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Mauskar S, Ngo T, Haskell H, Mallick N, Mercer AN, Baird J, Bardsley K, Berry JG, Copp K, Humphrey K, Kelly MM, Landrigan CP, Matherson S, McGeachey A, Pinkham A, Rogers JE, Khan A. In their own words: Safety and quality perspectives from families of hospitalized children with medical complexity. J Hosp Med 2023; 18:777-786. [PMID: 37559415 DOI: 10.1002/jhm.13178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/30/2023] [Accepted: 07/17/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Children with medical complexity (CMC) experience adverse events due to multiorgan impairment, frequent hospitalizations, subspecialty care, and dependence on multiple medications/equipment. Their families are well-versed in care and can help identify safety/quality gaps to inform improvements. Although previous studies have shown families identify important safety/quality gaps in hospitals, studies of inpatient safety/quality experience of CMC and their families are limited. To address this gap and identify otherwise unrecognized, family-prioritized areas for improving safety/quality of CMC, we conducted a secondary qualitative analysis of safety reporting surveys among families of CMC. OBJECTIVE Explore safety reports from families of hospitalized CMC to identify areas to improve safety/quality. DESIGNS, SETTINGS AND PARTICIPANTS We analyzed free-text responses from predischarge safety reporting surveys administered to families of CMC at a quaternary children's hospital from April 2018 to November 2020. Using a qualitative descriptive approach, we categorized responses into standard clinical categories. Three team members inductively generated an initial codebook to apply iteratively to responses. Reviewers coded responses collaboratively, resolved discrepancies through consensus, and generated themes. MAIN OUTCOME AND MEASURES Outcomes: family-reported areas of safety/quality improvement. MEASURES pre-discharge family surveys. RESULTS Two hundred and eight/two hundred and thirty-seven (88%) families completed surveys; 83 families offered 138 free-text safety responses about medications, feeds, cares, and other categories. Themes included unmet expectations of hospital care/environment, lack of consistency, provider-patient communication lapses, families' expertise about care, and the value of transparency. CONCLUSION To improve care of CMC and their families, hospitals can manage expectations about hospital limitations, improve consistency of care/communication, acknowledge family expertise, and recognize that family-observed quality concerns can have safety implications. Soliciting family input can help hospitals improve care in meaningful, otherwise unrecognized ways.
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Affiliation(s)
- Sangeeta Mauskar
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Tiffany Ngo
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Helen Haskell
- Mothers Against Medical Error, Columbia, South Carolina, USA
| | - Nandini Mallick
- Family Advisory Council, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alexandra N Mercer
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jennifer Baird
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Kristin Bardsley
- Department of Nursing, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jay G Berry
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine Copp
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kate Humphrey
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle M Kelly
- Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Christopher P Landrigan
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Matherson
- Department of Nursing, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amanda McGeachey
- Maine Children's Cancer Program, The Barbara Bush Children's Hospital at Maine Medical Center, Scarborough, Portland, Maine, USA
| | - Amy Pinkham
- Department of Nursing, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jayne E Rogers
- Department of Nursing, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alisa Khan
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Yanni E, Calaman S, Wiener E, Fine JS, Sagalowsky ST. Implementation of ED I-PASS as a Standardized Handoff Tool in the Pediatric Emergency Department. J Healthc Qual 2023; 45:140-147. [PMID: 37141571 DOI: 10.1097/jhq.0000000000000374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Communication, failures during patient handoffs are a significant cause of medical error. There is a paucity of data on standardized handoff tools for intershift transitions of care in pediatric emergency medicine (PEM). The purpose of this quality improvement (QI) initiative was to improve handoffs between PEM attending physicians (i.e., supervising physicians ultimately responsible for patient care) through the implementation of a modified I-PASS tool (ED I-PASS). Our aims were to: (1) increase the proportion of physicians using ED I-PASS by two-thirds and (2) decrease the proportion reporting information loss during shift change by one-third, over a 6-month period. METHODS After literature and stakeholder review, Expected Disposition, Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver (ED I-PASS) was implemented using iterative Plan-Do-Study-Act cycles, incorporating: trained "super-users"; print and electronic cognitive support tools; direct observation; and general and targeted feedback. Implementation occurred from September to April of 2021, during the height of the COVID-19 pandemic, when patient volumes were significantly lower than prepandemic levels. Data from observed handoffs were collected for process outcomes. Surveys regarding handoff practices were distributed before and after ED I-PASS implementation. RESULTS 82.8% of participants completed follow-up surveys, and 69.6% of PEM physicians were observed performing a handoff. Use of ED I-PASS increased from 7.1% to 87.5% ( p < .001) and the reported perceived loss of important patient information during transitions of care decreased 50%, from 75.0% to 37.5% ( p = .02). Most (76.0%) participants reported satisfaction with ED I-PASS, despite half citing a perceived increase in handoff length. 54.2% reported a concurrent increase in written handoff documentation during the intervention. CONCLUSION ED I-PASS can be successfully implemented among attending physicians in the pediatric emergency department setting. Its use resulted in significant decreases in reported perceived loss of patient information during intershift handoffs.
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Starmer AJ, Spector ND, O’Toole JK, Bismilla Z, Calaman S, Campos ML, Coffey M, Destino LA, Everhart JL, Goldstein J, Graham DA, Hepps JH, Howell EE, Kuzma N, Maynard G, Melvin P, Patel SJ, Popa A, Rosenbluth G, Schnipper JL, Sectish TC, Srivastava R, West DC, Yu CE, Landrigan CP. Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. J Hosp Med 2023; 18:5-14. [PMID: 36326255 PMCID: PMC10964397 DOI: 10.1002/jhm.12979] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Handoff miscommunications are a leading source of medical errors. Harmful medical errors decreased in pediatric academic hospitals following implementation of the I-PASS handoff improvement program. However, implementation across specialties has not been assessed. OBJECTIVE To determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication. DESIGN Prospective Type 2 Hybrid effectiveness implementation study. SETTINGS AND PARTICIPANTS Residents from diverse specialties across 32 hospitals (12 community, 20 academic). INTERVENTION External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews. MAIN OUTCOME AND MEASURES Systematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality. RESULTS 2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participated. 1942 error surveillance reports were collected. Major and minor handoff-related reported adverse events decreased 47% following implementation, from 1.7 to 0.9 major events/person-year (p < .05) and 17.5 to 9.3 minor events/person-year (p < .001). Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20% vs. 66%, p < .001, n = 4812) and written (10% vs. 74%, p < .001, n = 1787) handoffs, as well as increased frequency of handoffs with high quality verbal (39% vs. 81% p < .001) and written (29% vs. 78%, p < .001) patient summaries, verbal (29% vs. 78%, p < .001) and written (24% vs. 73%, p < .001) contingency plans, and verbal receiver syntheses (31% vs. 83%, p < .001). Improvement was similar across provider types (adult vs. pediatric) and settings (community vs. academic).
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Affiliation(s)
- Amy J. Starmer
- Department of Pediatrics, Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy D. Spector
- Section of General Pediatrics, Department of Pediatrics, St. Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
- Department of Pediatrics and Executive Leadership in Academic Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Jennifer K. O’Toole
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Zia Bismilla
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sharon Calaman
- Section of General Pediatrics, Department of Pediatrics, St. Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Maria-Lucia Campos
- Department of Pediatrics, Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maitreya Coffey
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Lauren A. Destino
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Lucile Packard Children’s Hospital Stanford, Palo Alto, California, USA
| | - Jennifer L. Everhart
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Lucile Packard Children’s Hospital Stanford, Palo Alto, California, USA
| | - Jenna Goldstein
- Society for Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Dionne A. Graham
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Jennifer H. Hepps
- Department of Pediatrics, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Eric E. Howell
- Society for Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Nicholas Kuzma
- Section of General Pediatrics, Department of Pediatrics, St. Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Greg Maynard
- Society for Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Patrice Melvin
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Shilpa J. Patel
- Department of Pediatrics, Kapi’olani Medical Center for Women and Children/University of Hawai’i John A. Burns School of Medicine, Honolulu, Hawaii, USA
| | - Alina Popa
- Department of Medicine, University of California Riverside, Riverside, California, USA
- Division of Hospital Medicine, University of California San Diego, San Diego, California, USA
| | - Glenn Rosenbluth
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, California, USA
| | - Jeffrey L. Schnipper
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Theodore C. Sectish
- Department of Pediatrics, Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rajendu Srivastava
- Department of Pediatrics, Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Healthcare Delivery Institute, Intermountain Healthcare, Murray, Utah, USA
| | - Daniel C. West
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clifton E. Yu
- Department of Pediatrics, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Christopher P. Landrigan
- Department of Pediatrics, Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Affiliation(s)
- David Shahian
- Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts, USA
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Abstract
Introduction Handoff miscommunications are a leading cause of medical errors. A structured handoff is an effective communication tool. We introduced the I-PASS Handoff Bundle for resident sign-out in the inpatient setting. We aimed to reduce preventable adverse events and unexpected floor calls while also improving residents' confidence and preparedness to care for patients overnight. Methods We conducted an observational study at a single-site family medicine residency between April 2019 and March 2020. Residents received trainings in the I-PASS standardized handoff through didactic lectures and on-the-job sessions in September and November 2019. We evaluated the effectiveness of the I-PASS Handoff Bundle by comparing pre- and postimplementation data including number of medical errors and unexpected floor calls, along with residents' reported levels of preparedness and confidence to care for patients overnight. Results Prior to the I-PASS intervention, more than half of resident surveys included at least one unexpected floor call whereas postintervention about one-third of resident surveys included unexpected floor calls (P<.05). However, the intervention did not significantly affect residents' confidence level in caring for patients overnight and residents' rating of the usefulness of anticipatory guidance for managing night floor calls. We did not identify any medical errors related to communication issues at patient handoff within the family medicine service. Conclusion I-PASS intervention significantly reduced unexpected floor calls. However, the intervention did not improve residents' reported confidence and preparedness to care for patients overnight.
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Affiliation(s)
- Kento Sonoda
- Department of Family Medicine, University of Pittsburgh Medical Center Shadyside, Pittsburgh, PA
| | - Lindsay Nakaishi
- Department of Family Medicine, University of Pittsburgh Medical Center Shadyside, Pittsburgh, PA
| | - Cynthia Salter
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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Abstract
BACKGROUND The Pediatric Hospital Medicine (PHM) Core Competencies define the expertise required of practitioners and provide a framework for educational activities. Since initial publication in 2010, the scope of practice for pediatric hospitalists has evolved in clinical, research, administrative, and educational arenas. OBJECTIVE To describe the methodology utilized in the revision of The PHM Core Competencies to ensure a product reflective of current roles and expectations for pediatric hospitalists across all training pathways and practice settings. METHODS The Society of Hospital Medicine (SHM) Pediatrics Special Interest Group supported the initiation of the revision. A diverse group of editors and authors was engaged from among members of SHM, the American Academy of Pediatrics and the Academic Pediatrics Association. Editorial roles were expanded to represent all practice settings. More than 80 individuals contributed, representing both university and community sites, and all US geographic regions. Editors conducted a two-part needs assessment; a survey related to content was distributed to the PHM community and content from recent conferences and PHM related publications was reviewed. The final compendium consists of 4 sections and 66 chapters, including 12 new chapters and 36 chapters with substantial changes. Individual chapters and the entire compendium underwent rigorous internal and external review. CONCLUSION The PHM Core Competencies: 2020 Revision reflects the work of a broad spectrum of PHM practitioners responding to the practice and educational changes in PHM over the past decade. The compendium can inform education, training, and career development for pediatric hospitalists practicing now and in coming years.
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Affiliation(s)
- Jennifer Maniscalco
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Sandra Gage
- Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona
- Division of Hospital Medicine, Phoenix Children's Hospital, Phoenix, Arizona
| | | | - Erin Stucky Fisher
- Department of Pediatrics, University of California San Diego School of Medicine, San Diego, California
- Rady Children's Hospital San Diego, San Diego, California
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Krishnan S, Kumar N, Diaz E, Thornton I, Ghoddoussi F, Ellis TA. Anesthesiology Handoff Simulation Case: A Handoff From Intensive Care Unit to Operating Room for Anesthesiology Learners. MedEdPORTAL 2020; 16:10887. [PMID: 32206703 PMCID: PMC7083603 DOI: 10.15766/mep_2374-8265.10887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 09/20/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Handoffs have been shown to be a potential cause of communication failures, leading to possible inefficiencies and patient harm. We noticed that our CA-1 residents were struggling with patient handoffs and designed this simulation to improve their handoff skills. METHODS This anesthesiology-specific simulation introduced learners to the perioperative handoff process. We designed it for anesthesiology learners, including junior residents, medical students, and student nurse anesthetists. The simulation centered upon an anesthesiology resident taking care of an ICU patient and handing that patient off to another anesthesiology provider, who took the patient to the OR. We charged learners with reviewing the patient's history and hospital course and giving a complete handoff. We evaluated learners on the completeness and quality of the handoff, as well as on their performance during the session. RESULTS Twenty-seven learners participated in this handoff simulation. The participants reported that the simulation improved their understanding of the anesthetic implications of medical conditions and gave them a better understanding of the essential elements of a handoff. Learners also indicated that the debriefing portion of the simulation was effective in filling some of their medical knowledge gaps and improving their handoff skills. DISCUSSION This simulation was found to be an effective educational experience for our CA-1 and CA-3 residents, medical students, and student nurse anesthetists. Feedback was positive from all learners. As a result, this simulation will be implemented in the early learning curriculum for all of our CA-1 residents.
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Affiliation(s)
- Sandeep Krishnan
- Associate Professor, Department of Anesthesiology, Wayne State University School of Medicine
- Program Director, Department of Anesthesiology, Wayne State University School of Medicine
- Chief of Cardiothoracic Anesthesiology, Department of Anesthesiology, Wayne State University School of Medicine
| | - Nakul Kumar
- Resident Physician, Department of Anesthesiology, The Cleveland Clinic
| | - Erik Diaz
- Resident Physician, Department of Anesthesiology, Wayne State University School of Medicine
| | - Imani Thornton
- Assistant Professor, Department of Anesthesiology, Wayne State University School of Medicine
| | - Farhad Ghoddoussi
- Research Associate, Department of Anesthesiology, Wayne State University School of Medicine
| | - Terry A. Ellis
- Associate Professor, Department of Anesthesiology, Wayne State University School of Medicine
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Abstract
BACKGROUND A formal handoff process, such as the I-PASS handoff program, can improve communication about patients among residents. Faculty observation of resident handoffs has served as the primary method for documenting adherence to I-PASS, and little is known about residents' use when they are not being observed. OBJECTIVE We determined how frequently pediatric residents use I-PASS when not being observed. METHODS We implemented I-PASS in the 2016-2017 academic year and anonymously surveyed residents (December 2016 and June 2017), asking them how they perceive the effectiveness of I-PASS at enhancing patient safety, their frequency of I-PASS use when not observed, co-residents' frequency of use, and open-ended questions regarding factors affecting use. RESULTS Fifty-one (52%) and 50 (51%) of 99 eligible residents completed the December and June surveys, respectively. All respondents thought I-PASS had some effectiveness in enhancing patient safety. In December, only 6 (12%) residents stated they used I-PASS more than 75% of the time and reported providing a synthesis statement during handoffs more than 75% of the time. The results were similar for both surveys. Commonly cited reasons for not using I-PASS included time (n = 30), prior knowledge of patients (n = 20), and patients with limited complexity (n = 9). CONCLUSIONS While most residents thought I-PASS was effective at enhancing patient safety, many reported that they do not use all 5 elements in most of their handoffs when not being observed. Barriers reported included time, familiarity with patients, and limited patient complexity.
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