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Patient Handoffs
Stephanie B Dewar, MD Children’s Hospital of Pittsburgh Linda A. Waggoner-Fountain, MD
University of Virginia School of Medicine
Disclosures
• We have nothing to disclose • We do have our opinions
Objectives
• Understand the critical elements of patient sign-out that should be exchanged by trainees
• Review the RRC requirements around transitions in care
• Learn techniques to teach trainees how to improve sign-out skills
Definitions and RRC requirements
“Transitions of care”
• The relaying of – complete and accurate – patient information – between individuals or teams – in transferring responsibility for patient care – in the healthcare setting.
• Program Director Guide to the Common Program Requirements
– Useful Resources – ACMGE Glossary of Terms and Common Acronyms in GME, p.10
IV.A.5.d Interpersonal & Communication Skills
• communicate effectively with physicians, other health professionals, and health related agencies;
• p.8 Common Program Requirements • p.37 Pediatric Program Requirements
VI.B. Transitions of Care, • VI.B.1. Programs must design clinical assignments to
minimize the number of transitions in patient 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.
• VI.B.3. Programs must ensure that residents are competent in communicating with team members in the hand-over process.
• VI.B.4. The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and residents currently responsible for each patient’s care.
– p.13 Common Program Requirements – p.44 Pediatric Program Requirements
Pediatric Milestones • Provide transfer of care that ensures seamless
transitions – Variability in transfer of information (content, accuracy,
efficiency and synthesis) from one patient to the next. • Frequent errors of omission and commission in the handoff.
– Uses a standard template for the information. Unable to deviate from that template for more complex situations.
• May have errors of omission and commission in the handoff. Neither anticipates nor attends to the receiver of the information
– Adapts and applies a standard template, relevant to individual contexts, reliably and reproducibly, with minimal errors of omission or commission.
• Allows ample opportunity for clarification and questions. Beginning to anticipate potential issues for the transferee.
– P11 The Pediatrics Milestone Project
Pediatric Milestones • Provide transfer of care that ensures seamless
transitions – Adapts and applies a standard template to
increasingly complex situations in a broad variety of settings and disciplines.
• Ensures open communication, whether in the receiver- or provider-or- information role through deliberative inquiry, including but not limited to read-backs, repeat-backs (provider), and clarifying questions (receivers).
– Adapts and applies the template without error and regardless of setting or complexity.
• Internalizes the professional responsibility aspect of handoff communication, as evidenced by formal and explicit sharing of the conditions of transfer (e.g., time and place) and communication of those conditions to patients, families, and other members of the health care team.
– P11 The Pediatrics Milestone Project
Introductory activity • Pair off in groups
• Goal is to have your partner obtain a
fair representation of your message
• Discuss challenges involved in this exercise
Background
Sign-Out
• a mechanism of transferring information, responsibility and/or authority from one set of care-givers to another
• primary objective is the accurate transfer of information about patient’s state and plan of care
Why Is This a Problem Now?
• As a result of duty-hour restrictions and changes in health care, the number of sign-outs between residents has increased while physician continuity of care during hospital stays has decreased • when caring for hospitalized patients, residents have
become increasingly dependent upon exchange of clinical information at sign-outs
• this is also due to de-emphasis of clinical communication/summarization in the “medical record” and emphasis on billing and compliance
Importance of Sign-Out
• Despite the critical importance of sign-out, few training programs formally teach residents how to sign-out, and even fewer programs assess a resident’s ability to sign-out to his or her colleagues • currently residents learn how to sign-out
informally, while on the job. • Sign-out is a lifelong life-long skill
• physicians continue to give and receive sign-out long after the complete residency
Sign-out vs. Sign-Over
• Culture change • “This is my patient right now”
• Care of the patient as a relay race
• Running your leg of the race • Hand off of the baton
Sign out vignettes
Barriers to Implementation
missing info 40 (82%)
no missing info 9 (18%)
no unexpected event 109 (69%)
unexpected event 49 (31%)
How often did something happen you weren’t prepared for?
In 33 of the 40 (79%) cases where information was missing, the problem/issue should have been anticipated during sign-out
No unexpected event (n=109)
Unexpected event (n=49) P value
How busy were you? (1 slow – 5 busy) 2.93 + 1.07 3.25 + 1.06 0.08
How many patients on service at beginning of call night?
14.85 + 4.33 14.33 + 4.56 0.49
How many admissions did you have while on call?
4.86 + 2.86 4.86 + 3.21 0.99
Quality of sign-out (1 inadequate – 5 adequate)
4.48 + 0.70 3.58 + 0.92 0.001
Were you Cross-covering?
Some Comments
• “Sign-out sheets are not useful if they are not correct!”
• “. . . I wasn’t aware she was having these done or why.”
• “ . . . sign-out is inadequate to manage general issues at night. It does not detail the day’s thinking and plan . . .”
• “Again, need direction on what to do in classic “what if” situations – fever, pain, etc.”
• “Each patient should have, on the sign-out, a few words about what to do in case of fever, pain, etc.”
• “The problem lists are not detailed enough”
duration (minutes) 33.6 + 18.4 (range 11 – 86)
number of interruptions 5.6 + 3.7 (range 0 – 13)
time between interruptions (minutes) 7.1 + 0.8 (range 2.8 - 15)
number of pager interruptions 3.4 + 6 (range 0 – 11)
number of phone call interruptions 1.0 + 0.2 (range 0 – 3)
number of direct interruptions 1.3 + 3 (range (0 – 4)
An Average Sign-Out
Characterization of Sign-out (15 sessions comprising 209 patients)
Success? Well…
Baseline After intervention
No unexpected event
Unexpected event
No unexpected event
Unexpected event
How busy were you? (1 slow – 5 busy) 2.93 + 1.07 3.25 + 1.06 3.29 + 1.12 3.32 + 1.10
How many pts on service at the beginning of your call shift?
14.85 + 4.33 14.33 + 4.56 20.09 + 4.54 20.50 + 4.23
How many admissions did you have while on call?
4.86 + 2.86 4.86 + 3.21 5.27 + 2.86 4.38 + 2.21
Quality of sign-out (1 inadequate – 5 adequate)
4.48 + 0.70 3.58 + 0.92 4.15 + 0.71 3.74 + 0.80
Where did you go to get additional information?
What did we do wrong?
• Were our premises wrong? – Perhaps the cognitive tasks of sign-out need
to be reframed • For a successful sign-out, physicians handing off
care and physicians assuming care must assemble a shared mental model of patients they are caring for (co-orientation)
• Co-orientation is necessary to recognize and analyze problems, make sense of the situation, and plan
• Co-orientation provides an opportunity for rescue and recovery (collaborative cross-checking)
Implementation of Curriculum
Process of implementation • Incorporation of structured, organized and
consistent approach to teaching, practicing, observing and evaluating the skill of patient sign-out.
• Overnight and weekend call teams were realigned
• Senior/intern teams are expected to attend team sign outs together in order to improve the communication between the on call resident team and allow for modeling of sign-out skills by more experienced residents.
Process of implementation
• Emphasis was placed on: – Face to face sign-out – Standardized location – Scheduled sessions – Verbal communication – Written sign-out tool
Team Care A culture change
• We care for our patients as a team • Team members must handover patient care via
verbal and written “sign-out” • Sign-out must contain complete, accurate and
concise information to allow for smooth transitions in care
• Your teammates’ care can only be as good as the Sign-out that they get from you
Teaching Sign-Out
• Sign-out means different things to different people • Levels of experience • Styles of caring for patients • Styles of learning
Approach to Learning the skill of patient handovers
• The process for completing both verbal and written sign-out is – introduced at intern orientation – reinforced throughout training including direct
observation and feedback from attending physicians.
• Teach it • Model it • Practice it • Evaluate it
Sign-out Format
• Demographics – The ID statement
• Active issues – Include access, new events of the day, better
or worse • To do list • Anticipatory Guidance
– Contingency plans – If…then… statements
Things to Include
1. Name and/or MRN 2. The big sentence 3. Current condition 4. Plan of care 5. Contingency plans (What if’s/questions that
might arise overnight) 6. Read back/summation from receiver 7. Co-orientation & collaborative cross-check
Things Not to Include
• Plans for next week that are not important for the next 24 hours
• Gossip • Too much time on background and pt ID • Things easily found elsewhere
• Sign out sheet • Hospital chart or EMR • Medication orders
CME Sign-Out Goals & Objectives
• All skills of resident plus mastery of collaborative cross check • PL-1 – Information and Accuracy • PL-2 – Synopsis and Query • PL-3 – Efficiency and Collaboration
PL-1 Goals & Objectives for Sign-Out
1. Will be able to identify the five key components for patient sign-out
2. Will recognize effective sign-out by others
3. Will be able to give all five essential components of sign-out without prompting by end of PL-1 year
PL-2 Goals & Objectives for Sign-Out
All skills of PL-1 plus 1. Will understand what read
back/synopsis role is in sign-out 2. Will recognize effective read back
by others 3. Will be able to elicit all 5
components of sign-out from other resident
PL-3 Goals & Objectives for Sign-Out
All skills of PL-2 plus 1. Will demonstrate effective & efficient
sign-out 2. Will demonstrate effective & efficient
read back as receiver in sign-out 3. Will utilize teaching opportunities 4. Will recognize collaborative cross check 5. Will work towards mastery of
collaborative cross check
Steps for Teaching, Observing and Evaluating Sign-out
• Senior Resident Leadership Workshops – Review expectations for SIGNOUT – Share EMR Sign-out template – Discuss plans for evaluation and feedback
• Intern Orientation – Review expectations for SIGNOUT – Model adequate vs. inadequate sign-out – Practice developing written sign-out
• Evaluation of verbal SIGNOUT – Verbal SIGNOUT observation tool – Direct observation by attendings each week
Optimal Sign-out Giver
– Arrives on time – Brings an updated written sign-out list – Invites questions – Makes sure that all patient issues are
understood before leaving
Optimal Sign-out Receiver
– Arrives on time – Is attentive to the Sign-out giver – Asks clarifying questions – Makes sure that he/she understands
all patient issues
Success after implementation
Perceptions of Improvement
• Pre intervention survey of 55 residents and 50 faculty
• Implementation of a standardized curriculum
• Post intervention survey of 64 residents and 50 faculty
Quality of information given “Clinical information
contained in my sign-out is:”
Quality of information received “The information that I receive in sign-out is”
Ability to care for patients “Because of information received in sign-out, I am able
to:”
Ability to care for patients “Because of information received in sign-out,
the resident is able to:”
Conclusions A structured sign-out curriculum increased : • the perceived quality of the information
exchanged • the perceived ability to care for patients.
Direct Observation
Future Directions
• Faculty development in giving feedback to residents on verbal sign-out
• Faculty review of written sign-out to give feedback on content
Who Gives Good Sign-Out and Why?
• We surveyed our housestaff and asked them to identify the three (out of 39) residents who give the best sign-out • Three individuals were identified by more
than 40% of their peers • “after signing out with them, I feel well prepared
for the next call shift” • “they help me anticipate what might go wrong
during my call shift” • “they give me a chance to ask questions”
Social Awareness Strategies
• Watch Body Language • Don’t Text at Meetings • Make Timing Everything • Clear Away the Clutter • Practice the Art of Listening • Go People Watching • Catch the Mood of the Room • Understand the Rules of the Culture Game
