Spotlight Case

1. Spotlight Case The Perils of Cross Coverage

2. Source and Credits • This presentation is based on the May 2012AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, University of Chicago Pritzker School of Medicine • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: John Q. Young, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and care transitions • Describe educational mechanisms available to ensure trainees execute standardized, safe, and effective handoffs, without omitting critical information • Identify the opportunities for handoff evaluation, including the application of a framework for clinical supervision

4. Case: Perils of Cross Coverage (1) A 70-year-old woman was admitted to the intensive care unit (ICU) with acute change in mental status a few days after lumbar laminectomy. Her medical history was significant for a ventriculoperitoneal (VP) shunt for suspected normal pressure hydrocephalus. She was febrile with nuchal rigidity. Her white blood cell (WBC) count was over 20,000 cells/µL. Blood cultures were positive for E. coli and appropriate antibiotic therapy was initiated. The patient responded well—she began to have brief but meaningful conversation with her family.

5. Case: Perils of Cross Coverage (2) Her WBC started to trend down, and she was afebrile for 48 hours.On day 4 of her ICU admission, a Friday, she exhibited fluctuating mental status with prolonged episodes of drowsiness. The ICU team attributed this to recent use of sedatives. Signout to the incoming night float team did not highlight the change in mental status. Over the course of the ensuing night she became drowsier. The night float team assumed it was her baseline mental status. After transfer to the incoming cross-covering team for the weekend, the patient was found comatose.

6. Case: Perils of Cross Coverage (3) Magnetic resonance imaging (MRI) showed ventriculitis with possible infectious cerebritis. The patient developed generalized tonic clonic seizures and was treated with IV phenytoin. She was emergently transferred to surgery for removal of the VP shunt and placement of ventricular drain for intraventricular gentamycin. The patient received 8 days of intraventricular gentamycin with resolution of ventriculitis as documented by negative E. coli cultures from the ventricular cerebrospinal fluid. She made a gradual recovery after spending 6 weeks in the ICU.

7. Case: Perils of Cross Coverage (4) Subsequent root cause analysis determined that earlier recognition of the change in mental status might have altered the patient’s course. It identified inadequate signout to the night float team as the primary reason why that team did not identify the patient’s deteriorating mental status.

8. New ACGME Regulations: Duty Hours • Effective as of July 2011 • Informed by a landmark Institute of Medicine report released in 2008 • Limits shifts for first-year residents to 16 hours or less • Further increases the frequency of handoffs • Also creates a patchwork of coverage systems, including day and night float services when residents care for patients for whom they lack primary knowledge See Notes for references.

9. New ACGME Regulations: Handoffs (1) • Address Handoffs across 3 Domains • Clinical service structure • Curriculum • Evaluation See Notes for reference.

10. New ACGME Regulations: Handoffs (2) Programs and sponsoring institutions must: • Design clinical assignments to minimize the number of transitions in patient care • Ensure and monitor effective, structured handoff processes that facilitate both continuity of care and patient safety • Ensure that residents are competent in communicating with team members in the handoff process • Ensure availability of schedules that inform all health care team members of attending physicians and residents currently responsible for each patient’s care See Notes for references.

11. Handoff Curricula (1) • No consensus on best approach • Multiple instructional methods: case discussion, observation, simulation, lecture • Verbal mnemonic to structure information transfer • Best practice from other high-risk, high-reliability industries • Dedicated space and protected time (overlapping shifts) with minimal interruptions and attending-level supervision • Evidence that these techniques improve clinical practice; unclear impact on patient outcomes See Notes for references.

12. Handoff Curricula (2) • Curricula must also focus on training the ‘receiver’ • Receivers could not identify most important issue for 60% of patients • Information overload, distraction, inability to prioritize appropriately • Egocentric heuristic: sender underestimates how much information receivers need and assumes receiver has access to same information they do • Importance of structured written sign-out to complement verbal; yet few curricula focus on written sign-out See Notes for references.

13. Handoff Curricula (3) • Objective Structured Handoff Experience (OSHE) • Simulation • Practice written and verbal sign-out • Receive feedback from trained ‘receiver’ • Practice-based audit tools to improvewritten sign-out See Notes for references.

14. Handoff Curricula (4) • Current approach does not sufficiently address how to ensure that the receiver has acquired a shared mental model of the patient • Future curricula need to focus on receiver ability to listen, comprehend, process, and prioritize information

15. Assessing Competence (1) • Numerous tools: simulation, direct observation, peer evaluation or multi-source feedback, chart audit • Limited validation of these tools • Direct observation: Handoff CEX—9-item, role-based anchor to assess handoff behaviors in the domains of setting, communication, professionalism, and overall performance See Notes for references.

16. Assessing Competence (2) • Peer evaluation • Vulnerable to halo effect • Can differentiate exceptional and below average learners • Should focus on both senders and receivers • Audit tools of written sign-out: patient synopsis, relevant action items, anticipatory guidance with corresponding rationale See Notes for references.

17. Supervision of Handoffs • Need to develop specific milestones that lead to competency at sending and receiving a handoff • Faculty supervision not a traditional feature • New ACGME supervision rules presents opportunity to enhance faculty supervision See Notes for reference.

18. Integrating handoff evaluation with supervision of trainees

19. Take-Home Points (1) • Structured templates and mnemonics can standardize information during handoffs to prevent omissions of critical data • Ensuring a member of the primary team with knowledge of the patient is present during handovers can preserve team–patient continuity and informed discussion of critical information • To address the egocentric heuristic, senders must appropriately calibrate the information they transmit to ensure receivers are able to properly understand

20. Take-Home Points (2) • Use of night float and coverage teams requires corresponding investments to improve clinical documentation of written signouts that not only focus on daily events, but also rationale for primary team actions and anticipatory guidance • A framework for enhancing supervision set forth by the ACGME presents an opportunity to guide, evaluate, and improve resident handoffs