morning report 6/28/13: handoffs
TRANSCRIPT
Improving signout skills
JHU/Sinai HospitalMorning report
6/28/13
Goals
Review common pitfalls during signout
Learn to create and update a written signout
Learn how to execute a verbal handoff
Sender oranizes &updates handoffinformation
Specific verbalexchange betweensender and receiver
Pre-handoff Arrival Dialogue Post-handoff•Lack of time, poor time management, fatigue or work prevent updating
•Lack of clinical judgement
•Vague language
•No set location or time
•Not able to contact sender or receiver
•Competing obligations
•Handoff not a priority over other tasks
Sender could:
•Provide disorganized info
•Use vague language
•Fail to provide clinical impression, anticipatory guidance, plan or rationale
Receiver could:
•Not listen
•Misunderstand
•Not clarify (ask)
•Forget key tasks or information
•Not document actions taken
•Act on plan without taking new information into account
•Not invest in the care of patient
Two-way street
Handoffs are dialoguesSender must paint a pictureReceiver must see it, understand it,
act on it, and, ultimately, communicate it to someone else.
Core components of handoffs
Verbal communicationin person or over the phone
Written communicationsign-out
Transfer of professional responsibility
Constructing a written sign-out
Abstracted from H&PInformation that may become important in a critical situation
code status, i.v. access, PCP, family info
admission diagnosis, date, teamAll patients, even those being d/c’d that dayAvoid vague language
tomorrow/today/yesterday…
9 Ds
iDentitiy / Doctor / DNR?Diagnosis and DiseaseDietDrugsDaily progressDirections:
if/then, to-do
iDentitiy
Room numberremember to update it
Patient nameAge, genderMedical record number
Diagnosis and Disease
Same columnDiagnosis first
Reason for admission and/orThe main problem that is being worked up
Then the disease (co-morbidities)
CHF exacerbationCAD, HTN, DM, asthma
Drugs
Sometimes difficult to list all, butyou can use abbreviationshighlight the important ones(antibiotics, narcotics, anticoagulants…)with a * … *
If you copy/paste from Rounds Report, have to spend some time removing cruft
Diet
Many calls about NPO statusEspecially in patients going to
surgery/procedures the next day
Daily progress/Plan
Things that explain patient’s *current* condition, progress, interventions, problems, plans
e.g. On Lasix 40 mg IV q12h, net –ve 1.5L/24hr, improving; echo: EF 30%; continuing diuresis, cardiology to evaluate
Directions
Items To Do: only important things that need to be addressed or require follow up, with special instructions for further plans and rationale—avoid “check BMP”
If/then: anticipatory guidance for what may happen, short and clear
Updating written sign-out
Update daily:DrugsDirections
Nearly 1/3 of signouts discrepant with chart:80% with at least 1 omission40% with one comission
CoPaGA syndrome
Copy/Paste Gone Amok
Repeated copying and pasting text from H&Ps and progress notes into singout
Crowds out useful information by gluts of useless data
Zombie-like propagation of inaccuracies
Information overload
Overreliance on signouts for your own workSignouts become unnecessarily long shadow chartOften becomes a personal tracker of information
But remember, your covering intern needs it simple
Verbal handoffs
Speakers systematically overestimate how well their messages are understood by listeners
Egocentric heuristic—senders assume that receiver has all the same knowledge that they do
Worsens the better you know someone
Biases in signout
The most important piece of information was not communicated 60% of the time, despite the sender believing it had been
Did not agree on the rationales provided for 60% of items
Some things more likely to be remembered:ToDo (65%), If/then (69%), more likely than knowledge items (35%)
What can senders do?
Relevant items that will be Rememberedfocus on the sickest patient firstdaily progressdirection: to-do and if/then items
Directions with Rationaleavoid ambiguity: “check CBC” without giving a reason why and what to do with results
Check for Receiver understanding
What can receivers do?
Actively listenstay focused, limit interruptionstaking notes can enhance memory
Ask questionsto ensure you understand dirctions
Use a systemto keep track of to-do items
Readback
Example 1
A nurse calls because the patient wants to know if they can eat.
Signout says “Patient is NPO for surgery tomorrow”
Always give datesAvoid use of today/tomorrow/yesterday
What procedure? How important?
Example 2
Your signout says“Check BMP at 8pm”
The patient has a sodium of 124.
What are you supposed to do with abnormalities?
What is the baseline?What are you looking for?
Example 3
The patient you are covering is being evaluated for SBO. The surgeon comes by after being in the OR and asks you what the patient’s coags are. You say: “I’m sorry, but that’s not my patient”.
Handoffs are more than just a transfer of content, but also a transfer of personal
responsibility.Every patient is your patient.