation 10.9). Fellows indicated that most fields were relevant and that the template was feasible to use.

CONCLUSION

I-PASS-to-PICU was technically feasible, usable, and relevant. The authors plan to further evaluate its effectiveness in improving information exchange during real-time PICU practice.

Getting Started With Multi-site Research: Lessons From the Eliminating Monitor Overuse (EMO) Study

Research in Pediatric Hospital Medicine is growing and expanding rapidly, and with this comes the need to expand single-site research projects into multisite research studies within practice-based research networks. This expansion is crucial to ensure generalizable findings in diverse populations; however, expanding Pediatric Hospital Medicine research projects from single to multisite can be daunting. We provide an overview of major logistical steps and challenges in project management, regulatory approvals, data use agreements, training, communication, and financial management that are germane to hospitalist researchers launching their first multisite project by sharing processes and lessons learned from running multisite research projects in the Pediatric Research in Inpatient Settings Network within the Eliminating Monitor Overuse study portfolio. This description is relevant to hospitalist researchers transitioning from single-site to multisite research or those considering serving as site lead for a multisite project.

A Quality Improvement Initiative to Reduce Adverse Effects of Transitions of Anesthesia Care on Postoperative Outcomes: A Retrospective Cohort Study

BACKGROUND

An intraoperative transfer of care from one anesthesia provider to another, or handover, may result in information loss and contribute to adverse patient outcomes. In 2019 the authors undertook a quality improvement effort to increase the use of a structured intraoperative handover tool incorporated in the electronic medical record. The authors hypothesized that intraoperative handovers of anesthesia care would be associated with adverse patient outcomes, and that increased use of a structured tool would attenuate this effect.

METHODS

This study included adult patients undergoing noncardiac surgery of at least 1 h duration performed during the period 2016 to 2021. Cases with a handover were identified if either there was a change of attending anesthesiologist or change of nurse anesthetist or resident for more than 35 min. The primary outcome was the occurrence of a composite of postoperative mortality and major postoperative morbidity. The effect of the intervention was analyzed by examining the quarterly change in odds ratio for the primary outcome for cases with and without a handover.

RESULTS

A total of 121,077 cases, 40.4% of which had a handover, were included. After weighting, the composite outcome was statistically associated with handovers (3,517 of 48,986 [7.2%] in handover cases vs. 4,470 of 72,091 [6.2%] in nonhandover cases; odds ratio, 1.08; 95% CI, 1.04 to 1.12). Time series analysis showed a marked increase in usage of the structured tool after the initial intervention. The odds ratio for the composite outcome showed a significant decrease over time after the initial intervention (t = -3.97; P < 0.001), with the slope of the odds ratio versus time curve decreasing from 0.002 (95% CI, 0.001 to 0.004; P = 0.018) to -0.011 (95% CI, -0.01 to -0.018; P < 0.001).

CONCLUSIONS

Intraoperative handovers are significantly associated with adverse outcomes even after controlling for multiple confounding variables. Use of a structured handover tool during anesthesia care may attenuate the adverse effect.

EDITOR’S PERSPECTIVE

Public opinion of resident physician work hours in 2022

OBJECTIVE

The purpose of this study was to characterize public awareness and opinion regarding resident physician work hours in the United States.

METHODS

We conducted a nationally representative cross-sectional survey among adults in the United States. Demographic quota-based sampling was conducted by Qualtrics to match 2020 United States Census estimates of age, sex, race, and ethnicity. Descriptive statistics are presented. Hypothesis testing was conducted to identify characteristics associated with agreement with current resident physician work-hour policies.

RESULTS

4763 adults in the United States participated in the study. 97.1% of the public believes that resident physicians should not work 24-hour shifts and 95.6% believe the current 80 hours resident work week is too long. 66.4% of the participants reported that the maximum shift duration should be 12 consecutive hours or fewer, including 22.9% who recommended a maximum shift length of 8 hours. Similarly, 66.4% reported that maximum weekly work hours should be 59 or fewer, including 24.9% who recommended a maximum of 40 weekly work hours.

CONCLUSIONS

Nearly all US adults disagree with current work-hour policies for resident physicians. Public opinion supports limiting shifts to no more than 12 consecutive hours and weekly work to no more than 60 hours, which is in sharp contrast to current regulations that permit of 28 hours shifts and 80 hours of work per week.

Implementing a Family-Centered Rounds Intervention Using Novel Mentor-Trios

BACKGROUND AND OBJECTIVES

Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites.

METHODS

Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents.

RESULTS

We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged.

CONCLUSIONS

Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected.

Goals of care and end-of-life communication needs of persons with chronic respiratory disease

PURPOSE OF THE REVIEW

To highlight recent advances in effective communication among persons with chronic respiratory diseases. The authors focus on communication science related to goals of care (GOC) discussions, medical devices, and life-sustaining invasive treatments. The authors discuss important considerations when working with individuals with low literacy and rurality. Communication handoffs between respiratory clinicians and/or palliative care to hospice clinicians are summarized to ensure effective person-centered and caregiver-centered care.

RECENT FINDINGS

Studies suggest the following communication approaches: (1) clarify differences between palliative and end of life; (2) conduct conversations early and gradual throughout the illness trajectory; (3) distinguish types of GOC discussions as they relate to treatment preferences; (4) for patients from rural communities, include family members and spiritual leaders; (5) assess literacy and employ supportive strategies; (6) apply time-limited-trial framework for life-sustaining treatment (LST) decisions; and (7) standardize processes for communication handoffs to hospice clinicians to improve communication fidelity.

SUMMARY

Effective communication tools for clinicians to engage in GOC discussions for persons with chronic respiratory diseases are grounded in a patient-centered framework. A trained clinician should lead these conversations and include interdisciplinary team members throughout the disease trajectory including at the end of life. These approaches may enable patients to express their values and care preferences as they evolve over time.

A Qualitative Study of the Work Systems and Culture Around End-of-Day Intraoperative Anesthesia Handoffs in a Tertiary Care Center

BACKGROUND

Intraoperative handoffs have been implicated as a contributing factor in many perioperative adverse events. Despite conflicting data around their impact on perioperative outcomes, they remain a vulnerable point in the perioperative system with significant attention focused on improving them. This study aimed to understand the processes in place surrounding the point of information transfer in intraoperative handoffs.

METHODS

We used semistructured interviews with anesthesia clinicians to understand the processes and systems surrounding intraoperative handoffs. Interview data were coded deductively using the Systems Engineering Initiative for Patient Safety model as a framework, with subthemes developed inductively.

RESULTS

Clinicians do a significant amount of work before and after the point of information transfer to ensure a smooth handoff and safe patient care. Despite not having standardization of handoffs, most clinicians have a typical handoff organization and largely agree on content that should be included. However, there is variability based on clinician and patient characteristics, including clinician discipline and patient acuity. These handoffs are additionally impacted by the overall culture in the operating room, including the teamwork and hierarchies present among the surgical and anesthesia teams. Finally, the broader operating room logistics, including scheduling practices for surgical cases and anesthesia teams, impact the quality of intraoperative handoffs and the ability of clinicians to prepare for these handoffs.

CONCLUSIONS

Handoffs involve processes beyond the point of information transfer and are embedded in the systems and culture of the operating rooms. These considerations are important when seeking to improve the quality of intraoperative handoffs.

Implementation of a standardised accept note to improve communication during inter-hospital transfer: a prospective cohort study

IMPORTANCE

The transfer of patients between hospitals (interhospital transfer, IHT), exposes patients to communication errors and gaps in information exchange.

OBJECTIVE

To design and implement a standardised accept note to improve communication during medical service transfers, and evaluate its impact on patient outcomes.

DESIGN

Prospective interventional cohort study.

SETTING

A 792-bed tertiary care hospital.

PARTICIPANTS

All patient transfers from any acute care hospital to the general medicine, cardiology, oncology and intensive care unit (ICU) services between August 2020 and June 2022.

INTERVENTIONS

A standardised accept note template was developed over a 9-month period with key stakeholder input and embedded in the electronic health record, completed by nurses within the hospital's Access Centre.

MAIN OUTCOMES AND MEASURES

Primary outcome was clinician-reported medical errors collected via surveys of admitting clinicians within 72 hours after IHT patient admission. Secondary outcomes included clinician-reported failures in communication; presence and 'timeliness' of accept note documentation; patient length of stay (LOS) after transfer; rapid response or ICU transfer within 24 hours and in-hospital mortality. All outcomes were analysed postintervention versus preintervention, adjusting for patient demographics, diagnosis, comorbidity, illness severity, admitting service, time of year, hospital COVID census and census of admitting service and admitting team on date of admission.

RESULTS

Of the 1004 and 654 IHT patients during preintervention and postintervention periods, surveys were collected on 735 (73.2%) and 462 (70.6%), respectively. Baseline characteristics were similar among patients in each time period and between survey responders and non-responders. Adjusted analyses demonstrated a 27% reduction in clinician-reported medical error rates postimplementation versus preimplementation (11.5 vs 15.8, adjusted OR (aOR) 0.73, 95% CI 0.53 to 0.99). Secondary outcomes demonstrated lower adjusted odds of clinician-reported failures in communication (aOR 0.88; 0.78 to 0.98) and rapid response/ICU transfer (aOR 0.57; 0.34 to 0.97), and improved presence (aOR 2.30; 1.75 to 3.02) and timeliness (-21.4 hours vs -8.7 hours, p<0.001) of accept note documentation. There were no significant differences in LOS or mortality.

CONCLUSIONS AND RELEVANCE

Among 1658 medical patient transfers, implementing a standardised accept note was associated with improved presence and timeliness of accept note documentation, clinician-reported medical errors, failures in communication and clinical decline following transfer, suggesting that improving communication during IHT can improve patient outcomes.

Improving Handoffs in the Perioperative Environment: A Conceptual Framework of Key Theories, System Factors, Methods, and Core Interventions to Ensure Success

BACKGROUND

Patient handoffs involve the transition of information and responsibility for care from one health care provider to another. They occur frequently during a patient's perioperative care continuum, potentially introducing communication errors that could result in harmful, even fatal consequences. The perioperative environment poses distinct challenges to team communication and patient safety, which in turn leaves the surgical patient uniquely vulnerable to adverse events.

CONCEPTUAL FRAMEWORK

The best way to achieve safe, coordinated handoffs throughout the perioperative continuum has yet to be established. However, a variety of theoretical principles, methods, and interventions have been used successfully in operative and nonoperative contexts among multiple disciplines. Informed by a literature review, the authors describe a conceptual framework for the development, implementation, and sustainment of a multimodal perioperative handoff improvement bundle. The conceptual framework presented here begins with overarching objectives for patient-centered handoff improvement efforts. The article outlines theoretical principles that could be used to guide and inform future multimodal interventions, as well as health care system factors to consider. Further, the authors propose employing data-driven quality improvement and research methodologies to conduct, measure, achieve, and sustain long-term success. Finally, this report describes essential evidence-based interventional components to employ.

IMPLICATIONS

Future efforts to improve handoff safety in the perioperative environment will require a comprehensive evidence-based approach. The authors believe the conceptual framework presented here outlines essential components for success. It integrates proven theoretical frameworks, consideration of system factors, data-driven iterative methods, and synergistic patient-centered interventions.

Leveraging the Science of Teamwork to Sustain Handoff Improvements in Cardiovascular Surgery

BACKGROUND

Improving the reliability of handoffs and care transitions is an important goal for many health care organizations. Increasing evidence shows that human-centered design and improved teamwork can lead to sustainable care transition improvements and better patient outcomes. This study was conducted within a cardiovascular service line at an academic medical center that performs more than 600 surgical procedures annually. A handoff process previously implemented at the center was poorly adopted. This work aimed to improve cardiovascular handoffs by applying human factors and the science of teamwork.

METHODS

The study's quality improvement method used Plan-Do-Study-Act cycles and participatory design and ergonomics to develop, implement, and assess a new handoff process and bundle. Trained observers analyzed video-recorded and live handoffs to assess teamwork, leadership, communication, coordination, cooperation, and sustainability of unit-defined handoff best practices. The intervention included a teamwork-focused redesign process and handoff bundle with supporting cognitive aids and assessment metrics.

RESULTS

The study assessed 153 handoffs in multiple phases over 3 years (2016-2019). Quantitative and qualitative assessments of clinician (teamwork) and implementation outcomes were performed. Compared with the baseline, the observed handoffs demonstrated improved team leadership (p < 0.0001), communication (p < 0.0001), coordination (p = 0.0018), and cooperation (p = 0.007) following the deployment of the handoff bundle. Sustained improvements in fidelity to unit-defined handoff best practices continued 2.3 years post-deployment of the handoff bundle.

CONCLUSION

Participatory design and ergonomics, combined with implementation and safety science principles, can provide an evidence-based approach for sustaining complex sociotechnical change and making handoffs more reliable.