Handoffs & Signouts

Handoffs & Signouts Ryutaro Hirose, MD Associate Program Director Surgical Residency University of California, San Francisco

UCSF Handoff Task force • Arpana Vidyarthi • Susan Promes • Glenn Rosenbluth • Brad Sharpe • John Young • Jonathan Carter • Bobby Baron

Handoff - definitions • A gap in care = Handoff • Caregiver 1 Caregiver 2 • Transfer of care • Represents patient vulnerability • SIGNOUT = information transfer to close gap in care • a source of potential error • miscommunication • can contribute to suboptimal care HANDOFF SIGNOUT

Handoffs • We in surgery have resisted handoffs • Continuity of care • Professionalism • Work ethic • anti-'shift mentality' • relationship between surgeon and patient • As a direct result of the changing environment, regulations, restrictions regarding duty hours, HANDOFFS ARE HERE TO STAY.

Needs • Understanding of the new medical landscape regarding handoffs • Understand the scope of discontinuity in inpatient care • Identify continuity of care (lack thereof) as a safety and malpractice vulnerability • To promote the quality of care through improvements in communication to counteract the challenges of discontinuity of care

ACGME Duty hours regulations (7/1/11) • VI.G.4.a) Duty periods of PGY-1 residents must not exceed 16 hours in • duration. • VI.G.4.b) Duty periods of PGY-2 residents and above may be scheduled to • a maximum of 24 hours of continuous duty in the hospital. • VI.G.4.b).(1) It is essential for patient safety and resident education that effective transitions in care occur. Residents may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours. • VI.G.4.b).(2) Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty. • VI.G.4.b).(3) In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family.

ACGME Common Program Requirements (effective 7/1/2011) • VI.B. Transitions of Care • VI.B.1. Programs must design clinical assignments to minimize the number of transitions in patient care. • VI.B.2. Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety. • VI.B.3. Programs must ensure that residents are competent in communicating with team members in the hand-over process.

Duty hours regulations • To fight fatigue • To reduce errors • with new ACGME regulations, by necessity, there will be more handoffs, more discontinuity • at UCSF – one day = 4000 handoffs (1.5 million handoffs/year)

Definition - Signout • The transfer of information, professional responsibility and accountability between individuals and teams • Joint Commission: " A contemporaneous, interactive process of passing patient information from one caregiver to another for the purpose of ensuring the continuity and safety of patient care"

Root cause of sentinel events - JC • Root Cause Information for Op/Post-op Complication Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) 2004 through Second Quarter 2011 (N=563) • The majority of events have multiple root causes • Human Factors 334 • Communication 315 • Assessment 295 • Leadership 240 • Information Management 121 • Operative Care 91 • Physical Environment 69 • Care Planning 67 • Medication Use 56 • Continuum of Care 47

The Joint Commission • JC data show that communication is identified in 65%-75% of root cause analyses • In 2006 National Patient Safety Goals • 'Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions'

Other calls to improve handoffs • World Health Organization, 2006 • prevention of handover errors part of "high fives" patient solutions • Institute of Medicine, 2008 re: Residency duty hours • Teaching programs "should train residents in how to hand over their patients using effective communications"

Medico-legal implications • Handoffs are a major contributing factor in trainee related malpractice cases and more frequently affect trainee cases than attending only cases • Missed and delayed diagnoses – studies of closed malpractice claims • COMMUNICATION FAILURES • ambulatory: 20% • ED: 24% • Trainees across specialties 70% linked to teamwork issues – the most prevalent type was HANDOFF failures

Root cause of errors-discontinuity of care • Studied factors associated with hospital based medical preventable adverse event • Most significant risk factor for preventable adverse events: presence of a CROSS COVERING MD • Odds ratio: 6.2 • Petersen Ann Intern Med 1994

Residents perception • Residents believe handoffs are dangerous • Handoffs result in suboptimal care practice • 59% report patient harm • increased errors from discontinuity

Is it the gap or is it the signout? • First year residents interviewed • Communication failures N=25 • Content omissions N=22 • failure to report an active medical problem • failure to report medication/other Rx • Failure to report pending/ordered dx tests or consult • Failure-prone communication processes N=8 • no face-to-face communication • interruptions • illegible/unclear notes • Led to uncertainty in clinical decisions AroraQualSaf Health Care 2005

Other analyses • Emergency medicine • Handoff is the gray zone • Errors due to communcation failures • Incomplete information • high workload • pending data • ambiguity • Surgery • Information transfer lapses • Blurred boundaries of responsibility • decreased familiarity of patients • diversion of attention • distorted or inhibited communication

Errors due to discontinuity • Delayed test ordering • Increased in-hospital complciations • increased medication errors • Presumed increase in LOS • Errors in communication result in preventable deaths

Hospitalists/faculty • Hospitalists report various categories of 'missed information' during service change (71%) • hospital course • future plans • disagreements over management • Adverse and near miss events arising from missed information (57%)

Structure: Non-Medical Handoffs • Aviation • NASA, Nuclear Plants, EMS, Railroad dispatch • F1 Racing

Strategies for effective handoff from other industries • Direct observations of handoffs at NASA, 2 Canadian nuclear power plants, a railroad dispatch center, and an ambulance dispatch center • Strategies include: • STANDARDIZE – use same order or template • Update information • Limit interruptions • Face to face verbal update • with interactive questioning • Structure includes • Read-back to ensure accuracy

Signoffs are a form of communication • Effective channels vs. ineffective channels

Efficacy of communication channels

Structure - Medical Mnemonics • AIDET, ANTIcipate, ASHICE, CUBAN, DeMIST, GRRRR, HANDOFFS, I PASS the BATON, Just Go NUTS, MIST, PACE, PEDIATRIC, SBAR, I-SBAR, SBARR, SBAR-T, SHARED, SHARQ, SIGNOUT, SOAP, STICC, 4P's, 5P's V.1, 5P's V.2 • SBAR: Situation-Background-Assessment-Recommendation • Most frequently cited (70%) • reported by anesthesiologists, ED staff, midlevels, nurses, OR staff, PACU staff, periop staff, pharmacists, physical therapists, physicians, transporters, radiologists

Structure – SIGNOUT? • Sick or DNR • Identifying data • General hospital course • New events (of the day/12-24 hours) • update the clinical data • Overall health status/clinical conditions/comorbidities • Upcoming possibilities/ possible problems/contingency plans/rationale • Tasks – Pending tests, anticipate results, Plan/Rationale • ?'s

SIGNOUT? • Sick/DNR – Focus on sick patients. Management plan, contingency plan, threshold for higher level of care. Residents should see the sick patients BEFORE they are called • Identifying Data – who the patient is, where they are located, age • General Hospital Course – Surgery date/type, post-op complications, Abx, Diet, Meds, general pathway • New events of the day – emphasize major events, those patients that went off trajectory

SIGNOUT? (continued) • Overall health status/clinical condition – Important comorbidities, medications, etc • Upcoming possibilities/plan rationale – Anticipate problems • Tasks/rationale/plan – Outstanding information to be gathered, outstanding labs/studies/consults. Who needs to be informed. • ?'s – Needs to be an active process, receiver understands, readback,

Elements of an effective signout • Face – to – face • Needs Structure/Template • Ensure enough time • Limit interruptions • Interactive process, communication, questions • Use a process of verification • Use a written tool – computerized, EMR • Up to date and accurate and succinct information • use as an opportunity to review important and relevant historical data • (It is a teaching/learning moment)

Psychology of miscommunication • Overestimation of understanding • Senders systematically overestimate how well their messages are understood by listeners • Egocentric heuristic • Senders assume that receiver has the same knowledge as they do • These worsens with the personal familiarity of the receiver

Does this occur in medical handoffs ? – U of C Pediatric • Ask senders to guess what receivers would say was THE MOST important piece of information for each patient • The most important piece of information was NOT communicated 60% of the time • Did not agree on the rationales provided for 60% of the items • at times completely contradictory

Receiver – what did the sender say? • Read-back/repeat back on all to-do items • If- then statements • Read back – reduces errors in communication • Examples in industry • Examples in medical environment: Lab reporting

Senders – think about the Reveiver (4R's) • Relevant items that will be Remembered • Focus on sickest patients first • Daily progress (today's baseline, updated events) • To Do items, IF/Then • Directions with Rationale • avoid ambiguity. Don't say 'check CBC' • check for Receiver Understanding • Encourage questions and Read-back • Overcome egocentric heuristic – put yourself in the shoes of the receiver • the handoff is a TEACHING opportunity

Receivers • Actively listen • stay focused, limit interruptions, take notes • Ask questions • to ensure you understand tasks and rationale • the handoff is a learning opportunity • Use a system • to keep prioritize, track of to do items that require action • Read-back • information, tasks, rationale to ensure you are both on the same page

EMR pitfalls - CoPaGA syndrome • Copy and Paste Gone Amok • Repeated selecting, copying and pasting text from past EMR notes into current notes, the physician-victim accomplishes the following: • avoids time-consuming work of actually talking to the patient • builds a documentation trail that portrays thorough, CMS compliant, level V billing faux work • crowds out useful information by a glut of useless, irrelevant, outdated data • zombie-like propagation and dissemination of inaccuracies, chart lore, myth, (mutations) that self-replicate and persist • CORRECT INACCURACIES in the EMR!

Written sign out tool pitfalls: TMI • the sign out tool becomes a unnecessarily long shadow chart • becomes a personal tracker of information • Used to keep track of everything – obscures what is going on right now • Loses its primary function for the receiver

Handoff Best Practices • A Written and Verbal component • There is a checklist for both • Think about • WHO: who is the sender and who is the receiver • level of experience • WHAT: • for how long • a few hours • for a weekend • for good? • HOW: • too often a one way street. NOT EFFECTIVE • has to be a dialogue. without questions, this is inadequate

the future… • Education • Technology • EMR • APEX • increase continuity? • monitoring? • culture change regarding handoffs

Summary • Discontinuity is harmful • Handoffs are complex • Signoffs can ameliorate or exacerbate effects of handoffs • Structure – Template - EMR • Improve process – make it an active process • Help our patients!

Handoffs & Signouts