Hand-OffResidents’ Perspective

Celia M. Divino, MDDepartment of Surgery

The Mount Sinai Medical SchoolNew York

October 14, 2008

Hand off not Drop off

1. Hand-off as a requirement for NPSG

2. Contributing Factors to Hand-off failures

3. Challenges for residents and training programs

4. Standardized Hand-off Protocols

Root Causes of Sentinel EventsAll Categories - 2007

The Mount Sinai Hospital

Communication (lack of) is the leading cause of sentinel events:

The Mount Sinai HospitalThe Mount Sinai Hospital

National Patient Safety Goal #2: Improve Effectiveness of

Communication Among Caregivers

Requirement 2E

Implement a standardize approach

to hand-off communications,

including an opportunity to

ask and respond to questions.

Definitions

Hand-Off: the transfer of responsibility and/or information about a patient from one caregiver to another.

Caregiver: any clinician, professional, or credentialed staff who provides direct patient care, treatment or service:– Nurse: RN, APN and LPN – Provider: Attending, fellow, house staff, PA– Therapist: OT/PT, respiratory therapist – Technician: radiologist– Consultant

Situations for Hand-Off

Nurse– Change of shift– Coverage during (lunch) break– Change in patient status: serious or deteriorating– Nurse to Provider - MD, APN, PA

Provider – Provider to nurse– Temporary or complete transfer responsibility of

providers • ED to floor / Anesthesiologist to PACU• Medicine service to Neurology service

– Primary provider to Radiologist / Specialist– On-call / weekend / vacation coverage

More Situations for Hand-Off

Transport (with attention to isolation status)– Ambulance to ED– ED to any service unit (radiology) or inpatient unit– Dialysis, cardiac cath lab– Pre-op to OR to post-op to unit

Reporting Critical Results (NPSG 2A)– Laboratory / Radiology / Diagnostic results

Reporting special patient condition/situation– Diabetic, Insulin delayed until after test is completed– Hold procedure until (lab test) result received

Transfer– to another hospital, nursing home, home health

Good Patient Care

Communication Related Incidents

Decreased surgeon familiarity with patients

Distorted or inhibited communication

Blurred boundaries of responsibility

Diverted surgeon attention

*Williams et al, Ann Surg, 2007.

80-Hour Work Week?

Consequences

15 hand-offs /patient in a 5 day hospitalization

Delayed test ordering

Increased adverse events

Medication errors

Longer length of stay

• Team Based Approach to Patient Care

Non-Physician Extenders

• Shift Work

• Resident Perception of responsibility

Challenges

• Work Flow Patterns

• Increased Multitasking

• Shift Changes

• Multispecialty Care

• Ownership of Patients

• Definition of Roles

• Empowerment

• Standardized Hand-off Protocol

Hand off Protocol

R edundancy

R ead Back

R espond to questions

R educe communication links

R estrict interruptions

The Joint Commission’s Elementsfor Effective Communication

1. Interactive with opportunity for questioning between giver and receiver.

2. Up to date information regarding patient’s condition including recent or anticipated changes.

3. Verify: Read back or read-back techniques.

4. Receiver is able to review relevant patient historical data.

5. Minimal interruptions.

Tools for Hand Off

UW Cores

U of Washington web-based computerized rounding and signout system

U of Chicago Microsoft Word document

Johns Hopkins Hospital

10-Point Guideline

Brigham & Women’s Hospital Computerized sign-out

The Mount Sinai Hospital Verbal and written SBAR

S B A R

At Mount Sinai we use SBAR as the standard format for Hand-Off

• SBAR is an acronym – S: Situation– B: Background – A: Assessment “your professional opinion”– R: Recommendation

• SBAR provides the framework for the communication.

• The content is patient specific.• Empowerment tool.

S B A R

• Situation: (introduction to situation)

– I am ____ (name) from____ (unit / area) – The patient is_____ (name / DOB) – I am concerned because _____

• Background: (patient’s background)

– The patient’s VS are____– Mental status is____– Pt received xyz medication and is not responding

• Assessment: (caregiver’s assessment) – I think the problem is____– I am not sure but the patient is deteriorating

• Recommendation: (Caregiver’s recommendation)

– I recommend you see the patient right away– I request you order x med / test

Apply SBARNurse:

Dr. Allen. This is Ms. Jones from 11 W. I’m calling about Sam Smith, your 45 yo with hx of pancreatic cancer. (S)

He was stable but suddenly has SOB - HR 120; R 28. (B) I think he might have thrown a pulmonary embolus. (A) I request you order blood gases and come see him. (R)

Dr. Allen to his colleague. Hey, I got to go. This sounds serious. And to Ms. Jones: Sorry about that. Seems like a good call. Yes, get O2 Sat,

if <90 start a facemask with and FL02 of 5 L and draw the blood gases. I’ll come right up.

Nurse: Thanks. I heard you say…. Yes, I will start O2 now. What’s next….? Elements / Criteria: Current Ask/Respond Clarify/Verify Anticipate Change Succinct

Residents: Know what to really expect!

• What does SBAR mean? – S__ B__ A__ R__ (similar to admitting note with ….) – OK, it really is the framework for how I communicate

• Ok, what does it really mean?– That a nurse can say she/he thinks VS indicate possible CVS and

that I need to order … and get to the floor immediately.– That if I don’t respond, the nurse can/will/should kick it up to the

PGY 2, or Fellow and/or Attending. I better respond but I can also ask for clarification.

– That surgery can be held if the critical test result is outside limits and puts patient at risk. And if I get the patient I better make sure I have what I need from the previous provider.

– That it’s not just a good idea to communicate, it’s a requirement.– That it’s not as easy as I thought – but that with practice I’m won’t

be so nervous.– That I don’t need to write more just more effectively so the next guy

knows what she’s doing.

TOOLS TO HELP YOU

MOUNT SINAI developed a

generic notepad

print shopED & Amb care

customized their own.

▲

TJCRequired elements

Sign-Out

National Patient Safety GoalSBAR to Improve Effective Communication for Hand-OffS Situation – Describe I am concerned because…B Background – Current status..…Pt VS / mental status is… A Assessment – Opinion I think the problem is...…R Recommend / RequestI recommend you………. √ Succinct √ Ask-Respond √ Clarify Verify√ Anticipate change√ Minimal interruption

NPSG / SBAR card Attach to ID badge

NPSGson reverse side

1237891315

And now 16

SBAR

p4: SBAR does not substitute

for other professional

responsibilities and policies.

Mount Sinai Policy A2-404

Common Questions

• Is Hand-off and SBAR only for nurses NO– Hand-off/SBAR applies to all caregivers

• Do I need to keep the note pad: NO– But make sure there is a confidentiality statement

on the top

• Do I need to document I used SBAR: NO – But it does not replace writing chart notes

• Do I need to give the pts life history: NO – But you need to communicate information that is

relevant, pertinent. Be succinct and with minimal interruption.