Transcript Transitions of Care in the Training

Transitions of Care in the
Training Environment:
ACGME Standards
Bradley F. Marple, MD
Professor and Vice-Chair Otolaryngology
Associate Dean Graduate Medical Ed
Designated Institutional Official
University of Texas Southwestern Medical Center
ACGME Highlights Its Standards on Resident Duty Hours - May
2001
• Work hour limits introduced in 2003 with intent to:
• Decrease fatigue
• resident safety
• safety and effectiveness of patient care
• “The ACGME believes that it is ill advised to "carve out" a
section of this environment - resident duty hours - in a way
that does not consider the other elements essential to the
quality of the educational process. There is a significant
potential for an unanticipated impact that may be detrimental
to high quality education and safe and effective patient care. “
http://www.acgme.org/acwebsite/resinfo/ri_osharesp.asp
• Objective
• ACGME implemented duty hours to mitigate fatigue-related risk
• Goal was to determine impact upon work hours, sleep, and safety
• Methods
• Prospective cohort study during implementation of duty hours
• 3 pediatric programs
• Reported MVCs, occupational exposures, med errors, educational
experience, depression, and burn-out
• 220 residents reported
• 6007 daily reports of work hours and sleep
• 16,158 medication orders
• Conclusions
• No change in
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Work hours
Sleep
Depression
Resident injuries
Educational ratings
• Improvements
• Resident burn-out
• Worsened
• Medication errors
CPR VI.B Transitions of Care
• VI.B.1 – Programs must design clinical
assignments to minimize the number of
transitions in patient care
Transitions of care
• Continuity of care
constitutes an important
aspect of quality
• Continuity of care is
challenged
• Teaching environment
• Multiple specialties
• Modalities of care
• Transitions
• Impact of ACGME
duty hours on
transitions
• Before 2003 - single
transfer of care
• After 2003 – 2 or more
physicians 2-3 times
per day.
• Providers
• Provider teams
• Units
Riebschleger M, Philibert I. 2011ACGME Duty Hour Standards
Transitions of care
• Each transition of care creates and opportunity for
information to be lost or distorted
• Handoffs are a major contributing factor in traineerelated malpractice cases
• Malpractice more frequent when trainees are involved
in care as compared to attending-only cases (19% vs
13%, p-0.02)
Scoglietti VC, et al. Am Surg. 2010;76(7):682-686.
Arora V, et al. J Gen Intern Med. 2007;22(12):1751-1755
Singh H et al. Arch Intern Med. 2007;167(19):2030-2036
CPR VI.B Transitions of Care
• VI.B.2 – Sponsoring institutions and programs
must ensure and monitor effective, structured
hand-over processes to facilitate both continuity
of care and patient safety
More unintended consequences
• Impact of increased
limits on duty hours
• More hand-overs
• Increased “Cross-cover”
(defined as outside the
primary care team)
• Increased likelihood for
unplanned changes in
care
• Asynchronous handoffs
• Fewer person to person
interactions
• Creates need for
• Structure
• Process
• Education
Impact upon Patient Safety
• Patients with potentially preventable AEs were more likely to
be covered by a physician from another team (cross-cover) at
the time of the event (OR 3.5;P=0.01)
• Peterson LA et al. “Academia and Clinic: Does Housestaff
Discontinuity of Care Increase the Risk for Preventable Adverse
Events?” Ann Int Med 1994;121:866-872.
• A member of the primary team was in the hospital for only
47% of the hospitalization
• Horwitz LI et al. “Transfers of patient care between house staff on
internal medicine wards: a national survey” Arch Intern Med
2006;166(11);1173-7.
Impact of Transition on Patient
Safety
• MGH Residents
• 59% reported “problematic handoffs” caused harm to
one or more patients on most recent clinical rotation
• 12% reported cases of “major” harm
• 31% reported quality of handoffs as “fair or poor”
• Handoffs were rarely quiet
• Handoffs were frequently interrupted
• Led to “handoff-safety education program” for
housestaff intended to improve safety and
effectiveness of handoffs
Kitch BT et al. Jt Comm J Qual Patient Saf. 2008;34(10):563-570.
2006 Joint Commission
• TJC data revealed that communication is identified in 65-70%
of root cause analyses
• TJC formalized a “standardized approach to hand-off
communications” in 2006, which included:
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Interactive communications
Up-to-date and accurate information
Limited interruptions
A process for verification
An opportunity to review relevant historical data
Adamski P. Nurs Manage. 2007;38:10-12.
AHRQ. “Patient Safety Primer: Handoffs and Signoffs.”
http://psnet.ahrq.gov/primer.asp?primerID=9
Arora V, et al. Jt Comm J Qual Patent Saf. 2006;31(11):646-655
CPR VI.B Transitions of Care
• VI.B.3 – Programs must ensure that residents are
competent in communicating with team
members in the hand-over process.
ACGME 2011 Common Program Requirements. www.acgme.org
Impact of Communication on
Patient Safety
• Audiotaped handoffs for 8 IM housestaff teams
and compared written handoff forms
• Median duration was 35 seconds per patient
• Only 50% of verbal and 38% of written handoffs included
comments on current clinical condition
• 59% included no questions from recipient
• 22% contained omissions of mischaracterizations on data
Horwitz LI et al. Qual Saf Health Care. 2009;18(4):248-255.
Impact of Communication on
Patient Safety
• Chang V et al. Pediatrics 2010;125(3):491-496
• 60% of handoffs did not include the “most
important piece of information” despite post-call
intern thinking it had
• 60% disagreement in on-call vs. post-call decision
rationale.
• McSweeny ME et al. Clin Pediatr. 2011;50:57-63
• Only 19% reported that written sign-outs reflected
actual current clinical information and
management plans.
Conclusions
• Changes in the work environment have increased the need to
focus upon various aspects of transition of care
• ACGME 2011 CPR focus upon three major areas
• Decreasing numbers of handoffs
• Creation of standardized handoffs
• Accurate communication
• Potential solutions
• Redundancy of systems
• Education
• Evaluation of the transitions process
• Focused supevision
• Feedback
• Skills-based examinations