Stephanie Dewar MD, Stephen Hart MD, & Linda Waggoner-Fountain, MD

Children’s Hospital of Pittsburgh of UPMC University of Virginia Department of Pediatrics

March 28, 2015, APPD Annual Meeting

OPTIMIZING THE OUTCOME OF PATIENT HANDOFFS: A PRACTICAL APPROACH TO IMPLEMENTING CURRICULUM

WITH OBSERVATION & FEEDBACK TO TRAINEES

Disclosures

We have nothing to disclose.

Objectives Understand the critical elements of

patient sign-out that should be exchanged by trainees

Review the RRC requirements around transitions in care

Learn techniques to teach trainees how to improve sign-out skills

Agenda Introduction & Overview Essential features of sign-out Delivery of Sign-out Review of available options of

standardized curriculum Observation and rating of sign-out Implementation techniques for home Summary

Simulation Exercise Person who has the

information:

May only use words to describe the information to the scribe

MAY NOT show the information to the receiver

MAY NOT look at the interpretation of their words

Person who is receiving the information:

May ask any questions of

the information giver

MAY NOT look at the information

MAY NOT display their work to the giver

Overview of Sign-out

IPCS as Related to Transitions of Care

Communicate effectively with physicians, other health professionals, & health related agencies

The relaying of complete and accurate patient information between individuals or teams in transferring responsibility for patient care in the healthcare setting

Transitions of Care Programs must design clinical assignments to

minimize the number of transitions in patient care.

Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety.

Programs must ensure that residents are competent in communicating with team members in the hand-over process.

o 2016 Pediatric Program Requirements, p 15, 16 o 2016 Common Program Requirements, p 11, 17

Pediatric Milestones Provide transfer of care that ensures seamless

transitions Variability in transfer of information (content, accuracy,

efficiency and synthesis) from one patient to the next. Frequent errors of omission and commission in the handoff.

Uses a standard template for the information. Unable to deviate from that template for more complex situations. May have errors of omission and commission in the handoff.

Neither anticipates nor attends to the receiver of the information

Adapts and applies a standard template, relevant to individual contexts, reliably and reproducibly, with minimal errors of omission or commission. Allows ample opportunity for clarification and questions.

Beginning to anticipate potential issues for the transferee. P11 The Pediatrics Milestone Project

Definition of Sign-Out A mechanism of transferring

information, responsibility and/or authority from one set of care-givers to another

Primary objective is the accurate transfer of information about patient’s state and plan of care

Importance of Sign-Out Many residents learn how to sign-out

informally, while on the job.

Sign-out is a lifelong life-long skill • Physicians continue to give and

receive sign-out long after the complete residency

Why Is This A Problem Now? Number of sign-outs between residents ↑ Physician continuity of care during

hospitalizations ↓ Residents have become more dependent

upon exchange of clinical info during sign-outs

De-emphasis of clinical communication in the ‘medical record’

Emphasis of billing and compliance

“EVERY PATIENT IS MY PATIENT!” Sign-out – the handover of patient information & responsibility

Sign-out vs. Sign-Over Culture change

• “This is my patient RIGHT NOW” • “My sign-out is UP TO DATE” • “My team is responsible for our sign-

out.”

Care of the patient as a relay race • Running your leg of the race • Hand off of the baton

Agenda Introduction & Overview Essential features of sign-out Delivery of Sign-out Review of available options of standardized

curriculum Observation and rating of sign-out Implementation techniques for home Summary

Curriculum What

What not

How

Verbal Sign-out Written Sign-out

Designated time & place Uninterrupted Organized Thorough Concise (2-3 min/pt) Time for questions

Legible Relevant Accurate Up to date Copy available for recipient

Location of Sign-out Designated place With computers Quiet place with minimal interruptions

Sign-out times Morning 6A/7A

Noon 11:30A

Short call 4P

Night Team 7P

Expectations

Verbal Sign-out Team sign-out is optimal Hospital initiatives Consider starting with sickest patients

first OK to go to the bedside

Expectations

Written Sign-out C/ Child and Complexity The ID statement

History/Active issues Include access, new events of the day, better or

worse Plan/To do list Anticipatory Guidance Contingency plans – If…then… statements

? Questions

Delete useless information and update daily

C-Child/Complexity The ID statement (The Big Sentence): Age, relevant PMH, reason for admission, up to

date assessment, pertinent hospital course and workup

Sick or not sick, getting better or not Example: A 6 week old infant admitted with fever, irritability,

poor oral intake and vomiting who has been found to have HSV meningitis is—

A 6 week old with HSV meningitis on IV acyclovir who is now afebrile, drinking well with good urine output

History New events of the day

Access

Example: The patient passed his hearing test today,

was able to wean off supplemental oxygen and has a right antecubital PICC line.

P-Plan Reasonable list of things colleagues

should do while you are away

Labs/Diagnostic tests Discharges with info about what is left to be done (scripts,

home health, etc.) Consults Should we order what the consultant wants?

Example: “Call radiology for MRI report, if it shows osteo,

consult ID for antibiotic recommendations.”

More Plan: Anticipatory Guidance This is your contingency planning. “If X then Y.” ANTICIPATE what will happen to your

patient. Medications, dosages and when to give the

medications, including medications NOT to use. Labs that need to be drawn or cultures that need to be

collected. Example: If patient seizes > 5 minutes, give him Ativan

0.05mg/kg. If he still seizes load him with 5mg/kg of fosphenytoin.

Pain – patient with thrombocytopenia, so don’t use NSAIDS

Cares---? -- Questions

If you are getting sign-out and you don’t know something ASK

If you don’t understand something, ASK

Don’t leave until all questions are asked and answered.

Cerner sign-out tool:

Agenda Introduction & Overview Essential features of sign-out Delivery of Sign-out Review of available options of standardized

curriculum Observation and rating of sign-out Implementation techniques for home Summary

Now Your Turn Work in trios

One person is the sign-out giver, one is

the sign-out received, one is the observer

Look at your script only

Agenda Introduction & Overview Essential features of sign-out Delivery of Sign-out Review of available options of standardized

curriculum Observation and rating of sign-out Implementation techniques for home Summary

Sign-Out Mnemonics SBAR – Situation, Background, Assessment, Read-

Back IDEAL – Identify, Determine, Evaluate, Act, Learn DATA – Demographics, Active Issues, To do list,

Anticipatory Guidance (if…then…) SIGNOUT? – Sick or DNR, Identifying Data,

General Hospital Course, New Events of the Day, Overall Health Status, Upcoming Possibilities with Plan, Tasks to Complete with plan, Questions

More Mnemonics SAIF-IR – Summary Statement, Active Issues, If-

then contingency planning, Follow-up Activities – Interactive Questioning, Read-back

SHOUT – Sick or Not Sick, History & Hospital Course, Objective Data (PE, vitals, results), Upcoming Plan, To Do including rationale

I-PASSTHEBATON → I-PASS – Illness Severity, Patient Summary, Action List, Situation Awareness & Contingency Planning, Synthesis by Receiver

Agenda Introduction & Overview Essential features of sign-out Delivery of Sign-out Review of available options of standardized

curriculum Observation and rating of sign-out Implementation techniques for home Summary

ED to Floor Handover ED-to-Inpatient #1

CHP Emergency Department Admission Worksheet: chp cares

Patient’s ED evaluation is complete and the patient is ready to be admitted. FirstNet “Eval Complete” has been posted.

Please carefully ensure that you are able to answer YES to the following questions.

Is the ED evaluation complete? The ED has completed an appropriate evaluation and will provide a pertinent and complete report to the in-patient team such that the team can safely continue care of the patient (this does not mean a definitive diagnosis or long term care plan has been completed).

Is the patient stable for the floor? Has report been given to the floor (using CHP Cares)? Post “REPORT GIVEN” under “What’s Next?” on Firstnet

C- Child

Who is this patient? (Jane Doe; 3 year old female) Brief HPI (pertinent history only)

Important/Pertinent PMH What is the diagnosis or working differential?

Asthma exacerbation; Cellulitis; Possible seizures Sick vs. Not Sick

H- Happenings in the ED Essential + Pertinent examination report

Vital signs including pO2 Pertinent examination findings

What are the active issues? Persistent wheezing; Dehydration;

What was done in terms of evaluation & management in the ED Nebulized treatments; Labs; Cultures; Procedures

P- Plan Rationale for the admission

Asthma therapy; Antibiotics pending culture results Items that need to be followed up on Reasons they are stable for the floor

Cares- clarifying questions from the admitting team, essential information that you need to communicate to them

C H P CARES

Team/Resident: Time of Report: Callback #:

ED to Floor Handover

ED-to-Inpatient #2

ED-to-Inpatient #3

Floor-to-Floor #1

Direct Observation

Floor-to-Floor #2

Agenda Introduction & Overview Essential features of sign-out Delivery of Sign-out Review of available options of standardized

curriculum Observation and rating of sign-out Implementation techniques for home Summary

Teaching Sign-Out

Sign-out means different things to different people • Levels of experience • Styles of caring for patients • Styles of learning

PL-1 Goals & Objectives for Sign-Out

1. Will be able to identify the five key components for patient sign-out

2. Will recognize effective sign-out by others

3. Will be able to give all five essential components of sign-out without prompting by end of PL-1 year

PL-2 Goals & Objectives for Sign-Out

All skills of PL-1 plus 1. Will understand what read

back/synopsis role is in sign-out 2. Will recognize effective read back

by others 3. Will be able to elicit all 5

components of sign-out from other resident

PL-3 Goals & Objectives for Sign-Out

All skills of PL-2 plus 1. Will demonstrate effective & efficient

sign-out 2. Will demonstrate effective & efficient

read back as receiver in sign-out 3. Will utilize teaching opportunities 4. Will recognize collaborative cross check 5. Will work towards mastery of

collaborative cross check

Attending Goals & Objectives for Sign-Out

All skills of resident plus mastery of collaborative cross check • PL-1 – Information and Accuracy • PL-2 – Synopsis and Query • PL-3 – Efficiency and Collaboration

Process of implementation Emphasis was placed on: Face to face sign-out Standardized location Scheduled sessions Verbal communication Written sign-out tool

Things to Include

1. Name and/or MRN 2. The big sentence 3. Current condition 4. Plan of care 5. Contingency plans (What if’s/questions that

might arise overnight) 6. Read back/summation from receiver 7. Co-orientation & collaborative cross-check

Things Not to Include

Plans for next week that are not important for the next 24 hours

Gossip Too much time on background and pt ID Things easily found elsewhere

• Sign out sheet • Hospital chart or EMR • Medication orders

Who Gives Good Sign-Out and Why?

We surveyed our housestaff and asked them to identify the three (out of 39) residents who give the best sign-out • Three individuals were identified by more than 40%

of their peers “after signing out with them, I feel well prepared for the next

call shift” “they help me anticipate what might go wrong during my call

shift” “they give me a chance to ask questions”

Optimal Sign-out Giver

Arrives on time Brings an updated written sign-out list Invites questions Makes sure that all patient issues are

understood before leaving = Co-orientation is key

Optimal Sign-out Receiver

Arrives on time Is attentive to the sign-out giver Asks clarifying questions Makes sure that he/she understands all patient issues

Social Awareness Strategies

Watch Body Language Don’t Text at Meetings Make Timing Everything Clear Away the Clutter Practice the Art of Listening Go People Watching Catch the Mood of the Room Understand the Rules of the Culture

Game

Steps for Teaching, Observing and Evaluating Sign-out

Senior Resident Leadership Workshops Review expectations for SIGNOUT Share EMR Sign-out template Discuss plans for evaluation and feedback

Intern Orientation Review expectations for SIGNOUT Model adequate vs. inadequate sign-out Practice developing written sign-out

Evaluation of verbal SIGNOUT Verbal SIGNOUT observation tool Direct observation by attendings each week

Agenda Introduction & Overview Essential features of sign-out Delivery of Sign-out Review of available options of standardized

curriculum Observation and rating of sign-out Implementation techniques for home Summary

Summary Trainees need to be taught the critical

elements of patient sign-out

The RRC has clear requirements around transitions in care

There are a variety of techniques to teach trainees how to improve sign-out skills

Contact information Stephanie Dewar MD Stephanie.dewar@chp.edu

Stephen A. Hart MD stephen.hart@chp.edu

Linda Waggoner-Fountain MD law4q@virginia.edu