Safe & Effective Handoffs Subha Airan-Javia Penn Hospitalist Medicine

PT INFO HPI PROB LIST MEDS To Do X Cover

Smith, John Bob F14 1465AMR: 34520XXX

56 yo male with shortness of breath for one week

**Asp Pna – on cefepime, still borderline**ARF on CKD: Cr 0.8 2.5, likely pre-renal

Cefepime 1gm IV q12Colace 100mg po bidMetoprolol100mg bid

---D/C Info---PMD Dr. Jones 444-2244

[] f/u 7pm Na – increase IVF if Na <130[] check renal note

Safe & Effective HandoffsSubha Airan-Javia

Penn Hospitalist Medicine

It happened at a hospital you know…

9am rounds: 70 yo woman with DVT & h/o GI bleed On heparin with 48 hours of very elevated ptts (>150) Altered mental status & low BP CBC ordered

1pm postcall signout: “f/u CBC” No mention of elevated PTTs or concern for GI Bleed as

potential cause of altered mental status and low BP

3pm: Hgb = 4.0 Wasn’t believed, another hgb was sent, no transfusion

5pm: Patient had melena, hypotension, transferred to the ICU.

Repeat CBC confirmed Hgb of 4. Patient quickly coded and expired in ICU

Think About it… Did a poor handoff contribute to

this patient outcome?

Did this patients get the care that she expected from our hospital? How about the care that you and I expected?

Fear of making a mistake and harming a patient

Natural fear You will make errors; we all do Did parts of the hospital system make

the error easy to happen? If so, someone else needs to know

(chief resident, program meeting, incident reporting system)

Take care of yourself and each other

Goals for Today

Get you ready to perform safe handoffs! Review the importance of handoffs Teach the components of a good

electronic and verbal handoff Practice handoffs in a simulated

environment

Facts Discontinuity in the hospital is inevitable

Discontinuity is increasing in teaching hospitals due to duty hour regulations

Lack of communication is the most common root cause of medical errors nationally

Communication breakdowns during handoffs can have deleterious effects on our patients

More Facts…

Improving Handoffs is a National Patient Safety Goal (NPSG 2E) Implement a standardized approach

to “handoff” communications including an opportunity to ask and respond to questions

Petersen, L. A. et. al. Ann Intern Med 1994;121:866-872

Being Covered by a cross-cover resident is a powerful risk factor for preventable adverse

events.

Bringing it closer to home…ED Resident

Nightfloat JAR

Intern A - Shortcall

On Call Intern #1

Intern A

On Call Intern #2

Intern A (now on Call)

Dayfloat

Day 1

Day 2

Day 3

Day 4

Day 5

6 Residents, 7 Handoffs in 5 days

Even more handoffs in the ICUs…

ED Resident

Primary On-Call team

Nightfloat

Dayfloat

Primary Team Nightfloat

Day 1

Day 2

Day 3

4-5 Residents, 5 Handoffs in 48 hours

A handoff example….

Location: Founders 14 nurses stationTime of Day: 12:30pm post-call

People: Two July interns who don’t really know each other yet.

What did you notice?

What did you notice? Noisy environment

Multiple interruptions

Delivery is not standardized

No time for questions, reiteration of plan

Safe Handoff Practices

Verbal Handoff Tips Location: as quiet as possible (away from

the nursing station, not in the ED) Minimize interruptions Start patient over if unavoidable

If you are worried about the patient…say it first!

Give on-call intern an opportunity to ask questions and repeat back important facts

Review every patient Follow the same format/order for all

patients

Verbal Handoff Format PROBLEM BASED

Sick/Not Sick Code status (if not full code) 1-3 sentences history PROBLEM LIST

Active issues for each Relevant Data and Meds

Crosscover list If/then statements, anticipatory guidance

Electronic Handoff: Purpose Reference for primary team

Reference for covering provider

Repository of informationDischarge summary

A Novel

Electronic handoff plan Problem list owned by Interns

Rest of handoff primarily resident responsibility July – Jan Interns should participate, edit what

they can handle Increase your share of handoff

involvement

Handoff Progress Note Problem List

50 Thousand foot view of problems with short assessment & overall plan

Important medications & radiology associated with problems

Antimicrobials, anticoagulation, immunosuppressants, Narcotics

Concise, bulleted

Problem list≠

Assessment and plan

Electronic Handoff Tips Standardize: Keep info in designated

location Exclude/Remove irrelevant information Clean-up and update handoff regularly Avoid non-standard abbreviations

MS: multiple sclerosis, mental status, or morphine sulfate?

HL: Hyperlipidemia or Hodgkin’s Lymphoma? Summarize findings. Do not cut and paste

results

Electronic Handoff Tips Problem list should be complete,

but concise Should not be your entire progress

note word for word This is the basis of your verbal

handoff Should be updated & reprioritized as

new problems arise and old ones change

SIGNOUT DISCHARGE SUMMARY

And don’t forget…

The sign-out is a TEAM document Read by ALL disciplines in the hospital Unprofessional language and

statements should never be written

Keys to a Good Handoff

The Nitty Gritty

Approach to verbal handoff

Sick not sickHistory, Hospital CourseObjective dataUpcoming plan, dispoTo do


Pt Info HPI Prob List MEDS To Do CrossCover

Smith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777

Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresis

DATA:11/3 CXR: LLL pna11/5 Chest CT: LLL consolidation

**Asp Pna – on cefepime, still borderline**ARF on CKD: Cr 0.8 2.5, likely 2/2 dehydration. Getting volume**CAD – EF 10%, on coumadin for low EF**DM – on insulin**HTN**Diarrhea – possibly CDIff, cx pending-Prostate ca – resected, cured

---PMH----hyperlipidemia-PTSD-chronic anemia

Cefepime 1gm IV q12Colace 100mg po bidDocusate 5mg po dailyFurosemide 20mg po dailyMetoprolol 50mg po bidMetronidazole 500mg po bidWarfarin 5mg po qHSDiet: Cardiac, mech grnd, NS @ 150---Other Med Info---Flagyl 500mg q12 11/2-4

---D/C Info---PMD Dr. Jones 444-2244[] needs gi appt---To Do ---[] f/u xxx test[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130-if looks bad, consider fungal coverage

S [H O U]

T











S = SICK/NOT SICK30 seconds-Name-Code Status-Culture/Family etc











H = History1-2 sentences (1 minute)What brought the patient to the hospitalSimilar to your ASSESSMENT statement on your A/P











“H O U”Active Problems, Hospital course, Objective data & Plan for eachMAIN AREA OF FOCUS











T = To DoSECOND AREA OF FOCUS-Go through each cross cover to do item, what needs to be done, rationale & action plan-If/Then statements or other guidance

Patient InformationPt Info HPI Prob List MEDS To Do CrossCover



DATA:11/3 CXR: LLL pna11/5 Chest CT: LLL consolidation w/ air bronchograms, some LADMICRO:11/2 UA neg, Ur cx neg-final11/2,3,4,5 bld cx x2 neg-final11/6 UA neg, cx neg-final11/6,7,8,9 bld cx x2 ngtd11/9 sputum cx – normal OP flora

**Asp Pna – on cefepime, still borderline**ARF on CKD: Cr 0.8 2.5, likely 2/2 dehydration. Getting volume**CAD – EF 10%, on coumadin for low EF**DM – on insulin**HTN**Hyponatremia – likely 2/2 dehydration**Diarrhea – possibly CDIff, cx pending

---PMH----Prostate ca – resected, cured-hyperlipidemia-PTSD-chronic anemia




Patient InformationPt InfoSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: DNR AAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777

Automatically imported from SCM

Patient InformationPt InfoSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: DNR AAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777

Start with name & status: If you are worried about the patient, say it now - up front. Write it in the crosscover section.“John Smith is very sick” ; “I’m worried about Mrs Jones”

Code Status: If not Full Code, always state this verbally. “He is DNR A”Access, Culture Limits, Precautions: mention if relevantContact information: Emergency contact for patient.“This family wants to be called with every change or new problem, even if in the middle of the night”; “No contact person has been located yet for this patient with dementia”

History & Relevant DataPt Info HPI Prob List MEDS To Do CrossCover









History & Relevant DataHPIAge, Gender, CC short of breath CC: aspiration pnaPatient w/ shortness of breath for 1 week & 10 pound weight loss. Found to have lung mass & post obstructive pna.Vitals on adm to ED: 100 140/80 30 88% RA

11/20 – desat last night, improved after diuresis

DATA:11/3 CXR: LLL pna11/5 Chest CT: LLL consolidation MICRO:11/2 UA neg, Ur cx neg-final11/6,7,8,9 bld cx x2 ngtd11/9 sputum cx – normal OP flora


HPIAge, Gender, CC short of breath CC: aspiration pnaPatient w/ shortness of breath for 1 week & 10 pound weight loss. Found to have lung mass & post obstructive pna.Vitals on adm to ED: 100 140/80 30 88% RA



History & Relevant DataHistory: State the chief complaint at first – once you know the diagnosis, you should UPDATE it. Short history. Admission vitals if they are relevant.“45 y/o female with abdominal pain”

“89 y/o male with pneumonia.”

Important Hospital Events: Mention things that could come up overnight“Desatted last night and responded to IV lasix”

Data and Micro: Summarize findings, do not cut and paste results!!

History & Relevant DataHPI

45 y/o F w/ Shortness of breath45yo female with history of multiple sclerosis, GERD, CAD, DM, hypothyroidism brought in by husband after 5 days h/o confusion, shortness of breath, and fever. Initial CXR negative, however CT from 11/16 showed pna suspicious for aspiration. ROS also notable for 10 pound weight loss, anorexia, and fatigue over past 6 months.Vitals on adm to ED: 100 140/80 30 88% RAGot lasix x 2 , Cefepime/Flagyl, and morphine in the ED. Duiresed in the ED to lasix through not thought to be volume overloaded by us.Also has UTI on levo, foley now out

DATA:11/5 Chest CT: Heart, mediastinum, and great vessels are normal. There is mild emphysema throughout the lung fields, there is a left lower lobe consolidation new since prior CT from 1/06. Suspect aspiration MICRO:

HPI

45 y/o F w/ Pneumonia45 yo female admitted with shortness of breath and confusion: suspected aspiration pna. Also has 10 pound weight loss.Vitals on adm to ED: 100 140/80 30 88% RA

11/18 – UTI diagnosed – now on Levo11/20 – desat last night, improved after diuresis


Too Wordy…

MUCH BETTER!

HistoryHPIAge, Gender, CC short of breath CC: aspiration pnaPatient w/ shortness of breath for 1 week & 10 pound weight loss. Found to have lung mass & post obstructive pna.Vitals on adm to ED: 100 140/80 30 88% RA



Problem ListPt Info HPI Prob List MEDS To Do CrossCover









Problem ListProb List**Asp Pna – on cefepime, pox 98% 2L**ARF on CKD: Cr 0.8 2.5, likely 2/2 dehydration. Getting volume**CAD – EF 10%, on coumadin for low EF**Dementia-Ox1 but still able to converse and give a history

---PMH----Prostate ca – resected, cured-hyperlipidemia-PTSD-chronic anemiaChronic Problems: place chronic or

inactive problems at the bottom of the list

List all Active Problems: Include salient points of plan and important results. “For aspiration pna – patient is on cefepime, 10 day course. He also has renal failure & hyponatremia – likely because of dehydration. Diarrhea is concerning for CDiff”Document Relevant Physical Exam Findings:“Mr S. has dementia but is able to converse well and can tell you if he is in pain”

“Mr J has CHF, her lungs always have rales..”

Info is nice to have, but too much! Makes the prob list too long to sort through in a rush

Summarize study in the Data section. Put relevance for day to day care here

Combine related problems to save space

Problem List Mention things that on-call interns have been called

about every night “This patient sundowns every evening…and here is the plan

should it happen tonight…”

Review important exam findings and always think about including mental status

“Mrs. J has severe asthma flare, lung exam is severe wheezing and little air movement on exam today”

“Mr S.has dementia and only oriented x 1, but always able to follow commands, tell you if he’s in pain, etc”

MedicationsPt Info HPI Prob List MEDS To Do CrossCover









MedicationsMEDSCefepime 1gm IV q12Colace 100mg po bidDocusate 5mg po dailyFurosemide 20mg po dailyMetoprolol 50mg po bidMetronidazole 500mg po bidWarfarin 5mg po qHSDiet: Cardiac, mech grnd, NS @ 150---Other Med Info---Flagyl 500mg q12 11/2-4


MEDSCefepime 1gm IV q12Colace 100mg po bidDocusate 5mg po dailyFurosemide 20mg po dailyMetoprolol 50mg po bidMetronidazole 500mg po bidWarfarin 5mg po qHSDiet: Cardiac, mech grnd, NS @ 150---Other Med Info---Flagyl 500mg q12 11/2-4

Medications

• Mention any important changes in meds:New meds, Discontinued meds, Dose Changes“For HTN he is on metoprolol, but we had to decrease his dose today because of bradycardia. So if he is hypertensive, I would use something else.”

• Important Meds Should Be Verbally Reviewed & Highlighted:

Antimicrobials, Anticoagulants, Narcotics, Benzos“For pneumonia, patient is on cefepime, plus flagyl for possible CDiff, and warfarin for a low EF.”

MEDSCefepime 1gm IV q12Colace 100mg po bidDocusate 5mg po dailyFurosemide 20mg po dailyMetoprolol 50mg po bidMetronidazole 500mg po bidWarfarin 5mg po qHSDiet: Cardiac, mech grnd, NS @ 150---Other Med Info---Flagyl 500mg q12 11/2-4

Medications

Other med info:Medications dosed by level, ordered daily, recent antibiotics, abnormal reactions

For warfarin, use “warfarin dose daily” order

D/C Info & To Do ListPt Info HPI Prob List MEDS To Do CrossCover









D/C Info & To Do ListTo Do---D/C Info---PMD Dr. Jones 444-2244[] needs gi appt---To Do ---[] f/u xxx test[] check TEN panel weekly[] daily pulm note

D/C Info – Outpatient MD information, appointments to be made after discharge, any discharge related item

To Do – Items for the primary team to do (today or later in the admission)

Crosscover teams will look at this too

Crosscover ItemsPt Info HPI Prob List MEDS To Do CrossCover









Crosscover Items BE SPECIFIC

Check box for each task you need done

Avoid vague statements “try to keep an eye on…”

If you want vitals followed up on or something “eyeballed” – make a separate task for it

Crosscover ItemsCrossCover[] f/u 7pm Na - If <130, then increase IVF to 150cc/hr

[]if any fever, delta MS, or low BP, then add vorizonazole

***SICK***

For Labs: give specifics“Follow up on the 7p Na – he has been hyponatremic and we think this is prerenal. Increase his IVF if Na is still lower than 130.”

Write here if your patient is sick or if you are worried about the patient

Anticipatory Guidance: use If…then statements“If he looks worse tonight (any fever, low BP, or called for confusion), evaluate him and add fungal coverage”

Tips for Cross-Cover Items Discuss each crosscover task to be done,

why it is being done (rationale), and what to do based on results (anticipatory guidance).

Anticipate overnight clinical scenarios, and give the cross-cover intern guidance on what to do if they occur…If/Then statements If the patient has a fever >101.5, then draw

blood cultures and consider starting vancomycin. We are worried about a line infection

Give specific lab & parameters:[] 1800 Hg – if <7, trf 2u PRBC

Give recs for meds to use:-if not, t/c 80mg IV lasix

Give antibiotic preferences to start

What are you looking for?

Don’t get “locked in” (anchoring bias)

Remember if/then statements are for guidance

You should still always: EVALUATE the patient first Then CONSIDER what they have

recommended on the sign-out. Independent thought is what you get paid the big bucks for!

Don’t feel bad!! We are all on the same team You will be doing the same thing for

your colleague when you are on call Be clear about what needs to be

done Avoid phrases like “If you can…”

Only signout out things that need to get done overnight

Responsibility of the Receiver

Responsibility of the Receiver READBACK & RECAP

Reiterate important parts of the plan

Take notes as you go You will pay attention to these notes

later in the night


Be gently assertive! Suggest a quiet place, suggest to sit

down, if the “giver” of the signout does not.

Do not be afraid to ask them to slow down

Similarly, do not let the receiver RUSH You! Don’t be afraid to ask them to pay

attention! Do not be afraid to ask questions or

repeat If you are uncomfortable with a plan of

care that is signed-out to you, get both of your residents involved.


Eyeball sick patients early in the evening Get a baseline for their clinical status

Write down all events overnight to relay the next morning


MEDS

Cefepime 1gm IV q12Colace 100mg po bidDocusate 5mg po dailyFurosemide 20mg po dailyMetoprolol 50mg po bidMetronidazole 500mg po bidMorphine SR 30mg po bidWarfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150---Other Med Info---Flagyl 500mg q12 11/2-4

Prob List

**Asp Pna – on cefepime, still borderline**ARF on CKD: Cr 0.8 2.5, likely 2/2 dehydration. Getting volume**CAD – EF 10%, on coumadin for low EF**DM – on insulin**HTN**Hyponatremia – likely 2/2 dehydration**Diarrhea – possibly CDIff,

• Circle or Highlight important issues on the sign-out.

• For Medications: Consider highlighting pressors, antibiotics, anticoagulants, narcotics

Morning Handoff When on Call Every call, or order placed should

be verbally reviewed Write down all calls/issues/orders

placed on handoff while on call to serve as a visual reminder the next morning

IMPORTANT: any changes in medications or clinical status, new or pending results

When to update? As frequently as possible

Less to do at the end of the day

Busy days: Take notes on signout Update at the end of the day If cant get to it all, update the most

important info, and keep notes to update the next day

Summary of “Best Practices” in Handoffs Quiet Location Minimize Interruptions Problem based verbal handoff Standardize both written and

verbal format as much as possible Use anticipatory guidance Make time for questions and

clarifications

PRIVACY Handoffs contain many patient

identifiers!

Do NOT leave the hospital with them

Do NOT leave them on tables, counters or anywhere other than your hands

Old signouts should be placed in locked containers for shredding

Questions?

Safe & Effective Handoffs Subha Airan-Javia Penn Hospitalist Medicine

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