Handoffs in clinical practice

1. Handoffs in clinical practice Dennis J Boyle, M.D. DHMC COPIC 2010

2. 1 2 3 Outline Overview The background of the problem • Examples of fumbles seen by COPIC Toolkit for handoffsand checklists

3. A handoff is defined as a transfer of information and responsibility from one provider to another Definition

4. What percent of sentinel events have communication as the root cause? • 25 % • 45% • 50% • 65%

5. 100 cases with error cared for by IM 7% no fault Rest divided between system issues and cognition 6 errors per case Graber Arch IM 2005 Systems issues - handoffs, poor processes (Colon CA F/U), teamwork Cognitive problems - error in synthesizing the scenario, Knowledge problems rare Handoffs as cause of error in IM

6. Malpractice claims in trainees over 20 years Errors divided equally among knowledge, teamwork and technical competence Teamwork problems were mainly handoffs Singh Arch IM 2007 Trainee lawsuits

7. Is there a problem? Handoffs are sloppy … • Informal • Incomplete • Inconsistent I3

8. A story • Healthy child of color is born and is seen by the neonatologist at 12 hours. A bilirubin is ordered. The covering neonatologist D/Cs the child at 24 hours not knowing of the lab. Neither the clerk or the RN chase the lab down • At 60 hours (4PM Friday) the baby sees the pediatrician. A bilirubin is again ordered. The pediatrician doesn’t know there was a hospital bilirubin. She then leaves on vacation • Patient returns Monday AM lethargic. Office calls the lab and the bilirubin from Friday was 24 • The baby is admitted to CH. The baby dies of kernicturus

9. You’re a victim of multiple failures. The neonatologist, the clerk, the RN, the pediatrician and the covering Doc all had a chance to rescue. Even being a child of color entered into the cascade. How come?

10. Disaster Hazards The system breaks down when the holes line up Unsafe organizational influence Poor supervision Unsafe preconditions Unsafe acts

11. What does the PCP do? • Direct communication between the hospitalist and the PCP is rare (3-20%) • Availability of the DC summary at the first post-op visit is low (12-34%) • DC summaries lack info. Tests pending 60% • The cure is computer generated summaries and use of patients as couriers Kripalani JAMA 2007

12. Frustration: So what should the specialist do? • In one study if their patient was having a Cath or PTCA, the PCP wanted to know: • At discharge—5% • During hospitalization—10% • Leave message—40% • Interrupt—45% • Only 56% of PCP were satisfied with their communication with hospitalists Pantilat S Am J of Med 2001

13. Two sides to the story • “It would be nice if the primary care doctor sent the patient to me with all the previous lab and x-ray data that were available and pertinent. A phone call would be nice.” • “It would be nice if the consultant called me back after seeing my patient so we could actually discuss the case.”

14. Specialist to PCP • 38 YO female feels a lump on BSE. PCP refers patient to surgeon. Surgeon appreciates no mass, recommends reexamination in one month. Letter states ”patient should be reexamined in one month.” PCP never sees report. He assumes the surgeon will follow

15. Specialist to PCP • 38 YO female feels a lump on BSE. PCP refers patient to surgeon. Surgeon appreciates no mass, recommends reexamination in one month. Letter states ”patient should be reexamined in one month.” PCP never sees report. He assumes the surgeon will follow Fuzzy transfer and report lost….

16. In the office • 59 YO male with 2 skin lesions removed from thigh and back. The back lesion shows melanoma. Wide excision performed. No malignancy on path-was it all removed? • One year later patient returns with an obvious melanoma on chest wall…. Labeling procedure not clear

17. Injection Case • Depo-provera instead of HCG at the PCP office

18. Who would be liable for this event? • The MA giving the injection • The MA who asked the second MA to give the injection • The doctor in the clinic at the time for negligent supervision • The primary physician for negligent supervision

19. Discharge is the high risk time • 62 YO female admitted with abdominal pain. Lesion found in spleen. Resection reveals abscess-MRSA. ID consult recommends 4 weeks of Vancomycin. 1 week later transferred to rehab.

20. Discharge is the high risk time • 62 YO female admitted with abdominal pain. Lesion found in spleen. Resection reveals abscess-MRSA. ID consult recommends 4 weeks of Vancomycin. 1 week later transferred to rehab. • Echocardiogram shows SBE. Report returns post discharge. Sent to the physician but he never sees the report. • NH PA has no records. Not sure as to why on Vancomycin and D/Ced after 2 weeks • Patient presents one month later with spinal abscess and paralysis Faulty info transfer- Doc, NP and MA could rescue

21. The CURE

22. Successful handoff • Requires two participants • A transfer of critical info • Clear delineation of who does what

23. Who does handoffs?

24. Where are your handoffs?

25. Preventing patient errors—blocks or barriers Communication Systems Documentation Patient management

26. Teamwork features • Good communication- a check system to prevent errors • Shared ideas and experience • Able to hear and use feedback • Honesty • Coordination • Kindness, empathy for each other

27. Situation Background Assessment Recommendation Michael Leonard MD SBAR

28. SBAR How it’s done

29. Handoffs • Face to face • Limit interruptions • Receiver listens and doesn’t talk • Standardize and simplify • Unambiguous transfer of responsibility • Use common style with read back SBAR Patterson Int J qual HC 2004 Streitenberger Peds clinic NA 2006

30. Checklist • Gawandhi the checklist New Yorker 2007

32. Patient safety at discharge • One third of post-discharge events are preventable • Another one third are considered ameliorable JACHO

33. What we can do to improve safety at discharge • In-hospital care management with intensive nurse follow up- reduced CHF readmits • Systematic follow-up phone calls to patients by pharmacist after discharge-reduced ED visits • Automate discharge summaries • Create hospital-based follow-up clinics on the medical ward • At the very least D/C patient with all info needed for a F/U visit Weinberger M, et al. Med Care.1988 Naylor MD, JAMA. 1999 Naylor MD Cardiovascular Nurs. 1999 Naylor MD. Nurs Res.1990;39:156-61; Nelson JR. Dis Mon. 2002

34. D/C Safety checklist office or hospital • D/C meds • D/C summaries • Follow up appointments • Communication with patient/family • Communication with the PCP • Recognize fragile patients • NH patient follow up

35. Involve the family Signs of relapse? contact for difficulties? Loop in the PCP Test results pending Does the pt understand? Med reconciliation F/U appointments? Safety checklist for patient

36. 1 2 3 4 5 Summary Where are your handoffs? You need to be on the same page How can you standardize? S.B.A.R. What’s best for the patient?

37. The rubber hits the road Where are your handoffs? Now – What one thing will you do differently in your handoffs? Dennis Boyle MD