We’ve done many columns on the problems associated with handoffs in healthcare (see the listing and links at the end of today’s column). And we’ve discussed the fact that our efforts to minimize errors due to fatigue of long working hours (for not only physicians but also nurses and others) must always be balanced against the errors that occur due to fumbled handoffs that increase when work hours are restricted.
When the Bell Commission in New York State first recommended restriction of housestaff hours in 1989, we queried what the evidence was that patient outcomes were improved when such restrictions were imposed. The answer was “incidents reported to the Department of Health are more frequent at night and on weekends”. Of course, those are also times when continuity of care is reduced because you may have physicians “covering” patients with whom they are less familiar. So even then it was not clear whether tired physicians or lack of familiarity and continuity were more problematic.
And we still don’t have the answer as to the net impact on patient outcomes of such restrictions in housestaff hours. There are some small studies showing worse outcomes (Laine 1993) and some showing improved outcomes (Horwitz 2007) but two systematic reviews (Fletcher2004, Moonesinghe 2011) have basically found no consistent impact on patient outcomes, either beneficial or harmful.
But that doesn’t mean we should not be doing everything possible to improve the handoff process and minimize errors arising from handoffs. A new study (Helms 2011) combined surveys of housestaff attitudes regarding handoffs with direct observations of handoffs to identify some best practices. They found considerable variation in handoffs, differences between “day” and “night” handoffs, and overall degradation of information across consecutive sign-outs. But they did identify 5 residents deemed by their peers to be superior at the handoff process and then identified 5 key strategies used by those ‘best performers”. These included:
· Discussing sickest patients first
· Minimizing discussion on the more straightforward patients
· Limiting plans to active issues
· Using a systematic approach
· Limiting error-prone chart duplication
The limitations of the study are that it included only a single institution, looked at only weekday handoffs, had some subjective variables, and most importantly did not assess impact on patient outcomes.
We’ve always stressed to our residents the following regarding handoffs:
· Allow sufficient time
· Do them where interruptions are less likely (the “sterile cockpit” analogy with aviation)
· Ensure the handoff is a 2-way communication (i.e. ensure the person receiving the handoff understands and has the opportunity to ask questions)
· Use structured communications formats and tools (eg. SBAR)
· Paper vs. verbal: use both (literature says outcomes better when both used)
· Involve the patient when you can
Ensuring that both parties agree on the important issues of a handoff is not so clear-cut. A study last year (Chang 2010) showed that the most important piece of information about a patient was not communicated about 60% of the time! To-do items (65%) and items related to anticipatory guidance (69%) were more likely to be adequately communicated compared with a knowledge items (38%).
All too often we realize that our handoffs are suboptimal only after we review an incident that has already occurred. We believe that recording handoffs can be a valuable educational and performance improvement tool that may help your organization identify problematic communication before adverse events occur. Video recording is preferable to audio since so much communication is nonverbal. When you play back the handoffs to those staff members who were involved, they usually readily recognize opportunities for improvement. As long as this is done in a constructive, nonpunative and nonderogatory fashion it helps staff at all levels of the organization improve their communication skills. And it reinforces to all staff the critical importance of handoffs.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “ ”
November 18, 2008 “ ”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “ ”
April 25, 2009 “ ”
April 13, 2010 “Update on Handoffs”
Laine C, Goldman L, Soukup JR, et al. The Impact of a Regulation Restricting Medical House Staff Working Hours on the Quality of Patient Care. JAMA 1993; 269(3): 374-378
Fletcher KE, Davis SQ, Underwood W. Systematic Review: Effects of Resident Work Hours on Patient Safety. Ann Intern Med 2004; 141(11): 851-857
Horwitz LI, Kosiborod M, Lin Z, et al. Changes in Outcomes for Internal Medicine Inpatients after Work-Hour Regulations. Ann Intern Med 2007; 147(2): 97-103
Moonesinghe SR, Lowery J, Shahi N, Millen A, Beard JD. Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review. BMJ 2011; 342:d1580
Helms AS, Perez TE, Baltz J, et al. Use of an appreciative-inquiry approach to improve resident sign-out in an era of multiple shift changes. Journal of General Internal Medicine 2011. DOI 10.1007/s11606-011-1885-4
Springer Press Release. Hospital patients suffer in shift shuffle. Shorter hours for residents and multiple patient care handovers result in poorer continuity of care.
Chang VY, Arora VM, Lev-Ari S, et al. Interns Overestimate the Effectiveness of Their Hand-off Communication. Pediatrics 2010; 125(3): 491 -496
In our October 18, 2011 Patient Safety Tip of the Week “High-Risk Surgical Patients” we discussed a recently released report from the Royal College of Surgeons of England (Royal College 2011) addressing high rates of mortality and morbidity in high-risk general surgery patients, especially patients undergoing emergency or unscheduled general surgery procedures. That report suggested use of tools such as the P-POSSUM scoring tool to estimate risk in patients undergoing surgery.
Mortality may be difficult to predict and most tools used to predict mortality have only modest accuracy, large variability across diseases and populations, and limited clinical utility (Siontis 2011).
But several studies have shown that much simpler tools may predict complications in elderly patients undergoing surgery. Those that include markers of frailty have been especially useful. In our June 2010 What’s New in the Patient Safety World column “The Frailty Index and Surgical Outcomes” we noted a study (Makary et al 2010) demonstrating use of the frailty index greatly improved the ability to predict post-surgical outcomes (post-op complications, LOS, and discharge to an SNF or assisted living setting) much better than existing methods. And in our August 9, 2011 Patient Safety Tip of the Week “Frailty and the Surgical Patient” we noted two studies by Robinson and colleagues (Robinson 2009, Robinson 2011) looked at outcomes in (mostly male) patients age 65 and older who were undergoing major elective surgical procedures in the VA medical system and correlated them with measures of frailty, disability, and comorbidity. Using a group of markers that were easy to use in a surgeon’s office setting they were able to predict 6-month postoperative mortality and post-discharge institutionalization.
That group has now expanded their study to a total of 223 subjects (Robinson 2011) and focused on discharge to an institutional setting. The burden of comorbidity was assessed using the Charlson index, the ASA score, the total number of medications taken, and anemia. Function was measured by the Katz ADL score and a timed up-and-go test. Nutrition was assessed by BMI, albumin level, and weight loss. Cognitive function was assessed by the Mini-Cog test and the Two-Question Depression Screen. And they added a measure of “geriatric syndromes” (eg. falls) and “extrinsic frailty” (eg. social isolation). Overall, 30% of patients were discharged to institutional settings and another 17% needed home care. The 3 variables most predictive of institutionalization were a timed up-and-go >15 seconds, Charlson score 3 or greater, and hematocrit <35%. Three or more frailty characteristics had a sensitivity of 82% and specificity of 84% for predicting institutionalization. Interestingly, age itself was not a predictor but rather the measures of frailty, function, and comorbidities were most important.
The timed up-and-go-test is a measure incorporated into several frailty indices. For those of you unfamiliar with the timed up-and-go test, you simply time a patient standing up from a chair, walking 10 feet, returning to the chair and sitting down. Now a new preliminary study suggests that the timed up-and-go test by itself is an excellent predictor of complications in elderly patients undergoing surgery (American College of Surgeons 2011). Daniel Wu, M.D. and colleagues at the University of Colorado, Denver studied 195 patients aged 65 and older who underwent cardiac or colorectal surgery. They stratified the patients into slow (>15 seconds), intermediate (11-14 serconds), and fast (less than 10 seconds) groups based on the timed get-up-and-go test. Compared to the fast group, the “slow” group was much more likely to be discharged to an institutional care facility and had longer hospital LOS. This applied to patients undergoing either cardiac or colorectal surgery. Though the authors state this was simply a “proof-of-concept” study and plan a multi-institutional trial to confirm their findings, this is exciting that a simple test that can be performed in the office may provide such important information. Note that the timed up-and-go test (>15 seconds) was one of 3 variables most predictive of institutionalization in the Robinson study noted earlier.
While we are waiting for more sophisticated risk prediction tools that are validated for the specific populations and procedures you are dealing with, it is helpful to know you can do at least this one simple test and get a pretty good idea of your patient’s surgical risk.
The Royal College of Surgeons of England / Department of Health. The Higher Risk General Surgical Patient: Towards Improved Care for a Forgotten Group. 2011
Siontis GCM, Tzoulaki I, Ioannidis JPA. Predicting Death. An Empirical Evaluation of Predictive Tools for Mortality. Arch Intern Med. 2011; 171(19): 1721-1726
Makary MA, Segeve DL, Pronovost PJ, et al. Frailty as a Predictor of Surgical Outcomes in Older Patients. Journal of the American College of Surgeons 2010;
Robinson TN, Eiseman B, Wallace JI, et al. Redefining Geriatric Preoperative Assessment Using Frailty, Disability and Co-Morbidity. Annals of Surgery 2009; 250(3): 449-455, September 2009
Robinson TN, Wallace JI, Wu DS, et al. Accumulated Frailty Characteristics Predict Postoperative Discharge Institutionalization in the Geriatric Patient. J Am Coll Surg 2011; 213(1): 37-42, July 2011
American College of Surgeons. Simple Timed Walking Test Is an Accurate Predictor of Adverse Outcomes for Older Surgical Patients. Newswise October 26, 2011
One of our pet peeves in primary care is that physicians readily order bone densitometry tests and prescribe drugs for osteoporosis yet almost never do fall risk assessments on those patients. CMS even uses ordering the bone densitometry test or prescribing the drugs in their quality measures yet also does not assess whether fall risk assessments were done. In that population, our real goal is to prevent fractures so why would you just look for osteoporosis and skip the fall risk assessment?
There are obviously many factors that predispose patients to falls (drugs, orthostatic hypotension, neuropathies with loss of proprioception, other neurological diseases, and multiple sensory deficits, among others) and there are numerous fall risk assessment tools out there.
But a recent paper noted the value of the time up-and-go test (yes, the same one we just described earlier in this month’s What’s New in the Patient Safety World column “Timed Up-and-Go Test and Surgical Outcomes”). Zhu and colleagues (Zhu 2011) looked at bone densitometry and the timed up-and-go test (“TUG”) in a cohort of women aged 70-85 who were followed for 5 years in a randomized clinical trial of calcium supplementation to prevent fractures. They found that the TUG (using a cutoff of 10.2 seconds) was an independent predictor of nonvertebral fracture.
The TUG is a measure incorporated into several frailty indices. For those of you unfamiliar with the TUG, you simply time a patient standing up from a chair, walking 10 feet, returning to the chair and sitting down.
The TUG costs nothing and takes almost no time to complete so it can be easily integrated into almost any practice setting.
The editorial accompanying the Zhu article (Bauer 2011) notes that some good existing algorithms to predict fracture, such as WHO’s FRAX, also lack inputs that assess fall risk and could be significantly improved by inclusion of such a variable. He notes that such a variable should be easy to measure, reproducible, and strongly predictive of fracture independent of bone density and other factors and notes that the timed up-and-go test has many of those attributes. Though advocating further studies to formally assess that combination, he suggests that adding the TUG to the FRAX tool may prove to be very useful.
Sometimes it’s remarkable how we overlook useful things that are right in front of us!
Zhu K, Devine A, Lewis JR, et al. "'Timed Up and Go' Test and Bone Mineral Density Measurement for Fracture Prediction. Arch Intern Med. 2011; 171(18): 1655-1661
Bauer DC. FRAX, Falls, and Fracture Prediction: Predicting the Future: Comment on " ‘Timed Up and Go’ Test and Bone Mineral Density Measurement for Fracture Prediction". Arch Intern Med. 2011;171(18):1661-1662
WHO’s FRAX algorhithm and scoring tool
We’ve highlighted in the past numerous issues and potential dangers associated with Dilaudid/HYDROmorphone (our Patient Safety Tips of the Week for July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression”, September 21, 2010 “Dilaudid Dangers”, and May 17, 2011 “Opioid-Induced Respiratory Depression – Again!”).
ISMP (Institute for Safe Medication Practices) in their most recent Medication Safety Alert Acute Care Edition highlighted some recent changes in labeling of HYDROmorphone products resulting from reports to ISMP, the FDA, and the Pennsylvania Patient Safety Authority among others (ISMP 2011).
The new labeling has some changes in format designed to bring to the attention of the prescriber some important aspects of using HYDROmorphone. But probably the two most important changes have to do with specific dosing issues:
1) The recommended intravenous starting dose is reduced to 0.2-1 mg (previously it was 1-2 mg)
2) A bolded warning notes that morphine and HYDROmorphone are not milligram-to-milligram conversion equivalents and they provide a conversion table for converting doses of other opioids to HYDROmorphone
We applaud the labeling changes. In our experience the biggest problems related to use of HYDROmorphone have been due to lack of understanding of the potency of HYDROmorphone relative to morphine and other opioids.
For a long list of recommendations regarding use of Dilaudid and other opioids see our Patient Safety Tip of the Week for September 21, 2010 “Dilaudid Dangers”.
ISMP (Institute for Safe Medication Practices). FDA Advise-ERR: FDA approves HYDROmorphone labeling revisions to reduce medication errors. ISMP Medication Safety Alert Acute Care Edition 2011; October 20, 2011
Another of our favorite topics: surgical fires (see list of our prior columns on this topic at the end of today’s column). The FDA has just launched an initiative aimed at preventing surgical fires. The resources contain a new video on surgical fires that nicely complements prior videos from ECRI and the Anesthesia Patient Safety Foundation. The video focuses on an approach taken by one healthcare organization after it experienced two surgical fires within an 8-month period. They incorporated a fire risk assessment into their Universal Protocol so that it gets done on virtually all surgical cases. The risk assessment is based on 3 simple questions about the fire triangle: (1) is there an open oxygen source? (2) is there a heat source present? and (3) how close are they to each other? (Note they assume that the “fuel” leg of the fire triangle is everpresent in the OR.) They then tie various protocols to the risk assessment score. The video describes the steps taken to mitigate the fire risk and also deals with improving communication among all members present in the OR and changing safety culture.
The October 13, 2011 FDA Safety Communication: Preventing Surgical Fires provides a concise summary of the scope of surgical fires and a list of good recommendations on how to prevent them. In addition, it has links to a variety of excellent resources on surgical fires and their prevention. The latter includes links to resources we’ve cited in our prior columns such as the ECRI and APSF resources, the Joint Commission Sentinel Event Alert on surgical fires, the AORN toolkit on surgical fire prevention, and a great reference we had not previously seen: a set of surgical fire safety documents from Christiana Care Health System.
Prevention of surgical fires requires an ever-present vigilance for risk factors, protocols to minimize those risks, and simulation training or drills so that all staff know what to do if a fire does occur.
Please also see our prior columns on surgical fires:
Patient Safety Tips of the Week:
· December 4, 2007 “Surgical Fires”
· April 29, 2008 “ASA Practice Advisory on Operating Room Fires”
What’s New in the Patient Safety World columns:
· November 2009 “ECRI: Update to Surgical Fire Prevention”)
· January 2011 “Surgical Fires Not Just in High-Risk Cases”
· March 2011 “APSF Fire Safety Video”
FDA. Preventing Surgical Fires.
Silverstein KL, Joseph S. FDA on Medscape: Surgical Fires: How They Start and How to Prevent Them. October 12, 2011
FDA. FDA Safety Communication: Preventing Surgical Fires. October 13, 2011
Christiana Care Health System. Surgical Fire Risk Assessment.