2017 HSC Section 2 - Practice Management

ARTICLE IN PRESS

Surgery j 2016

Hasan et al

Table I. Number of handoffs observed and number of source/receivers completing the evaluation form Number of handoffs observed

conversations by extraneous staff, and 58% of hand- offs were noted to have activated electronic devices unrelated to the handoff or patient care ( Table II ). The observers noted that some form of distrac- tion occurred in nearly every handoff; $ 3 distrac- tions occurred in up to 70% of handoffs; $ 6 distractions occurred in up to 35% of handoffs. The number of patients per service was found to inversely correlate with the amount of time spent handing off each patient (Rs = 0.298, P = .001; Fig 2 ). In addition, the observer rating of the handoff delivery directly correlated with amount of time spent per patient ( P = .048). Evaluation forms completed by the source and receiver(s) reported a distraction in up to 78% of handoffs. Internal distractions, or “noise,” occurred in up to 71% of handoffs, whereas external distractions were noted in up to 44% ( Table III ). Furthermore, the source and/or receiver acknowledged $ 1 type of distraction occurring in 78% of handoffs and 3 distinct types of distractions in up to 37% of handoffs. Fifty-four handoffs were delivered by a post- graduate year (PGY)-1 resident, and the remainder were delivered by a PGY-2 or higher resident. There was no difference in duration of handoffs (8.2 minutes for PGY-1 residents and 9.7 minutes for more senior residents, P = .24). Similarly, there was no difference in the number of distractions, including side conversations by handoff providers ( P = .27), interruptions by extraneous providers talking to handoff staff ( P = .25), pager/phone in- terruptions ( P = .42), or number of teaching dis- cussions ( P = .74). In contrast, the quality of handoff delivery was rated to be better by the Table II. Observer results per 1 service handoff Mean (SD) Duration of handoff (min) 9.1 (5.4) Number of patients in handoff 9.2 (4.6) Number of distractions counted, N (SD) 4.7 (3.4) Number of extraneous staff entering/ exiting the room 1.5 (1.9) Number of side conversations by handoff staff 0.7 (1.1) Number of pager beeps/phone calls interrupting handoff 0.8 (1.1) Number of handoff interruptions by extraneous staff talking to handoff staff 0.6 (0.8) Number of teaching discussions 0.2 (0.5) Background conversations by extraneous staff (% yes) 34 Were unrelated electronic devices on during the handoff? (% yes) 58 SD, Standard deviation.

126

Number of handoffs with 2 observers Number of handoffs with source completing the evaluation form Number of handoffs with 1 receiver completing the evaluation form Number of handoffs with 2 receivers completing the evaluation form

23 78

82

39

Participants in the handoff process, both the source and the receiver, used a standardized paper form to identify distractions and rate the quality of the handoff process according to the same Likert scale ( Fig 1 , A ). Evaluation forms were completed immediately following each service handoff. The source and receiver were also asked if hierarchy/ chain of command served as a barrier for effective communication at any point during the handoff (Yes/No) and to evaluate the source-receiver rela- tionship on a Likert scale (1–5, 5 = best; Fig 1 , B ). A subset of handoffs included 2 observers and/or 2 receivers to assess rater consistency. Statistical and data analysis. Data analysis was generated with SPSS software (version 21.0; IBM Corp, Armonk, NY) with Pearson/Spearman cor- relations and multivariate linear regressions. Re- sults are reported as mean (±standard deviation) for each individual service. Rater consistency was assessed with intraclass correlations (ICC 2,1). RESULTS During a 6-month period, 126 handoffs were observed by $ 1 trained observer; 23 handoffs included 2 observers. An evaluation form was completed by the source in 78 handoffs and by a receiver in 82 handoffs. Two receivers completed the evaluation form in 39 handoffs ( Table I ). The majority of handoffs observed in this study were part of the night-float system (92%). Seven percent of handoffs were completed over the phone, with the evaluation forms completed immediately and returned to the authors. The night-float team received handoffs from 6 separate services. An average service handoff included 9.2 ± 4.6 patients and lasted 9.1 ± 5.4 minutes. Observers identified an average of 4.7 ± 3.4 distractions per service handoff. Extra- neous staff entering and leaving the room was the most common type of distraction, occurring 1.5 ± 1.9 times per service handoff. Furthermore, 34% of handoffs included background

97