Transcript Document 7627753

Hand-Off
Residents’ Perspective
Celia M. Divino, MD
Department of Surgery
The Mount Sinai Medical School
New 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 Events
All Categories - 2007
The Mount Sinai Hospital
Communication (lack of) is the leading cause of
sentinel events:
The
TheMount
MountSinai
SinaiHospital
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 Elements
for 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
SBAR
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 SBAR
Nurse:
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 shop
ED & Amb care
customized their
own.
▲
TJC
Required elements
Sign-Out
NPSG / SBAR card
Attach to ID badge
SBAR
National Patient Safety Goal
SBAR to Improve Effective
Communication for Hand-Off
S 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 / Request
I recommend you……….
√ Succinct
√ Ask-Respond
√ Clarify Verify√ Anticipate change
√ Minimal interruption
NPSGs
on reverse side
1
2
3
7
8
9
13
15
And now 16
Mount Sinai Policy A2-404
p4: SBAR does
not substitute
for other
professional
responsibilities
and policies.
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.