Patient Hand-off in Internal Medicine

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Questions and Answers

According to the presentation, what is the primary purpose of patient hand-offs?

To allow doctors to take breaks and go home earlier.

To minimize paperwork and administrative tasks.

To allow patients to meet new providers.

To ensure seamless transitions in patient care responsibility and maintain patient safety. (correct)

Which of the following is NOT a phase of the patient hand-off process described in the presentation?

Interrogation (correct)

Pre-handoff

Arrival

Post-handoff

What is the role of the 'dialogue' phase?

To prepare and write any necessary reports or summaries as needed.

To gather any needed documents, paperwork, and materials.

To openly discuss the patient's case, including current status, anticipated needs, and future plans. (correct)

To establish a time for the next transfer of care.

According to the presentation, what is a potential barrier to effective hand-off communication?

Time constraints and interruptions. Signup and view all the answers

What methods does the presentation recommend to ensure shared understanding during a hand-off?

Active listening and asking clarifying questions. Signup and view all the answers

What is the primary purpose of a patient hand-off?

To maintain the continuity and safety of patient care. Signup and view all the answers

Which of the following is NOT a commonly used term for patient hand-off?

Case review Signup and view all the answers

According to the provided material, what is a significant consequence of poor hand-offs?

Uncertainty in clinical decision-making and potential harm. Signup and view all the answers

What type of communication is considered most critical for adequate information transfer during a hand-off?

Face-to-face communication with interactive questioning. Signup and view all the answers

Which of these elements is NOT typically included in a written hand-off?

Patient’s preferred meal choices. Signup and view all the answers

Which of the following is the correct order of the four phases of a patient handoff?

Pre-handoff, Arrival, Dialogue, Post-handoff. Signup and view all the answers

What should occur in the 'Arrival' phase of a hand-off?

Work is stopped to conduct the handoff. Signup and view all the answers

What does the 'Post-handoff' phase primarily involve?

The receiver assumes care and integrates information. Signup and view all the answers

Which element of the verbal hand-off includes the patient's name, age, and diagnosis?

Patient ID Signup and view all the answers

During a verbal hand-off, a patient is described as 'worsening' and 'worrisome'. Which category does this fall under?

Unstable Signup and view all the answers

In a hand-off report, what is the best practice for communicating a patient's code status?

Always state the code status, especially for those not full code, sicker, or potentially deteriorating. Signup and view all the answers

A patient's hand-off includes information about a recent toe amputation and T2DM. Under which component would this data be classified?

Medical History Signup and view all the answers

A patient was admitted from the ED for chest pain, which was determined to be a STEMI. Which section of the hand-off would contain this information?

Presenting Issue Signup and view all the answers

In a verbal hand-off, which of the following would be part of 'Course of Stay'?

Results of labs and any treatments completed during the current shift. Signup and view all the answers

What is the MOST important reason for including 'Upcoming Possibilities' in a hand-off?

To outline possible scenarios of the patient's stay and ensure staff are aware of what actions to take if these scenarios occur. Signup and view all the answers

Which element of a verbal hand-off would include details on tasks to complete such as following-up on results?

Task Signup and view all the answers

A patient's breathing improved after duonebs, steroids, and magnesium sulfate but is still experiencing shortness of breath (SOB). Which of the following interventions is suggested as a possible next step?

Consider BiPAP. Signup and view all the answers

Despite receiving two units of packed red blood cells (PRBCs), a patient's hemoglobin (Hgb) remains below 8. What action is being taken in response?

Awaiting a one unit of PRBC's from the blood bank for immediate administration. Signup and view all the answers

A patient meets sepsis criteria and is receiving broad-spectrum antibiotics and fluids. Although blood pressure (BP) is improving, pressors are still required. What specific pressor is the patient receiving and might need dosage adjustments?

Levophed Signup and view all the answers

A patient has a right internal jugular (IJ) central line placed. What is the next immediate step after placement, before starting fluids?

Confirming line placement with a chest x-ray (CXR). Signup and view all the answers

A patient undergoing evaluation is scheduled for a potential endoscopy in the morning. What specific step is required for the patient at midnight?

Ensuring the patient is NPO (nothing by mouth). Signup and view all the answers

What is the primary goal of a patient hand-off?

To create a shared understanding of the patient's condition and plan Signup and view all the answers

What is one critical action to reduce barriers during patient hand-off communication?

Ensuring protected time of adequate duration Signup and view all the answers

What does the 'S' stand for in the 'I-PASS' mnemonic?

Safety concerns and critical information Signup and view all the answers

In the 'SIGNOUT' mnemonic, what does the 'B' stand for?

Background information, including medical history Signup and view all the answers

Based on the information provided, what is the intended result of implementing standardized hand-off tools like I-PASS?

To reduce preventable adverse events. Signup and view all the answers

In the 'SIGNOUT' mnemonic, which element focuses on who is accountable for the patient?

Ownership Signup and view all the answers

What does the 'A' stand for when using the 'I-PASS' framework?

Assessment - present chief complaint, vital signs, symptoms and diagnosis Signup and view all the answers

During a hand-off, what does active listening mainly refer to?

Asking clarifying questions to ensure shared understanding. Signup and view all the answers

Study Notes

Patient Hand-off

Presented by Anastasia L. Rodriguez, DO, Assistant Professor, Internal Medicine, Department of Family Medicine, COMP - Pomona
Also presented by Frances Spiller, DO, Assistant Professor, Internal Medicine
Gina Miller, MD, Assistant Professor, Family Medicine, COMP - NW
No conflicts of interest were disclosed
Office hours will be Thursday, January 16th, from 3–4 pm in the CMR Lab with Anna and Michelle

Conflict of Interest

No conflicts of interest were disclosed

AMR Office Hours

Thursday, January 16th
3–4 pm
CMR Lab
With Anna and Michelle

Objectives

Define patient hand-off and its role in continuity and safety of patient care
Describe the four phases of patient hand-off: Pre-handoff, Arrival, Dialogue, and Post-handoff
Describe the components of an effective patient hand-off
Identify potential barriers to effective hand-off communication, such as distractions, interruptions, and time constraints
Discuss the role of active listening and clarifying questions to ensure shared understanding

What is a Hand-off?

Defined by The Joint Commission (2017): A hand-off is a transfer and acceptance of patient care responsibility achieved through effective communication. It's a real-time process of passing patient-specific information
Also known as sign out, sign off, or hand over

Background

Fragmentation of care increases gaps in safe patient care
Studies show the direct effect of improper hand-offs on patient safety
Joint Commission's National Patient Safety Goals stressed the need for systems to improve patient hand-offs
Poor hand-offs lead to uncertainty during clinical decision-making leading to potential harm and inefficient work
Accreditation Council for Graduate Medical Education (ACGME) called for improved information transfer among residents and interns

Importance of Face-to-Face AND Written Communication

Face-to-face communication with the ability to perform interactive questioning is critically important for adequate transfer of information – recommended by The Joint Commission and Society of Hospital Medicine
Essential elements of a written hand-off include: assessment of illness severity, patient summary, action items, situation awareness, contingency plans, allergies, medications, age, weight, date of admission, patient and hospital service identifiers, and code status

Four Phases

Pre-handoff: Sender organizes and updates information in preparation for the hand-off
Arrival: Work is stopped to conduct the hand-off. Ideally, time is protected
Dialogue: Exchange takes place between the sender and the receiver. Ideally, this is verbal and written/electronic
Post-handoff: Receiver integrates new information and assumes care of the patient

High Quality Patient Hand-off

Determine critical information that needs to be communicated face-to-face and in writing
Overall goal is to create and share understanding of the patient
Reduce potential barriers to effective hand-off communication, such as distractions and interruptions
Ensure protected time of sufficient duration for transfer of information
Transfer of professional responsibility is more than just transferring patient care information; it's recognizing accountability for the patient's care
Active listening and clarifying questions during the dialogue phase are essential to ensure shared understanding of the patient's care
Standardized tools are encouraged

Standardized Tools and Methods (IPASS)

Associated with a 30% decrease in preventable adverse events
Illness Severity
Patient Summary
Action List
Situation Awareness & Contingency Planning
Synthesis by Receiver

Standardized Tools and Methods (General)

Introduction: Introduce yourself and your role/job (include patient) Name, identifiers, age, sex, location
Patient/Resident: Include name, identifiers, age, sex, and location (specific to patient)
Assessment: Present chief complaint, vital signs, symptoms, diagnosis, and current status/circumstances including code status, level of (un)certainty, recent changes, and response to treatment
Safety Concerns: Critical lab values/reports, socioeconomic factors, allergies, alerts (such as falls or isolation), etc.
Background: Comorbidities, medications, family history, and previous episodes. Explain what actions were taken and rationale
Actions: Explain what actions were taken or are required, with rationale
Timing: Level of urgency and explicit timing and prioritization of actions
Ownership: Identify who is responsible, including patient and family members
Next: What will happen next, anticipated changes, and plan
Other Considerations : Other needed elements such as:
Patient ID
Stability
Code Status
Medical History
Presenting Issue
Course of Stay
Upcoming possibilities
Tasks, and Questions to ask

Effective Verbal Hand-off

List the needed elements and examples for a verbal hand-off

ID Data

Includes examples of how to provide ID data for patients (room/location, name, age, gender, diagnosis)
Example patient IDs and conditions were included

Stability

Define what the overall clinical status is (Sick/un/stable, worrisome/improving, etc.)
Include some patient examples

Code Status

Code Status (Full Code, DNR/DNI, No Pressors, No Escalation of Care)
Importance of communicating code status to the oncoming clinician

Medical History

Detailing patient medical history (uncontrolled T2DM, recent toe amputation, history of IVDU, and admission for endocarditis etc.)

Presenting Issue

Include reasons for admission (acute COPD exacerbation, RLQ abdominal pain, and chest pain with EKG STEMI)

Hospital Course

Details of what has been done during the shift, results, and patient response to treatment (e.g., duonebs, steroids, improvements, but still SOB)

Upcoming Possibilities

What to watch out for following treatment, need for increased breathing treatments and use of BiPAP , low HGB levels, and sepsis criteria met needing pressors

Tasks

What is ordered and needs to be followed up – includes imaging and labs, consultation

Questions

Receiving clinician to ask questions about the patient. Include any relevant questions

Practice the Hand-off

Utilizing the IPASS model for hand-off practice.
Using a case study from that day

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Description

This quiz focuses on the essential aspects of patient hand-off in the context of Internal Medicine. You'll learn about the phases involved, the significance of effective communication, and the potential barriers that can affect patient safety. Prepare to enhance your understanding of continuity in patient care.