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Spotlight Case September 2006

Triple Handoff


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Source and Credits

This presentation is based on the September 2006

AHRQ WebM&M Spotlight Case

See the full article at http://webmm.ahrq.gov CME credit is available through the Web site

Commentary by: Arpana Vidyarthi, MD, UCSF School of Medicine

Editor, AHRQ WebM&M: Robert Wachter, MD

Spotlight Editor: Tracy Minichiello, MD

Managing Editor: Erin Hartman, MS


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Objectives

At the conclusion of this educational activity,

participants should be able to:

Appreciate the prevalence of handoffs and signout-

related errors

Understand the key elements of a safe and effective

written and verbal signout List Kotters 8 steps to leading change


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Case: Triple Handoff

An 83-year-old man with a historyof COPD, GERD, and

paroxysmal atrial fibrillation with sick sinus syndrome is

admitted to the CardiologyService for initiation ofdofetilide and placement of a permanent pacemaker.

The patient underwent placement of the pacemaker via

the left subclavian vein at 2:30p.m. A routine post-op

single view radiograph was taken and showed nopneumothorax.


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The patient was sent to the recoveryunit for overnightmonitoring. At 5:00p.m. the patient stated he was short

of breath and requested his COPD inhaler. He alsocomplained of new left-sided back pain. The nursefound that his pulse oxygenation had dropped from 95%to 88%. Supplemental oxygen was started and the

nurse asked the coveringphysician to see the patient.


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Case: Triple HandoffThe patient was on the nurse practitioner (NP) non-housestaff

service; the on-call intern covers after the NPs leave for the day.

The intern, who had never met the patient, found him already

feelingbetter withimproved oxygenation on supplemental

oxygen. The nurse suggested a stat x-rayin lightofthe recent

surgery. The intern agreed, and a portable x-raywas done within

30minutes. An hour later, the nurse wondered aboutthe x-rayso

he asked the coveringintern ifhe had seen it.


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The coveringintern stated thathe was signingoutthe x-

rayto the nightfloatresident, who was comingon duty

at8:00p.m. Meanwhile,the patientcontinued to feelwell, exceptfor mild back pain. The nurse gave the

patientacetaminophen as prescribed and continued to

monitorhis heartrate and respirations.


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At10:00p.m. the nurse asked the nightfloatresident

aboutthe x-ray. The nightfloathad been busywithan

emergencybutpromised to look atthe x-rayand advisethe nurse of anyproblem. Finallyatmidnight,the nurse

signed outto nightshift, mentioningthe patient's

symptoms and notingthatthe nightfloathad notcalled

withanybad news.


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Signout Definition: mechanism by which patient care responsibility

and patient information is transferred from one practitioner

to another

All care providers, including RNs, NPs, and MDs, must sign

out patients

Housestaff duty-hour restrictions have

increased the number of handoffs

Vidyarthi A, et al. J Hosp Med. 2006;1:257-266.University HealthSystem Consortium; May 2006.


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Signout: Numbers

After duty-hours restrictions, signouts increased by 40%

Average number of times a resident signs out per month:

300 Estimated total number of signouts per day (including all

health care providers) in large academic hospital: 4,000

Estimated total number of signouts per year in a hospital:

1.6 million

HCUPnet, Healthcare Cost and Utilization Project.


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JCAHO Takes on Handoffs

JCAHO National Patient Safety Goal 2E:

All health care providers must implement a

standardized approach to handoff communicationsincluding an opportunity to ask and respond to

questions

Joint Commission on Accreditation of Healthcare Organizations. 2006.


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JCAHO Takes on Handoffs

Components ofJCAHO National Patient Safety Goal 2E

Include interactive communications

Up-to-date and accurate information

Limited interruptions

A process for verification

Opportunity to review relevant historical data

Joint Commission on Accreditation of Healthcare Organizations. 2006.


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Case (cont.): Triple Handoff

The next morning, the radiologist read the x-ray

performed at 4:00p.m. and notified the NP that it

showed a large left pneumothorax. Cardiothoracic

surgeryservice was consulted and a chest tube was

placed at 2:30p.m., nearly23hours after the x-raywas

performed. The patient ultimatelyrecovered.


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Signout Errors

Important information lost due to handoffs causing

diagnosis and treatment delay and a potentially

significant error Most signout errors are content omissions

in which critical information is not communicated

Omission errors occur at a rate of1/100

Many caught before harm reaches patient

Arora V, et al. Qual Saf Health Care. 2005;14:401-407.Nolan TW. BMJ. 2000;320:771-773.


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Signout: Making It Safe

Standardize or structure the signout

Include both written and verbal signout to optimize

information transfer ANTICipate:

Administrative data

New information

Tasks Illness

Contingency plans

Vidyarthi A, et al. J Hosp Med. 2006;1:257-266.See Notes for complete references.


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Signout: Making It Safe

Accurate administrative information

New informationbrief history and diagnosis, updated

medications and problem list, current baseline status and recentprocedures, significant events

Tasksto-do list

Illnessprimary providers subjective assessment of the severityof illness

Contingency planningstatements that assist cross-coverage inmanaging anticipated problems


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ANTICipateAdministrative data Name, MR number

New information 83-year-old man, history of COPD, GERD, paroxysmal atrial fibrillation with

sick sinus syndrome s/p initiation of dofetilide, placement of pacemaker

(today at 2:30 p.m.). Developed SOB after procedure, responded to inhalerTasks Check stat CXR given SOB

Illness Currently stable

Contingency plans Check CXR which was taken at 4:00 p.m. If clear, call nurse to communicate

results; ifPTX, call thoracic surgery. If the patient is short of breath, try an

albuterol inhaler, given COPD, but consider pneumothorax since he recentlyhad a subclavian line placed


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Written Signout

Computerized template

MS Word, FilemakerPro, MS Excel

Systems depend on user for accurate data entry Wide variability of content accuracy has been noted

Linking signout to hospital electronic medical record (EMR) may

decrease chances of inaccurate data

Olsen C, et al. Poster presented at:The Societyof Hospital Medicine Annual Meeting; May 2006.


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Computerized Written Signout: Synopsis*

Can import data from the EMR, including administrative

information, laboratory results, medications, allergies,

and code status Shown to improve resident efficiency and quality of

signout and to reduce the risk of signout-related medical

injuries

Van Eaton EG, et al. J Am Coll Surg. 2005;200:538-534.Petersen LA, et al. Jt Comm J Qual Improv. 1998;24:77-87.

* System used at UCSF Medical Center


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Synopsis: UCSF Medical Center Signout System


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Verbal Signout

Tailor to the receiver

Conduct in a quiet, distraction-free place at a

designated time

Provide access to up-to date information

Use structured format

Require receiver to repeat back or read back tasks

Leonard M, et al. Qual Saf Health Care. 2004;13(suppl 1):i85-i90.Barenfanger J, et al. Am J Clin Pathol. 2004;121:801-803.


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The teamsubsequentlylearned thatthe night

floatresidenthad mistakenlyexamined the

radiographdone immediatelypost-operatively,

ratherthan the chestx-raydone at4:00p.m.,

and therefore did notsee the filmwiththe large

pneumothorax.


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X-ray ofPneumothorax


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Kotter's 8-Step Approach to Leading Change

1. Establish urgency

2. Form a powerful guiding coalition

3. Create a vision

4. Communicate the vision

5. Empower others to act on the vision

6. Plan for short-term wins

7. Consolidate improvements, creating more change

8. Institutionalize new approach

Kotter JP. Harv Bus Rev. March 1995.


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The UCSF Experience

Establish urgency Residents needs and JCAHO patient safety goal

Form a powerful guiding coalition Information Technology (IT), Medical Center, and Graduate MedicalEducation (GME) leadership

Create a vision A sign-out system that could grow with our new EMR making resident

work more efficient and the sign-out process safer for patients

Communicate the vision Presented to leadership at numerous committee meetings


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The UCSF Experience Empower others to act on the vision

Engaged the medical center IT and GME leadership to help core group ofchampions move forward in development of Synopsis

Plan for short term wins Designed a rounds report linked to Synopsis facilitating information

consolidation and tracking increasing resident workflow efficiency

Consolidate improvements, creating more change Synopsis spread organically once residents saw its capacity on one of the pilot

units

Institutionalize new approach Policies passed at the GME and Medical Center level


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The UCSF Experience

Results

More than 50% of the patients at 600-bed acute care hospital

cared for with the assistance of Synopsis signout system


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Take-Home Points

Signouts and discontinuity are an inevitable part of todays

hospital systems

Patients are at risk for errors due to discontinuity and signouts Structured sign-out systems, including verbal and written

standards, can assist in improving the effectiveness of the sign-

out process

A change framework can be an effective strategy toimplementing safe and effective sign-out systems

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