Patient Hand-off PDF

Patient Hand-off A N A S TA C I A L. RO D R I G U EZ , D O F R A N C ES S P I L L E R , D O A S S I S TA N T P RO F ES S O R , I N T E R N A L M E D I C I N E A S S I S TA N T P RO F ES S O R , I N T E R N A L M E D I C I N E D E PA RT M E N T O F FA M I LY M E D I C I N...

Patient Hand-off A N A S TA C I A L. RO D R I G U EZ , D O F R A N C ES S P I L L E R , D O A S S I S TA N T P RO F ES S O R , I N T E R N A L M E D I C I N E A S S I S TA N T P RO F ES S O R , I N T E R N A L M E D I C I N E D E PA RT M E N T O F FA M I LY M E D I C I N E GINA MILLER, MD CO M P – P O M O N A A S S I S TA N T P RO F ES S O R , FA M I LY M E D I C I N E CO M P – N W  Conflict of Interest In relation to this presentation, the speaker has no financial or other conflicts of interest that need to be disclosed. AMR Office Hours Thursday 1/16 from 3-4pm in the CMR Lab with Anna and Michelle Objectives Define the concept of patient hand-offs and explain their role in ensuring continuity and safety in patient care. Describe the four phases of the patient hand-off process: Pre- handoff, Arrival, Dialogue, and Post-handoff. Describe the components of an effective patient hand-off Identify potential barriers to effective patient 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 is a real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care.” AKA sign out, sign off, or hand over Background Fragmentation of care increases gap in safe patient care Joint Commission’s National Patient Safety Studies have shown the direct effect of Goals stressed need for systems to improve improper hand-offs on patient safety patient hand-offs Accreditation Council for Graduate Medical Poor hand-offs lead to uncertainty during Education (ACGME) called for improved clinical decision-making leading to potential information transfer among residents and harm (near misses) and inefficient work interns  Face-to-face communication with the ability to perform interactive questioning is critical for adequate transfer of information— recommended by The Joint Commission and Society of Hospital Medicine Importance of Face-to-Face AND Written Essential elements of a written hand-off: Communication assessment of illness severity, patient summary, action items, situation awareness and 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 handoff. Arrival: Work stopped in order to conduct the handoff. Ideally, time is protected for the handoff to occur. Dialogue: Exchange takes place between the sender and the receiver. Ideally, this is verbal and written/electronic. Post-handoff: Receiver of the patient information integrates the new information and assumes care of the patient. High Quality Patient Hand-off Determine critical information that needs to Transfer of professional responsibility—it is be communicated face-to-face AND in writing more than just transferring patient care information; it is acknowledgement of the Overall goal of the hand-off is to create and accountability for the patient’s care shared understanding of the patient During the dialogue phase engage in active It is critical to reduce potential barriers to listening and ask clarifying questions to ensure effective patient hand-off communication: shared understanding of the patient’s care Reduce distractions Minimize interruptions Standardized tools are encouraged Ensure protected time that is of sufficient duration for transfer of information  Standardized Tools and Methods I-PASS SIGNOUT ◦ Associated with 30% decrease in preventable adverse events  Standardized Tools and Methods I Introduction Introduce yourself and your role/job (include patient) P Patient/Resident Name, identifiers, age, sex, location A Assessment Present chief complaint, vital signs, symptoms and diagnosis S Situation Current status/circumstances, including code status, level of (un)certainty, recent changes and response to treatment S SAFETY Concerns Critical lab values/reports, socioeconomic factors, allergies and alerts (falls, isolation, etc.) THE B Background Comorbidities, previous episodes, current medications and family history A Actions Explain what actions were taken or are required. Provide rationale. T Timing Level of urgency and explicit timing and prioritization of actions O Ownership Identify who is responsible (person/team), including patient/family members N Next What will happen next? Anticipated changes? What is the plan? Are there contingency plans? Derived from TeamSTEPPS  Effective Verbal Hand-off Element Examples Patient ID Name, Age, Gender, Diagnosis Stability Stable, Unstable, Watch Code Status Full Code, DNR/DNI, CPR only Medical History List medical history for case and Historic elements pertinent to the current presentation Presenting issue What brought them to the hospital Course of stay What has been done so far for them in the hospital (workup, txts) & what are results or trends after this has been done. Status of medical problems. Upcoming What can occur during the course of this stay and instructions on what to do if these things possibilities happen Task Anything to follow-up on. What to do with these results/actions (be specific). Questions Ask if there are any questions ID Data Room/Location. Name, Age, Gender, Diagnosis. “ICU Bed 2301. George Cortez is a 65 yo male with new onset heart failure.” “Room 4210. Sally Rhodes is a 42 yo female with hx of T2DM admitted for nonhealing R foot ulcer.” “I’m signing out Room 3204, Barry Lockhart—a 56 yo male with pneumonia.” Stability What is the overall clinical status? ◦ Sick/Unstable – Worrisome/Worsening ◦ Stable – Not worrisome/Improving ◦ Watch this one! – Not sure of patient trajectory “Patient is stable.” “Patient just moved from MICU this afternoon but worrisome breathing—might go back tonight.” “Patient coded twice today—he is our sickest. Not stable.” Code Status Full Code DNR/DNI No Pressors No Escalation of Care “He is full code.” “She is DNR/DNI” You should aim to always tell the oncoming clinician the Code Status for all of your patients, but especially for: ◦ Those that are not Full Code ◦ Those that are sicker ◦ Those that may deteriorate overnight Medical History What is the patient’s medical history? Include any features that contribute to their medical issues/reason for admission “Pt with uncontrolled T2DM and recent toe amputation” “Pt has history of IVDU and is admitted for endocarditis.” “Pt with EtOH use and history of gastric ulcers with hematemesis and Hgb 9.0 mg/dl” Presenting Issue What brought them to the hospital, Reason for Admission “Admitted for acute COPD exacerbation.” “Presented to the ED for RLQ abd pain x 4 days.” “Patient had complaint of chest pain with STEMI on EKG.” Hospital Course What has been done during the shift? Results? Are they responding to treatment? What is the status of their medical problems? “Pt received duonebs, steroids, azithromycin, magnesium sulfate in the ED—breathing is improved, but still SOB.” “Received 2 units of PRBCs, tolerated well but new CBC demonstrates Hgb still below 8.” “Sepsis criteria met so broad spectrum abx and fluids were started in ED. BP is improving but still needs pressors.” Upcoming possibilities One of the most essential components of an effective checkout. This lets the covering clinician know what to be aware of and what to watch out for! “Pt received duonebs, steroids, magnesium sulfate in the ED—breathing is improved, but still SOB.” ◦ May need to increase frequency of breathing treatments? Consider BiPAP? “Received 2 units of PRBCs, tolerated well but new CBC demonstrates Hgb still below 8.” ◦ Pending 1 unit PRBCs from blood bank—will be started soon. H/H checked q6H with next due at 7pm. “Sepsis criteria met so broad spectrum abx and fluids started in the ED. BP is improving but still needs pressors.” ◦ He is on levophed which might need to be titrated. Tasks What is ordered and needs to be followed up? ◦ Imaging? Labs? Consultations? “Pt had right IJ placed—still waiting for CXR after placement. Once confirmed then can start fluids.” “CMP is pending for patient—please check potassium level.” “Gastroenterology has not rounded, please follow up if Endoscopy in AM and ensure patient is NPO at midnight.” Questions Allow receiving clinician to ask questions Practice the Hand-off Use the CHF case from today and practice giving an effective hand-ff to your table partner using the IPASS model.