Bos­ton Chil­dren’s de­vises hand­off pro­ce­dures to re­duce er­rors and im­prove pa­tient safety

Modern Healthcare - - BEST PRACTICES - By Mau­reen McKin­ney

In 2009, clin­i­cian-re­searchers at Bos­ton Chil­dren’s Hospi­tal were alarmed by na­tional data sug­gest­ing a strong link be­tween poor com­mu­ni­ca­tion and er­rors. As many as 70% of med­i­cal er­rors and sub­se­quent ad­verse events can be traced to poor com­mu­ni­ca­tion, safety ex­perts say, and many of those com­mu­ni­ca­tion lapses oc­cur when trans­fer­ring pa­tients be­tween care providers.

The re­searchers saw that med­i­cal in­terns and se­nior res­i­dent physi­cians at the hospi­tal were do­ing their pa­tient hand­offs at each shift change in sep­a­rate leav­ing in­terns with­out the

rooms, ben­e­fit of much-needed su­per­vi­sion.

Im­prov­ing pa­tient hand­offs is a tough task be­cause hospi­tal care is fast­paced and com­plex, pa­tient acu­ity is in­creas­ing and busy clin­i­cians con­vey pa­tient in­for­ma­tion to one an­other in vastly dif­fer­ent ways, said Mary Ann Friesen, nurs­ing re­search co­or­di­na­tor at Inova Health Sys­tem, Falls Church, Va., whose own work fo­cuses on pa­tient-cen­tered ap­proaches to hand­offs. “It’s not just a mat­ter of de­liv­er­ing a mes­sage,” she said. “The (other) per­son has to re­ceive it.”

So the team at Bos­ton Chil­dren’s de­vel­oped a pro­gram to stan­dard­ize hand­offs and pro­tect against hap­haz­ard lapses that could lead to safety events and pa­tient harm. And they de­vel­oped a handy mnemonic de­vice, called I-PASS, for help­ing providers ef­fec­tively hand off pa­tients to each other at shift changes.

I-PASS stands for ill­ness sever­ity; pa­tient sum­mary; ac­tion list; sit­u­a­tion aware­ness and con­tin­gency plan­ning; and syn­the­sis or read-back. It pro­vides a struc­ture for res­i­dents to quickly and ef­fi­ciently brief each other on pa­tient in­for­ma­tion, said Dr. Christo­pher Lan­dri­gan, di­rec­tor of Bos­ton Chil­dren’s in­pa­tient pro­gram and lead in­ves­ti­ga­tor of a re­cently com­pleted mul­ti­cen­ter study that rolled out the I-PASS in­ter­ven­tion in 10 aca­demic med­i­cal cen­ters across the U.S. and Canada.

The I-PASS mnemonic is just one com­po­nent in a bun­dle of hand­off in­ter­ven­tions, in­clud­ing spe­cial­ized train­ing and a writ­ten handout, in­sti­tuted at the 395-bed hospi­tal.

The risks as­so­ci­ated with in­ad­e­quate hand­offs have grown in re­cent years, as res­i­dent work-hour lim­its took ef­fect and the fre­quency of such care­giver-to-care­giver tran­si­tions has in­creased.

In ad­di­tion to the I-PASS mnemonic, Bos­ton Chil­dren’s hand­off bun­dle in­cludes a com­put­er­ized hand­off tool, em­bed­ded in the elec­tronic health record, which au­to­mat­i­cally fills in pa­tient data. The in­ter­ven­tion also fea­tures two hours of ed­u­ca­tional train­ing for par­tic­i­pat­ing clin­i­cians.

Lan­dri­gan and his col­leagues also re­lo­cated pa­tient hand­offs to a quiet con­fer­ence room where all res­i­dent physi­cians and in­terns con­duct pa­tient hand­offs as a team.

Se­nior res­i­dents ini­tially wor­ried that watch­ing over hand­offs be­tween in­terns would in­ter­rupt their work­flow, said Dr. Bradley Podd, a chief res­i­dent at Bos­ton Chil­dren’s. “That turned out not to be the case at all,” he said. “The en­tire team was shar­ing in­for­ma­tion and it worked very well.”

The ear­li­est ver­sion of Bos­ton Chil­dren’s hand­off bun­dle, im­ple­mented over three months in late 2009 and early 2010, led to a 40% drop in over­all med­i­cal er­rors—from 33.8 per 100 ad­mis­sions to 18.3 per 100 ad­mis­sions—and a 50% re­duc­tion in er­rors that cause pa­tient harm—from 3.3 per 100 ad­mis­sions to 1.5 per 100 ad­mis­sions—com­pared with an ear­lier base­line mea­sure­ment pe­riod. That study’s re­sults, which in­cluded 1,255 pa­tients, ap­peared in the Dec. 4, 2013 is­sue of the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion.

Gal­va­nized by those re­sults, Lan­dri­gan and a team of re­searchers used the pi­lot as ground­work for an I-PASS study, which im­ple­mented a re­fined ver­sion of the hand­off bun­dle at Bos­ton Chil­dren’s and nine other hos­pi­tals. Those re­sults are ex­pected this sum­mer.

Friesen praised in­ter­ven­tions such as the one at Bos­ton Chil­dren’s that in­tro­duces a uni­form but cus­tom­iz­a­ble way to com­mu­ni­cate in­for­ma­tion ev­ery time. “That struc­ture is very im­por­tant be­cause it helps people or­ga­nize their thoughts and helps them to see any­thing they might have missed,” she said.

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