The LaryngoscopeVC 2013 The American Laryngological,Rhinological and Otological Society, Inc.

IMOUTA: A Proposal for Patient Care Handoffs

Matthew P. Connor, MD, Captain, USAF-MC; Anneke C. Bush, ScD, MHS;

Joseph Brennan, MD, Col, USAF-MC

Objectives/Hypothesis: An increased frequency of patient handoffs has occurred as a result of the new resident work-hour restrictions that have recently been instituted. Inadequate handoff of patient care has been associated with adversepatient events due to residents being unprepared for events that happen during cross cover periods. The objective of ourstudy was to develop and test the effectiveness of a patient handoff method in an otolaryngology residency program.

Study Design: Single-blinded controlled clinical trial.Methods: A standardized, anonymous questionnaire was developed that scored on-call residents’ understanding of

their patients’ diagnoses, hospital courses, active concerns, and treatment plans. For the first 45 days, residents used theirtraditional handoff. This handoff was prepared by the residents, relaying relevant patient information without any structuredformat. For the next 45 days, the residents followed the acronym of IMOUTA for handoffs. This mnemonic was developed tohelp residents identify data (I), medical course (M), outcomes possible tonight (OU), responsibilities to do tonight (T), and op-portunity to ask questions and give morning feedback in the AM (A). The questionnaires were then compared at the end ofthe study.

Results: The residents who used the IMOUTA acronym scored significantly higher on their perceived knowledge ofpatients diagnoses (P5 0.001), hospital courses (P <0.001), active concerns (P <0.001), and treatment plans (P <0.001).

Conclusion: Residents felt significantly better prepared for call duties when using the IMOUTA acronym. This standar-dized system of patient handoff may also be valuable to other residency programs.

Key Words: Handoffs, sign-out, residency, education.Level of Evidence: N/A.

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INTRODUCTIONEffective communication is essential in any enter-

prise. The issue becomes paramount when patient careis at stake. Physicians especially rely on communicationwhen they assume responsibility for patients whom theyhave never met. In 2003, the Accreditation Council forGraduate Medical Education (ACGME) institutedcommon program requirements to restrict residentwork-weeks to an average of 80 hours with no morethan 30 hours worked consecutively.1 To comply withthese requirements, most training programs adoptednew resident schedules that resulted in an increasednumber of patient handoffs causing a decrease in the

continuity of care for patients admitted to teachinghospitals.2

Inadequate handoff of care, or sign-out, leads tointerns and residents feeling unprepared for events thathappen during cross cover periods and has been associ-ated with adverse events.3 The discontinuity of care thataccompanies such turnover has previously been shownto lengthen hospital stays, increase the amount of labo-ratory tests, and increase self-reported preventableadverse events.4,5 In an Agency for Healthcare Researchand Quality 2008 survey, 51% of the 160,176 hospitalstaff respondents reported that “important patient careinformation is often lost during shift changes.” In onesurvey of residents, 70% agreed that improved handoffswould reduce medical mishaps.6,7 In a 2006 survey of161 internal medicine and general surgery residentsat Massachusetts General Hospital, 59% reported thatone or more patients had been harmed during theirmost recent clinical rotation secondary to problematichandoffs.8,9 This data highlights the necessity for aneffective handoff procedure.

Different handoff procedures have been publishedpreviously in the internal medicine, general surgery, andacademic medicine literature. They have gained variedsuccess and acceptance. However, review of the otolaryn-gology literature failed to reveal any published handoffprocedure or analysis thereof. Most residency programsdo not provide for formal teaching in the handoff pro-cess. This deficiency and reliance on on-the-job trainingis quickly gaining attention.9 An appropriate handoff

From the Clinical Investigations Division (A.C.B.), Wilford HallAmbulatory Surgical Center, Lackland, AFB, Department of Otolaryn-gology (M.P.C.), San Antonio Military Medical Center, Ft. Sam Houston,Texas, U.S.A, Department of Surgery (J.B.), San Antonio MilitaryMedical Center, Ft. Sam Houston, Texas, U.S.A

Editor’s Note: This Manuscript was accepted for publicationMarch 4, 2013.

Presented at the Triological Society Combined Sections Meeting,Scottsdale, AZ, January 25, 2013.

The authors have no funding, financial relationships, or conflictsof interest to disclose. The opinions expressed on this document aresolely those of the authors and do not represent an endorsement by orthe views of the United States Air Force, the Department of Defense, orthe United States Government.

Send correspondence to Matthew P. Connor, MD, Captain, USAF-MC Department of Otolaryngology, SSS/SG020, Wilford Hall MedicalCenter 2200 Bergquist Drive, Suite 100 Lackland AFB, TX 78236-9908.E-mail: matthew.p.connor@gmail.com

DOI: 10.1002/lary.24118

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would incorporate interactive, two-way communicationconveying up-to-date information in a standardized for-mat.9 Checklists can ensure completeness, and memoryaids promote rapid recall and implementation. NASAamong other industries have thoroughly researchedthese subjects and argue for the importance of such acomprehensive and systematic handoff.9 In this effort,we developed and tested a novel handoff algorithm inour residency program.

MATERIALS AND METHODS

Survey ProcessThis study was given approval by the Institutional Review

Board at San Antonio Military Medical Center. A standardizedquestionnaire was developed that scored on-call residents’understanding of their patients’ diagnoses, hospital courses,active concerns, and treatment plans (Fig. 1). The questionnairealso recorded how busy the residents were while on-call, if any-thing happened that they were not adequately prepared for

Fig. 1. Resident survey that was completed after each night on call. Responses ranging from “Not at all complete” to “Totally complete” or“Not at all busy” to “Extremely busy” were scaled 1 to 5, accordingly.

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after handoff, and overall impression of the handoff received.This questionnaire was completed after each night on call for90 days, and was completed in an anonymous fashion. For thefirst 45 days (group 1), the residents used their traditionalhandoff. This handoff was prepared by one resident relayingrelevant patient information without any structured format.For the next 45 days (group 2), the residents used the acronymIMOUTA. This acronym is also a mnemonic, and is pronouncedto rhyme with “I’m outta.” This procedure details identifyingdata (I), medical course (M), outcomes possible tonight (OU),obligations to do tonight (T), and opportunity to ask questionsand give morning feedback in the a.m. (A) (Fig. 2). Residentswere not instructed on this mnemonic until the first 45 handoffswere completed. The questionnaires were then compared at theend of the study.

Statistical AnalysisA database was created logging the scores on the survey.

IBM SPSS Statistics, version 17 (Armonk, NY) was used fordata analysis. Though the same 15 residents participated inboth phases, the data were not linked by any type of identifier,so it was not possible to compare the data using any type ofpaired analysis. Scale data were compared using nonparametricmethods (Mann-Whitney U test) and categorical data were com-pared using chi-square analysis. Responses ranging from “Notat all complete” to “Totally complete” or “Not at all busy” to“Extremely busy” were scaled 1 to 5, accordingly (Fig. 1). A

Student’s t test was used to calculate mean scores for compari-son of continuous variables. Appropriate nonparametric meth-ods were also used for corroboration.

RESULTSOne-hundred percent of surveys were filled out and

recorded accordingly. No surveys needed to be excluded.A total of 15 different residents participated. Each resi-dent participated equally in the first and second set ofsurveys. The authors of the study did not participate inthe surveys to prevent any bias. While the nature of thestudy did not allow for blinding of the participants, thestatistician on the study analyzed the data from the twogroups in a blinded fashion. The statistician was notinformed which dataset belonged to which group whenperforming the statistical analysis.

The Student’s t test found no difference in perceivedlevel of call activity (question 1). However, in Group 1,the residents were responsible for more patients (meanof 6.46 6 2.60 vs. 4.22 6 2.27, P <0.001) and performedmore procedures (mean 1.18 6 1.61 vs. 0.53 6 0.87,P 5 0.021). The two groups did not differ significantlybetween number of patients admitted or consulted on.

With responses scaled from 1 to 5 (“Totally com-plete” and “Extremely helpful” representing the maxi-mum score of 5), group 1 reported a mean score of 3.96for knowledge of patient diagnoses, 3.49 for knowledgeof hospital course, 3.49 for knowledge of active concerns,3.44 for knowledge treatment plans, and 3.62 for overallhelpfulness. When using the IMOUTA handoff system,group 2 reported a mean score of 4.60 for knowledge ofpatient diagnoses, 4.69 for knowledge of hospital course,4.69 for knowledge of active concerns, 4.60 for knowl-edge of treatment plans, and 4.71 for overall helpfulness.After comparing these scaled responses using the Mann-Whitney test, these scores were all found to be signifi-cantly different between the two groups (Fig. 3).

Chi-square analysis (or 1-sided Fisher’s exact testwhere appropriate) was used to evaluate the differencebetween the two groups when asked if something hap-pened while on call for which the residents were notadequately prepared. Surveys from group 1 were signifi-cantly more likely to respond positively (P 5 0.006). Ofthose who responded positively in group 1, 20% saidthere was missing handoff information that would havebeen useful, and the vast majority (89%) stated that itshould have been anticipated during the handoff. How-ever, in group 2 using the IMOUTA handoff, no residentresponded positively to this question.

DISCUSSIONAs resident work hours were being limited, the

ACGME simultaneously mandated that “it is essentialfor patient safety and resident education that effectivetransitions in care occur.”1 They refer to handoffs as astandardized process “in which information aboutpatient/client/resident care is communicated in a consist-ent manner.”10 They explain further that organizationsmust implement “a standardized approach to hand-offcommunications, including an opportunity to ask and

Fig. 2. IMOUTA acronym.MRN 5 medical record number; POD 5

postoperative day; S/P 5 status post.

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respond to questions.”10 In this effort, we developed andnow use a consistent, standardized approach using theIMOUTA acronym.

The results of our survey analysis clearly indicatethat residents felt more comfortable assuming responsi-bility for patient care when they used the IMOUTA acro-nym. Importantly, no resident who used the acronymhad something happen for which they were notadequately prepared for during the patient handoff.However, the analysis found that residents in group 1were responsible for more patients (mean of 6.46 vs.4.22) and performed more procedures (mean 1.18 vs.0.53), although the perceived level of activity was no dif-ferent. One could construe that this is not a fair compar-ison between the groups since group 1 may have hadmore responsibilities than group 2, and it is uncertainwhether the IMOUTA acronym would have proven assuccessful in the same circumstances. However, webelieve that, given the significantly improved scores ingroup 2 on preparedness for call in all categories, onecould expect a more effective handoff regardless ofon-call activity.

Although not directly studied, residents in the pro-gram did not have any difficulty adapting to the newIMOUTA handoff algorithm. Residents were onlyinstructed on the algorithm a single time at an educa-tional meeting, and then were given copies of the acro-nym for their personal reference (Fig. 2). No residentreported any difficulty using the new handoff system.The algorithm could generally be completed in under 3minutes, but would vary depending on patient complex-ity. This time is on par with what is reported in the liter-ature.11 We did not compare length of time per handoffbetween the two groups, which would be a useful topicfor a future study. However, it may be expected that thecomplete and systematic IMOUTA handoff would takelonger to perform. Alternatively, it may prove to be moreefficient due to its orderly and systematic progression ofdetails, which would leave less for questions and con-cerns from the on-call resident. Conciseness and organi-zation are known to be important qualities in handoffs,

since they decrease inattentiveness that occurs duringlong or unfocused handoffs.11 Using an acronym such asIMOUTA has the advantage of organization, and itenables the resident who is receiving the handoff toanticipate the flow of information.11

A potential weakness of our study is that theIMOUTA handoff was proven successful only at a singleprogram. A future study may expand on our researchand test its transferability to other programs by per-forming a multi-institutional trial of the IMOUTA hand-off. However, we believe that our results and successusing the IMOUTA may be translated to other pro-grams. There are 15 residents in our training program(three per year) who rotate at four different medical cen-ters in San Antonio. This extended coverage makeseffective handoffs even more critical as teams are spreadacross different hospital systems. As a consequence ofour broad coverage, many of our handoffs are done overthe phone. This may be different than a program that iscentered at a single institution. In such a program, theymay be able to take advantage of computer systems thatcould continuously update pertinent patient informationfor the on-call providers to reference. In fact, this has al-ready been shown to be effective in the general surgeryliterature.12

Research has proven that handoffs are most effectivewhen given face-to-face and without interference fromside conversations or background commotion.13 In thisrespect, handoffs over the phone may actually prove ad-vantageous when compared to a face-to-face handoff thatis located in busy and distracting environment. We didnot record how many of our handoffs were done over thephone as compared to face-to-face. Both methods areroutinely employed in our program, and although notdirectly studied, we would assume that there would notbe any difference between the two groups with regard tothis variable. We believe that that the qualities of theIMOUTA handoff make it advantageous in both situa-tions, because the acronym forces the resident to completeall of the components in the handoff, give read-back, andask questions to ensure clarity and comprehension.

Fig. 3. Mean scaled responsesregarding knowledge of patient diag-nosis, hospital course, active issues,treatment plans, and overall helpful-ness. Responses were scaled from 1to 5, with “Totally complete” and“Extremely helpful” representing themaximum score of 5. The twogroups had significantly differentscores with P values listed.

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The study could have also been stronger if all par-ticipants did not have to follow the same protocol by firstusing their traditional handoff followed by the IMOUTAhandoff. We would have preferred to have had 50% ofthe participants begin with the IMOUTA handoff andthen follow with their traditional handoff. However, wewere concerned that if we had introduced the IMOUTAfirst, the participants may have incorporated compo-nents of this new system into their own native techniquefor handoffs. This scenario would have skewed theresults and would not have given an accurate represen-tation of what their traditional handoff produced. Also,in our program, residents sign out to different residentsaccording to a variable call schedule, and controlling thetwo different study arms would not have been possiblewith half of the residents signing out one way and theother half using a different method. Another criticismalong this same line is that the residents may haveimproved their handoff technique as a function of timealone, and that the improved scores in the second groupmay only be due to the experience provided by the initial45 days in the study. However, this study was conductedin the middle of the academic year, and the residentshad, at a minimum, been working together for 6 monthsprior to the study onset. When analyzed in this back-ground, the additional 45 days of handoffs were veryunlikely to have made any difference in the quality oftheir handoffs. Therefore, we do not believe that thestudy was biased towards the IMOUTA group because ofits introduction after 45 days of using the traditionalhandoff.

Perhaps the greatest weakness of our studyremains that it did not objectively test resident knowl-edge. We only asked the individual residents how com-plete and helpful they believed their handoff to be, andif anything happened that they were not prepared for.We relied on the unbiased opinions of the respondentsfor accuracy. One may argue that the residents couldhave biased the study by trying to satisfy the studyauthors with more positive results during the IMOUTAportion of the study. However, those queried did nothave any direct interest in the study (as the authorsthemselves did not participate), and the residentresponses to the surveys were completely anonymous.Despite these attempts to control bias, these responsesstill remain imprecise opinions on the handoff theyreceived. A future study may query residents on objec-tive patient information that they should have learnedfrom their handoff. We did not have the capability toproduce this kind of intensive research, which wouldhave required a different and individualized survey aftereach call night.

CONCLUSIONReview of the literature clearly demonstrates that

the medical profession must improve its communicationskills. In review of malpractice claims, communicationproblems were contributing factors in 26% to 31% ofcases.6,14–16 A review of 70 medical mishaps made byresidents found that 91% of cases contained

communication failures.17 A review of 146 surgicalerrors found that 41 (28%) involved handoffs.18 The goalof this study was to develop and test a handoff proce-dure for the otolaryngology residents in our program.Mnemonics and acronyms have proven to be usefulmemory aids, and we wanted to create one for handoffsthat was easy to remember, efficient, and complete.19

Our survey study demonstrates that residents felt pre-pared when using the IMOUTA handoff system, and wehave consequently adopted this system in our practice.As the ACGME continues to limit the number of contin-uous resident duty hours, it is imperative that all pro-grams develop such a handoff system.

ACKNOWLEDGEMENTThe authors would like to thank the otolaryngology resi-dents of San Antonio Military Medical Center for their par-ticipation in the study.

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