2017 HSC Section 2 - Practice Management

ARTICLE IN PRESS

Surgery j 2016

Hasan et al

Hospital reported that 59% of residents could identify $ 1 patient harmed because of problem- atic handoffs, and 12% reported that the harm was major. 3 Due to the complexities of health care environ- ments and the substantial variation in clinical practice between different specialties, efforts to standardize the handoff process have been met with resistance, with creation of various handoff tools of questionable applicability and sustainabil- ity. In addition, evaluation of the handoff process lacks a unifying structure. In a recent study, Mohorek and Webb 4 suggested using the linear model of communication as a conceptual frame- work for handoff research. The handoff process is a linear transition of information from one per- son to another person or group, many of whom may not have participated in this patient’s care before and may have less career experience with the medical/surgical situation. The linear commu- nication model, when used as a framework, allows researchers to identify 3 separate areas in which er- rors occur: transmitter (message encoding), chan- nel, and receiver (signal decoding). 4 A recent editorial in the Journal of Graduate Med- ical Education recommended studying handoffs within an established framework. 5 The aim of this study was to evaluate handoffs in surgical services in the context of a communication framework to identify factors that adversely affect the handoff process. Once these factors are delineated clearly, a targeted intervention to improve handoff effec- tiveness could be developed. METHODS Study population and setting. A prospective, single-institution study was conducted to evaluate the process of handoff of surgical patients at a tertiary care teaching hospital. The conceptual framework published previously for handoffs using communication theory was used to develop evalu- ation tools for the source (resident giving the handoff), receiver (resident receiving the hand- off), and observer. 4 The observers in this study were involved in the development of the evaluation tools, and consensus was achieved through an iterative process. Our residency program implemented a night-float sys- tem to address patient care needs in the setting of work hour restrictions. General surgery residents at the Medical College of Wisconsin Affiliated Hospi- tals were observed giving and receiving patient handoffs at the evening shift change during a 6-month period. Handoffs were observed in 3 settings. The first setting was the handoff to the

night-float residents, which included 3 surgical oncology services, a colorectal surgery service, a vascular surgery service, and the minimally invasive general surgery service. This handoff took place in a remote room reserved for patient handoffs. Given the voluntary nature of this study, resi- dents were allowed to decline participation in the study entirely or participate intermittently. There- fore, data were collected for services individually, rather than the night-float handoff collectively as one large handoff of the 6 services. We could not therefore evaluate differences in handoff quality for those occurring earlier versus later in the handoff process. The second setting was the trauma service handoff, which took place in the physician work- room next to the nurses’ station and included the 2 services of trauma surgery and acute care surgery. The third setting was the surgical intensive care unit service, which occurred in the surgical inten- sive care unit. Residents of different postgraduate year levels were observed during the study period. The handoff was usually provided by one resident, the “source,” and was received by 2 residents, the “receivers,” a senior and a junior resident. This quality-improvement study was approved by the institutional review board (IRB). Partici- pants in the handoff process provided written consent. As part of the informed consent process for the IRB, all participants received an e-mail announcement as well as a group announcement describing the project design, objectives, and methods. This announcement included discussing the questions in Fig 1 , A that were used to evaluate the handoff process. Measures. Trained observers included 1 medical student, 2 senior residents, and 1 surgery faculty member. The observers did not participate in the handoff process. Junior residents gave handoffs in person, whereas senior residents provided hand- offs either in person or via telephone. We had no standardized tools for the handoff process, although all residents had received instruction on handoffs, including several handoff templates and mnemonics. Physicians discussed typically the level of acuity of patients, pertinent history, active problems, hospital course, and action plans. Eval- uation forms for the source, receiver, and observer were developed based on our linear model of communication published previously. 4 Observers utilized a standardized form to iden- tify distractions, including number of extraneous staff entering or leaving the room, background conversations, side conversations unrelated to pa- tient care, interruptions due to pager beeps,

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