Transitions of Care in the Training Environment: ACGME Standards

1. Transitions of Care in the Training Environment: ACGME Standards Bradley F. Marple, MD Professor and Vice-Chair Otolaryngology Associate Dean Graduate Medical Ed Designated Institutional Official University of Texas Southwestern Medical Center

2. ACGME Highlights Its Standards on Resident Duty Hours - May 2001 • Work hour limits introduced in 2003 with intent to: • Decrease fatigue • resident safety • safety and effectiveness of patient care • “The ACGME believes that it is ill advised to "carve out" a section of this environment - resident duty hours - in a way that does not consider the other elements essential to the quality of the educational process. There is a significant potential for an unanticipated impact that may be detrimental to high quality education and safe and effective patient care. “ http://www.acgme.org/acwebsite/resinfo/ri_osharesp.asp

3. Objective • ACGME implemented duty hours to mitigate fatigue-related risk • Goal was to determine impact upon work hours, sleep, and safety • Methods • Prospective cohort study during implementation of duty hours • 3 pediatric programs • Reported MVCs, occupational exposures, med errors, educational experience, depression, and burn-out • 220 residents reported • 6007 daily reports of work hours and sleep • 16,158 medication orders

6. Conclusions • No change in • Work hours • Sleep • Depression • Resident injuries • Educational ratings • Improvements • Resident burn-out • Worsened • Medication errors

7. CPR VI.B Transitions of Care • VI.B.1 – Programs must design clinical assignments to minimize the number of transitions in patient care

8. Transitions of care • Continuity of care constitutes an important aspect of quality • Continuity of care is challenged • Teaching environment • Multiple specialties • Modalities of care • Transitions • Providers • Provider teams • Units • Impact of ACGME duty hours on transitions • Before 2003 - single transfer of care • After 2003 – 2 or more physicians 2-3 times per day. Riebschleger M, Philibert I. 2011ACGME Duty Hour Standards

9. Transitions of care • Each transition of care creates and opportunity for information to be lost or distorted • Handoffs are a major contributing factor in trainee-related malpractice cases • Malpractice more frequent when trainees are involved in care as compared to attending-only cases (19% vs 13%, p-0.02) Scoglietti VC, et al. Am Surg. 2010;76(7):682-686. Arora V, et al. J Gen Intern Med. 2007;22(12):1751-1755 Singh H et al. Arch Intern Med. 2007;167(19):2030-2036

10. CPR VI.B Transitions of 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

11. More unintended consequences • Impact of increased limits on duty hours • More hand-overs • Increased “Cross-cover” (defined as outside the primary care team) • Increased likelihood for unplanned changes in care • Asynchronous handoffs • Fewer person to person interactions • Creates need for • Structure • Process • Education

12. Impact upon Patient Safety • Patients with potentially preventable AEs were more likely to be covered by a physician from another team (cross-cover) at the time of the event (OR 3.5;P=0.01) • Peterson LA et al. “Academia and Clinic: Does Housestaff Discontinuity of Care Increase the Risk for Preventable Adverse Events?” Ann Int Med 1994;121:866-872. • A member of the primary team was in the hospital for only 47% of the hospitalization • Horwitz LI et al. “Transfers of patient care between house staff on internal medicine wards: a national survey” Arch Intern Med 2006;166(11);1173-7.

13. Impact of Transition on Patient Safety • MGH Residents • 59% reported “problematic handoffs” caused harm to one or more patients on most recent clinical rotation • 12% reported cases of “major” harm • 31% reported quality of handoffs as “fair or poor” • Handoffs were rarely quiet • Handoffs were frequently interrupted • Led to “handoff-safety education program” for housestaff intended to improve safety and effectiveness of handoffs Kitch BT et al. JtComm J Qual Patient Saf. 2008;34(10):563-570.

14. 2006 Joint Commission • TJC data revealed that communication is identified in 65-70% of root cause analyses • TJC formalized a “standardized approach to hand-off communications” in 2006, which included: • Interactive communications • Up-to-date and accurate information • Limited interruptions • A process for verification • An opportunity to review relevant historical data Adamski P. Nurs Manage. 2007;38:10-12. AHRQ. “Patient Safety Primer: Handoffs and Signoffs.” http://psnet.ahrq.gov/primer.asp?primerID=9 Arora V, et al. JtComm J Qual Patent Saf. 2006;31(11):646-655

15. CPR VI.B Transitions of Care • VI.B.3 – Programs must ensure that residents are competent in communicating with team members in the hand-over process. ACGME 2011 Common Program Requirements. www.acgme.org

16. Impact of Communication on Patient Safety • Audiotaped handoffs for 8 IM housestaff teams and compared written handoff forms • Median duration was 35 seconds per patient • Only 50% of verbal and 38% of written handoffs included comments on current clinical condition • 59% included no questions from recipient • 22% contained omissions of mischaracterizations on data Horwitz LI et al. QualSaf Health Care. 2009;18(4):248-255.

17. Impact of Communication on Patient Safety • Chang V et al. Pediatrics 2010;125(3):491-496 • 60% of handoffs did not include the “most important piece of information” despite post-call intern thinking it had • 60% disagreement in on-call vs. post-call decision rationale. • McSweeny ME et al. ClinPediatr. 2011;50:57-63 • Only 19% reported that written sign-outs reflected actual current clinical information and management plans.

18. Conclusions • Changes in the work environment have increased the need to focus upon various aspects of transition of care • ACGME 2011 CPR focus upon three major areas • Decreasing numbers of handoffs • Creation of standardized handoffs • Accurate communication • Potential solutions • Redundancy of systems • Education • Evaluation of the transitions process • Focused supevision • Feedback • Skills-based examinations