Patient transfers have increased significantly over last 5 years Bree Kramer, D.O. Tara Petroski, M.D. Lorna Fitzpatrick, M.D. Resident efficiency has decreased Joint Commission of Accreditation of Health Organizations Communication is vulnerable to error during times of patient hand-offs 60% of sentinel events caused by failures in communication Leads to uncertainty in decisions May result in inefficient/suboptimal care Lead to patient harm Joint Commission of Accreditation of Healthcare Organizations released 2009 National Patient Safety Goals Requires a standardized approach to hand-off communications Studies have shown: No standardized sign-out process Sign-out practices vary widely amongst different institutions No formal training in sign-out skills Residents may be duplicating work and spending large amount of time on patient care transitions Studies show standardized sign-out procedures reduce communication errors Systems of transfer and communication have been showed to reduce information loss
Research done in development of computerized systems to aid in the sign-out process Computerized systems improved continuity of care Decreased patients missed on rounds Increased portion of pre-rounding time spent at bedside Improved resident reported quality of sign-out Improved resident efficiency Errors at patient handoff can contribute to discontinuity of care and adverse events Computerized systems reduce these Proposed standards recommend a computerassisted vehicle for patient information transfer Ensures accurate and up-to-date information Infoclique sign out lacking in many areas Communication Accuracy Efficiency Concerns remain regarding Patient safety Increased sign-outs due to changes to schedule to comply with 405 regulations Changed Infoclique to current sign-out system* The ACGME regulations are as follows: Maximum hours per week = 80 hours averaged over 4 weeks Maximum shift length = 24 hours + 6 for transitional activities* Minimum time off between shifts = 10 hours Mandatory time off duty = 24 hours off per week averaged over 4 weeks* Emergency room limits = 12 hours shift limit During the study period Nov 17, 2008 to Mar 8, 2009, we observed 141 work hour violations over 1,645 assessable shifts (8.6%). These violations were committed by 39 of the 49 residents under study (79.6%). Number of violations per specific ACGME work hour regulation: > 27 hours / shift 85 (60.3%) > 12 hours / ED shift 44 (31.2%) < 10 hours off between service obligations 12 (8.5%) > 80 hours / week averaged over 4 weeks 0 < 1 day off in 7 days averaged over 4 weeks 0 Total Violations 141
UB Graduate Medical Dental Education Program offers a Quality Improvement Award Encourages intellectual curiosity and promotes excellent patient care Targets resident/faculty team projects designed to improve patient safety 2009-2010 year, priority was given to projects focusing on handoffs and patient safety Problem: Resident work-hours violations identified in our pediatric training program Intervention: Implementation of new schedule Problem: Increased number of patient care transitions Signout now even more critical Intervention: Implementation of a systematic computer web based patient sign out system. Identify strengths and weaknesses in current sign-out system Implement a computerized sign-out system and educational patient hand-off workshops Improve resident efficiency Assess improvements in resident satisfaction and patient safety after implementation of the above systems 2 main areas that impact quality of resident sign-out Pre-rounding Verbal and written sign-out Evaluate resident s views on current sign-out system Surveys 1 (most) 2 3 4 5 (least) NR Effectiveness of signout 27% 52% 17% 4% Quality of signout 13% 58% 29% Usefulness of printed sheets 50% 42% 6% 2% usefulness of handwritten sheets 13% 15% 31% 10% 4% 27% unanticipated adverse events 10% 63% 21% events that res. not prepared for during signout 6% 13% 50% 31% relaying of pertinent labs during signout 8% 56% 33% 2% relaying of current meds during signout 10% 50% 35% 4% relaying of imaging/diagnostic tests 17% 56% 27% 0% relaying of current medical problem 52% 40% 8% 0% discussion of contingency plan 17% 52% 31% 0% documentation of overnight events 27% 54% 15% 4% feelings about signout duration 6% 21% 71% 2% importance of edu. session on signout 27% 23% 29% 8% 4% Survey Results Residents have identified what they consider the most important area of sign-out Anticipated problems and plan of action Few patients currently have information in their sign-out
Computer System WardManager Laptop Computers for each team Workshops Signouts Documentation Post-survey assessment of project Resident satisfaction Reductions in 405 violations Resident efficiency Identify new areas of improvement Perceived changes in patient safety It is expected that Residents will be more efficient with signout Errors in sign-out and patient hand-offs will be reduced Pre-rounding will become more efficient Pertinent problems will be less likely to be overlooked Contingency plans will be discussed 1. Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Statistics. http://www.jointcommission.org/sentinelevents/statistics/. Accessed April 2009. Evaluation of reductions in medical errors after implementing this computerized sign out system. Evaluation of improvements in sign out accuracy and efficiency after training workshops Identifying how best to teach and evaluate a resident s ability to sign out effectively 2. Arora V, et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005; 14:401-407. 3. Joint Commission on Accreditation of Healthcare Organizations. 2008 National Patient Safety Goals. http://www.jointcommision.org/patientsafety/nationalpatientsafetygoals/. Accessed April 2009. 4. Kemp CD, et al. The Top 10 List for a Safe and Effective Sign-out. Arch Surg. 2008; 143(10):1008-1010. 5. Horwitz LI, et al. Transfers of Patient Care Between House Staff on Internal Medicine Wards: a national survey. Arch Intern Med. 2006;166:1173-1177. 6. Borowitz SM, et al. Adequacy of information transferred at resident sign-out: a prospective survey. Qual Saf Health Care. 2008;17:6-10. 7. Horwitz LI, Moin T, Green ML. Development and Implementation of Oral Sign-out Skills Curriculum. J Gen Intern Med. 2007;22(10):1470-1474. 8. Vidyarthi AR, et al. Managing Discontinuity in Academic Medical Centers: Strategies for a Safe and Effective Resident Sign-Out. J Hosp Med. 2006;1:257-266. 9. Campion TR, et al. Analysis of a Computerized Sign-out Tool: Identification of Unanticipated Uses and Contradictory Content. Annual Symposium Proceedings/AMIA Symposium. 2007; page 99-103. 10. Van Eaton EG, et al. Organizing the transfer of patient care information: The development of a computerized resident sign-out system. Surgery. 2004;136(1):5-13. 11. Van Eaton EG, et al. A Randomized, Controlled Trial Evaluating the Impact of a Computerized Rounding and Sign- Out System on Continuity of Care and Resident Work Hours. J Am Coll Surg. 2005;200:538-545.
RM Name, DOB, MR, Weight Problems Allergy Meds Anticipated Problems Questions? 704 Name Medical Record Number DOB: M/D/Year DOA: M/D/Year Wt: 4.11 decreased 3.59 kg Intern: JaK GI 51/2 months old with FTT. Born at 35 weeks with Gastrochesis. Has GERD Following GI clinic and weight gain was concern. Developed vomiting and diarrhea for 3 weeks PICC NKDA Actigal Iron Lansoprazaole Simethacone GI: U/S Liver and gallbladder WNL. MWF wts, ph probe with significant reflux. Daily BMP, Qmon/ Thurs CMP, Mg, Phos, TG, prealb, T+D bili and GGT CBC QMW. Scintiscan normal no reflux. NG inserted on 6/4/09. f/u for bilious reflux. NG to vent. 6/7 Flat plate nl and glycerin no stool. UGI -distended bowel loops peristalsis diminished +to and fro peristalsis no stricture FEN: On TPN, Duocal ND 8ml/hr. Lipids in TPN 7d/7 **Call GI if emesis >3 times in one hour** 804 Name Medical Record Number DOB: M/D/Year DOA: M/D/Year Wt: 4.1 kg Intern: Katie GI 5 m old male ex 35 wkr with gastroschisis, s/p NEC resection w/ short bowel and GI bleed awaiting transplant. Broviac NKDA Vancomycin CTX Zantac in TPN Nystatin diaper cream Octreotide Ursodiol FENGI: On TPN. Q MWF lipids!!! Monitor for bleeding. NPO at this time. Check stool qbm for blood. Tuesday UGI/Colonoscopy NPO at midnight. Octreotide 10mcg SQ Bid. ID: abx vanco/ctx started 6/6 Bloodcx Pend, Vanco trough 6/7 normal. Heme: check CBC QAM, lytes, Triglycerides, clotters Monday, Hgb 7.1 (6/6) transfused 10 ml/kg x2. CBC pend post transfusion. FFP 10ml/kg x 1, check coags on 6/8. *