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Improving Transitions of Care: Implementing a Training Program for Incoming Interns
Erica Lescinskas MD, Diana Stewart MD, Chirayu Shah MD MEd FACP FHMBaylor College of Medicine
Conclusions
Background
1. Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfer of patient care between house staff on internal medicine wards: A national survey. Arch Intern Med. 2006;166:1173-1177.
2. Liston BW, Tartaglia KM, Evans D, Walker C, Torre D. Handoff practices in undergraduate medical education. J Gen Intern Med. 2014;29(5)765-769.
3. Accreditation council for graduate medical education. CLER pathways to excellence. https://www.acgme.org/Portals/0/PDFs/CLER/CLER_Brochure.pdf, Accessed January 11, 2017.
4. Starmer AJ, Spector ND, Srivastava R, et al. I-PASS, a mnemonic to standardize verbal handoffs. Pediatrics. 2012;129(2):201-204.5. Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med.
2014;371(19):1803-1812.
Contact Information Erica Lescinskas, email: [email protected]
Care Transitions Workshop Structure
• Transitions of care between physicians is a vulnerable time for patients during hospitalization.
• Clinical Learning Environment Review (CLER) focuses on handoffs and programs’ assessment of when residents can move from direct to indirect supervision.
• Simulation has been shown to be an effective way to teach handoffs, but longitudinal data is lacking.
• Limited data is available regarding the impact of incorporating handoff training in medical school on the comfort level of incoming interns
Care Transitions Workshop Structure• Large group: Didactic/discussion with videos of handoffs.• Small group: Discussion of cases and videos, facilitated by senior
resident or faculty.• Handoff simulation: One-on-one session with faculty or senior
resident to practice prioritizing patients and delivering handoffs, with opportunity to incorporate feedback in another simulated handoff.
• Despite an increased emphasis on handoffs in medical schools, incoming trainees still benefit from institution specific training.
• This Care Transitions Workshop leads to significant increases in trainee comfort and confidence in performing handoffs which is critical to patient safety.
• We recommend all training programs adopt care transitions training as part of orientation.
Discussion
Purpose
• Create a sustainable Care Transitions workshop as part of internal medicine intern bootcamp.
• Train all interns to use the IPASS method when performing handoffs.• Allow interns to simulate patient handoffs and receive real-time
feedback.• Evaluate written handoffs for complying with utilizing the illness
severity categories (star or unstable/watcher/stable)
Training in Medical School
Effect on Handoff Practices
of residents reported they are very likely or somewhat likely to change their patient handoffs
based on this workshop.
Large group session
Small group workshop
Simulation session
Intern Bootcamp (during orientation)
• With increased attention to transitions of care, medical schools are increasingly including handoff training for students.
• Despite these interventions, interns lack comfort and confidence with these skills when starting residency.
• Instituting a formal care transitions workshop during intern orientation consistently improved comfort and confidence of trainees in performing handoffs since implementation in 2014.
• Review of written handoff documents showed >99% compliance with the illness severity classification using IPASS
• Using formal assessments at the simulated sessions, residency programs can satisfy requirements by CLER and allow patient handoffs to move from direct to indirect supervision.
100% in 2014
100% in 2015
91% in 2016
Observation & Feedback
45%
59%63%
79%
88% 90%
51%
60%65%
30%
40%
50%
60%
70%
80%
90%
100%
2014 2015 2016Formal instruction on handoffs Experience with handoffs "Transition to Intern Year" course
% o
f in
com
ing
inte
rns
3.58 3.51 3.42
4.08 4.254.02
1.0
2.0
3.0
4.0
5.0
2014 2015 2016
BEFORE Bootcamp AFTER Bootcamp
3.343.69 3.56
4.32 4.354.16
2014 2015 2016
BEFORE Bootcamp AFTER Bootcamp
3.073.21 3.24
4.26 4.34.15
1.0
2.0
3.0
4.0
5.0
2014 2015 2016
BEFORE Bootcamp AFTER Bootcamp
Workshop Results
Comfort level with providing effective
handoffs
Confidence with using a standardized
tool for handoffs
Confidence in identifying factors
essential to an effective verbal handoff
References
p<0.05 p<0.05 p<0.05
13,203
28,498 Patient handoffs evaluated
Handoff documents reviewed
Year studied
99.4%compliance with illness severity†
†compared to 88.9% reported in the
original IPASS study5
n=73/73 n=73/73 n=79/83
Likert Scale: 1=low comfort/confidence levels, 5=high comfort/confidence levels