- Email: [email protected]
Implementation of a standardized electronic tool improves compliance, accuracy, and efficiency of trainee-to-trainee patient care handoffs after complex general surgical oncology procedures
ARTICLE IN PRESS
Implementation of a standardized electronic tool improves compliance, accuracy, and efficiency of trainee-to-trainee patient care handoffs after complex general surgical oncology procedures Callisia N. Clarke, MD,a Sameer H. Patel, MD,b Ryan W. Day, MD,b,c Sobha George, MSN,d Colin Sweeney, BA,e Georgina Avaloa Monetes De Oca, MS,e Mohamed Ait Aiss, BS,e Elizabeth G. Grubbs, MD,b Brian K. Bednarski, MD,b Jeffery E. Lee, MD,b Diane C. Bodurka, MD, MPH,f John M. Skibber, MD,b and Thomas A. Aloia, MD,b Milwaukee, WI, Houston, TX, and Phoeniz, AZ
Background. Duty-hour regulations have increased the frequency of trainee-trainee patient handoffs. Each handoff creates a potential source for communication errors that can lead to near-miss and patientharm events. We investigated the utility, efficacy, and trainee experience associated with implementation of a novel, standardized, electronic handoff system. Methods. We conducted a prospective intervention study of trainee-trainee handoffs of inpatients undergoing complex general surgical oncology procedures at a large tertiary institution. Preimplementation data were measured using trainee surveys and direct observation and by tracking delinquencies in charting. A standardized electronic handoff tool was created in a research electronic data capture (REDCap) database using the previously validated I-PASS methodology (illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis). Electronic handoff was augmented by direct communication via phone or face-to-face interaction for inpatients deemed “watcher” or “unstable.” Postimplementation handoff compliance, communication errors, and trainee work flow were measured and compared to preimplementation values using standard statistical analysis. Results. A total of 474 handoffs (203 preintervention and 271 postintervention) were observed over the study period; 86 handoffs involved patients admitted to the surgical intensive care unit, 344 patients admitted to the surgical stepdown unit, and 44 patients on the surgery ward. Implementation of the structured electronic tool resulted in an increase in trainee handoff compliance from 73% to 96% (P < .001) and decreased errors in communication by 50% (P = .044) while improving trainee efficiency and workflow. Conclusion. A standardized electronic tool augmented by direct communication for higher acuity patients can improve compliance, accuracy, and efficiency of handoff communication between surgery trainees. (Surgery 2016;j:j-j.) From the Division of Surgical Oncology, Department of Surgery,a The Medical College of Wisconsin, Milwaukee, WI; the Department of Surgical Oncology,b The University of Texas, M.D. Anderson Cancer Center, Houston, TX; the Department of Surgery,c Programs in Arizona, Mayo School of Graduate Medical Education, Mayo Clinic College of Medicine, Phoenix, AZ; and the Department of Clinical Operations Informatics,d the Department of Process Improvement and Quality Education,e and the Department of Clinical Education,f The University of Texas, M.D. Anderson Cancer Center, Houston, TX Presented at the 11th Annual Academic Surgical Congress in Jacksonville, FL, February 2–4, 2016.
Center, Box 301402, Unit 1484, 1400 Pressler Street, Houston, TX 77230-1402. E-mail: [email protected].
Accepted for publication September 7, 2016.
0039-6060/$ - see front matter
Reprint requests: Thomas A. Aloia, MD, Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer
Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2016.09.004
SURGERY 1
ARTICLE IN PRESS 2 Clarke et al
THE RELEASE of To err is human: Building a safer health system in 2000 by the Institute of Medicine raised major concerns about the state of medical errors in the United States.1 In response, the Accreditation Council for Graduate Medical Education (ACGME) investigated potential sources of errors related specifically to trainees and later enacted restricted duty-hour policies.2 After these changes, the number and complexity of trainee-to-trainee handoffs of patient information and care increased markedly. The hand-off process has become an integral part of patient care, but as the number of handoffs has increased, the potential for communication errors has increased dramatically and remains one of the leading causes of sentinel events reported to the Joint Commission.3 Patients undergoing an operation constitute a cohort at high risk of sustaining an in-hospital adverse event.4 Complex general surgical oncology patients have unique risks, including cytopenias, cancer-related pain, immunosuppression, long operative times, and need for multiple surgical teams, that render them particularly susceptible to perioperative complications. With the addition of cancer-specific morbidity to pre-existing patient-related factors, the need to accomplish handoffs with complete and accurate communication of clinical information is paramount to prevent medical errors.5 The ACGME has acknowledged the importance of handoffs and requires training programs to provide “effective, structured hand-over processes to facilitate both continuity of care and patient safety.”6 This position statement has resulted in emphasis being placed on evaluating the effectiveness of handoffs and has led to the development and implementation of a wide variety of handoff tools, each with different strengths and weaknesses. The I-PASS mnemonic (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) was developed as a guide for oral and written handoffs between residents and has been tested primarily at academic pediatric residency programs. The I-PASS method of communicating handoffs has found increasing popularity due to its intrinsic ability to risk-stratify patients, allowing for early identification of those most likely to decompensate and facilitating rescue by encouraging providers to include contingency plans for potential patient care issues that may arise. Importantly, implementation of the I-PASS handoff bundle has been shown to decrease medical errors and preventable adverse events.7-9
Surgery j 2016
Although it is accepted widely that standardized handoff systems have improved sign out efficiency and accuracy, barriers in the human interface remain.10 Furthermore, there is a paucity of data examining the role of standardized handoffs by trainees overseeing the care of surgical patients. Overlapping operating room responsibilities and other aspects of surgical training present unique physical barriers to effective handoffs that may be overcome by the use of centralized electronic repositories. To address these issues, this project was designed to evaluate prospectively the utility, efficacy, and trainee experience related to introduction of a novel standardized electronic handoff tool for surgical patients undergoing complex general surgical oncology procedures. METHODS Study design. At our single, tertiary cancer center, a task-force of attending surgeons, trainees, and quality improvement personnel was established to improve the trainee-to-trainee process of patient care handoff. This collaboration produced a prospective intervention study of handoffs between surgery trainees within an ACGMEaccredited, complex general surgery oncology fellowship for patients admitted to high-acuity wards postoperatively. The project received approval from our institutional Quality Improvement Assessment Board. Root cause analysis and process mapping of the current handoff system was performed to identify existing deficiencies and to determine preintervention (baseline) measures, including handoff compliance, accuracy, and efficiency. Preintervention outcomes were assessed from 203 traineetrainee handoffs during a 2-month period using a combination of direct observation, trainee surveys, and chart audit of delinquencies in postoperative notes. Intervention. The I-PASS methodology was used to create a standardized electronic tool within the research electronic data capture (REDCap) database framework hosted at M.D. Anderson Cancer Center. REDCap is a secure, Web-based application designed to support data capture for research studies, which provides an intuitive interface for validated data entry, audit trails for data manipulation, and export procedures.11 All trainees completed training in the I-PASS Handoff Bundle, a previously validated training curriculum consisting of computer modules and an interactive workshop in which the I-PASS mnemonic was emphasized as the method of communicating
ARTICLE IN PRESS Surgery Volume j, Number j
patient information during oral and electronic handoffs.12,13 This 3-hour workshop included a role-playing and simulation session led by taskforce members, including attending physicians and Quality Improvement personnel. Additionally, fellows were trained on the appropriate categorization of patients. For example, patients with vasopressor requirements, patients who underwent massive transfusion (>10 units of packed red blood cells), or those requiring additional resuscitation were classified as “unstable” by these criteria. Similarly, recently extubated patients or patients undergoing prolonged operations (>8 hours), or those with large-volume intraoperative blood loss (>1 L) were categorized as “watcher.” During the 4-month intervention period, all trainees were required to utilize the standardized electronic handoff tool to complete patient handoffs. Each trainee was provided a daily e-mail link to the REDCap database. The centralized electronic tool in REDCap prompted trainee responses through a structured data form with point-andclick and drop-down menu functionality to speed entry of patient identifiers, acuity, ongoing issues, on-call tasks, and attending preferences (eg, crystalloid versus colloid resuscitation and use of ketorolac) using the I-PASS format. Patients were stratified as “stable,” “watcher,” or “unstable” based on the potential for postoperative complications or ongoing medical issues. Patients identified as greater risk were recommended to have the electronic handoff augmented by either a phone call (watcher designation) or a face-to-face sign out (unstable designation). The on-call trainee was sent a separate link to the REDCap database that automatically presented him or her with all patient data aggregated into a single, structured worklist for his or her on-call shift. Postintervention metrics included percent of handoffs completed, accuracy of handoffs, and number of documented postoperative checks. Compliance of handoffs and postoperative check metrics were calculated objectively by measuring the number of completed handoffs within the database as a percentage when compared to the census of patients admitted to the observed units. Time required for the on-call trainee to create an action list for all patients was measured as a surrogate for trainee workflow and efficiency. The American College of Surgeons National Surgical Quality Improvement Program database was queried to compare mortality, hospital duration of stay, and 30-day readmission rates during the preintervention versus postintervention study period.
Clarke et al 3
Statistical analysis. Statistical analysis was performed by 2-tailed t test or a 1-way analysis of variance with subsequent Student-Newman-Keuls test. Data are reported as mean ± standard error of the mean. All statistical analyses were performed using SPSS software (vX; IBM Corp, Armonk, NY). RESULTS During the 2-month preintervention and 4-month postintervention periods, we analyzed 474 trainee-trainee handoffs (203 preintervention and 271 postintervention) on surgical oncology patients undergoing complex abdominal operations admitted to the surgical step-down unit (TPACU) and the surgical intensive care unit (SICU). The average daily census in each unit was 7 patients and 2 patients, respectively. I-PASS training was completed between the preintervention and postintervention periods to avoid contamination of the baseline data. Eleven of 13 trainees (85%) who participated in the call pool provided responses for the postshift surveys which were used to capture methods of communications, communications errors, workflow efficiency, and documentation of postoperative notes. Survey response rates were similar preintervention (72%) and postintervention (66%). Chart audits were also performed to capture percent compliance of documented postoperative notes. Preintervention. Preintervention baseline data were compiled during a 2-month period. Baseline compliance of trainee-trainee patient handoffs was 73 ± 3% for all patients. Unit-specific compliance was 77 ± 3% and 53 ± 11% for the TPACU and the SICU, respectively. Postoperative check notes were documented on 60 ± 4% of patients admitted to these floors. On-call trainees reported communication errors in 13 ± 2% of all handoffs, and the mean time to compile an on-call action list was 15 ± 2 minutes. Trainees used e-mails preferentially (67%) to perform handoffs, followed by phone calls (19%) and face-to-face handoffs (14%). Oncall trainees reported a delay in receiving handoffs at the beginning of the call shift 29% of the time, with all of these delays due to overlapping responsibilities in the operating room (Fig 1). Process mapping and analysis were performed by the handoff taskforce (Fig 2). Several barriers to effective handoffs were identified, including a nonstandardized method of communicating handoffs leading to a wide variation in the amount of information provided to the on-call trainee, unclear expectations and task assignments, no risk
ARTICLE IN PRESS 4 Clarke et al
Fig 1. Preintervention data were collected during a 2-month period to assess the existing handoff process. On-call trainees reported a delay in receiving handoffs at the beginning of the call shift 29% of the time due to overlapping responsibilities in the operating room.
stratification of patients, and distance (approximately 0.5 miles) between trainee offices and patient care areas. Development of a structured handoff tool. The framework of the REDCap database hosted at M.D. Anderson was used to house the handoff tool. This application was chosen, because all patient information could be encrypted, and its ease of use and formatting allowed for a standardized output that aggregated these data automatically into a single, structured worklist for the on-call fellow. The widely used and previously validated I-PASS mnemonic was used to structure handoffs primarily because of its incorporation of patient illness severity and its inclusion of situational awareness and contingency planning. All trainees then completed I-PASS Handoff Bundle training prior to the pilot period. Postintervention. Throughout the 4-month pilot, trainees received a daily reminder sent to all pagers with a direct link to the REDCap-housed handoff tool. When entering patient data into the tool, trainees received an immediate prompt to augment the electronic handoff with either a phone call for patients designated “watcher” or a face-to-face handoff at the bedside for all “unstable” patients. A total of 271 handoffs were analyzed during this period. A structured electronic handoff tool ensured that all handoffs had the key quality elements validated previously in various I-PASS handoffs studies. As such, every handoff included an illness-severity assessment, a patient summary (summary statement, operative events, hospital course, and ongoing assessment), action list
Surgery j 2016
(a list of “to-do” items, including whether a postoperative check was documented or a statement of “nothing to do”), and contingency plans (directly addressing preferred methods of resuscitation and additional options of pain control). Seventy-nine percent of these patients were identified as stable, requiring only an electronic handoff. The remaining 21% of patients were deemed greater risk. All “watcher” and “unstable” patients had their electronic handoffs appropriately augmented by phone calls or face-to-face handoffs. Postintervention, all measured outcomes improved (Fig 3). Overall, handoff compliance increased from 73% to 96% (P < .001). In the TPACU, handoff compliance increased by 17 percentage points from 77% to 94% (P < .001), and in the SICU, handoff compliance improved from 53% to 99% (P < .001). Documented postoperative checks on patients admitted to either unit increased from 60 ± 4% to 92 ± 3% (P < .001). Routine use of the structured electronic handoff tool resulted in a decrease in communication errors from 13 ± 3% to 7 ± 2% (P = .044). The electronic handoff tool also improved trainee work flow and efficiency with a decreased time for on-call trainees to compile a nightly action list which decreased from 15 ± 2 minutes to only 5 ± 1 minutes (P < .001). The National Surgical Quality Improvement Program database was interrogated to capture a randomly sampled 14% of all surgical oncology cases performed at our institution during the study period. There were no mortalities. There was no change in duration of stay with a preintervention of 4.8 days (1–23) vs 4.2 days (1–24; P = .19) postintervention. Similarly, there was no decrease in 30-day readmission rates postintervention (8.3% vs 5.9%; P = .43). DISCUSSION This single-institution, prospective study demonstrates that implementation of a structured electronic handoff tool can increase trainee handoff compliance, improve workflow efficiency, and decrease communication errors between trainees. We found that implementation of the structured electronic handoff tool was associated with a 50% relative decrease in the rate of communication errors between trainees. Our results also demonstrated a significant improvement in overall and unit-specific handoff rates and documented postoperative checks. Additionally, these observed improvements were achieved using a system that improved trainee workflow and efficiency. These
ARTICLE IN PRESS Surgery Volume j, Number j
Clarke et al 5
Fig 2. Process mapping demonstrated a circular process starting with the sender (outgoing trainee) handing off to the receiver (on-call trainee). Analysis revealed wide variation in compliance of the trainee handoffs and content, because this nonstructured method of handoff resulted in communication inconsistencies. Several areas were noted to be heavily subjective and are highlighted in the shaded box. These areas were also associated with poor trainee workflow and overall inefficiency. (Color version of this figure is available online.)
Fig 3. Implementation of a structured electronic tool resulted in significant improvements of all measured, postintervention outcome metrics. HO, Hand off; POC, post operative check.
results add to the expanding body of evidence that structured handoffs are efficient and effective in improving trainee communication during transitions of care and help to create a safe environment for postoperative surgical patients. Although there has been a preponderance of evidence supporting structured oral and written handoff communication as an effective way of decreasing medical errors and preventable adverse events,7,14,15 there is little evidence to support the role of centralized electronic databases to aid in these efforts. Additionally, the majority of handoff tools that have been developed were validated in pediatric or medical patient populations, with
minimal investigation into the utility of structured handoff tools in the care of complex surgical patients. Here, we developed and validated a concise structured handoff tool customized to address issues relevant for surgery trainees, as they provide the highest level of care for high-risk surgical patients undergoing complex surgical oncology operations. As discussed previously, process mapping and analysis identified several barriers to effective handoffs, including several challenges unique to tertiary medical centers. The University of Texas M.D. Anderson Cancer Center has increased in size by >50% in the last 10 years resulting in a 600
ARTICLE IN PRESS 6 Clarke et al
inpatient-bed hospital, a separate outpatient surgery building with short stay capabilities, and administrative buildings all located blocks apart. This distance creates a substantial physical barrier to effective handoff communication between trainees and was noted to contribute to a number of workflow inefficiencies. Our overall handoff compliance prior to implementation of the electronic tool was low at 73% and surprisingly even less at 53% in the SICU. Patients admitted to the SICU are managed primarily by the intensivist on call, and during the preintervention period, trainees cited this fact as the main reason for the low rate of completed surgery trainee handoffs in that patient population. Additionally, patients admitted to either the SICU or the stepdown-down unit for greater than 2 days were less likely to have a handoff completed. We therefore sought to create a handoff tool customized to our specialty needs. We hypothesized that a centralized, easily accessible, electronic handoff tool would increase handoff compliance, improve overall workflow, and standardize communication. By implementing a centralized, electronic handoff database, trainees were able to complete handoffs regardless of their physical location within the hospital complex. The electronic tool allowed for storage of information that could be edited easily over time, especially for patients with prolonged stays. By incorporating patient risk-stratification, we were able to identify patients appropriately and prompt an augmented handoff by direct communication using either a phone call or a face-to-face/bedside handoff. We chose to pilot the intervention in our highest acuity surgical patients admitted to the TPACU and SICU for several reasons. First, the on-call surgery trainee (and not a physician extender) is directly responsible for the care of these patients at all times. Second, by focusing on this smaller subset of patients, we were able to capture more consistently pre- and postintervention data that could be translated easily to the general surgical, postoperative population. The biggest challenge to the widespread utilization of centralized electronic handoff tools is the need to encrypt and protect patient information while still making the tool accessible to trainees. Many research databases have invested time and resources on encrypting protected patient information. REDCap is one such database, and as it was hosted already at our institution, we were able to capitalize on these functions to create a handoff tool that was secure and easily accessible but only within our institution’s network. The added ability
Surgery j 2016
of REDCap to aggregate data into a single worklist was paramount to increasing workflow efficiency for on-call trainees. Additionally, using an electronic format with mandated fields, we were able to assure conformity to the I-PASS mnemonic structure, a benefit that is not possible with unstructured oral and written communications. We acknowledge several limitations. Although long-term follow-up is needed, the short-term outcomes presented in this study demonstrate improvement in overall handoff compliance, increase in workflow efficiency, and decrease in communication errors between trainees at our institution after implementation of a standardized electronic handoff tool. This study was not powered to demonstrate a difference in patient adverse events related to errors in communication. While no statistical differences were seen in duration of hospital stay or readmission rates, our findings suggest that improved communication achieved through the use of a structured electronic handoff tool may improve patient outcomes and does not cause harm. Our intervention demonstrated improved information transmission among surgery trainees; its application to trainees from other disciplines is unknown. Although the need to encrypt electronic data in order to protect patient information limits this application to single-institutional efforts, the template of this methodology is transferable to other institutions with REDCap or other encrypted electronic capabilities. As with any quality improvement effort, active measures are needed to maintain our observed gains. For this study specifically, future efforts are being aimed at continued surveillance of compliance and efficiency of handoffs using this electronic tool and expansion of its use to other surgical specialties to increase its validity. Training on IPASS and the use of the electronic tool has been incorporated into the orientation curriculum for incoming surgery trainees. Additionally, we are working to integrate this electronic tool within our electronic medical record, which could allow for further improvements in workflow and easier compliance and tracking of sentinel events.
REFERENCES 1. Committee on Quality of Health Care in America, Institute of Medicine. In: Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington (DC): National Academies Press; 2000. 2. Duty hours [Internet]. Chicago (IL): Accreditation Council for Graduate Medical Educaton; 2016. Available from:
ARTICLE IN PRESS Surgery Volume j, Number j
3.
4.
5.
6.
7.
8.
http://www.acgme.org/What-We-Do/Accreditation/DutyHours/History-of-Duty-Hours. Sentinel event data: root causes by event type (2004-2015). 2016. Available from: https://www.jointcommission.org/ sentinel_event_statistics_quarterly/. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008;17:216-23. Riesenberg LA, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, et al. Residents’ and attending physicians’ handoffs: a systematic review of the literature. Acad Med 2009;84:1775-87. Common Program Requirements NAS 21: VI.B.2 Transitions of Care. 2016. Available from: www.acgme.org/WhatWe-Do/Accreditation/Common-Program-Requirements. Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014;371:1803-12. Rosenbluth G, Bale JF, Starmer AJ, Spector ND, Srivastava R, West DC, et al. Variation in printed handoff documents: results and recommendations from a multicenter needs assessment. J Hosp Med 2015;10:517-24.
Clarke et al 7
9. Starmer AJ, Landrigan CP. Changes in medical errors with a handoff program. N Engl J Med 2015;372:490-1. 10. Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg 2005;200:538-45. 11. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–a metadatadriven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42:377-81. 12. Calaman SN, Starmer AJ. I-PASS handoff curriculum: computer module, 9: MedEdPORTAL; 2013. Available from: https://www.mededportal.org/. 13. Spector N, Starmer AJ, Allen A. I-PASS handoff curriculum: core resident workshop, 9: MedEdPORTAL; 2013. Available from: https://www.mededportal.org/. 14. Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC, et al. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics 2012;129:201-4. 15. Gordon M, Findley R. Educational interventions to improve handover in health care: a systematic review. Med Educ 2011;45:1081-9.
Implementation of a standardized electronic tool improves compliance, accuracy, and efficiency of trainee-to-trainee patient care handoffs after complex general surgical oncology procedures Callisia N. Clarke, MD,a Sameer H. Patel, MD,b Ryan W. Day, MD,b,c Sobha George, MSN,d Colin Sweeney, BA,e Georgina Avaloa Monetes De Oca, MS,e Mohamed Ait Aiss, BS,e Elizabeth G. Grubbs, MD,b Brian K. Bednarski, MD,b Jeffery E. Lee, MD,b Diane C. Bodurka, MD, MPH,f John M. Skibber, MD,b and Thomas A. Aloia, MD,b Milwaukee, WI, Houston, TX, and Phoeniz, AZ
Background. Duty-hour regulations have increased the frequency of trainee-trainee patient handoffs. Each handoff creates a potential source for communication errors that can lead to near-miss and patientharm events. We investigated the utility, efficacy, and trainee experience associated with implementation of a novel, standardized, electronic handoff system. Methods. We conducted a prospective intervention study of trainee-trainee handoffs of inpatients undergoing complex general surgical oncology procedures at a large tertiary institution. Preimplementation data were measured using trainee surveys and direct observation and by tracking delinquencies in charting. A standardized electronic handoff tool was created in a research electronic data capture (REDCap) database using the previously validated I-PASS methodology (illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis). Electronic handoff was augmented by direct communication via phone or face-to-face interaction for inpatients deemed “watcher” or “unstable.” Postimplementation handoff compliance, communication errors, and trainee work flow were measured and compared to preimplementation values using standard statistical analysis. Results. A total of 474 handoffs (203 preintervention and 271 postintervention) were observed over the study period; 86 handoffs involved patients admitted to the surgical intensive care unit, 344 patients admitted to the surgical stepdown unit, and 44 patients on the surgery ward. Implementation of the structured electronic tool resulted in an increase in trainee handoff compliance from 73% to 96% (P < .001) and decreased errors in communication by 50% (P = .044) while improving trainee efficiency and workflow. Conclusion. A standardized electronic tool augmented by direct communication for higher acuity patients can improve compliance, accuracy, and efficiency of handoff communication between surgery trainees. (Surgery 2016;j:j-j.) From the Division of Surgical Oncology, Department of Surgery,a The Medical College of Wisconsin, Milwaukee, WI; the Department of Surgical Oncology,b The University of Texas, M.D. Anderson Cancer Center, Houston, TX; the Department of Surgery,c Programs in Arizona, Mayo School of Graduate Medical Education, Mayo Clinic College of Medicine, Phoenix, AZ; and the Department of Clinical Operations Informatics,d the Department of Process Improvement and Quality Education,e and the Department of Clinical Education,f The University of Texas, M.D. Anderson Cancer Center, Houston, TX Presented at the 11th Annual Academic Surgical Congress in Jacksonville, FL, February 2–4, 2016.
Center, Box 301402, Unit 1484, 1400 Pressler Street, Houston, TX 77230-1402. E-mail: [email protected].
Accepted for publication September 7, 2016.
0039-6060/$ - see front matter
Reprint requests: Thomas A. Aloia, MD, Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer
Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2016.09.004
SURGERY 1
ARTICLE IN PRESS 2 Clarke et al
THE RELEASE of To err is human: Building a safer health system in 2000 by the Institute of Medicine raised major concerns about the state of medical errors in the United States.1 In response, the Accreditation Council for Graduate Medical Education (ACGME) investigated potential sources of errors related specifically to trainees and later enacted restricted duty-hour policies.2 After these changes, the number and complexity of trainee-to-trainee handoffs of patient information and care increased markedly. The hand-off process has become an integral part of patient care, but as the number of handoffs has increased, the potential for communication errors has increased dramatically and remains one of the leading causes of sentinel events reported to the Joint Commission.3 Patients undergoing an operation constitute a cohort at high risk of sustaining an in-hospital adverse event.4 Complex general surgical oncology patients have unique risks, including cytopenias, cancer-related pain, immunosuppression, long operative times, and need for multiple surgical teams, that render them particularly susceptible to perioperative complications. With the addition of cancer-specific morbidity to pre-existing patient-related factors, the need to accomplish handoffs with complete and accurate communication of clinical information is paramount to prevent medical errors.5 The ACGME has acknowledged the importance of handoffs and requires training programs to provide “effective, structured hand-over processes to facilitate both continuity of care and patient safety.”6 This position statement has resulted in emphasis being placed on evaluating the effectiveness of handoffs and has led to the development and implementation of a wide variety of handoff tools, each with different strengths and weaknesses. The I-PASS mnemonic (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) was developed as a guide for oral and written handoffs between residents and has been tested primarily at academic pediatric residency programs. The I-PASS method of communicating handoffs has found increasing popularity due to its intrinsic ability to risk-stratify patients, allowing for early identification of those most likely to decompensate and facilitating rescue by encouraging providers to include contingency plans for potential patient care issues that may arise. Importantly, implementation of the I-PASS handoff bundle has been shown to decrease medical errors and preventable adverse events.7-9
Surgery j 2016
Although it is accepted widely that standardized handoff systems have improved sign out efficiency and accuracy, barriers in the human interface remain.10 Furthermore, there is a paucity of data examining the role of standardized handoffs by trainees overseeing the care of surgical patients. Overlapping operating room responsibilities and other aspects of surgical training present unique physical barriers to effective handoffs that may be overcome by the use of centralized electronic repositories. To address these issues, this project was designed to evaluate prospectively the utility, efficacy, and trainee experience related to introduction of a novel standardized electronic handoff tool for surgical patients undergoing complex general surgical oncology procedures. METHODS Study design. At our single, tertiary cancer center, a task-force of attending surgeons, trainees, and quality improvement personnel was established to improve the trainee-to-trainee process of patient care handoff. This collaboration produced a prospective intervention study of handoffs between surgery trainees within an ACGMEaccredited, complex general surgery oncology fellowship for patients admitted to high-acuity wards postoperatively. The project received approval from our institutional Quality Improvement Assessment Board. Root cause analysis and process mapping of the current handoff system was performed to identify existing deficiencies and to determine preintervention (baseline) measures, including handoff compliance, accuracy, and efficiency. Preintervention outcomes were assessed from 203 traineetrainee handoffs during a 2-month period using a combination of direct observation, trainee surveys, and chart audit of delinquencies in postoperative notes. Intervention. The I-PASS methodology was used to create a standardized electronic tool within the research electronic data capture (REDCap) database framework hosted at M.D. Anderson Cancer Center. REDCap is a secure, Web-based application designed to support data capture for research studies, which provides an intuitive interface for validated data entry, audit trails for data manipulation, and export procedures.11 All trainees completed training in the I-PASS Handoff Bundle, a previously validated training curriculum consisting of computer modules and an interactive workshop in which the I-PASS mnemonic was emphasized as the method of communicating
ARTICLE IN PRESS Surgery Volume j, Number j
patient information during oral and electronic handoffs.12,13 This 3-hour workshop included a role-playing and simulation session led by taskforce members, including attending physicians and Quality Improvement personnel. Additionally, fellows were trained on the appropriate categorization of patients. For example, patients with vasopressor requirements, patients who underwent massive transfusion (>10 units of packed red blood cells), or those requiring additional resuscitation were classified as “unstable” by these criteria. Similarly, recently extubated patients or patients undergoing prolonged operations (>8 hours), or those with large-volume intraoperative blood loss (>1 L) were categorized as “watcher.” During the 4-month intervention period, all trainees were required to utilize the standardized electronic handoff tool to complete patient handoffs. Each trainee was provided a daily e-mail link to the REDCap database. The centralized electronic tool in REDCap prompted trainee responses through a structured data form with point-andclick and drop-down menu functionality to speed entry of patient identifiers, acuity, ongoing issues, on-call tasks, and attending preferences (eg, crystalloid versus colloid resuscitation and use of ketorolac) using the I-PASS format. Patients were stratified as “stable,” “watcher,” or “unstable” based on the potential for postoperative complications or ongoing medical issues. Patients identified as greater risk were recommended to have the electronic handoff augmented by either a phone call (watcher designation) or a face-to-face sign out (unstable designation). The on-call trainee was sent a separate link to the REDCap database that automatically presented him or her with all patient data aggregated into a single, structured worklist for his or her on-call shift. Postintervention metrics included percent of handoffs completed, accuracy of handoffs, and number of documented postoperative checks. Compliance of handoffs and postoperative check metrics were calculated objectively by measuring the number of completed handoffs within the database as a percentage when compared to the census of patients admitted to the observed units. Time required for the on-call trainee to create an action list for all patients was measured as a surrogate for trainee workflow and efficiency. The American College of Surgeons National Surgical Quality Improvement Program database was queried to compare mortality, hospital duration of stay, and 30-day readmission rates during the preintervention versus postintervention study period.
Clarke et al 3
Statistical analysis. Statistical analysis was performed by 2-tailed t test or a 1-way analysis of variance with subsequent Student-Newman-Keuls test. Data are reported as mean ± standard error of the mean. All statistical analyses were performed using SPSS software (vX; IBM Corp, Armonk, NY). RESULTS During the 2-month preintervention and 4-month postintervention periods, we analyzed 474 trainee-trainee handoffs (203 preintervention and 271 postintervention) on surgical oncology patients undergoing complex abdominal operations admitted to the surgical step-down unit (TPACU) and the surgical intensive care unit (SICU). The average daily census in each unit was 7 patients and 2 patients, respectively. I-PASS training was completed between the preintervention and postintervention periods to avoid contamination of the baseline data. Eleven of 13 trainees (85%) who participated in the call pool provided responses for the postshift surveys which were used to capture methods of communications, communications errors, workflow efficiency, and documentation of postoperative notes. Survey response rates were similar preintervention (72%) and postintervention (66%). Chart audits were also performed to capture percent compliance of documented postoperative notes. Preintervention. Preintervention baseline data were compiled during a 2-month period. Baseline compliance of trainee-trainee patient handoffs was 73 ± 3% for all patients. Unit-specific compliance was 77 ± 3% and 53 ± 11% for the TPACU and the SICU, respectively. Postoperative check notes were documented on 60 ± 4% of patients admitted to these floors. On-call trainees reported communication errors in 13 ± 2% of all handoffs, and the mean time to compile an on-call action list was 15 ± 2 minutes. Trainees used e-mails preferentially (67%) to perform handoffs, followed by phone calls (19%) and face-to-face handoffs (14%). Oncall trainees reported a delay in receiving handoffs at the beginning of the call shift 29% of the time, with all of these delays due to overlapping responsibilities in the operating room (Fig 1). Process mapping and analysis were performed by the handoff taskforce (Fig 2). Several barriers to effective handoffs were identified, including a nonstandardized method of communicating handoffs leading to a wide variation in the amount of information provided to the on-call trainee, unclear expectations and task assignments, no risk
ARTICLE IN PRESS 4 Clarke et al
Fig 1. Preintervention data were collected during a 2-month period to assess the existing handoff process. On-call trainees reported a delay in receiving handoffs at the beginning of the call shift 29% of the time due to overlapping responsibilities in the operating room.
stratification of patients, and distance (approximately 0.5 miles) between trainee offices and patient care areas. Development of a structured handoff tool. The framework of the REDCap database hosted at M.D. Anderson was used to house the handoff tool. This application was chosen, because all patient information could be encrypted, and its ease of use and formatting allowed for a standardized output that aggregated these data automatically into a single, structured worklist for the on-call fellow. The widely used and previously validated I-PASS mnemonic was used to structure handoffs primarily because of its incorporation of patient illness severity and its inclusion of situational awareness and contingency planning. All trainees then completed I-PASS Handoff Bundle training prior to the pilot period. Postintervention. Throughout the 4-month pilot, trainees received a daily reminder sent to all pagers with a direct link to the REDCap-housed handoff tool. When entering patient data into the tool, trainees received an immediate prompt to augment the electronic handoff with either a phone call for patients designated “watcher” or a face-to-face handoff at the bedside for all “unstable” patients. A total of 271 handoffs were analyzed during this period. A structured electronic handoff tool ensured that all handoffs had the key quality elements validated previously in various I-PASS handoffs studies. As such, every handoff included an illness-severity assessment, a patient summary (summary statement, operative events, hospital course, and ongoing assessment), action list
Surgery j 2016
(a list of “to-do” items, including whether a postoperative check was documented or a statement of “nothing to do”), and contingency plans (directly addressing preferred methods of resuscitation and additional options of pain control). Seventy-nine percent of these patients were identified as stable, requiring only an electronic handoff. The remaining 21% of patients were deemed greater risk. All “watcher” and “unstable” patients had their electronic handoffs appropriately augmented by phone calls or face-to-face handoffs. Postintervention, all measured outcomes improved (Fig 3). Overall, handoff compliance increased from 73% to 96% (P < .001). In the TPACU, handoff compliance increased by 17 percentage points from 77% to 94% (P < .001), and in the SICU, handoff compliance improved from 53% to 99% (P < .001). Documented postoperative checks on patients admitted to either unit increased from 60 ± 4% to 92 ± 3% (P < .001). Routine use of the structured electronic handoff tool resulted in a decrease in communication errors from 13 ± 3% to 7 ± 2% (P = .044). The electronic handoff tool also improved trainee work flow and efficiency with a decreased time for on-call trainees to compile a nightly action list which decreased from 15 ± 2 minutes to only 5 ± 1 minutes (P < .001). The National Surgical Quality Improvement Program database was interrogated to capture a randomly sampled 14% of all surgical oncology cases performed at our institution during the study period. There were no mortalities. There was no change in duration of stay with a preintervention of 4.8 days (1–23) vs 4.2 days (1–24; P = .19) postintervention. Similarly, there was no decrease in 30-day readmission rates postintervention (8.3% vs 5.9%; P = .43). DISCUSSION This single-institution, prospective study demonstrates that implementation of a structured electronic handoff tool can increase trainee handoff compliance, improve workflow efficiency, and decrease communication errors between trainees. We found that implementation of the structured electronic handoff tool was associated with a 50% relative decrease in the rate of communication errors between trainees. Our results also demonstrated a significant improvement in overall and unit-specific handoff rates and documented postoperative checks. Additionally, these observed improvements were achieved using a system that improved trainee workflow and efficiency. These
ARTICLE IN PRESS Surgery Volume j, Number j
Clarke et al 5
Fig 2. Process mapping demonstrated a circular process starting with the sender (outgoing trainee) handing off to the receiver (on-call trainee). Analysis revealed wide variation in compliance of the trainee handoffs and content, because this nonstructured method of handoff resulted in communication inconsistencies. Several areas were noted to be heavily subjective and are highlighted in the shaded box. These areas were also associated with poor trainee workflow and overall inefficiency. (Color version of this figure is available online.)
Fig 3. Implementation of a structured electronic tool resulted in significant improvements of all measured, postintervention outcome metrics. HO, Hand off; POC, post operative check.
results add to the expanding body of evidence that structured handoffs are efficient and effective in improving trainee communication during transitions of care and help to create a safe environment for postoperative surgical patients. Although there has been a preponderance of evidence supporting structured oral and written handoff communication as an effective way of decreasing medical errors and preventable adverse events,7,14,15 there is little evidence to support the role of centralized electronic databases to aid in these efforts. Additionally, the majority of handoff tools that have been developed were validated in pediatric or medical patient populations, with
minimal investigation into the utility of structured handoff tools in the care of complex surgical patients. Here, we developed and validated a concise structured handoff tool customized to address issues relevant for surgery trainees, as they provide the highest level of care for high-risk surgical patients undergoing complex surgical oncology operations. As discussed previously, process mapping and analysis identified several barriers to effective handoffs, including several challenges unique to tertiary medical centers. The University of Texas M.D. Anderson Cancer Center has increased in size by >50% in the last 10 years resulting in a 600
ARTICLE IN PRESS 6 Clarke et al
inpatient-bed hospital, a separate outpatient surgery building with short stay capabilities, and administrative buildings all located blocks apart. This distance creates a substantial physical barrier to effective handoff communication between trainees and was noted to contribute to a number of workflow inefficiencies. Our overall handoff compliance prior to implementation of the electronic tool was low at 73% and surprisingly even less at 53% in the SICU. Patients admitted to the SICU are managed primarily by the intensivist on call, and during the preintervention period, trainees cited this fact as the main reason for the low rate of completed surgery trainee handoffs in that patient population. Additionally, patients admitted to either the SICU or the stepdown-down unit for greater than 2 days were less likely to have a handoff completed. We therefore sought to create a handoff tool customized to our specialty needs. We hypothesized that a centralized, easily accessible, electronic handoff tool would increase handoff compliance, improve overall workflow, and standardize communication. By implementing a centralized, electronic handoff database, trainees were able to complete handoffs regardless of their physical location within the hospital complex. The electronic tool allowed for storage of information that could be edited easily over time, especially for patients with prolonged stays. By incorporating patient risk-stratification, we were able to identify patients appropriately and prompt an augmented handoff by direct communication using either a phone call or a face-to-face/bedside handoff. We chose to pilot the intervention in our highest acuity surgical patients admitted to the TPACU and SICU for several reasons. First, the on-call surgery trainee (and not a physician extender) is directly responsible for the care of these patients at all times. Second, by focusing on this smaller subset of patients, we were able to capture more consistently pre- and postintervention data that could be translated easily to the general surgical, postoperative population. The biggest challenge to the widespread utilization of centralized electronic handoff tools is the need to encrypt and protect patient information while still making the tool accessible to trainees. Many research databases have invested time and resources on encrypting protected patient information. REDCap is one such database, and as it was hosted already at our institution, we were able to capitalize on these functions to create a handoff tool that was secure and easily accessible but only within our institution’s network. The added ability
Surgery j 2016
of REDCap to aggregate data into a single worklist was paramount to increasing workflow efficiency for on-call trainees. Additionally, using an electronic format with mandated fields, we were able to assure conformity to the I-PASS mnemonic structure, a benefit that is not possible with unstructured oral and written communications. We acknowledge several limitations. Although long-term follow-up is needed, the short-term outcomes presented in this study demonstrate improvement in overall handoff compliance, increase in workflow efficiency, and decrease in communication errors between trainees at our institution after implementation of a standardized electronic handoff tool. This study was not powered to demonstrate a difference in patient adverse events related to errors in communication. While no statistical differences were seen in duration of hospital stay or readmission rates, our findings suggest that improved communication achieved through the use of a structured electronic handoff tool may improve patient outcomes and does not cause harm. Our intervention demonstrated improved information transmission among surgery trainees; its application to trainees from other disciplines is unknown. Although the need to encrypt electronic data in order to protect patient information limits this application to single-institutional efforts, the template of this methodology is transferable to other institutions with REDCap or other encrypted electronic capabilities. As with any quality improvement effort, active measures are needed to maintain our observed gains. For this study specifically, future efforts are being aimed at continued surveillance of compliance and efficiency of handoffs using this electronic tool and expansion of its use to other surgical specialties to increase its validity. Training on IPASS and the use of the electronic tool has been incorporated into the orientation curriculum for incoming surgery trainees. Additionally, we are working to integrate this electronic tool within our electronic medical record, which could allow for further improvements in workflow and easier compliance and tracking of sentinel events.
REFERENCES 1. Committee on Quality of Health Care in America, Institute of Medicine. In: Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington (DC): National Academies Press; 2000. 2. Duty hours [Internet]. Chicago (IL): Accreditation Council for Graduate Medical Educaton; 2016. Available from:
ARTICLE IN PRESS Surgery Volume j, Number j
3.
4.
5.
6.
7.
8.
http://www.acgme.org/What-We-Do/Accreditation/DutyHours/History-of-Duty-Hours. Sentinel event data: root causes by event type (2004-2015). 2016. Available from: https://www.jointcommission.org/ sentinel_event_statistics_quarterly/. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008;17:216-23. Riesenberg LA, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, et al. Residents’ and attending physicians’ handoffs: a systematic review of the literature. Acad Med 2009;84:1775-87. Common Program Requirements NAS 21: VI.B.2 Transitions of Care. 2016. Available from: www.acgme.org/WhatWe-Do/Accreditation/Common-Program-Requirements. Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014;371:1803-12. Rosenbluth G, Bale JF, Starmer AJ, Spector ND, Srivastava R, West DC, et al. Variation in printed handoff documents: results and recommendations from a multicenter needs assessment. J Hosp Med 2015;10:517-24.
Clarke et al 7
9. Starmer AJ, Landrigan CP. Changes in medical errors with a handoff program. N Engl J Med 2015;372:490-1. 10. Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg 2005;200:538-45. 11. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–a metadatadriven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42:377-81. 12. Calaman SN, Starmer AJ. I-PASS handoff curriculum: computer module, 9: MedEdPORTAL; 2013. Available from: https://www.mededportal.org/. 13. Spector N, Starmer AJ, Allen A. I-PASS handoff curriculum: core resident workshop, 9: MedEdPORTAL; 2013. Available from: https://www.mededportal.org/. 14. Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC, et al. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics 2012;129:201-4. 15. Gordon M, Findley R. Educational interventions to improve handover in health care: a systematic review. Med Educ 2011;45:1081-9.