Transitions of Care in the Training Environment: ACGME Standards

Bradley F. Marple, MDProfessor and Vice-Chair OtolaryngologyAssociate Dean Graduate Medical EdDesignated Institutional OfficialUniversity of Texas Southwestern Medical Center

ACGME Highlights Its Standards on Resident Duty Hours - May 2001

• Work hour limits introduced in 2003 with intent to:• Decrease fatigue

• resident safety• safety and effectiveness of patient care

• “The ACGME believes that it is ill advised to "carve out" a section of this environment - resident duty hours - in a way that does not consider the other elements essential to the quality of the educational process. There is a significant potential for an unanticipated impact that may be detrimental to high quality education and safe and effective patient care. “

http://www.acgme.org/acwebsite/resinfo/ri_osharesp.asp

• Objective• ACGME implemented duty hours to mitigate fatigue-related risk• Goal was to determine impact upon work hours, sleep, and safety

• Methods• Prospective cohort study during implementation of duty hours

• 3 pediatric programs• Reported MVCs, occupational exposures, med errors, educational

experience, depression, and burn-out• 220 residents reported

• 6007 daily reports of work hours and sleep• 16,158 medication orders

• Conclusions• No change in• Work hours• Sleep• Depression• Resident injuries• Educational ratings

• Improvements• Resident burn-out

• Worsened• Medication errors

CPR VI.B Transitions of Care

• VI.B.1 – Programs must design clinical assignments to minimize the number of transitions in patient care

Transitions of care• Continuity of care

constitutes an important aspect of quality• Continuity of care is

challenged• Teaching environment• Multiple specialties• Modalities of care• Transitions • Providers• Provider teams• Units

• Impact of ACGME duty hours on transitions• Before 2003 - single

transfer of care• After 2003 – 2 or more

physicians 2-3 times per day.

Riebschleger M, Philibert I. 2011ACGME Duty Hour Standards

Transitions of care

• Each transition of care creates and opportunity for information to be lost or distorted• Handoffs are a major contributing factor in trainee-

related malpractice cases• Malpractice more frequent when trainees are involved

in care as compared to attending-only cases (19% vs 13%, p-0.02)

Scoglietti VC, et al. Am Surg. 2010;76(7):682-686.Arora V, et al. J Gen Intern Med. 2007;22(12):1751-1755Singh H et al. Arch Intern Med. 2007;167(19):2030-2036

CPR VI.B Transitions of Care

• VI.B.2 – Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety

More unintended consequences

• Impact of increased limits on duty hours• More hand-overs• Increased “Cross-cover”

(defined as outside the primary care team)

• Increased likelihood for unplanned changes in care

• Asynchronous handoffs• Fewer person to person

interactions

• Creates need for• Structure• Process• Education

Impact upon Patient Safety• Patients with potentially preventable AEs were more likely to

be covered by a physician from another team (cross-cover) at the time of the event (OR 3.5;P=0.01)• Peterson LA et al. “Academia and Clinic: Does Housestaff

Discontinuity of Care Increase the Risk for Preventable Adverse Events?” Ann Int Med 1994;121:866-872.

• A member of the primary team was in the hospital for only 47% of the hospitalization• Horwitz LI et al. “Transfers of patient care between house staff on

internal medicine wards: a national survey” Arch Intern Med 2006;166(11);1173-7.

Impact of Transition on Patient Safety

• MGH Residents• 59% reported “problematic handoffs” caused harm to

one or more patients on most recent clinical rotation• 12% reported cases of “major” harm• 31% reported quality of handoffs as “fair or poor”• Handoffs were rarely quiet• Handoffs were frequently interrupted• Led to “handoff-safety education program” for

housestaff intended to improve safety and effectiveness of handoffs

Kitch BT et al. Jt Comm J Qual Patient Saf. 2008;34(10):563-570.

2006 Joint Commission• TJC data revealed that communication is identified in 65-70%

of root cause analyses• TJC formalized a “standardized approach to hand-off

communications” in 2006, which included:• Interactive communications• Up-to-date and accurate information• Limited interruptions• A process for verification• An opportunity to review relevant historical data

Adamski P. Nurs Manage. 2007;38:10-12.AHRQ. “Patient Safety Primer: Handoffs and Signoffs.” http://psnet.ahrq.gov/primer.asp?primerID=9Arora V, et al. Jt Comm J Qual Patent Saf. 2006;31(11):646-655

CPR VI.B Transitions of Care

• VI.B.3 – Programs must ensure that residents are competent in communicating with team members in the hand-over process.

ACGME 2011 Common Program Requirements. www.acgme.org

Impact of Communication on Patient Safety

• Audiotaped handoffs for 8 IM housestaff teams and compared written handoff forms• Median duration was 35 seconds per patient• Only 50% of verbal and 38% of written handoffs included

comments on current clinical condition• 59% included no questions from recipient• 22% contained omissions of mischaracterizations on data

Horwitz LI et al. Qual Saf Health Care. 2009;18(4):248-255.

Impact of Communication on Patient Safety

• Chang V et al. Pediatrics 2010;125(3):491-496• 60% of handoffs did not include the “most

important piece of information” despite post-call intern thinking it had• 60% disagreement in on-call vs. post-call decision

rationale.• McSweeny ME et al. Clin Pediatr. 2011;50:57-63• Only 19% reported that written sign-outs reflected

actual current clinical information and management plans.

Conclusions• Changes in the work environment have increased the need to

focus upon various aspects of transition of care• ACGME 2011 CPR focus upon three major areas• Decreasing numbers of handoffs• Creation of standardized handoffs• Accurate communication

• Potential solutions• Redundancy of systems• Education• Evaluation of the transitions process

• Focused supevision• Feedback• Skills-based examinations