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Dropping the Baton at UCSF

Find a process to improveOrganize the team and its resourcesClarify current knowledge about the processUnderstand sources of variation and clarify steps in the processSelect an improvement or interventionPlan how you will implement the interventionDo it (preferably on a small scale)Stu

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Dropping the Baton at UCSF

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    1. Dropping the Baton at UCSF Improving the quality of ED to Medicine patient handoffs at Parnassus campus

    3. FOCUS Find a process to improve

    4. FOCUS Organize the team and resources

    5. FOCUS Clarify current knowledge - Most of prior literature on transfer of care has focused on intra-department handoffs Arora (2005) - Communication failures in pt signout -Interviewed interns Issues w/ content:    -active problem    -medication/treatment    -pending or ordered diagn. test or consult Issues with communcation:    -double sign out    -no face-to-face    -illegible or unclear notes

    6. Vulnerabilities in Transfer of Care Medicine Perspective -time expectations -auxillary information -lack of reevaluation -Resource utilization / Lack of feedback ED Perspective -Exclusive Medicine Admitting service? -w/u should end -ed throughput

    7. FOCUS Understand sources of variation and clarify steps in the process

    8. InterDepartment Actions 2007-2008: Department QI Representatives Meeting     -Brad Sharpe, MD (Dept of Medicine)          -Steve Polevoi, MD (Dept of Emergency Medicine)                                                                             Goal:     Simplify                                                                       Standardize                                                                          Improve Transfer of Care Guidelines established:     "What Info"      "How"      "Time Limits" --> 30-60 sec suggestion --> infamously known as the  "Brad Sharpe Rule"

    9. "The Brad Sharpe Rule"  Practice evolved where EM residents would "stop talking" at 60 seconds, citing "Well, Brad Sharpe says...." With time, the "rule" for better or for worse, was forgotten.

    10. Currently... "Brad Sharpe Rule" EFFECTIVE, but…………    Needs to be adjusted to: Include new information (interventions, patient trajectory) Taught and explained  Refocus on organization     Actively disseminated and supported by faculty in the departments

    11. FOCUS Understand sources of variation and clarify steps in the process

    12. Understand sources of variation and clarify steps in the process FOCUS

    13. Understand sources of variation and clarify steps in the process FOCUS

    14. Understand sources of variation and clarify steps in the process FOCUS

    15. Understand sources of variation and clarify steps in the process FOCUS

    16. Understand sources of variation and clarify steps in the process FOCUS

    17. Meeting Between Medicine and ED Action plan / Future Goals QI team:  Clarifying/finalizing signout protocol other institutions - challenging admissions Medicine: signout protocol Clarifying avenues for feedback ED: signout protocol access to ED charts Select an improvement or intervention

    18. New EM-IM Rule to Assess UCSF's Current State of Affairs Four Categories explored:    Faith Comraderie Communication Resources

    19. EM Perspective Faith in sign out whether it helps IM physicians and/or patient care Believe Filemaker documentation helps IM team Camaraderie How well received is the signout by IM in the opinion of EM Feels the IM team in comfortable asking questions Communication Labs, tests, studies working dx Resources repeat labs, tests, studies time to IM handoff--> verbal and physical

    20. IM Perspective Faith in sign out does sign out help me in patient care? Review Filemaker Camaraderie ED staff cooperate well with my team Feel comfortable asking questions or requesting studies Communication Know who is the attending who saw my patient Labs, tests, studies working dx Resources repeat labs, tests, studies time to IM handoff--> verbal and physical

    21. References Schwarz S, Landis M, Rowe JE, A Team Approach to Quality Improvement: To realize change, rely on the knowledge and experience of a team such as the authors', which improved the care of patients with diabetes. Family Practice Management, March 1999.  Coleman MT, Endsley S, Quality Improvement: First Steps: QI can bring about substantial, lasting, positive change in your practice. It all begins with identifying the opportunities. Family Practice Management. March 1999 23.  Thakore S and Morrison W. A survey of the perceived quality of patient handover by ambulance staff in the resuscitation room. Journal of Emergency Medicine, 2001; 18:293-296. Ye K, Taylor DM, Knott JC, et al. Handover in the emergency department: Deficiencies and adverse effects. Emergency Medicine Australasia, 2007; 19:433-441  Beach C, Croskerry P, Shapiro M. Profiles in Patient Safety: Emergency Care Transitions. Academic Emergency Medicine, 2003; 10:364-367 Perry S. Transitions in Care: Studying Safety in Emergency Department Signovers. Focus on Patient Safety, 2004;7:1-3 Lee R, Woods R, Bullard M, Holroyd B, and Rowe B. Consultations in the emergency department: a systematic review of the literature. Emergency Medicine Journal, 2008;25:2-9 Toncich G, Cameron P, et al. Institute for Health Care Improvement Collaborative Trial to improve process times in an Australian emergency department. J Qual. Clin. Practice; 2000; 20, 79-86 Brandwijk M, Nemeth C, et al.  Distributing Cognition; ICU Handoffs Conform to Grice’s Maxims. Poster Presentation, University of Chicago, 2003 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, 2004; 13; i85-i90 Van Eaton EG, Horvath KD, et al. 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; 4; 538-545 Arora V, Johnson J, et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.  Qual. Saf. Health Care. 2005; 14; 401-407 Horowitz LI, Meredith T, et. al. Dropping the Baton: A Qualitative Analysis of Failures During the Transition From Emergency Department to Inpatient Care. Annals of emergency Medicine. 2008 Epub ahead of print

    22. Acknowledgments UCSF depts. of Internal Medicine and Emergency Medicine at Parnassus Alejandra Casillas, Lorie Leard, Steve Polevoi, Christina Lee, Rebecca Nessel, Heather Nye, Susan Promes, Ralph Wang Faculty at other institutions Michael Strong, Rebecca Sturges, Jason Krupp, Leora Horowitz, Ian Jenkins, Neil Wenger, Debbie Craig, Michael Lukela, David Krakaw, Taimur Habib, Kathleen Clem, Azita Hamedani, Theodore Chan Project advisors Karen Hauer, Arpana Vidyarthi, Brad Sharpe, Steve Polevoi

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