AAIMJWS 115_Teaching Handoff Skills_Evans

7/27/2019 AAIMJWS 115_Teaching Handoff Skills_Evans

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Achieving Competence WhileMaximizing Faculty Resources

A Joint Educational Project of:

Northwestern University

The Ohio State University

Workshop outline:

Intro on handoffs (15min interactive case)

v ence or an o s caus ng arm

Brief handoff quiz (audience participation)

Results: confidence, knowledge, outcomes

Residency program perspective

Assessin SBP & PBLI com etencies

OSU experience with our web-based cases

Program coordinator perspective, logistics

Invitation for other sites, questions



The importance of

A cautionary tale …



Patient Handoffs & Adverse Events

Why the big fuss over handoffs?

70% of >7,000 RCA’s at the VAmp ca e commun ca on a ure

Joint Commission estimatedcommunication failures were the rootcause of >70% of hospital sentinelevents between ears 1994-2004

More than half of thesecommunication failures resulted frompoor handoffs



And since ‘04 things v w …

ACGME work-hrs restrictions in

of handoffs by 10-40%

(? consequences of 2011?)

Some sobering handoff facts:

Average inpatient will have 15 handoffs

A member from the 1° team is present just 48% of the time and cross-coverageis estimated to triple the odds of AE’s

An intern may have 300 handoffs in 1 mth

A recent review of IM signouts found that

7% were inadequate or contained an error And don’t even get me started about

discharge handoffs!



Let’s do the math…

an a m ss on s na equa e orof admissions – then an intern might harm2 patients over the course of a month

If the same intern has inadequacies ono e r an o s - en ey cou

harm as many as 20 patients in 1 month

We emphasize H&P skills

v y

But as recently as 2004 -- just 8% of

formal teaching on handoffs skills



u

So let’s test your knowledge

handoff pitfalls

Brief Handoff Quiz



True or false: The incidence of an adverse eventur ng a typ ca osp ta stay s approx mate y - .

True or false: In a study analyzing written nightfloat

signout documents- medication discrepancies were

found to be common but these discrepanciesa po en a or arm.



In a prospective 12 day observational study of 300+

consecutive signouts, which of the following wasfound to be the most common cause of signout

errors ne c enc es m ss ons o …

On a general medicine service, how many patients (on

average) would you need to discharge to cause one

adverse MEDICATION event b the end of 4 weeks.



Which of the following statements is the best way toend a verbal handoff to a nightfloat colleague

So we’ve identified some clear

handoff knowledge blindspots

Therefore our trainees should

-issues – right?



Handoff Confidence:

On a 5 pt Likert scale- 60% of PGY1s rated their’ ’

60% of M4 subinterns rated their baselineconfidence at 4 or 5 -- in spite of having anaverage of just 1 hour of prior instruction!

M4 subinterns were just as confident as PGY1’s

In spite o scoring an average o 45% on ourknowledge pre-test … trainee self-rating of

handoff knowledge was 3.6

A silver lining … our trainee’s

are recept ve to teac ng

We created a 3 hour, independent

PGY1 trainees …

And they actually liked it!



“The web-based handoff modules

were a good use of my time”

ur rs year o s u en s = :

Strongly disagree 2

Disagree 8

Uncertain 15

Agree 79

Strongly agree 39

Average rating: 4.0

Can a web-based curriculum work?

Confidence improved across the board

va ues . or a ques ons

Scores on our pre/post knowledge testimproved from 45% to 76% (P < 0.001)

Self report: “The web-based handoff

mo u es mprove my c n ca per ormanceduring ACTUAL patient handoffs”

Average rating 4.0

119 out of 143 agreed or strongly agreed

Only 5 disagreed



Why use a web-based format?

Handoffs are important- but not very exciting to

Delivering all the core material would takemultiple sessions and significant use of facultyresources on a recurrent basis

Faculty development and EBM update issues

Competency issues: we need to capture 100% of

-M4 or PGY1 trainees

We captured 98% of our target audience



Evaluating SBP & PBLI

Handoffs are a great opportunity to-

Reflecting on handoffs can be a greatchance for practice-based learning

Ways to assess handoff performance

OSCE evaluation

e ec on on wr en an o s w scorecar

Reflection on discharge summaries (scorecard)

Encouraging handoff “ownership”

A common problem voiced by handoff “ ’ ”

mentality of some swing shift MDs

How can you change this culture?

Use data/statistics to reinforce the risk of AE’s

rea on o a con rac or sa e an o s



Best reason to use a

-

Because it’s portable!



www.medicine.northwestern.edu /students/osu-students

Experience with a web-

u u u

The Ohio State Handoff study

o a ora ve



A coordinator’sperspective on using a

we - ase curr cu um



References: Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-

to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12):1094-9.

Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing Discontinuity in Academic Medical- -. .

Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW,Bates DW, Czeisler CA. Effect of reducing interns' work hours on serious medical errors in intensive careunits. N Engl J Med. 2004 Oct 28;351(18):1838-48.

Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internalmedicine wards: a national survey. Arch Intern Med. 2006 Jun 12;166(11):1173-7.

Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase therisk for preventable adverse events? Ann Intern Med. 1994 Dec 1;121(11):866-72.

Horowitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of Inadequate Signout for PatientCare. Arch Int Med 2008 Sept; 168(16):1755-1760.

Wong BM, Etchells EE, Kuper A, Levinson W, Shojania KG. Teaching Quality Improvement and Patient Safetyto Trainees: A Systematic Review. Acad Med. 2010 Jun 10.

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inpatient to an outpatient setting. J Gen Intern Med. 2003 Aug;18(8):646-51. Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, Khan A, van Walraven C. Adverse events

among medical patients after discharge from hospital. CMAJ. 2004 Feb 3;170(3):345-9. Erratum in: CMAJ.2004 Mar 2;170(5):771.

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication andinformation transfer between hospital-based and primary care physicians: implications for patient safety andcontinuity of care. JAMA. 2007 Feb 28;297(8):831-41.

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References: Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital

discharge. J Gen Intern Med. 2005 Apr;20(4):317-23.

Roy CL, Poon EG, Karson AS, Ladak-Merchant Z, Johnson RE, Maviglia SM, Gandhi TK. Patient safety. .

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Flacker J, Park W, Sims A. Hospital discharge information and older patients: do they get what they need?J Hosp Med. 2007 Sep;2(5):291-6.

Halasyamani L, Kripalani S, Coleman E, Schnipper J, van Walraven C, Nagamine J, Torcson P, Bookwalter T,Budnitz T, Manning D. Transition of care for hospitalized elderly patients--development of a dischargechecklist for hospitalists. J Hosp Med. 2006 Nov;1(6):354-60.

Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospitaldischarge: a review of key issues for hospitalists. J Hosp Med. 2007 Sep;2(5):314-23. Review.

Singh H, Thomas EJ, Petersen LA, Studdert DM. Medical errors involving trainees: a study of closedmalpractice claims from 5 insurers. Arch Intern Med. 2007 Oct 22;167(19):2030-6.

Mason WT, Strike PW. See one, do one, teach one--is this s till how it works? A comparison of the medicaland nursing professions in the teaching of practical procedures. Med Teach. 2003 Nov;25(6):664-6.

Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out andsuggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005 Dec;14(6):401-7.

Arora V, Kao J, Lovinger D, Seiden S, Meltzer D. Medication Discrepancies in Resident Sign-outs and theirPotential to Harm. J Gen Intern Med. Oct 2007; 22(12): 1751-5.

Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients?Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009 Aug;18(4):248-55.

Kitch BT, Cooper JB, et al. Handoffs causing patient harm: survey of medical & surgical housestaff. Jt CommJ Qual Patient Saf. 2008 Oct;34(10):563-70.

References: Horwitz LI, Moin T, Green ML. Development and implementation of an oral sign-out skills curriculum. J Gen

Intern Med. 2007 Oct;22(10):1470-4.

Chu E., Reid M, et al. A Structured Handoff Program for Interns. Acad Med 2009; 84: 347-352.

r , ., v - r u , r r , .

Myers JS, Jaipaul CK, Kogan JR, Krekun S, Bellini LM, Shea JA. Are discharge summaries teachable? Theeffects of a discharge summary curriculum on the quality of discharge summaries in an internal medicineresidency program. Acad Med. 2006 Oct;81(10 Suppl):S5-8.

Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002 Mar;17(3):186-92.

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Petersen LA, Orav EJ, Teich JM, O'Neil AC, Brennan TA. Using a computerized sign-out program to improvecontinuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998 Feb;24(2):77-87.

O’Leary KJ, Liebovitz DM, Feinglass J, LissDT, Evans DB, Kulkarni N, Landler MP, Baker DW. Creating aBetter Discharge Summary: Improvement in Quality and Timeliness Using an Electronic DischargeSummary. Journal of Hospital Medicine,2009;4:219-225.



Summary outline:

Intro on handoffs (15min interactive case)

v ence or an o s caus ng arm

Brief handoff quiz (audience participation)

Results: confidence, knowledge, outcomes

Residency program perspective

Assessin SBP & PBLI com etencies

OSU experience with our web-based cases

Program coordinator perspective, logistics

Invitation for other sites, questions

Documents

AAIMJWS 115_Teaching Handoff Skills_Evans