- Email: [email protected]
Physician Transition of Care: Benefits of I-PASS and an Electronic Handoff System in a Community Pediatric Residency Program
Accepted Manuscript Physician Transition of Care: The benefits of I-PASS and the Electronic Handoff System in a Community Pediatric Residency Program Jasmine Walia, MD, Zainab Qayumi, MD, Nayaab Khawar, BA, Beata Dygulska, MD, Ilya Bialik, MD, Carolyn Salafia, Ms, MD, Pramod Narula, MD PII:
S1876-2859(16)30129-2
DOI:
10.1016/j.acap.2016.04.001
Reference:
ACAP 845
To appear in:
Academic Pediatrics
Received Date: 30 June 2015 Revised Date:
4 April 2016
Accepted Date: 10 April 2016
Please cite this article as: Walia J, Qayumi Z, Khawar N, Dygulska B, Bialik I, Salafia C, Narula P, Physician Transition of Care: The benefits of I-PASS and the Electronic Handoff System in a Community Pediatric Residency Program, Academic Pediatrics (2016), doi: 10.1016/j.acap.2016.04.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Physician Transition of Care: The benefits of I-PASS and the Electronic Handoff System in a Community Pediatric Residency Program
Bialik1 MD, Carolyn Salafia1 Ms, MD, and Pramod Narula1 MD.
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Affiliation: 1New York Methodist Hospital, Brooklyn, NY, USA,
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Jasmine Walia1 MD, Zainab Qayumi1 MD, Nayaab Khawar1 BA, Beata Dygulska1 MD, Ilya
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Address correspondence to: Jasmine Walia, New York Methodist Hospital, 506 6th St Brooklyn NY, 11215. [email protected] (718) 780-5260
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Funding Source: No external funding was secured for this study.
Financial Disclosure: The authors have no financial relationships relevant to this article to
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disclose.
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Conflict of Interest: The authors have no financial conflicts of interest to disclose.
Word Count Manuscript: 2000
Word Count Abstract: 306
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Abstract Background: Miscommunication is a leading cause of adverse events in hospitals. Optimizing
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the handoff process improves communication and patient safety. Objective: To assess how the components of I-PASS, a standardized handoff bundle, improved the quality of handoffs in a pediatric residency program based in a community hospital.
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Methods: Pediatric residents in a university affiliated community teaching hospital were
observed on the pediatric inpatient floor and in the newborn nursery. One hundred resident
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handoffs per setting were analyzed in three phases, with a total of 600 handoffs assessed. Phase 1: Pre-intervention handoffs prior to I-PASS, Phase 2: Initiating I-PASS mnemonic and educational session, and Phase 3: implementing a handoff tool, electronic physician handoff (EPH), into the electronic medical record (EMR). One attending physician at each setting assessed the handoff process using an 11-item survey. A resident satisfaction survey assessed the
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resident’s experience after Phase 3.
Results: Comparing Phase 1 with Phase 2, there was improved situational awareness with
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contingency planning (nursery: 12% to 83%, p-value=0.001; floor: 21% to 84%, p-value=0.001). Incidence of tangential conversation decreased in both settings (nursery: 100% to 23%, p-
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value=0.001; floor: 84% to 11%, p-value=0.001). Comparing Phase 2 with Phase 3, there was improvement in identification of illness severity (nursery: 62% to 99%, p-value=0.001; floor: 41% to 64%, p-value=0.001) and fewer omission of important information (nursery: 14% to 0%, p-value=0.001; floor: 33% to 17%, p-value=0.007). 93% of residents found the new EPH system to be beneficial. Conclusion: Specific components of a standardized handoff system, including a mnemonic, an
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educational intervention, and an EPH improved the clarity and organization of key information in handoff.
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What’s New: The study evaluates the importance of specific components of the I-PASS handoff bundle in a university affiliated community hospital in order to improve resident handoff. A resident satisfaction survey highlights comfort level in using the new handoff system.
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Abbreviations:
Electronic Physician Handoff = EPH Electronic Medical Record = EMR New York Methodist Hospital = NYMH
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Post-Graduate Year = PGY
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Illness severity, Patient summary, Action list, Situational awareness with contingency planning, Synthesis by the receiver = I-PASS
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INTRODUCTION: Physician handoff, the process of transferring patient-specific clinical information between
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health care providers, is a critical moment in which communication failures may reduce quality of patient care.1, 2 Communication errors during patient handoffs constitute a majority of adverse events in medical care.3, 4 With the increasing complexities of medical treatment and care in hospitals, the importance of effective measures of communication between providers has never
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been more important. Furthermore, the Accreditation Council for Graduate Medical Education’s
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(ACGME) new policy on duty hours has led to increased handoffs between residents, increased omissions of important patient information, and reduced continuity of patient care.1, 5—7 .With these new regulations, standardized physician-to-physician handoffs are recommended for the provision of medical care.8-10
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Recent studies have shown communication deficiencies among physicians and discrepancies in the quality of handoffs between different institutions.5, 8, 9 Recommended strategies to enhance handoffs and decrease medical errors include educational lectures, communication training,
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mnemonics to standardize handoffs, reduction of interruptions during handoffs, and computerized tools.11—20 Some benefits of utilizing an electronic medical record (EMR) as a
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standardized handoff tool include decreasing transcription errors, increasing in-house and remote accessibility, reducing data collection time, and improving legibility.7, 21-22 In this study the objective was to assess the quality of handoffs by implementing specific components of the I-PASS handoff bundle, a standardized method derived from a multicenter study initiated at Boston Children’s Hospital.11,23,24 Prior I-PASS studies have evaluated handoffs in academic centers, but this study was based in a community hospital pediatric
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residency. This study aimed to implement specific I-PASS components, the mnemonic and educational intervention, faculty training and observation, and an Electronic Physician Handoff (EPH), on the pediatric inpatient floor and in the newborn nursery, and assess the quality of
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resident handoffs. The secondary aim was to determine the effectiveness of each individual component on the overall handoff.
METHODS:
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Setting and Participants
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The study took place in a university affiliated community hospital at New York Methodist Hospital (NYMH), which consists of 16 pediatric inpatient beds and includes 5,500 births per annum. The pediatric academic residency program includes 28 residents. The project was implemented in two settings, on the pediatric floor and in the newborn nursery. These two
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settings were chosen to compare the diverse environment and acuity of patient care. The participants were a two resident team including one post graduate year-1 (PGY-1) resident and one PGY-2 or PGY-3 resident for every 12 hour shift. The components of the I-PASS bundle
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utilized in this study were created by the I-PASS study group from Boston Children’s Hospital.11 We chose from the I-PASS bundle the mnemonic and educational intervention, faculty training
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and observation, and the EPH.11 The study was from January 2013 to December 2013, with all participants working at the institute for a minimum of six months. Phase 1 began in January 2013, Phase 2 initiated in April 2013, and Phase 3 started in September 2013. New interns joined in the middle of Phase 2 and were educated according to the same protocol. During all phases, handoffs were observed by one faculty member in each setting.11,25 The study was approved by the Institutional Review Board at NYMH.
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Education and Intervention In Phase 1 (pre-I-PASS), PGY-1 residents led verbal handoffs, supervised by their senior
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resident and an attending physician. The verbal handoff included patient name, working diagnosis, hospital day number, current health status, current medications, and a ‘to-do’ list to be completed during the shift. Residents made notes on a printed patient census, generated from the
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hospital’s EMR, Cerner Corp. Power Chart. During Phase 2 (post-mnemonic/education), all residents participated in a 90-minute educational session. The intervention focused on training
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residents to organize handoffs by using the mnemonic “I – PASS” (Illness severity, Patient summary, Action list, Situational awareness with contingency planning, Synthesis by the receiver).11,23,24 The residents were educated on the importance of handoff, ideal content of handoffs, proper use of the mnemonic, and consequences of poor handoffs. Following the educational session, an interactive workshop had resident’s role-playing cases using the new
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verbal handoff. Each example highlighted the components and strategies of effective handoffs. In Phase 3 (post-EPH), the EPH was incorporated into the EMR, with a template of the I-PASS
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mnemonic. A 90-minute interactive session taught residents how to efficiently use the EPH. Every resident, prior to handoff, completed the EPH in the EMR, printed a copy of the EPH, and
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referred to the EPH during the handoff process. Residents completed an anonymous questionnaire after Phase 3, rating the new system, their comfort level of the handoff, and listing any concerns with the system. Faculty Development and Observation Two attending physicians were trained to assess the handoffs in an educational session given by the I-PASS study group from Boston’s Children Hospital, based off faculty development as 6
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designed in the I-PASS bundle.25 An 11-item survey to assess handoffs was modified from a 17item survey created by the I-PASS group. The 11 items included the elements of the mnemonic and evaluation of the handoff giver. Unlike the original survey, which used a scale to rate the
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quality of each category, each attending documented a yes or no to indicate if the element was present. The original survey rated the pace of the handoff (too fast, fast, optimal, slow, too slow), while the attending in this study labeled each handoff as optimal or not (without including the
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actual pace). To assess the resident’s sign-out in each phase, 100 handoffs were evaluated on the pediatric floor and in the newborn nursery by the same attendings. The attending completed the
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survey without feedback to the residents during the handoff. Analysis
Statistical analysis was performed using IBM Statistics SPSS version 20 software. The study
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analyzed categorical variables using contingency tables and Chi Square analysis.
RESULTS:
One hundred patient specific handoffs were evaluated in the three consecutive phases from both
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the pediatric floor and the newborn nursery, with a total of 600 handoffs assessed.
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Comparing Phase 1 and Phase 2 on the Floor (Pre-I-PASS with Post-mnemonic/education) On the pediatric floor, situational awareness with contingency planning (21% vs. 84%; pvalue=0.001) and active engagement of receiver (8% vs. 59%; p-value=0.001) significantly improved, with a significant decline in the incidence of tangential or unrelated conversation (84% vs. 11; p-value=0.001). However, there was a significant increase in omission of important information (19% vs. 33%; p-value=0.010) (Table 1). Comparing Phase 1 and Phase 2 in the Nursery (Pre-I-PASS with Postmnemonic/education)
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In the newborn nursery, situational awareness with contingency planning (12% vs. 83%; pvalue=0.001) and synthesis of receiver (24% vs. 83%; p-value=0.001) was significantly increased and there was a decrease in tangential or unrelated conversation (100% vs. 23%; pvalue=0.001). However, statement of illness severity significantly decreased (100% vs. 62%; p-
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value=0.001) (Table 2).
Comparing Phase 2 and Phase 3 on the Floor (Post-mnemonic/education with Post-EPH) In comparing Phase 2 with Phase 3 on the pediatric floor, significant improvement was noted for
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patient identification (91% vs. 99%; p-value=0.008), illness severity (41% vs. 64%; pvalue=0.001), and reduction in omission of important information (33% vs. 17%; p-
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value=0.007). In Phase 3, there was a significant decline in communicating patient summary (98% vs. 91%; p-value=0.029), listing situation awareness with contingency planning (84% vs. 55%; p-value=0.001), prioritizing key information (92% vs. 78%; p-value=0.005), and an optimally paced handoff (94% vs. 80; p-value=0.003) (Table 1).
Comparing Phase 2 and Phase 3 in the Nursery (Post-mnemonic/education and Post-EPH)
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Comparing Phase 2 and Phase 3 in the newborn nursery, significant improvement was demonstrated with statement of illness severity (62% vs. 99%; p-value=0.001), situational awareness with contingency planning (83% vs. 95%; p-value=0.006), active engagement of receiver (15% vs. 98%; p-value=0.001), omission of important information (14% vs. 0%; p-
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value=0.001), and reduction of tangential conversation (23% vs. 2%; p-value=0.001) (Table 2). Resident Satisfaction:
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From the resident survey completed, 93% (26/28) of residents found EPH to be beneficial during handoff, while only 71% (22/28) found EPH to be efficient.
DISCUSSION:
This study, involving a pediatric residency based in a community hospital, utilized specific components of a standardized handoff tool to improve handoff quality and pinpoint the effectiveness of each component. Unlike other studies, this study highlighted factors of the I8
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PASS bundle that made handoff more accurate and efficient, while some factors produced hurdles. Overall, the I-PASS mnemonic was more helpful on the pediatric floor, with some challenges with the EPH. In the newborn nursery, there was an overall trend towards
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improvement.
Following Phase 2, tangential or unrelated conversation during handoff, situational awareness with contingency planning, and the active engagement of receiver improved in both settings,
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indicating the mnemonic and educational session were effective. Overall Phase 2 demonstrated
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an improvement in the handoff on the pediatric floor, illustrating the importance of the mnemonic. An increase in the omissions of important information may have been due to an adjustment of the new system. In the nursery, statement of illness severity decreased in Phase 2, alluding to how a majority of the patients in the nursery were normal newborns, thus residents
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may not have found this category applicable.
With the incorporation of the EPH in Phase 3, there was an improvement in documentation of illness severity and improvement in the omissions of important information on the pediatric
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floor, illustrating some benefit of the EPH. However, there was a decline in the recording of patient summary, which may have been due to the word limit for this section. Although not ideal,
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situational awareness with contingency planning and prioritization of key information most likely declined due to a discomfort in the new EPH, acute changes in the status of the patient’s clinical status, or the challenges faced with time consuming issues limiting the resident from completing a successfully prepared EPH. With the presence of computers, there may have been increased distractions that negatively affected the optimal pacing of the handoff. This highlights that the mnemonic provided a more efficient and accurate handoff than the EPH, on the floor. The accessibility to EPH in the nursery streamlined handoffs, with improvement in 9
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documentation of illness severity, situational awareness with contingency planning, and active engagement of receiver, as most involved a simple click for the normal newborns.
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Although a unique aspect regarding this study involved being based in a community hospital, there were several limitations. One drawback includes this study involving only a single site, limiting the number of handoffs surveyed. Other limitations include the residents not receiving feedback during handoff observations by attendings and the faculty survey not scoring the pace
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of the handoffs to indicate if it was fast or slow. Additionally, new interns joined in the middle of
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Phase 2, however, each team included one senior resident and one junior resident during handoffs, to ensure guidance to the new intern. Also, being in a smaller hospital, there was an inadequate amount of computers available for resident use. Many of the issues with the computers, including a word limit in the EPH and limited number of computers, have now been
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rectified, allowing for a possible future study with these modifications. As opposed to previous studies assessing the I-PASS bundle in academic centers, this study focused on evaluating effects of the individual components of the bundle on residents’ handoffs
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in a community hospital.11-25 Overall, the residents found the changes to be beneficial. Future work includes measuring outcomes such as medical errors, adverse events, and resident
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workflow through the model presented by Starmer et al.5 It would also be essential to utilize the EPH to improve the interdisciplinary communication between residents and nursing staff, and to extend the EPH to the Pediatric Intensive Care Unit (PICU) and the Neonatal Intensive Care Unit (NICU).
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Conclusion In conclusion, our study evaluated various components of a standardized handoff bundle,
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including a mnemonic, an educational workshop, a faculty assessment, and a computerized tool, to improve communication, quality, and effectiveness of handoffs between residents in a
community hospital. Unlike prior studies, this study highlighted how the I-PASS mnemonic proved to be more helpful on the pediatric floor than the EPH, while the EPH seemed to have a
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smoother transition in the newborn nursery.
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ACKNOWLEDGEMENTS:
The study utilized components of a handoff bundle created by the I-PASS study group at Boston
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Children’s Hospital.
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REFERENCES: 1. Borowitz SM, Waggoner- Fountain LA, Bass EJ, et al. Adequacy of information transferred at resident sign out (in-hospital handover of care): a prospective survey. Qual Saf Health Care. 2008;17:6-10.
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2. Riesenberg LA, Leitzsch J, Massucci JL, et al. Residents' and attending physicians' handoffs: a systematic review of the literature. Acad Med. 2009;84(12):1775.
3. The Joint Commission. Sentinel event statistics data: root causes by event type. http:// http://www.jointcommission.org/assets/1/18/root_causes_by_event_type_2004-2014.pdf;2014 Accessed 09.27.2011.
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4. The Joint Commission. Improving hand off communications: meeting national patient safety goal 2E. Joint Commission Perspectives on Patient Safety. 2006;6(8):9-15.
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5. Starmer AJ, Spector ND, Srivastava R, et al. Study Group Changes in Medical Errors after Implementation of a Handoff Program. N Engl. J Med. 2014;371:1803-1812. 6. Starmer AJ, Sectish TC, Simon DW, et al. Rates of Medical Errors and Preventable Adverse Events among Hospitalized Children Following Implementation of a Resident Handoff Bundle. JAMA. 2013;310(21): 2262-2270.
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7. DeRienzo CM, Frush K, Barfield ME, et al. Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements. Acad Med. 2012;87(4):403–410. 8. Bigham MT, Logsdon TR, Manicone PE, et al. Decreasing handoff-related care failures in children's hospitals. Pediatrics. 2014;134(2):572-9.
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9. Chu ES, Reid M, Schulz T, et al. A structured handoff program for interns. Acad Med. 2009;84(3):347-52.
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10. Farnan JM, Paro JA, Rodriguez RM, et al. Hand-off education and evaluation: piloting the observed simulated hand-off experience (OSHE). J Gen Intern Med. 2010;25(2):12934. 11. Starmer AJ, O'Toole JK, Rosenbluth G, et al. I-PASS Study Education Executive Committee. Development, implementation, and dissemination of the I-PASS handoff curriculum: A multisite educational intervention to improve patient handoffs. Acad Med. 2014;89(6):876-84. 12. McSweeney ME, Lightdale JR, Vinci RJ, Moses J. Patient Handoffs: Pediatric Resident Experiences and Lessons Learned. Clinical Pediatrics. 2011;50:57-63. 13. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 12
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2004;13: i85-i90. 14. Riesenberg LA, Leitzsch J, Little BW. Systemic review of handoff mnemonics literature. Am J Med Qual. 2009;24(3):196-204.
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15. Patterson ES, Roth EM, Woods DD, et al. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16(2):125-132.
16. Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646-655.
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17. Bernstein JA, Imler DL, Sharek P, Longhurst CA. Improved Physician Work Flow After Integrating Sign-out Notes into the Electronic Medical Record. The Joint Commission Journal on Quality and Patient Safety 36. 2010;(2):72-78.
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18. Gordon M, Findley R. Educational interventions to improve handover in health care: a systematic review. Med Educ. 2011;45:1081-1089. 19. Van Eaton EG, McDonough K, Lober WB, et al. Safety of using a computerized rounding and sign-out system to reduce resident duty hours. Acad Med. 2010;85(7):118995.
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20. Horwitz LI, Moin T, Green ML. Development and Implementation of an Oral Sign-out Skills Curriculum. J Gen Intern Med. 2007;22(10):1470–1474. 21. Rose AF, et al. Using qualitative studies to improve the usability of an EMR. J Biomed Inform. 2005;38:51-60.
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22. Peterson LA, et al. Using a computerized sign out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24:77-87.
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23. Sectish TC, Starmer AJ, Landrigan CP, Spector ND; I-PASS Study Group. Establishing a multisite education and research project requires leadership, expertise, collaboration, and an important aim. Pediatrics. 2010;126(4):619-22. 24. Starmer AJ, Spector ND, Srivastava R, et al. Sectish TC; I-PASS Study group. I – PASS, a Mnemonic to Standardize Verbal Handoffs. Pediatrics.2012;129;201-204. 25. O’Toole JK, West DC, Starmer AJ, et al. Placing Faculty Devleopment Front and Center in a Multisite Educational Initiative: Lessons from the I-PASS Handoff Study. Academic Pediatrics. 2014;14(3):221-224.
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Table 1: FLOOR: Comparison of Phase 1 and Phase 2 and Comparison of Phase 2 and Phase 3
Phase 2 Phase 3
Phase 2
(n=100)
(n=100)
%
%
p-value
%
1. Patient Identification data
85
91
0.075
91
99
0.008*
2. Illness Severity
30
41
0.070
41
64
0.001*
3. Patient Summary
100
98
0.249
98
91
0.029*
4. Action List
92
84
0.063
84
84
0.153
5. Situation Awareness, Contingency Planning 6. Synthesis of Receiver
21
84
0.001*
84
55
0.001*
47
52
0.088
52
55
0.103
7. Actively engage receiver
8
59
0.001*
59
54
0.284
95
92
0.284
92
78
0.005*
19
33
0.010*
33
17
0.007*
84
11
0.001*
11
18
0.201
95
94
0.231
94
80
0.003*
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8. Appropriately prioritize key information 9. Omissions of important information 10. Tangential or unrelated conversation 11. Optimally paced Handoff
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11-item Survey
(n=100) (n=100)
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PEDIATRIC FLOOR (n=200)
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Phase 1
p-value
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Table 2: NURSERY: tables comparing Phase 1 with Phase 2 and Phase 2 with Phase 3 in Nursery Phase 1
Phase 2
Phase 2
Phase 3
(n=100)
(n=100)
(n=100)
(n=100)
11-item Survey
%
%
p-value
1. Patient Identification data
100
100
1.000
2. Illness Severity
100
62
0.001*
3. Patient Summary
100
100
1.000
4. Action List
100
100
5. Situation Awareness, Contingency Planning 6. Synthesis of Receiver
12 24
7. Actively engage receiver
9
8. Appropriately prioritize key information 9. Omissions of important information 10. Tangential or unrelated conversation 11. Optimally paced Handoff
98
%
p-value
100
1.000
62
99
0.001*
100
97
0.123
1.000
100
100
1.000
83
0.001*
83
95
0.006*
83
0.001*
83
83
0.149
15
0.075
15
98
0.001*
98
0.379
98
100
0.249
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100
23
14
0.072
14
0
0.001*
100
23
0.001*
23
2
0.001*
100
100
1.00
100
100
1.000
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Nursery (n=200)
S1876-2859(16)30129-2
DOI:
10.1016/j.acap.2016.04.001
Reference:
ACAP 845
To appear in:
Academic Pediatrics
Received Date: 30 June 2015 Revised Date:
4 April 2016
Accepted Date: 10 April 2016
Please cite this article as: Walia J, Qayumi Z, Khawar N, Dygulska B, Bialik I, Salafia C, Narula P, Physician Transition of Care: The benefits of I-PASS and the Electronic Handoff System in a Community Pediatric Residency Program, Academic Pediatrics (2016), doi: 10.1016/j.acap.2016.04.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Physician Transition of Care: The benefits of I-PASS and the Electronic Handoff System in a Community Pediatric Residency Program
Bialik1 MD, Carolyn Salafia1 Ms, MD, and Pramod Narula1 MD.
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Affiliation: 1New York Methodist Hospital, Brooklyn, NY, USA,
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Jasmine Walia1 MD, Zainab Qayumi1 MD, Nayaab Khawar1 BA, Beata Dygulska1 MD, Ilya
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Address correspondence to: Jasmine Walia, New York Methodist Hospital, 506 6th St Brooklyn NY, 11215. [email protected] (718) 780-5260
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Funding Source: No external funding was secured for this study.
Financial Disclosure: The authors have no financial relationships relevant to this article to
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disclose.
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Conflict of Interest: The authors have no financial conflicts of interest to disclose.
Word Count Manuscript: 2000
Word Count Abstract: 306
1
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Abstract Background: Miscommunication is a leading cause of adverse events in hospitals. Optimizing
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the handoff process improves communication and patient safety. Objective: To assess how the components of I-PASS, a standardized handoff bundle, improved the quality of handoffs in a pediatric residency program based in a community hospital.
SC
Methods: Pediatric residents in a university affiliated community teaching hospital were
observed on the pediatric inpatient floor and in the newborn nursery. One hundred resident
M AN U
handoffs per setting were analyzed in three phases, with a total of 600 handoffs assessed. Phase 1: Pre-intervention handoffs prior to I-PASS, Phase 2: Initiating I-PASS mnemonic and educational session, and Phase 3: implementing a handoff tool, electronic physician handoff (EPH), into the electronic medical record (EMR). One attending physician at each setting assessed the handoff process using an 11-item survey. A resident satisfaction survey assessed the
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resident’s experience after Phase 3.
Results: Comparing Phase 1 with Phase 2, there was improved situational awareness with
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contingency planning (nursery: 12% to 83%, p-value=0.001; floor: 21% to 84%, p-value=0.001). Incidence of tangential conversation decreased in both settings (nursery: 100% to 23%, p-
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value=0.001; floor: 84% to 11%, p-value=0.001). Comparing Phase 2 with Phase 3, there was improvement in identification of illness severity (nursery: 62% to 99%, p-value=0.001; floor: 41% to 64%, p-value=0.001) and fewer omission of important information (nursery: 14% to 0%, p-value=0.001; floor: 33% to 17%, p-value=0.007). 93% of residents found the new EPH system to be beneficial. Conclusion: Specific components of a standardized handoff system, including a mnemonic, an
2
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educational intervention, and an EPH improved the clarity and organization of key information in handoff.
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What’s New: The study evaluates the importance of specific components of the I-PASS handoff bundle in a university affiliated community hospital in order to improve resident handoff. A resident satisfaction survey highlights comfort level in using the new handoff system.
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Abbreviations:
Electronic Physician Handoff = EPH Electronic Medical Record = EMR New York Methodist Hospital = NYMH
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Post-Graduate Year = PGY
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Illness severity, Patient summary, Action list, Situational awareness with contingency planning, Synthesis by the receiver = I-PASS
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INTRODUCTION: Physician handoff, the process of transferring patient-specific clinical information between
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health care providers, is a critical moment in which communication failures may reduce quality of patient care.1, 2 Communication errors during patient handoffs constitute a majority of adverse events in medical care.3, 4 With the increasing complexities of medical treatment and care in hospitals, the importance of effective measures of communication between providers has never
SC
been more important. Furthermore, the Accreditation Council for Graduate Medical Education’s
M AN U
(ACGME) new policy on duty hours has led to increased handoffs between residents, increased omissions of important patient information, and reduced continuity of patient care.1, 5—7 .With these new regulations, standardized physician-to-physician handoffs are recommended for the provision of medical care.8-10
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Recent studies have shown communication deficiencies among physicians and discrepancies in the quality of handoffs between different institutions.5, 8, 9 Recommended strategies to enhance handoffs and decrease medical errors include educational lectures, communication training,
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mnemonics to standardize handoffs, reduction of interruptions during handoffs, and computerized tools.11—20 Some benefits of utilizing an electronic medical record (EMR) as a
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standardized handoff tool include decreasing transcription errors, increasing in-house and remote accessibility, reducing data collection time, and improving legibility.7, 21-22 In this study the objective was to assess the quality of handoffs by implementing specific components of the I-PASS handoff bundle, a standardized method derived from a multicenter study initiated at Boston Children’s Hospital.11,23,24 Prior I-PASS studies have evaluated handoffs in academic centers, but this study was based in a community hospital pediatric
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residency. This study aimed to implement specific I-PASS components, the mnemonic and educational intervention, faculty training and observation, and an Electronic Physician Handoff (EPH), on the pediatric inpatient floor and in the newborn nursery, and assess the quality of
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resident handoffs. The secondary aim was to determine the effectiveness of each individual component on the overall handoff.
METHODS:
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Setting and Participants
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The study took place in a university affiliated community hospital at New York Methodist Hospital (NYMH), which consists of 16 pediatric inpatient beds and includes 5,500 births per annum. The pediatric academic residency program includes 28 residents. The project was implemented in two settings, on the pediatric floor and in the newborn nursery. These two
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settings were chosen to compare the diverse environment and acuity of patient care. The participants were a two resident team including one post graduate year-1 (PGY-1) resident and one PGY-2 or PGY-3 resident for every 12 hour shift. The components of the I-PASS bundle
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utilized in this study were created by the I-PASS study group from Boston Children’s Hospital.11 We chose from the I-PASS bundle the mnemonic and educational intervention, faculty training
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and observation, and the EPH.11 The study was from January 2013 to December 2013, with all participants working at the institute for a minimum of six months. Phase 1 began in January 2013, Phase 2 initiated in April 2013, and Phase 3 started in September 2013. New interns joined in the middle of Phase 2 and were educated according to the same protocol. During all phases, handoffs were observed by one faculty member in each setting.11,25 The study was approved by the Institutional Review Board at NYMH.
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Education and Intervention In Phase 1 (pre-I-PASS), PGY-1 residents led verbal handoffs, supervised by their senior
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resident and an attending physician. The verbal handoff included patient name, working diagnosis, hospital day number, current health status, current medications, and a ‘to-do’ list to be completed during the shift. Residents made notes on a printed patient census, generated from the
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hospital’s EMR, Cerner Corp. Power Chart. During Phase 2 (post-mnemonic/education), all residents participated in a 90-minute educational session. The intervention focused on training
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residents to organize handoffs by using the mnemonic “I – PASS” (Illness severity, Patient summary, Action list, Situational awareness with contingency planning, Synthesis by the receiver).11,23,24 The residents were educated on the importance of handoff, ideal content of handoffs, proper use of the mnemonic, and consequences of poor handoffs. Following the educational session, an interactive workshop had resident’s role-playing cases using the new
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verbal handoff. Each example highlighted the components and strategies of effective handoffs. In Phase 3 (post-EPH), the EPH was incorporated into the EMR, with a template of the I-PASS
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mnemonic. A 90-minute interactive session taught residents how to efficiently use the EPH. Every resident, prior to handoff, completed the EPH in the EMR, printed a copy of the EPH, and
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referred to the EPH during the handoff process. Residents completed an anonymous questionnaire after Phase 3, rating the new system, their comfort level of the handoff, and listing any concerns with the system. Faculty Development and Observation Two attending physicians were trained to assess the handoffs in an educational session given by the I-PASS study group from Boston’s Children Hospital, based off faculty development as 6
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designed in the I-PASS bundle.25 An 11-item survey to assess handoffs was modified from a 17item survey created by the I-PASS group. The 11 items included the elements of the mnemonic and evaluation of the handoff giver. Unlike the original survey, which used a scale to rate the
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quality of each category, each attending documented a yes or no to indicate if the element was present. The original survey rated the pace of the handoff (too fast, fast, optimal, slow, too slow), while the attending in this study labeled each handoff as optimal or not (without including the
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actual pace). To assess the resident’s sign-out in each phase, 100 handoffs were evaluated on the pediatric floor and in the newborn nursery by the same attendings. The attending completed the
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survey without feedback to the residents during the handoff. Analysis
Statistical analysis was performed using IBM Statistics SPSS version 20 software. The study
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analyzed categorical variables using contingency tables and Chi Square analysis.
RESULTS:
One hundred patient specific handoffs were evaluated in the three consecutive phases from both
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the pediatric floor and the newborn nursery, with a total of 600 handoffs assessed.
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Comparing Phase 1 and Phase 2 on the Floor (Pre-I-PASS with Post-mnemonic/education) On the pediatric floor, situational awareness with contingency planning (21% vs. 84%; pvalue=0.001) and active engagement of receiver (8% vs. 59%; p-value=0.001) significantly improved, with a significant decline in the incidence of tangential or unrelated conversation (84% vs. 11; p-value=0.001). However, there was a significant increase in omission of important information (19% vs. 33%; p-value=0.010) (Table 1). Comparing Phase 1 and Phase 2 in the Nursery (Pre-I-PASS with Postmnemonic/education)
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In the newborn nursery, situational awareness with contingency planning (12% vs. 83%; pvalue=0.001) and synthesis of receiver (24% vs. 83%; p-value=0.001) was significantly increased and there was a decrease in tangential or unrelated conversation (100% vs. 23%; pvalue=0.001). However, statement of illness severity significantly decreased (100% vs. 62%; p-
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value=0.001) (Table 2).
Comparing Phase 2 and Phase 3 on the Floor (Post-mnemonic/education with Post-EPH) In comparing Phase 2 with Phase 3 on the pediatric floor, significant improvement was noted for
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patient identification (91% vs. 99%; p-value=0.008), illness severity (41% vs. 64%; pvalue=0.001), and reduction in omission of important information (33% vs. 17%; p-
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value=0.007). In Phase 3, there was a significant decline in communicating patient summary (98% vs. 91%; p-value=0.029), listing situation awareness with contingency planning (84% vs. 55%; p-value=0.001), prioritizing key information (92% vs. 78%; p-value=0.005), and an optimally paced handoff (94% vs. 80; p-value=0.003) (Table 1).
Comparing Phase 2 and Phase 3 in the Nursery (Post-mnemonic/education and Post-EPH)
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Comparing Phase 2 and Phase 3 in the newborn nursery, significant improvement was demonstrated with statement of illness severity (62% vs. 99%; p-value=0.001), situational awareness with contingency planning (83% vs. 95%; p-value=0.006), active engagement of receiver (15% vs. 98%; p-value=0.001), omission of important information (14% vs. 0%; p-
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value=0.001), and reduction of tangential conversation (23% vs. 2%; p-value=0.001) (Table 2). Resident Satisfaction:
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From the resident survey completed, 93% (26/28) of residents found EPH to be beneficial during handoff, while only 71% (22/28) found EPH to be efficient.
DISCUSSION:
This study, involving a pediatric residency based in a community hospital, utilized specific components of a standardized handoff tool to improve handoff quality and pinpoint the effectiveness of each component. Unlike other studies, this study highlighted factors of the I8
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PASS bundle that made handoff more accurate and efficient, while some factors produced hurdles. Overall, the I-PASS mnemonic was more helpful on the pediatric floor, with some challenges with the EPH. In the newborn nursery, there was an overall trend towards
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improvement.
Following Phase 2, tangential or unrelated conversation during handoff, situational awareness with contingency planning, and the active engagement of receiver improved in both settings,
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indicating the mnemonic and educational session were effective. Overall Phase 2 demonstrated
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an improvement in the handoff on the pediatric floor, illustrating the importance of the mnemonic. An increase in the omissions of important information may have been due to an adjustment of the new system. In the nursery, statement of illness severity decreased in Phase 2, alluding to how a majority of the patients in the nursery were normal newborns, thus residents
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may not have found this category applicable.
With the incorporation of the EPH in Phase 3, there was an improvement in documentation of illness severity and improvement in the omissions of important information on the pediatric
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floor, illustrating some benefit of the EPH. However, there was a decline in the recording of patient summary, which may have been due to the word limit for this section. Although not ideal,
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situational awareness with contingency planning and prioritization of key information most likely declined due to a discomfort in the new EPH, acute changes in the status of the patient’s clinical status, or the challenges faced with time consuming issues limiting the resident from completing a successfully prepared EPH. With the presence of computers, there may have been increased distractions that negatively affected the optimal pacing of the handoff. This highlights that the mnemonic provided a more efficient and accurate handoff than the EPH, on the floor. The accessibility to EPH in the nursery streamlined handoffs, with improvement in 9
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documentation of illness severity, situational awareness with contingency planning, and active engagement of receiver, as most involved a simple click for the normal newborns.
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Although a unique aspect regarding this study involved being based in a community hospital, there were several limitations. One drawback includes this study involving only a single site, limiting the number of handoffs surveyed. Other limitations include the residents not receiving feedback during handoff observations by attendings and the faculty survey not scoring the pace
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of the handoffs to indicate if it was fast or slow. Additionally, new interns joined in the middle of
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Phase 2, however, each team included one senior resident and one junior resident during handoffs, to ensure guidance to the new intern. Also, being in a smaller hospital, there was an inadequate amount of computers available for resident use. Many of the issues with the computers, including a word limit in the EPH and limited number of computers, have now been
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rectified, allowing for a possible future study with these modifications. As opposed to previous studies assessing the I-PASS bundle in academic centers, this study focused on evaluating effects of the individual components of the bundle on residents’ handoffs
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in a community hospital.11-25 Overall, the residents found the changes to be beneficial. Future work includes measuring outcomes such as medical errors, adverse events, and resident
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workflow through the model presented by Starmer et al.5 It would also be essential to utilize the EPH to improve the interdisciplinary communication between residents and nursing staff, and to extend the EPH to the Pediatric Intensive Care Unit (PICU) and the Neonatal Intensive Care Unit (NICU).
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Conclusion In conclusion, our study evaluated various components of a standardized handoff bundle,
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including a mnemonic, an educational workshop, a faculty assessment, and a computerized tool, to improve communication, quality, and effectiveness of handoffs between residents in a
community hospital. Unlike prior studies, this study highlighted how the I-PASS mnemonic proved to be more helpful on the pediatric floor than the EPH, while the EPH seemed to have a
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smoother transition in the newborn nursery.
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ACKNOWLEDGEMENTS:
The study utilized components of a handoff bundle created by the I-PASS study group at Boston
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Children’s Hospital.
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REFERENCES: 1. Borowitz SM, Waggoner- Fountain LA, Bass EJ, et al. Adequacy of information transferred at resident sign out (in-hospital handover of care): a prospective survey. Qual Saf Health Care. 2008;17:6-10.
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2. Riesenberg LA, Leitzsch J, Massucci JL, et al. Residents' and attending physicians' handoffs: a systematic review of the literature. Acad Med. 2009;84(12):1775.
3. The Joint Commission. Sentinel event statistics data: root causes by event type. http:// http://www.jointcommission.org/assets/1/18/root_causes_by_event_type_2004-2014.pdf;2014 Accessed 09.27.2011.
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4. The Joint Commission. Improving hand off communications: meeting national patient safety goal 2E. Joint Commission Perspectives on Patient Safety. 2006;6(8):9-15.
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5. Starmer AJ, Spector ND, Srivastava R, et al. Study Group Changes in Medical Errors after Implementation of a Handoff Program. N Engl. J Med. 2014;371:1803-1812. 6. Starmer AJ, Sectish TC, Simon DW, et al. Rates of Medical Errors and Preventable Adverse Events among Hospitalized Children Following Implementation of a Resident Handoff Bundle. JAMA. 2013;310(21): 2262-2270.
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7. DeRienzo CM, Frush K, Barfield ME, et al. Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements. Acad Med. 2012;87(4):403–410. 8. Bigham MT, Logsdon TR, Manicone PE, et al. Decreasing handoff-related care failures in children's hospitals. Pediatrics. 2014;134(2):572-9.
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9. Chu ES, Reid M, Schulz T, et al. A structured handoff program for interns. Acad Med. 2009;84(3):347-52.
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10. Farnan JM, Paro JA, Rodriguez RM, et al. Hand-off education and evaluation: piloting the observed simulated hand-off experience (OSHE). J Gen Intern Med. 2010;25(2):12934. 11. Starmer AJ, O'Toole JK, Rosenbluth G, et al. I-PASS Study Education Executive Committee. Development, implementation, and dissemination of the I-PASS handoff curriculum: A multisite educational intervention to improve patient handoffs. Acad Med. 2014;89(6):876-84. 12. McSweeney ME, Lightdale JR, Vinci RJ, Moses J. Patient Handoffs: Pediatric Resident Experiences and Lessons Learned. Clinical Pediatrics. 2011;50:57-63. 13. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 12
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2004;13: i85-i90. 14. Riesenberg LA, Leitzsch J, Little BW. Systemic review of handoff mnemonics literature. Am J Med Qual. 2009;24(3):196-204.
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15. Patterson ES, Roth EM, Woods DD, et al. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16(2):125-132.
16. Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646-655.
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17. Bernstein JA, Imler DL, Sharek P, Longhurst CA. Improved Physician Work Flow After Integrating Sign-out Notes into the Electronic Medical Record. The Joint Commission Journal on Quality and Patient Safety 36. 2010;(2):72-78.
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18. Gordon M, Findley R. Educational interventions to improve handover in health care: a systematic review. Med Educ. 2011;45:1081-1089. 19. Van Eaton EG, McDonough K, Lober WB, et al. Safety of using a computerized rounding and sign-out system to reduce resident duty hours. Acad Med. 2010;85(7):118995.
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20. Horwitz LI, Moin T, Green ML. Development and Implementation of an Oral Sign-out Skills Curriculum. J Gen Intern Med. 2007;22(10):1470–1474. 21. Rose AF, et al. Using qualitative studies to improve the usability of an EMR. J Biomed Inform. 2005;38:51-60.
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22. Peterson LA, et al. Using a computerized sign out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24:77-87.
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23. Sectish TC, Starmer AJ, Landrigan CP, Spector ND; I-PASS Study Group. Establishing a multisite education and research project requires leadership, expertise, collaboration, and an important aim. Pediatrics. 2010;126(4):619-22. 24. Starmer AJ, Spector ND, Srivastava R, et al. Sectish TC; I-PASS Study group. I – PASS, a Mnemonic to Standardize Verbal Handoffs. Pediatrics.2012;129;201-204. 25. O’Toole JK, West DC, Starmer AJ, et al. Placing Faculty Devleopment Front and Center in a Multisite Educational Initiative: Lessons from the I-PASS Handoff Study. Academic Pediatrics. 2014;14(3):221-224.
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Table 1: FLOOR: Comparison of Phase 1 and Phase 2 and Comparison of Phase 2 and Phase 3
Phase 2 Phase 3
Phase 2
(n=100)
(n=100)
%
%
p-value
%
1. Patient Identification data
85
91
0.075
91
99
0.008*
2. Illness Severity
30
41
0.070
41
64
0.001*
3. Patient Summary
100
98
0.249
98
91
0.029*
4. Action List
92
84
0.063
84
84
0.153
5. Situation Awareness, Contingency Planning 6. Synthesis of Receiver
21
84
0.001*
84
55
0.001*
47
52
0.088
52
55
0.103
7. Actively engage receiver
8
59
0.001*
59
54
0.284
95
92
0.284
92
78
0.005*
19
33
0.010*
33
17
0.007*
84
11
0.001*
11
18
0.201
95
94
0.231
94
80
0.003*
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8. Appropriately prioritize key information 9. Omissions of important information 10. Tangential or unrelated conversation 11. Optimally paced Handoff
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11-item Survey
(n=100) (n=100)
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PEDIATRIC FLOOR (n=200)
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Phase 1
p-value
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Table 2: NURSERY: tables comparing Phase 1 with Phase 2 and Phase 2 with Phase 3 in Nursery Phase 1
Phase 2
Phase 2
Phase 3
(n=100)
(n=100)
(n=100)
(n=100)
11-item Survey
%
%
p-value
1. Patient Identification data
100
100
1.000
2. Illness Severity
100
62
0.001*
3. Patient Summary
100
100
1.000
4. Action List
100
100
5. Situation Awareness, Contingency Planning 6. Synthesis of Receiver
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7. Actively engage receiver
9
8. Appropriately prioritize key information 9. Omissions of important information 10. Tangential or unrelated conversation 11. Optimally paced Handoff
98
%
p-value
100
1.000
62
99
0.001*
100
97
0.123
1.000
100
100
1.000
83
0.001*
83
95
0.006*
83
0.001*
83
83
0.149
15
0.075
15
98
0.001*
98
0.379
98
100
0.249
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100
23
14
0.072
14
0
0.001*
100
23
0.001*
23
2
0.001*
100
100
1.00
100
100
1.000
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Nursery (n=200)