Transcript Just keep ‘em alive until the morning! January 17, 2006 Case • A 73-year-old female with history of HTN, DM, and CKD admitted for.

Just keep ‘em alive until
the morning!
January 17, 2006
Case
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• A 73-year-old female with history of HTN, DM, and CKD
admitted for an elective sigmoid resection.
• On POD 2, the patient was tachycardic, despite a low-dose betablocker. Later, she developed LLE pain. Assuming it was related
to the epidural placed pre-op, the nurse called anesthesia, and
they decreased the epidural rate. Primary team not called.
• On POD 3, she had no complaints on morning rounds. Later
that evening, the cross-covering intern called for LLE pain.
Primary team not informed the next morning.
• On POD 4, she complained of mild chest discomfort. Seen by
housestaff within 20 minutes and attending several hours later.
Exam was unremarkable. A workup initiated, but BP dropped to
70/40, followed shortly by a PEA arrest, from which she could
not be resuscitated. Post-mortem examination revealed PE.
Case
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71 yo woman with CHF, ESRD and CAD. No preadmission diagnosis of diabetes.
In the step-down, patient had a routine lab drawn, and blood sugar was 674 mg/dL.
At 11:30 pm, nurse notified covering intern, who telephone-ordered 10 U of reg
insulin sq.
At 1:10 am, a finger-stick glucose level was 50 mg/dL, the intern verbally ordered 1
amp of D50 IV.
At 3:00 am, a phlebotomized specimen revealed glucose level of 19 mg/dL, the
intern verbally ordered another amp of D50 IV, as well as a D10 drip.
At 5:27 am, a finger-stick glucose was 99 mg/dL.
At 11:00 am, a phlebotomy sample revealed a blood glucose level of 351 mg/dL.
Another covering intern was notified, and 8 units of regular insulin were ordered to be
given sq.
At 3:40 pm, the patient was unresponsive, and a finger-stick glucose level was 13
mg/dL. Two amps of D50 were verbally ordered, and follow up finger sticks were in
the normal range.
Later, it was discovered that many of the phlebotomy specimens had been drawn
above an IV line infusing dextrose solution.
Case
3
Case
• The patient did not have any pulmonary symptoms and no fever or chills.
Little further history was obtained.
• His vital signs were normal, and his lung examination revealed scattered
rhonchi. A CXR again revealed previous granulomatous disease and
persistent active cavitary process characterized as "probable active
tuberculosis," with development of increased infiltrates in RML and left lung.
• Mr. Woods was admitted to the medical service by a night-float resident, who
(inexplicably) entered the following note in the medical chart: "Chest
radiograph—unremarkable." In the morning, the patient and 4 other new
night-float admissions were handed over to a new team. This particular
medical team was very busy, and the senior medical resident was switching
teams the next day. Although this resident's practice was usually to scan old
radiology records to inform himself fully about his patients, in this instance
he did not do so because he was pressed for time, and the patient had no
pulmonary symptoms. Furthermore, the resident rationalized that the new
resident joining the team the next day would more thoroughly investigate Mr.
Woods’ history.
Case
• Patient worked up for anemia, attributed to
vitamin B12 deficiency and diverticulosis.
• Transferred to NH due to deconditioning.
• Two months later, admitted again with further
weight loss, fatigue, SOB, and cough.
• CXR revealed active TB (similar CXR 4 months
prior). TB treatment started, but patient had
poor course and died.
Background
• According to the Institute of Medicine, between 44,000
and 98,000 patients die annually in the U.S. due to
medical errors.
• Communication errors were the leading cause of
adverse events in an Australian study involving 28
hospitals. Twice as many deaths as clinical inadequacy.
• With more hospitalist use and the ACGME residency
duty-hour rules, the number of times a patient’s care is
transferred during a hospital stay has increased. Thus,
augmenting the chances of miscommunication.
Background
• No physician can be in the hospital 24/7.
• Hours worked and numbers of signouts are inversely related.
• A handoff is defined as the transfer of role and responsibility
from one person to another.
• Involves the transfer of rights, duties, and obligations from one
person or team to another
• In medicine, a wide variation exists in the handoffs of patients
from one physician to another.
• Most emphasis has been in good communication between
physician-patient, not physician-physician.
• Little formal attention has been paid to handoff of patients
between physicians.
Background
• Most worrisome about handoffs is diffused
responsibility, which may lead providers to assume that
someone else will follow up on test results.
• Cross-coverage can be complicated by discontinuity of
care plans, incomplete transmission of information,
and subsequent errors in judgment by unfamiliar
covering physicians.
• Given human factors, cultural norms, disruptions
during verbal communication, and the inadequacies of
the written signout, it is not surprising that information
is often lost during information transfer.
Background
• From a resident's perspective, cross-coverage is hard - must
make clinical decisions about unfamiliar patients, often with
inadequate information.
• Without a complete history, a physical exam, and a full
assessment of a patient's problems, providing high-quality care is
challenging.
• Published literature supports this notion: discontinuity, and by
definition, cross-coverage, in the care of hospitalized patients
can lead to increased lengths of stay, in-hospital complications,
and preventable adverse events.
• And yet, no structured training in efficient triage and quality care
of unfamiliar patients
Objective
• To examine some general principles and pitfalls
observed in physician-to-physician
communication, describe current patient
handoff practices in one complex medical
system, discuss communication barriers, and
offer recommendations for improvement in the
patient handoff process.
Methods
• A review of the literature on patient handoffs (a
comprehensive literature search using Medline’s
OVID database and PsychInfo).
• Evaluate patient handoff practices at Indiana
University School of Medicine’s internal
medicine residency, where three hospitals use
computer based checkouts and a fourth uses
standard written checkouts.
Results
• Great variability in preparation, content, and
method of handoffs across the four teaching
hospitals.
• Two most critical pieces of information were
reason for admission and active problems with
suggested therapies should complications arise.
Results
• Barriers to handoffs:
– Physical setting: private and quiet; good writing space
– Social setting: parties should feel comfortable (status
differences) discussing treatment options
– Language barriers: use “common medical language”
– Communication barriers:
• Mediated (indirect) vs. nonmediated (direct)
• Face-to-face handoffs preferred since they can convey
more information (raise index of concern). More effective
exchange of information and better opportunity to ask
questions.
Results
• Handoff process can be time consuming (average time
18.7 minutes).
• RCT at University of Washington evaluated impact of
computerized rounding and sign-out system on
continuity of care and resident work hours of 14
surgery and IM residents over 5 months.
– Decrease in missed patients on rounds
– Decrease by up to 3 hours per week rounding time
– Facilitated meeting 80 hour work week
Results
• Lack of standard practices lead to high degree
of variability in handoffs.
• Only 8% of medical schools teach students how
to handoff patients in a formal didactic session.
• Majority (86%) of medical students are taught
by their interns or residents who were taught by
their interns or residents and so on.
Results
• Comparisons between physician communications
and aviation communications.
• In past two decades, aviation industry has
decreased human errors by 50-81% through safety
training and standardization.
• Their studies have shown consistency in language
and focus are important to optimize performance
in coordinating complex activities like flying an
airplane.
Results
• Pilots and doctors have common interpersonal
problem areas and similarities in professional
culture.
• Patterns of authority-status differences can create
tensions.
– “Two challenge rule”- a subordinate
empowered to take control if pilot is clearly
challenged twice about unsafe situation during
a flight without a satisfactory reply.
Essential Elements for Successful
Handoffs
Recommendations
• During first month, interns should receive
interactive lecture on effective handoffs.
• Standardized handoffs (see previous slide).
• Shift from concept of “babysitting overnight”
to assumption of primary care responsibilities.
• After first month, small group meetings to
discuss problems encountered and questions.
Conclusion
• Precise, unambiguous, face-to-face
communication for effective handoffs of
hospitalized patients.
• Standardize handoffs.
• Teach medical students and residents effective
and efficient handoffs.
• Inform primary team of relevant night
events/write short note.
Conclusion
• Causes of error include fatigue, workload, and
fear as well as cognitive overload, poor
interpersonal communications, imperfect
information processing, and flawed decision
making.
• Error management is based on understanding
the nature and extent of error, changing the
conditions that induce error, determining
behaviors that prevent or mitigate error, and
training personnel in their use.
Future
• At Indiana University School of Medicine,
senior medical students and residents are now
being instructed on the proper method of
handing off patients and the essential
components of the handoff.
• Results of this intervention will be published in
the future.
References
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www.webmm.ahrq.gov/case.aspx?caseID=55
www.webmm.ahrq.gov/case.aspx?caseID=70
Gandhi TK. Fumbled Handoffs: One Dropped Ball after Another. Ann Intern Med.
2005; 142 : 352-358
Solet, Darrell J. Norvell, J. Michael, Rutan, et al: Lost in Translation: Challenges and
Opportunities in Physician-to-Physician Communication During Patient Handoffs
Acad Med 2005 80: 1094-1099
Petersen, LA Troyen AB O’Neill, AC, et al: Does Housestaff Discontinuity of Care
Increase the Risk for Preventable Adverse Events? Ann Intern Med.1990
Helmreich, RL: On Error Management: Lessons from Aviation. BMJ 2000 320: 781-85