Explore this issue:September 2013
It was the beginning of an overnight shift, and the junior resident was the only one in house. He had been briefed about the group of patients he was responsible for, and one patient—who had a complex cancer and underlying cardiac issues and had just come out of a long surgery—had been prescribed a specific antibiotic following the procedure. But what step would the resident take next, when the patient developed a cardiac arrhythmia due to intraoperative blood loss or fluid shifts at 2 a.m.? Would it be something the junior resident had decided on the fly, or had a senior attending physician already envisioned this possibility and discussed how to respond, hours before?
How well these questions are answered depends on how the patient handoff—the information the day’s group of doctors presented to the overnight shift—went earlier in the shift. The handoff procedure is a crucial part of patient care, and standards to strengthen it were implemented in 2011 by the Accreditation Council for Graduate Medical Education (ACGME). In light of the 2003 resident duty hour restrictions—limiting residents to working 80 hours a week, overnight shifts every third or fourth night and at least 10 hours off between shifts—most people admitted to a medical center for care will be seen by at least two shifts of health care workers as one group takes over for the next.
For residents, knowing how to communicate crucial handoff details is a skill learned on the job. Those details boil down to two questions: 1) What is the bottom line for each patient? and 2) What are the potential interventions if a patient deviates from what is expected? With more groups of people overseeing patients in an era of restricted medical resident work hours, the potential for missed details has increased.
How should handoffs work? “There is a basic expectation that physicians transfer relevant information to colleagues in instances in which they are not available to their patients 24/7,” said Ingrid Philibert, PhD, MBA, ACGME’s senior vice president of the department of field activities. “This predated the duty hour limits, but the limits increased the frequency of handoffs and made the consequences of no, or suboptimal, handoffs much more prominent.” With additional people taking over responsibility for patients over any given day or week, there are “more opportunities for missed, erroneous or distorted information being transferred during these handoffs,” she added.
In a surgical specialty such as otolaryngology, things “operate in a culture in which the physician has traditionally been available to his or her patients 24/7,” Dr. Philibert said. “There are patient safety and learning benefits in peri-operative continuity that are not fully compensated by good handoffs—particularly if there are post-operative complications where the surgeons who performed the operation are in a better position to provide treatment than another physician, even when armed with complete and accurate handoff information.”
But with current work hour limits, how can physicians make the handoff process both smooth and smart so that patient care isn’t compromised? It’s important to know. According to research published in 2009, 26 to 31 percent of malpractice suits pointed to errors that occurred during the handoff process (Acad Med. 2009;84:1775-1787).
How the System Works and Why There Are Problems
Each otolaryngology program, like programs in other medical specialties, typically has its own method through which its residents learn the handoff process. Currently, universal protocols aren’t in place due to the variables among institutions, said Mark A. Zacharek, MD, a clinical associate professor and associate program director at the University of Michigan Health System’s department of otorhinolaryngology, and director of the Michigan Sinus Center in Ann Arbor.
“Some day we may have a nationally accepted standard by which the patient handoff occurs,” said Dr. Zacharek. “This may be difficult because programs vary in size, geography, size of hospitals and whether a Veteran’s Administration Hospital or Community Hospital systems are part of an otolaryngology training program.”
Such differences also affect how the handoffs take place—whether in person in a group meeting, over the phone via conference call or through online formats such as Skype or Facetime, said Dr. Zacharek.
In a 2012 editorial about the surgical handoff, Dr. Zacharek and colleague Waleed M. Abuzeid, MD, a clinical instructor in rhinology and advanced sinus surgery at Stanford University, wrote that “poorly performed handoffs generate medical errors, increase the length of hospital stays, elevate costs and cause patient harm” (Ear Nose Throat J. 2012;91:460-464).
One way to fix these issues? Supervision is a key component for an effective handoff. “Most programs rely upon the senior/chief residents to closely monitor how junior residents provide hand off information,” said Dr. Zacharek. It is through this method that doctors learn, said Anna Messner, MD, professor, vice chair and residency program director in the department of otolaryngology/head and neck surgery at Stanford University. “I think most residents get good at handoffs over time, so that by the time they finish they are fully competent,” she said. “But one of the ways they get good is that they learn from suboptimal experiences. In my opinion, the best way to speed up the learning process is to have senior residents observe junior residents doing actual handoffs. The senior or chief residents are the best at knowing what information is important, what does not need to be said, where are the potential problems.”
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.”
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.
IMOUTA “is a great method for us,” said Dr. Brennan, whose department continues to use it. “Before, when I asked residents about patient details after patient handoffs, there was no standardized method or format for ensuring they knew exactly what needed to be done that night,” he said. “Clearly, things were missed.“
“With the structured format being the same way every time, it helps with communication,” said Dr. Connor. “You become faster and more efficient at delivering the message, and on the receiving end, you know what the progression is going to be. You expect the information and you are better able to receive it.” The process also helped streamline communication.
Better Handoffs Moving Forward
Emphasizing the importance of the handoff can go a long way in making it better. “Enhanced teaching and oversight, including supervision of junior resident handoffs with senior residents,” can make them better, said Dr. Philibert. On the communication side, there’s been a relative lack of focus on the resident ‘receiving’ the handoff. “The role of the receiving resident is just as important. By asking the right questions, the receiving resident can contribute to a complete and accurate handoff,” she said. Dr. Philibert also said she’s been surprised by the emphasis on teaching the handoff as predominantly a communication and memory activity, rather than as a clinical task. For example, for a resident to communicate with accuracy about how likely it is that a patient may need extra attention over the next shift, the resident “needs to know the relative probabilities of different clinical events or complications occurring,” she said.
And knowing that is something that comes with experience. “A lot of times, the issues are minor and can be corrected, but there is a much smaller but still significant proportion of time when there are critical issues for the patient, resulting in major morbidity or death,” due to missed details during a handoff, said Dr. Abuzeid. “The actual gravity of the surgical handoff is something I probably didn’t appreciate until I did the research. My knowledge base as a second-year resident was such that I probably didn’t realize what I didn’t know until I completed my residency.”Multi-Page