A Review of Verbal and Written Patient Handoffs Applicable to the U.S. Military's Expeditionary Care System

INTRODUCTION

Long considered a danger point in patient care, handoffs and patient care transitions contribute to medical errors and adverse events. Without standardization of patient handoffs, communication breakdowns arise and critical patient information is lost. Minimal training and informal learning have led to a lack of understanding the process involved in this vital aspect of patient care. In 2017, the U.S. Army commissioned a report to study the process of patient handoffs and identify training gaps. Our report summarizes that process and makes recommendations for implementation.

MATERIALS AND METHODS

Scoping literature review of 139 articles published between 1999 and 2017 using PubMed, CINAHL, Cochrane, and Medline databases. Verbal tools for handoffs were evaluated against 12 criteria including patient ID, history, current situation, contingency planning, ability to ask questions, ownership, and read back. Written tools were evaluated against a matrix of 126 casualty/treatment attributes.

RESULTS

Among verbal communication protocols, the highest scoring handoff mnemonics were HAND ME AN ISOBAR, IPASS the BATON, and I-SBARQ. Among written handoff tools, the highest scoring documents were the Special Operations Forces (SOF) Mechanism, Injuries, Signs, and Treatment (MIST) Casualty Treatment Card and the Department of Defense (DD) Form 1380 Tactical Combat Casualty Care (TCCC) Card. Four critical process elements for patient handoffs and transfers were identified: (1) interactive communications, (2) limited interruptions, (3) a process for verification, and (4) an opportunity to review any relevant historical data.

CONCLUSIONS

The findings in this review highlight the need for standardized tools and techniques for patient handoffs in the U.S. Military's expeditionary care system. Future research is needed to trial verbal and nonverbal handoffs under field conditions to gather observational data to assess effectiveness. The results of our gap analyses may provide researchers insight for determining which handoffs to study. If standardized handoffs are utilized, training programs should incorporate the four critical elements into their curricula.

Switching a magnetic vortex by interlayer coupling in epitaxially grown Co/Cu/Py/Cu(001) trilayer disks

Epitaxial Py/Cu/Co/Cu(001) trilayers were patterned into micron sized disks and imaged using element-specific photoemission electron microscopy. By varying the Cu spacer layer thickness, we study how the coupling between the two magnetic layers influences the formation of magnetic vortex states. We find that while the Py and Co disks form magnetic vortex domains when the interlayer coupling is ferromagnetic, the magnetic vortex domains of the Py and Co disks break into anti-parallel aligned multidomains when the interlayer coupling is antiferromagnetic. We explain this result in terms of magnetic flux closure between the Py and Co layers for the antiferromagnetic coupling case.

Predictors of arteriovenous graft patency after radiologic intervention in hemodialysis patients

Arteriovenous grafts in hemodialysis patients are prone to recurrent stenosis and thrombosis, requiring frequent radiologic and surgical interventions to optimize their long-term patency. Little is known about the factors that determine graft outcome after a radiologic intervention. The present study examined the clinical and radiologic predictors of intervention-free graft survival after elective angioplasty or thrombectomy. A prospective computerized database was used to determine the outcomes subsequent to all graft angioplasties (n = 330) and thrombectomies (n = 326) performed at the University of Alabama at Birmingham between April 1, 1996, and June 30, 1999. Primary graft survival rates after angioplasty and thrombectomy were 86% versus 43% at 1 month, 71% versus 30% at 3 months, 51% versus 19% at 6 months, and 28% versus 8% at 12 months, respectively. The median intervention-free graft survival time was substantially longer after angioplasty than thrombectomy (6.7 versus 0.6 months; P < 0.001). The superior outcome of angioplasty over thrombectomy was observed even for the subset of procedures with no residual stenosis (median survival, 6.9 versus 2.5 months; P < 0.001). The median graft survival was inversely related to the magnitude of residual stenosis for both elective angioplasty and thrombectomy. Median intervention-free graft survival after angioplasty was inversely related to the postangioplasty intragraft to systemic systolic pressure ratio (7.6, 6.9, and 5.6 months for ratios <0.4, 0.4 to 0.6, and >0.6, respectively; P < 0.001). Intervention-free graft survival after angioplasty or thrombectomy was not affected by graft location (forearm versus upper arm), number of stenotic sites, or presence of diabetes. In conclusion, graft survival is substantially longer after elective angioplasty than thrombectomy, even when the radiologic appearance after the procedure suggests complete resolution of the stenotic lesion. Moreover, the risk for requiring a subsequent graft intervention can be predicted from two simple radiologic measurements: grade of stenosis and intragraft to systemic systolic blood pressure ratio. These parameters may help determine the frequency of monitoring for recurrent stenosis in a given graft.

Natural history of arteriovenous grafts in hemodialysis patients

Most hemodialysis patients in the United States have an arteriovenous graft as their vascular access. Grafts have a relatively short life span and are prone to recurrent stenosis and thrombosis, requiring multiple salvage procedures to maintain their patency. There is little information in the literature regarding the clinical factors that determine graft survival and complications. We evaluated prospectively the outcomes of 256 grafts placed at a single institution during a 2-year period. A salvage procedure to maintain graft patency (thrombectomy, angioplasty, or surgical revision) was required in 29% of the grafts at 3 months, 52% at 6 months, 77% at 12 months, and 96% at 24 months. Thus, primary graft survival (time from graft placement to the first intervention) was only 23% at 1 year and 4% at 2 years. Primary graft survival was significantly less among patients with hypoalbuminemia compared with patients with a normal serum albumin level (P = 0.003). Secondary graft survival (time from graft placement to permanent graft failure) was 65% at 1 year and 51% at 2 years. Neither primary nor secondary graft survival was significantly correlated with patient age, sex, diabetic status, body mass index, or graft site. A mean of 1.22 interventions per graft-year were required to maintain access patency, including 0.51 thrombectomies, 0.54 angioplasties, and 0.17 surgical revisions. In conclusion, hypoalbuminemia is a strong predictor of the requirement for an early graft intervention. Patients with hypoalbuminemia may require a heightened index of suspicion in monitoring their grafts for evidence of stenosis.

Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies

BACKGROUND

Tunneled dialysis catheters are often used for temporary vascular access in hemodialysis patients, but are complicated by frequent systemic infections. The treatment of bacteremia associated with infected tunneled catheters requires both antibiotic therapy and catheter replacement. We compared the outcomes of two treatment strategies for catheter-associated bacteremia: exchange of the existing catheter with a new one over a guidewire versus catheter removal with delayed replacement.

METHODS

We retrospectively analyzed the outcomes of all cases of tunneled dialysis catheter-associated bacteremia during a two-year period. The infection-free survival time of the subsequent catheter was evaluated in two groups of patients: group A (31 catheters), exchange of the existing infected catheter with a new catheter over a guidewire, and group B (38 catheters), removal of the infected catheter followed by delayed catheter replacement 3 to 10 days later. Patients in both groups received three weeks of systemic antibiotic therapy. Cox proportional hazard models were used to evaluate the factors predictive of infection-free survival time of the replacement catheter.

RESULTS

On univariate proportional hazard regression analysis, the infection-free survival time of the replacement catheter was similar for groups A and B (P = 0.72), whereas the hazard of infection was significantly greater for patients with hypoalbuminemia (serum albumin < 3.5 g/dL), as compared with patients with a normal serum albumin (hazard ratio 2.81, 95% CI, 1. 21, 6.53, P = 0.016). The infection-free survival time was not affected by patient age, sex, diabetic status, or type of organism (gram-positive coccus vs. gram-negative rod).

CONCLUSIONS

The infection-free survival time associated with the subsequent catheter is similar for the two treatment strategies. However, exchanging the catheter for a new one over a guidewire minimizes the number of separate procedures required by the patient. Hypoalbuminemia is the major risk factor for recurrent bacteremia in the replacement catheter.

Brain death in children: characteristic common carotid arterial velocity patterns measured with pulsed Doppler ultrasound

The clinical criteria for brain death in children remain controversial. An accepted confirmatory test for brain death is the documented absence of intracranial blood flow, the most common methods being arteriography and radionuclide cerebral angiography. We correlated the common carotid arterial blood velocity patterns measured by pulsed Doppler ultrasound in 32 brain-dead infants and children with results of their clinical examinations and, whenever possible, with radionuclide cerebral angiography. A distinct, characteristic carotid arterial blood velocity waveform indicating absent cerebral blood flow appeared in 19 of the 23 brain-dead patients 4 months of age or older. The velocity patterns of the other four older children were similar, but not identical, to the characteristic waveform. The remaining nine brain-dead patients were infants 4 months of age or younger. These infants had velocity waveforms different from those of healthy infants, but also were totally different from the characteristic brain death pattern of older children. No patient had the characteristic brain death waveform without being clinically brain dead. Measurement of carotid arterial blood velocity with pulsed Doppler ultrasound is a repeatable, noninvasive, portable test useful for confirmation of brain death in children.

A comparative assessment of home versus hospital comprehensive treatment for advanced cancer patients

A prospective comparative analysis of home and hospital comprehensive treatment for advanced non-ambulatory cancer patients was conducted. Patients were assigned to hospital (group A) and home (group B) treatment groups based on geographic location. Home treatment was provided by the Don Monti Home Oncology Medical Extension (HOME) program. A multidisciplinary health team, including an oncologist, oncology nurse, social worker, dietitian, and medical technologist, was transported to the home in a medically equipped van. Services included physical examinations, pain control, psychosocial interventions, chemotherapy and blood transfusions, nutrition consultation, and bereavement counseling. One hundred seventy-four patients were treated at home and 44 in the hospital. Pretreatment characteristics were similar for both groups, with the exception that age under 50 years was more frequent in the hospital group, and home patients were more likely to have gastrointestinal (GI) cancer. Medical benefits for home treatment included decreased narcotic analgesic requirements, decreased hospitalization and length of stay, and improved measurements of fat stores for female patients. Improved survival for home patients was related to Karnofsky performance status, since there was no difference in survival for sicker patients with lower performance status whether they received home or hospital treatment. Patient and family acceptance of home treatment was excellent. Comprehensive home treatment provided by a multispecialty oncology team is an effective alternative to hospitalization for terminal cancer patients.