Work Hour Limits for Medical Residents Spur Otolaryngologists to Rethink Patient Handoffs

The devil is in the details—countless details. “There are so many variables that go into the care of a sick patient,” said Dr. Zacharek. “If a resident is to start from point A, the initial evaluation of a new patient is in the emergency room. There are multiple, possibly hundreds, of specific information points as well as decisions that the resident must make regarding the care of that patient. When a resident has five to 10, or possibly more, patients admitted in one night, there are then a tremendous number of variables that have been set in motion by the one caretaker or resident physician. It is then quite complex as far as what critical points of information need to be transferred to the next team.”

Otolaryngology Handoffs

While handoff procedures have been studied for internal medicine, academic medicine and general surgery, and medical researchers have looked into the handoff protocols for those who work at NASA and the U.S. Military, until recently there was little reported on the otolaryngology residents handoff. In studying the literature, Joseph Brennan, MD, the chief of surgery at San Antonio Military Medical Center at Fort Sam Houston developed a proposal for patient care handoffs he called “IMOUTA,” a mnemonic that incorporates a series of steps to be taken by the physicians handing off care and by those taking over care for the new work shift. IMOUTA, designed to sound like “I’m outta” here (“I had to think of something that people would remember,” Dr. Brennan explained), incorporates what Dr. Brennan said he took from the best handoff practices he had read about for other specialties.

The IMOUTA handoff covers five areas in the handoff process, said Matthew Connor, MD, a fourth-year otolaryngology resident at the San Antonio Military Medical Center and, with Dr. Brennan, a co-author of a paper about IMOUTA that appeared in the Laryngoscope earlier this year (Laryngoscope. April 25, 2013; doi: 10.1002/lary.24118). The areas covered are:

• I—Identify Data, covers basics such as the patient’s name, the staff surgeon and on-call staff overseeing that patient, and the patient’s room number.
• M—Medical Course, addresses details about the patient’s diagnosis and the post-operative day. “This would include discussion of any complicating issues, the important things the physician on call would need to know,” said Dr. Connor.
• OU—Outcomes Possible Tonight and includes things to be on the lookout for, such as patients who are at risk for airway complications. “This is a way to talk through potential management options for the patient,” said Dr. Connor.
• T—To Do Tonight, such as performing post-operative checks or reviewing radiology films or important labs. Residents are also required to read back the to-do list.
• A—Asking questions and giving feedback the morning after the shift.

The IMOUTA procedures were studied as a single-blind, controlled clinical trial at San Antonio Military Medical Center in 2012. Otolaryngology residents filled out a questionnaire for 45 days that asked residents about their traditional handoff methods, which had involved one resident relaying relevant patient information without any structured format. Then, for the next 45 days, residents answered the questionnaire using the IMOUTA format. The results using IMOUTA were universally preferred, said Dr. Connor. “Residents felt more comfortable with the handoff, and there were significantly [fewer] events that happened that the residents didn’t feel prepared for,” he said.