Transcript I-PASS - SBH Peds Res

Better handoffs.
Safer care.
Overview
 Introduction
• Role of communication in medical errors
 The I-PASS Handoff
• Content, structure, and process
• Verbal
• Printed
 Handoff Simulation Exercise
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Role of Communication in
Medical Errors
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New ACGME Training Requirements
 Teamwork training
 Communication skills during transitions of
care
 Supervision and monitoring of handoffs
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Root Causes of Sentinel Events
Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type
(2004 - Third Quarter 2011)1
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Check-Back
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Handoffs
 Transfer of:
• Information
• Authority
• Responsibility
 Occur during
transitions in care
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•
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•
Shift changes
End of service block
Unit transfers
Discharges
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Essentials of Team Function
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Structured Team Communication Techniques
Technique
Function
Example
Brief
Plan team activities
Day one discussion for
team orientation
Debrief
Analyze an interim event Recap of events at the
end of a shift
Huddle
Problem solve
Planning for a
procedure
Cross monitoring /
Feedback
Improve performance
Commenting about a
decision (selected test)
Assertive
statement
Advocate for safe, high
quality care
Recognizing a potential
error
Check-back
Ensure accurate
information transfer
Reading back a verbal
order
Handoff
Transfer care and
responsibility
Transitions of care
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Key Points
 Effective communication is critical to
ensure effective handoffs of care
 Development of a shared mental model is
critical to the handoff process
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The I-PASS Handoff
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Elements of Verbal Handoffs
 Structured format
• Begins with high-level overview
 Appropriate pace
 Closed-loop communication  shared
mental model
• Solicit check back of salient points
• Prompt for clarifying questions
• Be aware of non-verbal communication
• Nodding approval, eye rolling, puzzled look
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The Printed Handoff Document
 Supplements the verbal handoff
• Allows receiver to follow
• Provides more comprehensive information
 Creates efficient information transfer
 Requires daily updates
• High-quality information
• Don’t copy and paste
• Senior/supervising resident should edit and
ensure quality
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Verbal Handoff Complements
Printed Handoff Tool
 Printed handoff is foundation
 Content / length of verbal handoff depends
on
• Level of training
• Prior contact with and knowledge of patients
• Length of time on rotation
• Verbal summary is more lengthy during
handoffs on the first few days of the rotation
 Should provide an opportunity for discussion
• Creates a shared mental model
• Facilitates active participation by receiver
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Large Group Discussion
 What techniques did they use that were
particularly effective?
 What pitfalls did you notice?
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The I-PASS Handoff
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I
P
A
S
S
Illness Severity
Patient Summary
Action List
Situation Awareness &
Contingency Planning
Synthesis by Receiver
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The I-PASS Mnemonic
I Illness Severity
Stable, “Watcher,” Unstable
P Patient Summary
Summary statement; events leading up to admission;
hospital course; ongoing assessment; plan
A Action List
To do list; timeline and ownership
S Situation Awareness & Contingency Planning
Know what’s going on; plan for what might happen
S Synthesis by Receiver
Receiver summarizes what was heard; asks
questions; restates key action/to do items
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I
Illness Severity
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Illness Severity
A Continuum
 Watcher : any clinician’s “gut feeling” that a
patient is at risk of deterioration or “close to
the edge”
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P
Patient Summary
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High Quality Patient Summaries
 Create a shared mental model
 Facilitate the transfer of information and
responsibility
 Transmit information concisely
 Describe unique features of the patient’s
presentation
 Use semantic qualifiers
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Semantic Qualifiers
 Dichotomous qualifiers along an axis
• Provide clarity
• Enable clear communication of representative
clinical features
 Examples
Onset
Site
Course
Severity
Acute, sub-acute, chronic
Proximal, distal
Intermittent, progressive
Mild, moderate, severe
Quality
Burning, dull, sharp
Context
Nocturnal, at rest
Patient Characteristics Female, infant, adolescent
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Make an Assessment
Using Semantic Qualifiers
 Swelling developed in
both this child’s knees
over a two day span.
 Acute, polyarticular
swelling of both knees
Image courtesy of Dana Toib, MD
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Make an Assessment
Using Semantic Qualifiers
 Jane has bouts of upper
abdominal pain over the
past 6 months that come
and go
 Recurrent, intermittent
epigastric pain
Photo courtesy of Stockbyte/Thinkstock
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A
Action List
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Action List
 To do list
 Includes specific elements
• Timeline
• Level of priority
• Clearly-assigned responsibility (if not
receiver)
• Indication of completion
 Needs to be up-to-date
• If no action items anticipated,
clearly specify “nothing to do”
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Action List
To Do:
☐
☐
☐
☐
☐
☐
Check respiratory exam now
Monitor respiratory exam Q2h overnight
Check pain scores Q4h
Check ins and outs at midnight
Follow up 6PM electrolytes
Follow up blood culture results
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S
Situation Awareness &
Contingency Planning
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Situation Awareness
Team level
Patient level
 “Know what is going
on around you”
 “Know what’s going
on with your patient”
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•
•
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Status of patients
Team members
Environment
Progress toward team
goals
• Status of patient’s
disease process
• Team members’ role
in this patient’s care
• Environmental factors
• Progress toward goals
of hospitalization
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Contingency Planning
 Problem solving before things go wrong
Photo courtesy of Photodisc/Thinkstock
 “If this happens, then…”
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Importance of Contingency Planning
 Is critical for patient safety
 Provides the receiver with specific
instructions for what might go wrong
 Ensures accepting team is prepared to
• Anticipate changes in patient status
• Respond to potential events or changes in
status
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Effective Contingency Planning
 Articulate what might go wrong
 Define the plan
• List interventions that have/have not worked
• Consider code status
• Identify resources and chain of command
 Provide details based on receiver’s
• Level of experience
• Knowledge of disease process
• Familiarity with service and/or patient
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S
Synthesis by Receiver
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Synthesis by Receiver
 Opportunity for receiver to
• Clarify elements of handoff
• Ensure there is a clear understanding
• Have an active role in handoff process
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Importance of Synthesis by Receiver
 Provides brief re-statement of essential
information in a cogent summary
• Demonstrates information is received and
understood
• Includes verbal and written elements
 Ensures effective transfer of information
and responsibility
 Promotes a shared mental model
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Elements of Synthesis by Receiver
 Vary in length and content
• More complex, sicker patients require more
detail
• At times may focus more on action items,
contingency planning
 Address priorities for individual patients
 Affirm understanding by receiver
It is not a re-stating of entire verbal handoff!
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Key Points
 Effective handoffs
• Ensure transfer of accurate
information
• Facilitate transfer of
responsibility
 Verbal handoffs
• Are structured
• Employ closed-loop
communication
 Printed handoff documents
Photo courtesy of Comstock/Thinkstock
• Provide more detail
• Integrate with verbal handoffs
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Handoff Simulation Exercises
Practice Cases
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Back to SSD case
Photo courtesy of John Howard/Thinkstock
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Patient Summary Exercise 1
 Review the admission history and physical
examination for the next five minutes.
 Create a patient summary to include in the
printed handoff document
• Use bulleted format and word limit < 200
• Summary statement
• Events leading up to admission
• Ongoing assessment by
problems/diagnoses
• Plan by problems/diagnoses
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Patient Summary Exercise 1
Summary Statement: AJ is a 4 year old male with history of ex 26week gestation admitted with hypoxia and respiratory distress
secondary to a left lower lobe pneumonia. In the ED was found to
have a Na of 130, likely secondary to volume depletion versus
SIADH.
Events Leading Up to Admission:
Two days PTA–cough and high grade fevers
Day of admission –worsening respiratory distress
Hospital Course
O2 increased to 2.5 L on arrival to the floor
S/P fluid bolus in ED
Ongoing Assessment
LLL Pneumonia
Hyponatremia
Plan
1. Continue ampicillin
2. Wean O2 as tolerated
1. D5NS at maintenance
2. Repeat electrolytes Q8H
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Patient Summary Exercise 2
 You are the day intern leaving and need to
handoff back to the night intern.
 Based on the updated hospital course,
compose a patient summary on the patient
after 48 hours in the hospital.
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48 Hours Later
Summary Statement:
AJ is a 4 year old male admitted two days ago with a left lower lobe
pneumonia and resolving hyponatremia now with worsening
respiratory distress and left sided effusion s/p chest tube
placement today with resultant improvement in status.
Hospital Course
Left sided pleural effusion noted on CXR with decubitus films
Chest tube placed with improving clinical status
Serum sodium is normal
Ongoing Assessment
Plan
LLL Pneumonia
1. Continuing ampicillin and O2
• Complicated by empyema
2. Chest tube to low wall suction
3. Surgery following
4. Repeat chest X-Ray in am
Hyponatremia
1. No further laboratory studies 48
Large Group Questions
 Did they capture all of the essential
elements?
 Did the verbal handoff differ from your
written patient summary?
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Better handoffs.
Safer care.