Patient Care Hand OffPassing the Torchwithout Passing the Buck!

Rommie L. Duckworth, LPhttp://www.flickr.com/photos/christianacare/9915278814/

WHODoctors

Nurses

Paramedics

EMTs

Allied Health

WHEREFirst Response to Ambulance

Ambulance to Paramedic

Paramedic to ED

ED to Interventional Staff

Interventional Staff to Critical Care Staff

And so on…

Hand-offs involve the transfer of [patient care information,] rights, duties and obligations from one person or team to another.

– Solet D, Norvell J, Rutan G, et al. Lost in translati on: Challenges and opportuniti es in physician-to-physician communicati on during pati ent

hand-off s. Acad Med . 2005;80(12):1094–1099.

WHERE

The primary objective of a “hand off ” is to provide accurate information about a [patient’s] care, treatment, and services, current condition and any recent or anticipated changes.

– Joint Commission Nati onal Pati ent Safety Goal 2: Improve Staff Communicati on

To facilitate effi cient movement of the patient through the continuum of care.

- Rom Duckworth, LP

Problem

Opportunity

Patient Care Hand-Off Communications have been identified as a critical safety and quality problem.

– The Joint Commission Center for Transforming Healthcare

In 2005, this increased to 70%, with

50%during the hand-off.

– The Joint Commission. Improving handoff communicati ons: Meeti ng Nati onal Pati ent Safety Goal 2 E. Joint Perspect Pati ent Safety . 2006;6:9-15.

More than 3,000 sentinel events from 1995 to 2004 revealed

65% of reported problems caused by

poor communication. – The Joint Commission. Improving handoff communicati ons: Meeti ng

Nati onal Pati ent Safety Goal 2 E. Joint Perspect Pati ent Safety . 2006;6:9-15.

Communication failure was the primary

root cause of 65% of reported sentinel events in 2006.

– Joint Commission. Improving America’s hospitals: the Joint Commission’s annual report on quality and safety, 2007.

Medical Errors

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When patients see multiple providers in different setti ngs, none of whom have access to complete information, it is easier for something to go wrong than when care is better coordinated.

– America, C. O. Q. O. H. C. I . , Insti tute of Medicine. (2000). To Err Is Human. Nati onal Academies Press.

In critical care settings, communication loads can be extremely high, complex and cognitively taxing. Interruptions and multiple concurrent tasks may lead to clinical errors due to disrupted memory processes.

– Coiera E, Javasuriya R, Hardy J, et al. Communication loads on clinical staff in the emergency department. Med J Aust. 2002;176(9):415–518.

3 AM

St. Anywhere E.D.Anytown, U.S.A.

Delay in treatment

Inappropriate treatment

Adverse events

Omission of care

Increased hospital length of stay

Avoidable readmissions

Increased costs

Inefficiency from rework

Other minor or major patient harm. UH OH!

Can I get a Witness?•None•One•Some•All

“TheBermudaTriangleof

Healthcare”

PatientHandOff

Communication failures continue to be a common cause of inadvertent patient harm, and methods to improve communication remain an important focus for further education and research in EMS.

– Leonard M, Graham S & Bonacum D. The human factor: The criti cal importance of eff ecti ve teamwork and communicati on in providing safe care. Qual Saf Health Care . 2004;13(Suppl 1):i85–i90.

Miscommunication is common and can disrupt memory and lead to mistakes; hence, it’s not surprising that ED staff members remember less than half of the information EMS crews give them at verbal hand-offs.

– Talbot R, Bleetman A. Retenti on of informati on by emergency department staff at ambulance handover: Do standardised approaches work? Emerg Med J . 2007;24(8):539–542.

GeneralCulture: Lack of teamwork and respect

Expectations between sender and receiver differ

Ineffective communication method, e.g. verbal, recorded, bedside, written

Timing of physical transfer of the patient and the hand-off are not in sync

Inadequate amount of time provided for successful hand-off

Interruptions occur during hand-off

Lack of standardized procedures in conducting successful hand-off

Inadequate staffing to accommodate successful hand-off

Patient not included during hand-off http://www.flickr.com/photos/christianacare/5395571917/

SendingSender provides inaccurate or incomplete information, e.g. medication list, DNR, concerns/ issues, contact information

Sender, who has little knowledge of patient, is handing off patient to receiver

Sender unable to provide up-to-date information, e.g. lab tests, radiology reports, because not available at the time of hand-off

Inability of sender to follow up with receiver if additional information needs to be shared

Sender asked to repeat information that has already been shared

http://www.flickr.com/photos/christianacare/5395571917/

ReceivingReceiver has competing priorities and is unable to focus on

transferred patient

Receiver unaware of patient transfer

Inability for receiver to follow up with sender if additional information is needed

Lack of responsiveness by receiver

Receiver has little knowledge of patient being transferred

http://www.flickr.com/photos/christianacare/5395571917/

Resources

4 AMSt. Anywhere E.D.

Anytown, U.S.A.

Problem

Opportunity

Opportunity

When EMS provided hospital staff with advanced notification of incoming stroke patients, the number of patients eligible for thrombolytic therapy significantly improved.

– Abdul lah A, Smith E, Biddinger P, et a l . Advance hospital noti fi cati on in acute stroke is associated with shorter door-to-computed tomography ti me and increased l ikel ihood of administrati on of ti ssue-plasminogen acti vator. Prehosp Emerg Care . 2008;12(4):426–431.

Alerts Glasgow Coma Scale GCS

Face Arm Speech Time ER FASTER

Boston Operation Stroke Scale BOSS

Cincinnati Prehospital Stroke Scale CPSS

Melbourne Ambulance Stroke Screen MASS

Age, Blood Pressure, Clinical Features, Duration Score ABCD

Brooklyn Stroke Scale

Los Angeles Prehospital Stroke Screen LAPSS

Miami Emergency Neurological Deficit Checklist MEND

National Institute of Health Stroke Scale NIHSS

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Don’t Bury The Headline

Evidence Based Systematic Approach

Situation

Background

Assessment

Recommendations

Age/GenderPoint of Entry / CCPriority Concerns

MOI/NOI/OnsetPriority Med Hx.High Risk Meds

Vital SignsPert. Physical FindingsScales / Scores

Treatment & ResponseRecapRequests

EMS Alternative Approach

Mechanism

Injuries / Illness

Symptoms

Treatment

Age/GenderPoint of Entry / CCPriority Concerns

MOI/NOI/OnsetPriority Med Hx.High Risk Meds

Vital SignsPert. Physical FindingsScales / Scores

Treatment & ResponseRecapRequests

CAN Reports

Conditions

Actions

Needs

Slow is SmoothABC’s

Moment of Silence

Allow Time

Echo Answer

Smooth is Fast

Add a Q

Questions

Quantify

Qlarifyhttp://www.flickr.com/photos/miwo76/30807445/

Opportunity

In A World

In A World

In A World

Reduce errors!

Facilitate the continuum of care!

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SHAREStandardize

Hardwire

Allow Questions

Reinforce

Educate & Coach

Handoff communication is… a dialogue between health professionals…that fosters empathy, equity, common ground, in addition to transferring necessary information.

– Communicati on, Communicati on, Communicati on: The Art of the Handoff 2009 by the American College of Emergency Physicians

Email: romduckworth@NECREM.org

Twitter: @romduck

@RescueDigest

Resources: www.bit.ly/HandOff

Websites: www.RescueDigest.com

www.RomDuck.comhttp://www.flickr.com/photos/22458831@N04/3676369069/