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Dennis J Boyle, M.D. DHMCCOPIC 2010

Handoffs in clinical practice

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Outline

Overview

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2 Examples of fumbles seen by COPIC

The background of the problem

Toolkit for handoffs and checklists

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Definition

A handoff is defined as a transfer of information and responsibility from one provider to another

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What percent of sentinel events have communication as the root cause?

A) 25 %B) 45%C) 50%D) 65%

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Handoffs as cause of error in IM

100 cases with error cared for by IM

7% no fault Rest divided between

system issues and cognition

6 errors per case Graber Arch IM 2005

Systems issues - handoffs, poor processes (Colon CA F/U), teamwork

Cognitive problems - error in synthesizing the scenario, Knowledge problems rare

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Trainee lawsuits

Malpractice claims in trainees over 20 years

Errors divided equally among knowledge, teamwork and technical competence

Teamwork problems were mainly handoffs

Singh Arch IM 2007

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Is there a problem? Handoffs are sloppy …

Informal Incomplete Inconsistent

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A story Healthy child of color is born and is seen by the

neonatologist at 12 hours. A bilirubin is ordered. The covering neonatologist D/Cs the child at 24 hours not knowing of the lab. Neither the clerk or the RN chase the lab down

At 60 hours (4PM Friday) the baby sees the pediatrician. A bilirubin is again ordered. The pediatrician doesn’t know there was a hospital bilirubin. She then leaves on vacation

Patient returns Monday AM lethargic. Office calls the lab and the bilirubin from Friday was 24

The baby is admitted to CH. The baby dies of kernicturus

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How come?

You’re a victim of multiple failures. The neonatologist, the clerk, the RN, the pediatrician and the covering Doc all had a chance to rescue. Even being a child of color entered into the cascade.

Hazards

Disaster

The system breaks down when the holes line up

Unsafe organizational

influence

Poor supervision

Unsafe preconditions

Unsafe acts

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Direct communication between the hospitalist and the PCP is rare (3-20%)

Availability of the DC summary at the first post-op visit is low (12-34%)

DC summaries lack info. Tests pending 60% The cure is computer generated summaries and use of

patients as couriers

What does the PCP do?

Kripalani JAMA 2007

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Frustration: So what should the specialist do?

In one study if their patient was having a Cath or PTCA, the PCP wanted to know:

At discharge—5% During hospitalization—10% Leave message—40% Interrupt—45% Only 56% of PCP were satisfied with their

communication with hospitalists

Pantilat S Am J of Med 2001

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Two sides to the story

“It would be nice if the primary care doctor sent the patient to me with all the previous lab and x-ray data that were available and pertinent. A phone call would be nice.”

“It would be nice if the consultant called me back after seeing my patient so we could actually discuss the case.”

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Specialist to PCP

38 YO female feels a lump on BSE. PCP refers patient to surgeon. Surgeon appreciates no mass, recommends reexamination in one month. Letter states ”patient should be reexamined in one month.” PCP never sees report. He assumes the surgeon will follow

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Specialist to PCP

38 YO female feels a lump on BSE. PCP refers patient to surgeon. Surgeon appreciates no mass, recommends reexamination in one month. Letter states ”patient should be reexamined in one month.” PCP never sees report. He assumes the surgeon will follow

Fuzzy transfer and report lost….

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In the office

59 YO male with 2 skin lesions removed from thigh and back. The back lesion shows melanoma. Wide excision performed. No malignancy on path-was it all removed?

One year later patient returns with an obvious melanoma on chest wall….

Labeling procedure not clear

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Injection Case

Depo-provera instead of HCG at the PCP office

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Who would be liable for this event?

A)The MA giving the injectionB)The MA who asked the second MA to give the

injectionC)The doctor in the clinic at the time for negligent

supervisionD)The primary physician for negligent supervision

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Discharge is the high risk time

62 YO female admitted with abdominal pain. Lesion found in spleen. Resection reveals abscess-MRSA. ID consult recommends 4 weeks of Vancomycin. 1 week later transferred to rehab.

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Discharge is the high risk time

62 YO female admitted with abdominal pain. Lesion found in spleen. Resection reveals abscess-MRSA. ID consult recommends 4 weeks of Vancomycin. 1 week later transferred to rehab.

Echocardiogram shows SBE. Report returns post discharge. Sent to the physician but he never sees the report.

NH PA has no records. Not sure as to why on Vancomycin and D/Ced after 2 weeks

Patient presents one month later with spinal abscess and paralysis

Faulty info transfer- Doc, NP and MA could rescue

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The CURE

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Successful handoff

Requires two participants

A transfer of critical info

Clear delineation of who does what

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Who does handoffs?

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Where are your handoffs?

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Preventing patient errors—blocks or barriers

Communication Systems Documentation Patient management

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Teamwork features

Good communication- a check system to prevent errors

Shared ideas and experience Able to hear and use feedback Honesty Coordination Kindness, empathy for each

other

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SBAR

Situation Background Assessment Recommendation

Michael Leonard MD

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SBAR How it’s done

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Handoffs

Face to face Limit interruptions Receiver listens and

doesn’t talk Standardize and simplify Unambiguous transfer of

responsibility Use common style with

read back SBAR

Patterson Int J qual HC 2004 Streitenberger Peds clinic NA 2006

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Checklist

Gawandhi the checklist New Yorker 2007

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Patient safety at discharge

One third of post-discharge events are preventable

Another one third are considered ameliorable

JACHO

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What we can do to improve safety at discharge

In-hospital care management with intensive nurse follow up- reduced CHF readmits

Systematic follow-up phone calls to patients by pharmacist after discharge-reduced ED visits

Automate discharge summaries Create hospital-based follow-up clinics on the

medical ward At the very least D/C patient with all info needed

for a F/U visit

Weinberger M, et al. Med Care.1988 Naylor MD, JAMA. 1999 Naylor MD Cardiovascular Nurs. 1999 Naylor MD. Nurs Res.1990;39:156-61; Nelson JR. Dis Mon. 2002

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D/C Safety checklist office or hospital

D/C meds D/C summaries Follow up appointments Communication with patient/family Communication with the PCP Recognize fragile patients NH patient follow up

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Safety checklist for patient

Involve the family Signs of relapse? contact for difficulties? Loop in the PCP

Test results pending Does the pt understand? Med reconciliation F/U appointments?

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Summary

Where are your handoffs?

You need to be on the same page

How can you standardize?

S.B.A.R.

What’s best for the patient?

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Now – What one thing will you do differently in your handoffs?

Dennis Boyle MD

Where are your handoffs?

The rubber hits the road