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Clinical Handoffs The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group Clinical Handoffs The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group Ayse P. Gurses, Ph. D agurses [email protected] edu April 1, 2011 Immersion Call

Immersion Call Schedule Title Date /Time 13: 00 EST Presented by Program Overview Feb Immersion Call Schedule Title Date /Time 13: 00 EST Presented by Program Overview Feb 18, 2011 Peter Pronovost MD Ph. D Science Of Safety February 25, 2011 Jill Marsteller, Ph. D, MPP Comprehensive Unit-Based Safety Program CUSP Central Line Blood Stream Infection Elimination Surgical Site Infection Elimination Ventilator-Associated Pneumonia Reduction Hand-Offs/ Transitions in Care March 4, 2011 Christine Goeschel MPA MPS Sc. D RN March 11, 2011 David Thompson DNSC, MS March 18, 2011 Elizabeth Martinez, MD, MHS March 25, 2011 Sean Berenholtz, MD April 1, 2011 Ayse P. Gurses, Ph. D Data we Can Count on Team Building April 8, 2011 Lisa Lubomski, Ph. D. April 15, 2011 Jill Marsteller, Ph. D, MPP Physician Engagement April 22, 2011 Peter Pronovost, MD, Ph. D 2 © 2011

Communication breakdowns as Root Cause of Errors Communication breakdowns are frequently the root cause Communication breakdowns as Root Cause of Errors Communication breakdowns are frequently the root cause of… undesirable outcomes 3 © 2011

Definitions of Handoff • “The transfer of information, along with authority and responsibility, during Definitions of Handoff • “The transfer of information, along with authority and responsibility, during transitions in care across the continuum for the purpose of ensuring the continuity and safety of the patient’s care. ” 1 • “When responsibility for a patient is passed from one caregiver to another or when patient information is transferred from one type of healthcare organization to another or to a patient’s home” 2 • “To communicate patient information to facilitate continuity in the plan of care” 3 1. Standardizing Handoffs for Patient Safety, AORN, 2010. 2. Communication during patient hand-overs, Joint Commission, 2007. 3. Streitenberger K, Pediatric Clinics of North America, 2006. 4 © 2011

Primary Objective • “The primary objective of a “hand off ” is to provide Primary Objective • “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. The information communicated during a hand off must be accurate in order to meet [patient] safety goals. ” 1 1. Meeting the Joint Commission 2008 National Patient Safety Goals, Joint Commission, 2007. 5 © 2011

Different types of handoffs • Within hospital – One care provider to another Nurse Different types of handoffs • Within hospital – One care provider to another Nurse to nurse handoff intra-operatively – One unit/ team of care providers to another unit/ team of care provider – Handoff of patient from • OR to PACU/ICU after cardiac surgery • ICU to floor • Transfers to and from hospital – Transfer to skilled nursing facility or home after having cardiac surgery 6 © 2011

Patient Safety Hazards in Handoffs • Patients are particularly vulnerable during handoffs because pertinent Patient Safety Hazards in Handoffs • Patients are particularly vulnerable during handoffs because pertinent care information may be incorrectly communicated or not communicated at all • Nearly 70% of sentinel events were caused by communication breakdowns 1 • Evidence suggested that at least half of these communication breakdowns occurred during patient handoffs 1 1. Improving Handoff Communications: Meeting National Patient Safety Goal 2 E, Joint Comm Perspectives on Patient Safety, 2006. 7 © 2011

Evidence of Harm • Medication errors 1, 2 • Delays – Test ordering 3 Evidence of Harm • Medication errors 1, 2 • Delays – Test ordering 3 – Medical diagnosis 4 – Treatment 4 • Increased number of hospital complications 3 • Wrong treatment 5 • Increased length of stay 6, 7 • Higher costs 8 8 • • Higher readmission rates 8 Malpractice claims 9 Serious adverse events 10 Redundancies in – Procedures 11 – Tests 11 1. Lofgren RP, Gottlieb D, Williams RA, et al. , J Gen Intern Med, 1990. 2. Gottlieb DJ, Parenti CM, Peterson CA, et al. , Arch Intern Med, 1991. 3. Laine C, Goldman L, Soukup JR, et al. , JAMA, 1993. 4. Patterson ES, Wears RL, Jt Comm J Qual Patient Saf, 2010. 5. Australian Council for Safety and Quality in Health Care, 2005. 6. Lofgren RP, Gottlieb D, Williams RA, et al. , J Gen Intern Med, 1990. 7. Gottlieb DJ, Parenti CM, Peterson CA, et al. , Arch Intern Med, 1991. 8. Lawrence R. H. , et al. , BMC Health Serv Res, 2008. 9. Kachalia A, Gandhi TK, Puopolo AL, et al. , Ann Emerg Med, 2007. 10. Risser D. T. , et al. , Ann Emerg Med, 1999. 11. Lawrence R. H. , et al. , BMC Health Serv Res, 2008. © 2011

Barriers to Effective Handoffs • Physical environment – Background noise, poor lighting 1 • Barriers to Effective Handoffs • Physical environment – Background noise, poor lighting 1 • Organizational factors – Culture, social hierarchy 1 – Vast inconsistency in how handoffs are performed 2, 3 – No formal training on how to give handoff report 1 • Provider and patient factors – Language barriers, diversity in patient and physician populations 1 1. Solet DJ, Norvell JM, Rutan GH, et al. , Acad Med, 2005. 2. Horwitz LI, Krumholz HM, Green ML, et al. , Arch Intern Med, 2006. 3. Sinha M, Shriki J, Salness R, et al. , Acad Emerg Med, 2007. 9 © 2011

Barriers to Effective Handoffs • Task – High workload, hectic schedules and multiple responsibilities Barriers to Effective Handoffs • Task – High workload, hectic schedules and multiple responsibilities 1 – Ambiguity in roles and responsibilities 1 • Tools and Technologies – Ineffective use of cognitive tools 1 • Appropriate measures for evaluating effectiveness of handoffs still need to be established and validated 1 1. Solet DJ, Norvell JM, Rutan GH, et al. , Acad Med, 2005. 10 © 2011

Joint Commission’s Handoff Process Strategies 1 • Interactive communications • Up-to-date and accurate information Joint Commission’s Handoff Process Strategies 1 • Interactive communications • Up-to-date and accurate information transfer • Limiting interruptions during handoffs • A process for verification • An opportunity for the receiver to review any relevant historical data 1. Joint Commission. National Patient Safety Goals: History Tracking Report 2008 -2009. 11 © 2011

Other Strategies to Improve Handoffs • Consider using structured tools that can facilitate consistency Other Strategies to Improve Handoffs • Consider using structured tools that can facilitate consistency in communication exchanges 1 • Set aside sufficient time to promote complete and accurate communication 1, 2, 3 • Assure unambiguous transfer of responsibility and accountability 4, 5 • Teach and practice how to give/receive handoff reports using established, common language 1 • Document that a handoff has taken place 1. 2. 3. 4. 5. Cooper A, The OR Connection, 2010. Hand-off Communications: Recommendations, AORN, 2010. Standardizing Handoffs for Patient Safety and Handoff Talking Points, AORN, 2010. Patterson ES, Wears RL, Jt Comm J Qual Patient Saf, 2010. Gurses AP, Seidl KL, Vaidya V, et al. , QSHC, 2008. 12 © 2011

Other Strategies to Improve Handoffs • Include outgoing care provider’s opinion(s) toward changes to Other Strategies to Improve Handoffs • Include outgoing care provider’s opinion(s) toward changes to (contingency) plans 1 • Limit initiation of other activities (unless critical) during the handoff 1 • Delay transfer of responsibility during critical time periods of the care process 1 • Monitor the effectiveness of handoffs and providers’ adherence to guidelines concerning handoffs; ascertain feedback from staff 2 • When appropriate, use computers and available technology (e. g. EMR) to encourage the efficient exchange of pertinent, correct information. 2, 3 1. Patterson ES, Wears RL, Jt Comm J Qual Patient Saf, 2010. 2. Cooper A, The OR Connection, 2010. 3. Vidyarthi AR, Arora V, Schnipper JL, et al. , J Hosp Med, 2006. 13 © 2011

Interventions to improve handoffs between hospital units • Very few interventions (almost none for Interventions to improve handoffs between hospital units • Very few interventions (almost none for cardiac surgery) – A new handover protocol of pediatric patients after congenital heart surgery from OR to ICU. 1 • Based on Formula 1 pit-stop and aviation models (e. g. , clarifying responsibilities, standardizing processes, improving situation awareness, anticipation, and communication) • Reduced the number of technical errors (e. g. , drains not located safely) and information handover omissions. – Implementation of a paper-based discharge survey nearly eliminated ICU discharge medication errors 2 – Few other intervention studies that have not found any 1. Catchpole KR, de Leval MR, Mc. Ewan A et al. Patient handover from significant impact. surgery to intensive care: using Formula 1 pit-stop and aviation models 2. 14 to improve safety and quality. Paediatr Anaesth 2007 May; 17(5): 470 -8. Pronovost P, Weast B, Schwarz M et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. J Crit Care 2003 December; 18(4): 201 -5. © 2011

Interventions to Improve the Discharge Process • A package of discharge services significantly reduced Interventions to Improve the Discharge Process • A package of discharge services significantly reduced emergency visits and readmissions among medical patients 1 – a nurse discharge advocate to coordinate the discharge process and educate patients – an individualized after-hospital care plan for each patient – pharmacist contacting the patient 2 -4 days post- discharge. • Multi-faceted intervention among elderly reduced readmissions 2 – medication self-management system – ensuring that patients complete physician follow-up visits – educating patients about health indications to watch for. • A Cochrane review (11 RCTs included) did not find any significant impact of using an individualized discharge plan on mortality, hospital LOS, or readmissions. 3 1. Jack BW, Chetty VK, Anthony D et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009 February 3; 150(3): 178 -87. 2. Coleman EA, Smith JD, Frank JC et al. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc 2004 November; 52(11): 1817 -25. 3. Shepperd S, Parkes J, Mc. Claren J et al. Discharge planning from hospital to home. Cochrane Database Syst Rev 2004; (1): CD 000313. 15 © 2011

Interventions (Summary) • • Very few Almost none in cardiac surgery Conflicting findings Most Interventions (Summary) • • Very few Almost none in cardiac surgery Conflicting findings Most of the interventions implemented without being informed by detailed hazard analysis 16 © 2011

Action Items for Handoffs/Transitions in Care • For now, NOT MUCH! • We will Action Items for Handoffs/Transitions in Care • For now, NOT MUCH! • We will contact you as we make progress on the detailed study plan and next steps for this study component. • Sites that will be part of the initial handoff study will be determined based on – Their interests – Variability (hospital characteristics and variations in handoff/transitions of care processes) – Resources available (i. e. , travel costs of researchers) • Will share findings from the initial handoff study • Other sites will – self-identify hazards and develop appropriate interventions using the tools developed – have an opportunity to implement several tools • GOAL: Learn from each other and find ways to improve transitions of care/handoffs 17 © 2011

Aims in this study • To improve the safety of care transitions from cardiac Aims in this study • To improve the safety of care transitions from cardiac OR to ICU, from ICU to inpatient floor, and from inpatient floor to hospital discharge. – To identify and prioritize safety hazards during these transitions of care – To implement a patient safety program and evaluate its impact on the prioritized hazards (i. e. , from OR to ICU, ICU to floor). – To pilot test interventions aimed at reducing/mitigating floor to hospital discharge hazards. Hazard: Anything that has the potential to cause failure. 18 © 2011

Conceptual Frameworks • Systems Engineering Initiative for Patient Safety (SEIPS Model) • Systems Ambiguity Conceptual Frameworks • Systems Engineering Initiative for Patient Safety (SEIPS Model) • Systems Ambiguity Framework • Trajectory Framework 19 © 2011

SEIPS Model of Work System and Patient Safety Carayon, P. , Hundt, A. S. SEIPS Model of Work System and Patient Safety Carayon, P. , Hundt, A. S. , Karsh, B. -T. , Gurses, A. P. , Alvarado, C. J. , Smith, M. and Brennan, P. F. “Work System Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i 50 -i 58, 2006. 20 © 2011

Ambiguity Framework AMBIGUITY TYPE Task Responsibility Expectation Method Exception EXAMPLES - Status: Which additional Ambiguity Framework AMBIGUITY TYPE Task Responsibility Expectation Method Exception EXAMPLES - Status: Which additional tasks need to be completed before this patient can get discharged? - Plan: Which task(s) need to be completed? - Timing: When should a particular task be completed? - Goal: What are the goal(s) that should be achieved? - Role: Who is responsible for a particular task (e. g. , monitoring patient’s anticoagulation medication)? - Accountability: Who is accountable for the consequences of a particular action? - Authority: Who has the authority to make a particular decision? - Standards: What are the acceptable practices in this unit or organization for providing handoff reports? What are the expectations of the admitting unit? What is the regular practice? - Performance: How is my performance in providing handoff reports? - Feasibility: Is it feasible for me to provide a comprehensive handoff report in addition to my other responsibilities? - Procedural: How should this piece of information be conveyed to the admitting unit? - Source: Where can I find information on which medications the patient is taking? - Supplies and equipment: Where and how can I find this special device that the patient being transferred from the ICU to my step-down unit needs? - Help: Who should I contact for help for a particular task? How do I contact him? - For what conditions is a deviation from the standard procedures acceptable? 21 © 2011

Trajectory Framework Trajectory: A sequence of actions toward a goal (e. g. , timely Trajectory Framework Trajectory: A sequence of actions toward a goal (e. g. , timely and safe discharge) including any contingencies. Shaping a trajectory requires combined efforts of the individuals involved including care providers, patients and families (Corbin & Strauss, 1991). Content of the discharge-related communication can be described in three major dimensions using this framework: – Patient’s status on the discharge trajectory – Deviations from/complications on the trajectory – Anticipating/planning for the rest of the trajectory 22 © 2011

Activities • • Sample – 5 hospitals: OR-ICU, ICU-Floor – 2 -3 hospitals: Discharge Activities • • Sample – 5 hospitals: OR-ICU, ICU-Floor – 2 -3 hospitals: Discharge Process Prospective hazard identification – Observations (one HFE + one clinician pair) at each transition point – Semi-structured interviews with care providers and patients – Artifact analysis – Shadowing of patients from surgery to discharge and post-discharge Retrospective hazard identifications – If possible, hospitals will review data from adverse event reporting systems (AERS) – Clinical incident technique interviews Development of tools/methods/other interventions – Self-assessment tools to identify and prioritize hazards – Tools/methods/other interventions to improve transitions of care 23 © 2011

Study Plan 24 © 2011 Study Plan 24 © 2011

QUESTIONS agurses 1@jhmi. edu QUESTIONS agurses [email protected] edu

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