At Virginia Commonwealth University (VCU) Health System, incoming interns begin their next phase of medical training with an orientation known as Walk the Walk, a two-day boot camp where they learn about their new responsibilities by working in interdisciplinary teams before hitting the hospital floor. For the past two years, Walk the Walk organizers have focused on one topic in particular: patient handoffs.
“Every incoming practitioner needs to be introduced to and trained in handoffs,” said Ryan Vega, MD, liaison for house staff quality and safety initiatives at VCU Health.
According to research cited by the Joint Commission Center for Transforming Healthcare, about 4,000 patient handoffs occur each day in a typical teaching hospital, places that take care of complex patients. This means that even if the great majority are done correctly, care must always be taken to avoid errors. Indeed, research has found that communication errors are a leading cause of adverse medical events.
The Joint Commission mandates all hospitals develop a uniform handoff method, though it doesn’t require a particular approach. However, many health care systems have turned to a system known as I-PASS Handoff Bundle, communication tools and training to improve handoffs. At the center of the system, developed by researchers at Boston Children’s Hospital, is the I-PASS mnemonic that stands for illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by receiver. A study published in 2014 in the New England Journal of Medicine found that preventable adverse events declined by 30 percent after implementing I-PASS in nine hospitals.
VCU Health first rolled out I-PASS to internal medicine residents in 2014. Today, Vega and colleagues are working to integrate I-PASS throughout the health system, engaging residents in developing and piloting customized handoff reports for each department. Vega noted that residents report significant improvements in handoff knowledge and skills after being trained in I-PASS.
“If we commit to this,” Vega said, “it will become the new culture.”
Diverse paths to better patient handoffs
Beyond I-PASS, teaching hospitals are taking a variety of approaches to improving the communication underlying patient handoffs, also referred to as transitions of care.
At University of Missouri (MU) Health Care, patient satisfaction scores in 2014 and 2015 were on a downward trend, especially for doctor-nurse communication, according to Tamara Day, RN, a performance improvement professional with MU Health Care. Previously, Day said, the hospital had attempted to improve bedside communication by ensuring nurses were present for physician rounds. But providers soon realized that being physically present wasn’t enough—they needed a structured plan to facilitate communication between providers, said Natalie Long, MD, assistant professor of clinical family and community medicine at University of Missouri School of Medicine.
So in June 2015, with the help of outside consultants, staff from across disciplines came together to improve bedside communication. As a result, the teaching hospital piloted a new protocol in its family medicine unit that same summer—and in time for a new batch of incoming interns—in which nurses joined physicians on rounds and were actively engaged in conversations about patient care. While the intervention is still relatively new, Day reported that patient satisfaction scores for doctor-nurse communication have dramatically improved.
“From a nursing perspective, it offers an opportunity for a nurse to always know what the care plan is,” Day said. “And our residents can see that good communication not only benefits patients, but can improve patient safety.”
“Every incoming practitioner needs to be introduced to and trained in handoffs.”
Ryan Vega, MD
Virginia Commonwealth University Health System
Handing off patients with complex and challenging health issues can be particularly difficult—a task that the University of Arkansas for Medical Sciences (UAMS) is now tackling with residents. About three years ago within its family medicine residency program, the hospital established a Balint group, a group of clinicians who regularly meet to discuss challenging cases and the patient-provider relationship. According to J. Chris Rule, MSW, an instructor of psychiatry and family medicine at UAMS, the monthly group—named for the psychoanalysts Michael and Enid Balint who developed the concept—allows residents to discuss difficult cases and their emotional responses in a safe environment.
“It runs counter to probably about 95 percent of what [residents] do,” Rule said. “It’s much more about being, rather than doing. They’re always thinking about solving problems and often don’t get the chance to just sit and process difficult cases.”
Rule said residents report that the group experience has helped improve their communication skills and, in turn, their handoff skills. Charles Smith, MD, director of the UAMS Primary Care Service Line, noted that the Balint group can facilitate a deeper understanding of a patient’s condition.
“The better we know our patients, the more effectively we can complete these handoffs,” Smith said.
Patient handoff in the classroom
While many patient handoff interventions focus on residents, handoff skills should be mastered in the medical school classroom. Several medical schools provide handoffs education, and a 2014 article in the journal Medical Teacher suggested that residents who received handoffs instruction during medical school were better prepared to handle handoffs during residency.
At Tufts University School of Medicine in Massachusetts, Elena Aragona, MD, MS, an assistant professor of pediatrics, received one of the school’s 2016 Innovations in Education Intramural Grants to study the effectiveness of a handoff curriculum for medical students. Aragona noted that while more medical schools are beginning to offer formal handoff education, many undergraduate medical students still get the bulk of their handoff knowledge informally through observing residents.
“It makes … sense to start this training in medical school and let students practice these skills with supervision,” said Aragona, a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center.
Aragona’s curriculum is currently being piloted in the School of Medicine’s pediatrics clerkship and includes didactic and simulation work. For example, students learn about effective communication, the I-PASS mnemonic, and the elements of an ideal handoff, such as conducting a handoff face-to-face in an uninterrupted environment. The ultimate goal, she said, is to expand the handoff curriculum to all clerkships.
“This makes sense to students,” Aragona said. “When you go through all of the elements [of the curriculum] and the situations for potential errors, it becomes clear why we need this to improve patient care.”