REVIEW OF IPASS

Robin Mackin PGY-3

GOALS OF THE PRESENTATION:

Familiarize with IPASS format

Emphasize importance of following IPASS

WHY IPASS?

IPASS

Miscommunication is the leading cause of adverse events

As a result of decreased duty hours, there is an increased frequency of handovers

IPASS came from a prospective systems based intervention study on inpatient units across 9 children hospitals

Implemented IPASS handoff bundle (written and oral) to resident physicians.

The medical-error rate decreased by 23% from the preintervention period to the postintervention period

Rate of preventable adverse events decreased by 30%

Avg time per patient pre intervention 2.4min, post 2.5 min

ARRIVING TO HANDOVER

The Senior Resident (or delegate) should introduce their team with the following

information:

Number of Patients on their team

Number of Watchers on their team

Proceed with handing over the Watchers

Continue with handing over the rest of the patients in order of the team’s list

Pearl: Think to yourself, what information would I require if I were receiving this

patient to care for overnight

IPASS – HOW TO HANDOVER PATIENT INFORMATION

I – ILLNESS SEVERITY

Patients are either “Stable” or a “Watcher” when they are admitted to the Pediatric

CTU ward.

In areas with more acute patients, the illness severity continuum encompasses

“Stable” “Watcher” or “Unstable”

A watcher is someone that the team feels requires close monitoring overnight for

concern of deterioration

P – PATIENT SUMMARY

Highlight the following information:

Reason for admission (summary statement)

Relevant events leading to admission

Brief hospital course

Ongoing assessment

Plan for hospitalization

STABLE

2yo with ________

Presented with _______

Treated with _____, improved

1. Issue – assessment, plan

2. Issue – assessment, plan

3. Issue-assessment, plan

A – ACTION LIST

To Do List for the accepting team

Include specific elements:

Timeline (ie. what time will the bloodwork be drawn?)

Level of priority

Relevant information for interpretation of lab work/imaging etc.

Specific directions

If no action items anticipated, please clearly specify “Nothing to do overnight”

S – SITUATIONAL AWARENESS & CONTINGENCY PLANNING

Patient Level

Know what is going on with your patient

Status of patients’ disease process

Team members role in the patients’ care

Environmental factors

Progress toward goals

Team Level

Know what is going on around you

Status of patients

Team members

Environment

Effective Contingency Planning

Identify concerns

Articulate what might go wrong

Define the plan!

List interventions that have/have not worked

Identify resource for assistance

For stable patients “I don’t anticipate anything

will go wrong”

S – SYNTHESIS BY RECEIVER

Brief re-statement of essential information to

demonstrate understanding

Opportunity for receiver to clarify elements of the

handover

“Check back”

Determine who should be doing the synthesis

before handover (junior resident vs senior resident)

TIME FOR SOME EXAMPLES….

EXAMPLE 1: STABLE, NON ACTIVE PATIENT

I: A.B is stable

P: He is a previously healthy 8 month male with bronchiolitis who was admitted 2

days ago for respiratory distress requiring supplemental oxygen. He has been

tolerating room air for the past 12 hours with no WOB. He is feeding well with no

IV.

A: There is nothing to be done overnight.

S: I don’t anticipate anything happening overnight and this patient will likely go home

in the morning if no oxygen is required overnight.

EXAMPLE 2: STABLE PATIENT WITH ACTIVE ISSUES

I: A.B is stable

P: She is a 6yo female, previously healthy, admitted for gastroenteritis and moderate

dehydration last night. She had 24h of ongoing diarrhea, vomiting and fever prior to

presentation. Her vomiting has resolved with anti-emetics, but she is still having diarrhea.

She is tolerating some po intake so her IVF were decreased to ½ maintenance at noon.

A: She has a set of lytes to be checked at 18:00. We are following up her potassium level as

she is currently running D5NS with no K+. I would like you to check her ins/outs in the

evening to ensure she had adequate po intake, and adjust her IVF accordingly.

S: I do not anticipate any issues overnight.

EXAMPLE 3: WATCHER *HAND THIS PATIENT OVER FIRST

I: A.B is a watcher.

P:

She is a 6mos F with a past medical history significant for a VSD and presented in congestive heart failure with intercurrent viral

illness. She was admitted for worsening tachypnea and difficulty feeding.

From a cardiac standpoint, she has been tachycardic in the 150s with normal blood pressures and good CRT. Her current cardiac

regimen includes Lasix, metoprolol and captopril. She is in moderate heart failure with a liver 3cm BCM. Her Lasix dose was

increased to 3mg TID today and her u/o has been about 5cc/kg/hr.

From a respiratory standpoint, she is currently on 1L via NC maintaining sats >90%. I am most concerned about her work of

breathing. Her RR have been 60-80/min with nasal flaring. She was PACED this afternoon but felt safe to stay on the ward. PACE is

still following.

She is currently NPO for tachypnea, previously TFI of 130cc/kg/d via NG. While NPO she is running IVF D5NS + 20KCl @ 3/4M.

A: From a respiratory standpoint, she requires ongoing reassessment as she may need HFNC if symptoms progress. I

would like you to follow up her fluid balance at 20:00 and consider an extra dose of Lasix (3mg) if she is >200cc positive

with a corresponding clinical exam. If her tachypnea significantly improves, consider restarting feeds and stopping IVF.

S: Monitor her respiratory status closely with a low threshold to PACE.

COMPLEX PATIENTS

For patients with multiple system issues. It is helpful to present their active issues in a systems based manner.

CNS -

CVS -

Resp -

GI/Feeding/Nutrition -

GU -

Heme -

ID –

Any POST? (Goals of care ie. NO CPR)

EXAMPLE OF THE HANDOVER LIST

HANDOVER ETIQUETTE

Create a positive, respectful environment!

Zero tolerance policy for “eye rolling” culture

Minimize distractions to handover

No side conversations should be taking place in the handover room

If your team is not presenting, it would be optimal to wait outside of the room until the other team is

finished.

Minimize interruptions of junior learners

Wait until they are finished presenting to add pertinent details

If a junior learner was away in the afternoon for teaching, ensure they know the updates about their

patients if you are expecting them to present at handover.

GENERAL REMINDERS FOR RESIDENTS

Senior residents should model handover of the clerk’s patient on their first day of CTU

Try to make time to run the list before the end of the day so everyone is on the same

page and the list is up to date

Try to practice handing over patients with junior learners prior to handover (Float &

CTU) & provide feedback after handover

Encourage standardization of the handover list

Attempts to keep templates on the bottom of the list

Delete irrelevant information (ie. lab work)

THANK YOU FOR LISTENING!