National data suggest that up to 70 percent of sentinel events—the most serious errors in hospitals—stem at least in part from miscommunications. Communication problems are especially apt to occur during hospital shift changes, when a patient’s care is transferred to incoming doctors and nurses—known in health care as the “handoff.”
More than a year ago, a team led by Amy Starmer, MD, MPH, of the Division of General Pediatrics at Boston Children’s Hospital, developed and began testing a bundle of interventions to ensure that the hospital’s residents were thoroughly and accurately briefed on each patient’s medical history, status and treatment plan in a standardized way.
Through measures such as communications training, a mnemonic to help residents remember key information to pass on and a computerized handoff tool that integrated with the patient’s electronic medical record, they managed to move the needle: Medical errors fell by 40 percent—from 32 percent of admissions at baseline to 19 percent of admissions three months after the program started.
But that wasn’t all. Doctors spent more time with patients, logging an average of 225 minutes per 24-hour period, versus just 122 before the handoff program. Time at the computer fell from 408 to 370 minutes per 24 hours.
Handoffs were about twice as likely as before the intervention to occur in a private or quiet location, and handoff documents contained significantly more information. For example, the number of sign-outs that included a “To-Do” list for the patient increased from 29 to 82 percent. Medication lists went from being included 3 percent of the time to 100 percent of the time, largely because the handoff form could pull them directly from the medical record.
Results of the pilot study were shared at the Pediatric Academic Societies annual meeting that wraps up today in Boston, along with details on an ongoing study that’s spread from Boston Children’s to nine other pediatric training programs in the United States and Canada.
The pilot study served as the foundation for I-PASS, a medical education curriculum developed through a collaboration with educators, hospitalists and health services researchers in the U.S. and Canada, led by Starmer and Nancy Spector, MD, associate residency program director at St. Christopher’s Hospital for Children in Philadelphia. The curriculum is now available to any hospital in the world via www.ipasshandoffstudy.com.
“Despite many efforts, medical errors continue to be very common worldwide, and frequently cause harm to patients,” says I-PASS principal investigator Christopher P. Landrigan, MD, MPH, research and fellowship director of the inpatient pediatrics service at Boston Children’s. “By reducing handoff errors, we hope that I-PASS will improve the safety of care across pediatric and adult hospitals once it’s widely disseminated.”
Here, in slightly more detail, are the major elements of I-PASS:
1. Team training in communication and teamwork skills
Clinicians first complete a 3-hour interactive workshop, where they practice giving and receiving handoffs under different clinical scenarios and real-world constraints. The workshop is based on best practices for handoffs and uses elements of the TeamSTEPPS program developed by the military and the Agency for Healthcare Research and Quality. There are also frequent refreshers and “tips of the day” that Starmer, the I-PASS project leader, likens to fortune-cookie messages. Here’s one of about 40 so far: With a shared mental model, team members are “on the same page.” Are you thinking what I’m thinking?
2. A mnemonic device
Easy to remember, the I-PASS mnemonic acts as a checklist for information to include in the handoff:
I – Illness severity
P – Patient summary (the standard clinical summary)
A – Action list for the next team
S - Situation awareness/contingency plans (Starmer calls these “if/then scenarios” – things that can wrong with the patient and what should happen if they do.)
S – Synthesis – a chance for a “read-back” of the information by the provider being briefed.
3. A printed handoff document
Clinicians work together to produce a document that ideally integrates the information exchanged during handoff with the hospital’s electronic medical record system. “Previously, residents were retyping a lot of information that wasn’t always updated as things changed,” says Starmer, now at Oregon Health and Science University. “The new tool lets you import information automatically, and standardizes the written documentation with the I-PASS mnemonic.”
4. Observation and feedback
As part of ongoing training, senior clinicians periodically conduct direct, structured observation of handoffs, giving real-time feedback to residents and other trainees.
All of these measures require some degree of culture change. Recognizing that people tend to be reluctant to change their behaviors, the I-PASS team deliberately bundled the interventions with the intent of having them be mutually reinforcing. So far it seems to be working well.
“You really have to do multiple things, not just a single intervention,” says Theodore Sectish, MD, program director of the pediatric residency program at Boston Children’s Hospital. “The whole is bigger than the sum of its parts.”