The hand-off of a patient from one doctor to another is an episode ripe for potential problems. Important data about the patient's condition might not be transferred, and there is also the potential for miscommunication between the caregivers. In academic medical centers, the responsibility for the hand-off is often in the hands of the interns, i.e., the first year residents. As duty hours for residents have become more restricted to avoid overtired doctors, the number of hand-offs that occur has necessarily increased -- by something like 40%.
(The trade-offs between the dangers associated with tired doctors and those associated with increased hand-offs has been well discussed elsewhere, and it is not my purpose here to argue the case. For the former, you find serious medical errors, medication errors, diagnostic errors, car crashes, depression, and burn-out. For the latter, you find longer lengths of stay, medication errors, and more adverse events, especially those associated with communication failures.)
Three years ago, the Risk Management Foundation published an edition of its Forum entirely devoted to the subject of how to reduce risks during hand-offs. It remains a good summary of the issues, and you can view it here.
Last year, one of our Senior Residents, Kelly Graham, decided to use the research phase of her residency to test out some interventions to see if they could reduce the likelihood of hand-off related errors. She compiled the following baseline assessment for BIDMC (which, as noted, was similar to a previous assessment at Brigham and Women's Hospital):
Kelly decided to focus on three aspects of hand-offs: The systems in place, the written communications, and the oral communications. Her hypothesis was that by taking a systematic approach to intervening in each component of the patient hand-off, we could improve the quality of sign-outs, patient safety, and intern satisfaction.
The "prior" that Kelly was trying to change is the age-old system: Interns learn how to do hand-offs on the floors by watching their senior residents. Process improvement folks reading this know that is a recipe for a high degree of variation in practice and for a systematic transmittal through time of bad habits and approaches that increase the likelihood of harm.
So, Kelly's aims were to provide resident physicians and patients with safe hand-off practices; to promote a “standard operating procedure” for hand-off; and to take hand-offs out of the hidden curriculum of medical training and make it part of our formal education process.
On the system side of the equation, she noted that many hand-offs actually did not occur between the doctor leaving the service and the doctor arriving. Instead, an intermediary person often took the information from the departing doctor and later relayed it to the arriving doctor. Like the old game of telephone, this increased the likelihood of flawed information transfer. (In fact, prior studies indicated a loss of 22% of the desirable information that should be passed along at the time of transfer.)
The alternative was to require direct communication between the departing intern and the arriving intern, in a standard location (the house officer lounge). Doctor-to-doctor interaction increased from 25% to 100%.
The next intervention was designed to present a common template of information to be transferred. Pull-down menus on the computer helped to ensure that standard categories would be discussed, and standard language would be used as much as possible to reduce variation in the transmittal of patient data.
And the final intervention, the one that is likely to raise eyebrows among my lay readers, is the idea of teaching how to do a sign-out in the classroom before arriving on the medical floors. Huh?
Well, the baseline assessment was that interns are not prepared for hand-offs during medical school. 91.3% of interns at BIDMC reported no hand-off training prior to residency; and 92% interns nationally report no hand-off training prior to residency. So Kelly designed and implemented a case-based, interactive, sign-out workshop during the interns' orientation.
As the year went along, she surveyed the residents and also kept track of patient data. She reached the following conclusions:
Interns are ill-prepared for transitions of care; “double hand-offs” may reduce work hours slightly, however the trade-off is that they may be unsafe for patients; involving the primary team in the hand-off process has a powerful effect of patient safety and physician satisfaction; electronic templates are reliable tools to ensure sign-outs are complete; and interns respond well to incorporating hand-off training into their education.
And, now look at the clinical efficacy of the experiment. There was a dramatic reduction in adverse events, near misses, and data omissions. In fact, the first two interventions were so powerful that it was not possible to fully evaluate the strength of the last one -- but the training did help to improve interns' job satisfaction.
The interventions are now embedded in our Department of Medicine's system of training and care. The interns who just arrived don't know enough to know that they are doing something different from the past because they never experienced the ad hoc system that was in place before. Congratulations to Kelly and her colleagues for demonstrating how an academic medical center can contribute to the improvement of clinical processes, something just as important as our contributions to basic and translational research about disease.