The Good Word: Improving Patient Handoffs

Posted by • November 5th, 2014

Starting at six in the evening, the surgery residents at my hospital gather for sign-out.  This is when residents from the day shift hand over care of their patients to those working overnight.  Sign-out takes place in the residents’ lounge — a room furnished with computers, couches, and a makeshift ping-pong table — and tends to be an informal affair.  Multiple conversations happen at once, and interruptions are not uncommon, whether by phone call or passerby or stray ping-pong ball.

If you ask any of the residents, they’ll tell you this system works just fine.  But as shift changes have become more frequent in recent years to accommodate work hour restrictions, there is concern that the growing number of handoffs may be leading to medical errors.  As in a game of “telephone,” information can get distorted each time it is relayed.  If reducing the quantity of handoffs isn’t an option, is there a way to improve the quality?

A few years ago, a group of researchers developed a tool called I-PASS that attempted to standardize the sign-out process.  I-PASS, which stands for Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver, acts as a checklist — a way to summarize a patient’s history and care plan and “employ closed loop communication” to ensure that the receiver understands.

The investigators built a handoff-improvement program around this tool and tested it in a pediatrics residency program, measuring the rate of medical errors among residents before and after they received I-PASS training.  They found that implementation of the program reduced miscommunications and preventable errors.  Encouraged by these results, they tweaked the tool and expanded it to a total of nine pediatrics programs.  The results of this multi-center study, published this week in NEJM, again show that the I-PASS tool is effective: medical errors decreased by 23%, preventable adverse events decreased by 30%, and critical information was included more frequently in written and verbal handoffs.  And, importantly, handoffs weren’t any more time-consuming than before.

“Our study shows that the risk of handoff-related errors can be significantly reduced,” the authors concluded. “Implementing handoff-improvement programs such as the I-PASS Handoff Bundle may potentiate the effectiveness of work-hour reductions, because doing both together may concurrently reduce both fatigue and handoff-related errors.”

This may be why, within a week of starting residency earlier this year, my co-interns and I underwent mandatory I-PASS training.  The three-hour session involved signing out fictional patients to each other – “Mrs. So-and-So is a ‘watcher’,” we’d say to practice using the I-PASS terminology, glancing at the cheat sheets we’d been given.

The session was helpful, but in the months that followed, sign-out reverted to old habits.   “I don’t think we need it,” the night shift resident said when I suggested one evening that we incorporate I-PASS into our sign-out.  We decided to give it a try anyway.  At first, things went smoothly; the cheat sheet was a nice reminder of points to cover.  Soon, though, I found myself taking shortcuts.  Was it really necessary to summarize the events leading up to a patient’s admission (the “Patient summary” step), when all I needed the night resident to do was make sure the patient urinated?  And did he really need to repeat information (“Synthesis by receiver”) that I’d given him literally seconds before?

When surgical checklists were first proposed, they were criticized as being cumbersome and unnecessary.  It turned out using them could reduce errors in the operating room.  Still, proof of efficacy wasn’t enough to spur adoption; the surgical culture also had to change.  People had to want to change.

The same might be said for handoffs.  In the I-PASS study, an intervention “bundle” involved not only resident training but also faculty engagement and a process- and culture-change campaign.  The intervention period lasted a full six months, and post-intervention outcomes were measured over an additional six months.  Sign-outs were taped, and residents were followed around by research assistants for 8 to 12 hours at a time, their every activity recorded.  By Hawthorne effect alone (people modifying their behavior because they know they’re being observed), it’s plausible that study participants were more compliant with the I-PASS methodology than they might have been otherwise.  Outside the study environment, getting residents to embrace I-PASS as their own is more challenging.

Continuity of care in an era of many handoffs does not have to be a futile aspiration.  The I-PASS study suggests that thoughtfully implemented interventions can make care transitions safer.  That may require, among other things, redefining the sign-out ritual.  It’s easier said than done, to be sure, but it’s also worth trying — especially for those of us who are just starting our medical careers and learning how to care safely and meaningfully for others.

For more on I-PASS, join the conversation on the new NEJM Group Open Forum, powered by Medstro, a social professional network for physicians.  We’re piloting a series of live interactive discussions among authors, experts, and fascinating physicians, surrounding topics including the intricacies of modern medicine, cutting edge research, career development, and more. Look for new discussions, coming soon.  

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