The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group

1. The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group Clinical Handoffs Ayse P. Gurses, PhD agurses1@jhmi.edu April 1, 2011 Immersion Call

2. Immersion Call Schedule

3. Communication breakdowns as Root Cause of Errors Communication breakdowns are frequently the root cause of… undesirable outcomes

4. Definitions of Handoff • “The transfer of information, along with authority and responsibility, during transitions in care across the continuum for the purpose of ensuring the continuity and safety of the patient’s care.”1 • “When responsibility for a patient is passed from one caregiver to another or when patient information is transferred from one type of healthcare organization to another or to a patient’s home”2 • “To communicate patient information to facilitate continuity in the plan of care”3 1. Standardizing Handoffs for Patient Safety, AORN, 2010. 2. Communication during patient hand-overs, Joint Commission, 2007. 3. Streitenberger K,Pediatric Clinics of North America, 2006.

5. Primary Objective • “The primary objective of a “hand off ” is to provide accurate information about a [patient’s] care, treatment, and services, current condition and any recent or anticipated changes. The information communicated during a hand off must be accurate in order to meet [patient] safety goals.”1 1. Meeting the Joint Commission 2008 National Patient Safety Goals, Joint Commission, 2007.

6. Different types of handoffs • Within hospital • One care provider to another Nurse to nurse handoff intra-operatively • One unit/ team of care providers to another unit/ team of care provider • Handoff of patient from • OR to PACU/ICU after cardiac surgery • ICU to floor • Transfers to and from hospital • Transfer to skilled nursing facility or home after having cardiac surgery

7. Patient Safety Hazards in Handoffs • Patients are particularly vulnerable during handoffs because pertinent care information may be incorrectly communicated or not communicated at all • Nearly 70% of sentinel events were caused by communication breakdowns1 • Evidence suggested that at least half of these communication breakdowns occurred during patient handoffs1 1. Improving Handoff Communications: Meeting National Patient Safety Goal 2E, Joint Comm Perspectives on Patient Safety, 2006.

8. Evidence of Harm • Higher readmission rates8 • Malpractice claims9 • Serious adverse events10 • Redundancies in • Procedures11 • Tests11 • Medication errors1,2 • Delays • Test ordering3 • Medical diagnosis4 • Treatment4 • Increased number of hospital complications3 • Wrong treatment5 • Increased length of stay6,7 • Higher costs8 1. Lofgren RP, Gottlieb D, Williams RA, et al., J Gen Intern Med, 1990. 2. Gottlieb DJ, Parenti CM, Peterson CA, et al., Arch Intern Med, 1991. 3. Laine C, Goldman L, Soukup JR, et al., JAMA, 1993. 4. Patterson ES, Wears RL, Jt Comm J Qual Patient Saf, 2010. 5. Australian Council for Safety and Quality in Health Care, 2005. 6. Lofgren RP, Gottlieb D, Williams RA, et al., J Gen Intern Med, 1990. 7. Gottlieb DJ, Parenti CM, Peterson CA, et al., Arch Intern Med, 1991. 8. Lawrence R.H., et al., BMC Health Serv Res, 2008. 9. Kachalia A, Gandhi TK, Puopolo AL, et al., Ann Emerg Med, 2007. 10. Risser D.T., et al., Ann Emerg Med, 1999. 11. Lawrence R.H., et al., BMC Health Serv Res, 2008.

9. Barriers to Effective Handoffs • Physical environment • Background noise, poor lighting1 • Organizational factors • Culture, social hierarchy1 • Vast inconsistency in how handoffs are performed2,3 • No formal training on how to give handoff report1 • Provider and patient factors • Language barriers, diversity in patient and physician populations1 1. Solet DJ, Norvell JM, Rutan GH, et al., Acad Med, 2005. 2. Horwitz LI, Krumholz HM, Green ML, et al., Arch Intern Med, 2006. 3. Sinha M, Shriki J, Salness R, et al., Acad Emerg Med, 2007.

10. Barriers to Effective Handoffs • Task • High workload, hectic schedules and multiple responsibilities1 • Ambiguity in roles and responsibilities1 • Tools and Technologies • Ineffective use of cognitive tools1 • Appropriate measures for evaluating effectiveness of handoffs still need to be established and validated1 1. Solet DJ, Norvell JM, Rutan GH, et al., Acad Med, 2005.

11. Joint Commission’s Handoff Process Strategies1 • Interactive communications  • Up-to-date and accurate information transfer • Limiting interruptions during handoffs  • A process for verification  • An opportunity for the receiver to review any relevant historical data 1. Joint Commission. National Patient Safety Goals: History Tracking Report 2008-2009.

12. Other Strategies to Improve Handoffs • Consider using structured tools that can facilitate consistency in communication exchanges1 • Set aside sufficient time to promote complete and accurate communication1,2,3 • Assure unambiguous transfer of responsibility and accountability4,5 • Teach and practice how to give/receive handoff reports using established, common language1 • Document that a handoff has taken place 1. Cooper A, The OR Connection, 2010. 2. Hand-off Communications: Recommendations, AORN, 2010. 3. Standardizing Handoffs for Patient Safety and Handoff Talking Points, AORN, 2010. 4. Patterson ES, Wears RL, JtComm J Qual Patient Saf, 2010. 5. Gurses AP, Seidl KL, Vaidya V, et al., QSHC, 2008.

13. Other Strategies to Improve Handoffs • Include outgoing care provider’s opinion(s) toward changes to (contingency) plans1 • Limit initiation of other activities (unless critical) during the handoff1 • Delay transfer of responsibility during critical time periods of the care process1 • Monitor the effectiveness of handoffs and providers’ adherence to guidelines concerning handoffs; ascertain feedback from staff 2 • When appropriate, use computers and available technology (e.g. EMR) to encourage the efficient exchange of pertinent, correct information. 2,3 1. Patterson ES, Wears RL, Jt Comm J Qual Patient Saf, 2010. 2. Cooper A, The OR Connection, 2010. 3. Vidyarthi AR, Arora V, Schnipper JL, et al., J Hosp Med, 2006.

14. Interventions to improve handoffs between hospital units • Very few interventions (almost none for cardiac surgery) • A new handover protocol of pediatric patients after congenital heart surgery from OR to ICU.1 • Based on Formula 1 pit-stop and aviation models (e.g., clarifying responsibilities, standardizing processes, improving situation awareness, anticipation, and communication) • Reduced the number of technical errors (e.g., drains not located safely) and information handover omissions. • Implementation of a paper-based discharge survey nearly eliminated ICU discharge medication errors2 • Few other intervention studies that have not found any significant impact. • Catchpole KR, de Leval MR, McEwan A et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth 2007 May;17(5):470-8. • Pronovost P, Weast B, Schwarz M et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. J Crit Care 2003 December;18(4):201-5.

15. Interventions to Improve the Discharge Process • A package of discharge services significantly reduced emergency visits and readmissions among medical patients1 • a nurse discharge advocate to coordinate the discharge process and educate patients • an individualized after-hospital care plan for each patient • pharmacist contacting the patient 2-4 days post- discharge. • Multi-faceted intervention among elderly reduced readmissions2 • medication self-management system • ensuring that patients complete physician follow-up visits • educating patients about health indications to watch for. • A Cochrane review (11 RCTs included) did not find any significant impact of using an individualized discharge plan on mortality, hospital LOS, or readmissions.3 1. Jack BW, Chetty VK, Anthony D et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009 February 3;150(3):178-87. 2. Coleman EA, Smith JD, Frank JC et al. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc 2004 November;52(11):1817-25. 3. Shepperd S, Parkes J, McClaren J et al. Discharge planning from hospital to home. Cochrane Database Syst Rev 2004;(1):CD000313.

16. Interventions (Summary) • Very few • Almost none in cardiac surgery • Conflicting findings • Most of the interventions implemented without being informed by detailed hazard analysis

17. Action Items for Handoffs/Transitions in Care • For now, NOT MUCH! • We will contact you as we make progress on the detailed study plan and next steps for this study component. • Sites that will be part of the initial handoff study will be determined based on • Their interests • Variability (hospital characteristics and variations in handoff/transitions of care processes) • Resources available (i.e., travel costs of researchers) • Will share findings from the initial handoff study • Other sites will • self-identify hazards and develop appropriate interventions using the tools developed • have an opportunity to implement several tools • GOAL: Learn from each other and find ways to improve transitions of care/handoffs

18. Aims in this study • To improve the safety of care transitions from cardiac OR to ICU, from ICU to inpatient floor, and from inpatient floor to hospital discharge. • To identify and prioritize safety hazards during these transitions of care • To implement a patient safety program and evaluate its impact on the prioritized hazards (i.e., from OR to ICU, ICU to floor). • To pilot test interventions aimed at reducing/mitigating floor to hospital discharge hazards. Hazard: Anything that has the potential to cause failure.

19. Conceptual Frameworks • Systems Engineering Initiative for Patient Safety (SEIPS Model) • Systems Ambiguity Framework • Trajectory Framework

20. SEIPS Model of Work System and Patient Safety Carayon, P., Hundt, A.S., Karsh, B.-T., Gurses, A.P., Alvarado, C.J., Smith, M. and Brennan, P.F. “Work System Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i50-i58, 2006.

21. Ambiguity Framework

22. Trajectory Framework Trajectory: A sequence of actions toward a goal (e.g., timely and safe discharge) including any contingencies. Shaping a trajectory requires combined efforts of the individuals involved including care providers, patients and families (Corbin & Strauss, 1991). Content of the discharge-related communication can be described in three major dimensions using this framework: • Patient’s status on the discharge trajectory • Deviations from/complications on the trajectory • Anticipating/planning for the rest of the trajectory

23. Activities • Sample • 5 hospitals: OR-ICU, ICU-Floor • 2-3 hospitals: Discharge Process • Prospective hazard identification • Observations (one HFE + one clinician pair) at each transition point • Semi-structured interviews with care providers and patients • Artifact analysis • Shadowing of patients from surgery to discharge and post-discharge • Retrospective hazard identifications • If possible, hospitals will review data from adverse event reporting systems (AERS) • Clinical incident technique interviews • Development of tools/methods/other interventions • Self-assessment tools to identify and prioritize hazards • Tools/methods/other interventions to improve transitions of care

24. Study Plan

25. QUESTIONS agurses1@jhmi.edu

26. Works Consulted • Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005 ;14(6):401-7. • Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 2006 Nov;32(11):646-55. Review • Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety Literature Review Report; March 2005. Accessed August 24, 2010. Available at: http://www.health.gov.au/internet/safety/publishing.nsf/Content/F3D3F3274D393DFCCA257483000D8461/$File/clinhovrlitrev.pdf • Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety Literature Review Report; March 2005. Accessed August 24, 2010. Available at: http://www.health.gov.au/internet/safety/publishing.nsf/Content/F3D3F3274D393DFCCA257483000D8461/$File/clinhovrlitrev.pdf • Carayon, P., Hundt, A.S., Karsh, B.-T., Gurses, A.P., Alvarado, C.J., Smith, M. and Brennan, P.F. “Work System Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i50-i58, 2006. • Catchpole KR, de Leval MR, McEwan A, Pigott N, Elliott MJ, McQuillan A, MacDonald C, Goldman AJ. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Pediatric Anesthesia. 2007; 17(5): 470-478. • Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc 2004 November;52(11):1817-25. • Communication during patient hand-overs, Joint Commission, 2007. Accessed August 24, 2010. Available at: http://www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/PS-Solution3.pdf

27. Works Consulted • Communication during patient hand-overs, Joint Commission, 2007. Accessed August 24, 2010. Available at: http://www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/PS-Solution3.pdf • Cooper A. Applying Evidence-Based Information to Improve Hand-Off Communication in Perioperative Services. Back to Basics Ninth in a Series. The OR Connection. 2010;3(3):18-21,23-24. Accessed August 2010. Available at: http://www.scribd.com/doc/29542046/OR-Connection-Magazine-Volume-3-Issue-3. • Gottlieb DJ, Parenti CM, Peterson CA, Lofgren RP. Effect of a change in house staff work schedule on resource utilization and patient care. Arch Intern Med. 1991 Oct;151(10):2065-70. • Gurses AP, Seidl KL, Vaidya V, et al. Systems ambiguity and guideline compliance: A qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. QSHC. 2008:17:351-359. • Gurses et al. (2007). Systems ambiguity framework to assess risks and predict potential system failures. Human Factors Annual Proceedings, Health Care. • Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006 ;32(3):167-75. • Hand-off Communications: Recommendations. In Perioperative Patient Hand-Off Tool Kit. AORN. 2010. Accessed August 2010. Available at: http://www.aorn.org/docs_assets/55B250E0-9779-5C0D-1DDC8177C9B4C8EB/44F543CC-17A4-49A8-865FDDF56132C37B/HandOff_Recommendations.pdf • Hand-Off Toolkit Executive Summary. AORN. 2010. Accessed August 2010. Available at: http://www.aorn.org/docs_assets/55B250E0-9779-5C0D-1DDC8177C9B4C8EB/44F40E88-17A4-49A8-86B64CAA80F91765/HandOff_Executive.pdf

28. Works Consulted • Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006 ;166(11):1173-7. • Improving Handoff Communications: Meeting National Patient Safety Goal 2E. Jt Comm Perspectives on Patient Safety. 2006;6(8): 9-15. • Improving Handoff Communications: Meeting National Patient Safety Goal 2E. Jt Comm Perspectives on Patient Safety. 2006;6(8): 9-15. • Jack BW, Chetty VK, Anthony D et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009 February 3;150(3):178-87. • Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Residents report on adverse events and their causes. Arch Intern Med. 2005 Dec 12-26;165(22):2607-13. • Joint Commission on Accreditation of Healthcare Organizations: 2007 National Patient Safety Goals Hospital Version Manual Chapter, including Implementation Expectations. • Joint Commission. National Patient Safety Goals: History Tracking Report 2008-2009. • Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan TA, Studdert DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007 Feb;49(2):196-205. Epub 2006 Sep 25. • Laine C, Goldman L, Soukup JR, Hayes JG. The impact of a regulation restricting medical house staff working hours on the quality of patient care. JAMA. 1993 Jan 20;269(3):374-8. • Lawrence R.H., et al.: Conceptualizing handover strategies at change of shift in the emergency department: A grounded theory study. BMC Health Serv Res. 2008;8:256. In Patterson ES, Wears RL, Patient Handoffs: Standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf. 2010;36(2):52-61. • Lofgren RP, Gottlieb D, Williams RA, Rich EC. Post-call transfer of resident responsibility: its effect on patient care. J Gen Intern Med. 1990 Nov-Dec;5(6):501-5.

29. Works Consulted • Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003 ;18(8):646-51. • National Patient Safety Goals. Joint Commission. Accessed August 24, 2010. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals • Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health. 2004;16(2): 125-132. • Patterson ES, Wears RL. Patient Handoffs: Standardized and Reliable Measurement Tools Remain Elusive. Jt Comm J Qual Patient Saf . 2010;36(2):52-61. • Risser D.T., et al. The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium. Ann Emerg Med. 1999;34:370–372. • Shendell-Falik N, Feinson M, Mohr BJ. Enhancing patient safety: improving the patient handoff process through appreciative inquiry. J Nurs Adm. 2007 ;37(2):95-104. • Shepperd S, Parkes J, McClaren J, Phillips C. Discharge planning from hospital to home. Cochrane Database Syst Rev 2004;(1):CD000313. • Sinha M, Shriki J, Salness R, Blackburn PA. Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors. Acad Emerg Med. 2007;14(2):192-6. Epub 2006 Dec 27 • 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 ;80(12):1094-9. • Standardizing Handoffs for Patient Safety (Presentation) and Handoff Talking Points (Presentation). AORN. 2010. Accessed August 2010. Available at: http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/

30. Works Consulted • “Strategies to Improve Hand-off Communication: Implementing a process to resolve questions” Jt Comm Perspectives on Patient Safety . 2005:5(7):11. • Streitenberger K, Breen-Reid K, Harris C. Handoffs in Care – Can We Make Them Safer? Pediatric Clinics of North America. 2006; 53:1185-1195. • Streitenberger K, Breen-Reid K, Harris C. Handoffs in Care – Can We Make Them Safer? Pediatric Clinics of North America. 2006; 53:1185-1195. • The Joint Commission: 2010 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: Joint Commission Resources, 2009. In Anderson J, Shroff D, Curtis A, The Veteran’s Affairs Shift Change Physician-to-Physician Handoff Project. Jt Comm J Qual Patient Saf. 2010;36(2):62-72. • The Joint Commission: Handoff Communications: Toolkit for Implementing the National Patient Safety Goal. Oakbrook Terrace, IL: Joint Commission Resources, 2008. In Anderson J, Shroff D, Curtis A, The Veteran’s Affairs Shift Change Physician-to-Physician Handoff Project. Jt Comm J Qual Patient Saf. 2010;36(2):62-72. • The Joint Commission: Meeting the Joint Commission 2008 National Patient Safety Goals. Oakbrook Terrace, IL: Joint Commission Resources, 2007. In Patterson ES, Wears RL, Patient Handoffs: Standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf. 2010;36(2):52-61. • Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg. 2005 Apr;200(4):538-45. • Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1:257-266. • Wears R, Roth E, Patterson E, Perry S. "Shift Change Signovers as a Double-Edged Sword: Technical Work Studies in Emergency Medicine". Society for Academic Emergency Medicine, Annual Meeting. New York, NY; May 25 2005. Available at: http://www.saem.org/meetings/05hand/wears.ppt