House officers and hospital intensivists now have shorter shifts than in the past due to healthcare reform measures designed to reduce the physician exhaustion factor and prevent errors. These reforms have caused a new problem related to care continuity such that the handoffs from one care team to another become much more important. The incoming team needs to be efficiently and adequately briefed on the status of all of the patients under their care (see: Hospitalists Add to Medicare Costs According to Recent Study).
Presenting a succinct verbal summary for complex patients is an art that inexperienced house officers learn on-the-fly, some better than others. An inadequate briefing can obviously lead to clinical errors. It was anticipated that EHRs would ameliorate some of these handoff problems but this is not always the case, partly because complicated patients have complicated electronic records. Part of the failure of EHRs to solve this problem is also attributed to their inadequate design. Below is an excerpt of an article discussing the standardization of handoffs designed to reduce patient harm (see: Standardized handoffs reduce patient harm):
Significant reductions in medical errors and preventable adverse events are possible when healthcare providers standardize the way patients are handed off from one physician to the next during shift changes, according to a new study. Medical-error rates dropped 23% and adverse events decreased by 30% among nine pediatric hospitals that all implemented one consistent handoff process for medical residents. Between January 2011 and May 2013, the inpatient units of nine pediatric residency training programs in the U.S. and Canada began implementing a bundle of handoff interventions called I-PASS. The term is a mnemonic for the communications that are vital during a handoff: illness severity; patient summary; action list; situational awareness and contingency planning; and synthesis by receiver. The I-PASS program was created by researchers from Boston Children's Hospital in 2009, and had previously been used only at its 395-bed hospital....Each pediatric institution was required to hold mandatory education workshops and simulations, institute a process and culture-change campaign, and use a standardized oral and written handoff process that was either built into the organization's electronic health record system or its word-processing programs. Once the program was in place, medical-record and post-shift surveys were conducted and reviewed daily....The overall rate of medical errors dropped from 24.5 per 100 admissions to 18.8 per 100 admissions. Preventable adverse events decreased from 4.7 per 100 admissions to 3.3 per 100 admissions. The program also significantly reduced the number of near misses, which dropped from 19.7 per 100 admissions to 15.5 per 100 admissions. The researchers additionally concluded that the revised handoff process was not more time consuming. Residents spent 2.4 minutes on handoff sessions before adopting the program and 2.5 minutes after its adoption.
There is nothing particularly shocking or revolutionary about the ideas described here. Take some special verbal communication process that may be prone to errors and standardize it. Teach people to go about the process in the same predefined way in order to perform it completely and accurately, Create a mnemonic such as I-PASS so that the actors in the process can remember it: [I]llness severity; [P]atient summary; [A]ction list; [S]ituational awareness and contingency planning; and [S]ynthesis by receiver. Now that we have definitive, experimental evidence that I-PASS reduces errors in hospital hand-offs, look for it to be more widely adopted.
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