1. PT INFOHPIPROB LISTMEDSTo DoX Cover Smith, John Bob F14 1465A MR: 34520XXX 56 yo male with shortness of breath for one week **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely pre-renal Cefepime 1gm IV q12 Colace 100mg po bid Metoprolol 100mg bid ---D/C Info--- PMD Dr. Jones 444- 2244 [] f/u 7pm Na – increase IVF if Na <130 [] check renal note Safe & Effective Handoffs Subha Airan-Javia Penn Hospitalist Medicine

2. It happened at a hospital you know… 9am rounds: 70 yo woman with DVT & h/o GI bleed On heparin with 48 hours of very elevated ptts (>150) Altered mental status & low BP  CBC ordered 1pm postcall signout: “f/u CBC” No mention of elevated PTTs or concern for GI Bleed as potential cause of altered mental status and low BP 3pm: Hgb = 4.0 Wasn’t believed, another hgb was sent, no transfusion 5pm: Patient had melena, hypotension, transferred to the ICU. Repeat CBC confirmed Hgb of 4. Patient quickly coded and expired in ICU

3. Think About it… Did a poor handoff contribute to this patient outcome? Did this patients get the care that she expected from our hospital? How about the care that you and I expected?

4. Fear of making a mistake and harming a patient Natural fear You will make errors; we all do Did parts of the hospital system make the error easy to happen? If so, someone else needs to know (chief resident, program meeting, incident reporting system) Take care of yourself and each other

5. Goals for Today Get you ready to perform safe handoffs! Review the importance of handoffs Teach the components of a good electronic and verbal handoff Practice handoffs in a simulated environment

6. Facts Discontinuity in the hospital is inevitable Discontinuity is increasing in teaching hospitals due to duty hour regulations Lack of communication is the most common root cause of medical errors nationally Communication breakdowns during handoffs can have deleterious effects on our patients

7. More Facts… Improving Handoffs is a National Patient Safety Goal (NPSG 2E) Implement a standardized approach to “handoff” communications including an opportunity to ask and respond to questions

8. Petersen, L. A. et. al. Ann Intern Med 1994;121:866-872 Being Covered by a cross-cover resident is a powerful risk factor for preventable adverse events.

9. Bringing it closer to home… ED Resident Nightfloat JAR Intern A - Shortcall On Call Intern #1 Intern A On Call Intern #2 Intern A (now on Call) Dayfloat Day 1 Day 2 Day 3 Day 4 Day 5 6 Residents, 7 Handoffs in 5 days

10. Even more handoffs in the ICUs… ED Resident Primary On-Call team Nightfloat Dayfloat Primary Team Nightfloat Day 1 Day 2 Day 3 4-5 Residents, 5 Handoffs in 48 hours

11. A handoff example…. Location: Founders 14 nurses station Time of Day: 12:30pm post-call People: Two July interns who don ’ t really know each other yet.

12. What did you notice?

13. Noisy environment Multiple interruptions Delivery is not standardized No time for questions, reiteration of plan

14. Safe Handoff Practices

15. Verbal Handoff Tips Location: as quiet as possible (away from the nursing station, not in the ED) Minimize interruptions Start patient over if unavoidable If you are worried about the patient…say it first! Give on-call intern an opportunity to ask questions and repeat back important facts Review every patient Follow the same format/order for all patients

16. Verbal Handoff Format PROBLEM BASED Sick/Not Sick Code status (if not full code) 1-3 sentences history PROBLEM LIST Active issues for each Relevant Data and Meds Crosscover list If/then statements, anticipatory guidance

17. Electronic Handoff: Purpose Reference for primary team Reference for covering provider Repository of information Discharge summary A Novel

18. Electronic handoff plan Problem list  owned by Interns Rest of handoff  primarily resident responsibility July – Jan Interns should participate, edit what they can handle Increase your share of handoff involvement

19. Handoff  Progress Note Problem List 50 Thousand foot view of problems with short assessment & overall plan Important medications & radiology associated with problems Antimicrobials, anticoagulation, immunosuppressants, Narcotics Concise, bulleted

20. Problem list ≠ Assessment and plan

21. Electronic Handoff Tips Standardize: Keep info in designated location Exclude/Remove irrelevant information Clean-up and update handoff regularly Avoid non-standard abbreviations MS: multiple sclerosis, mental status, or morphine sulfate? HL: Hyperlipidemia or Hodgkin ’ s Lymphoma? Summarize findings. Do not cut and paste results

22. Electronic Handoff Tips Problem list should be complete, but concise Should not be your entire progress note word for word This is the basis of your verbal handoff Should be updated & reprioritized as new problems arise and old ones change

23. SIGNOUT DISCHARGE SUMMARY

24. And don ’ t forget… The sign-out is a TEAM document Read by ALL disciplines in the hospital Unprofessional language and statements should never be written

25. Keys to a Good Handoff The Nitty Gritty

26. Approach to verbal handoff S ick not sick H istory, Hospital Course O bjective data U pcoming plan, dispo T o do

27. Approach to verbal handoff Pt InfoHPIProb ListMEDSTo DoCrossCover Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: FULL Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215- 777-7777 Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pna Race, pertinent PMH, presentation to ED, HPI. -relevant ROS -relevant ED issues (vitals, meds given) -relevant things done o/n -important events during hospitalizaton 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Diarrhea – possibly CDIff, cx pending -Prostate ca – resected, cured ---PMH--- -hyperlipidemia -PTSD -chronic anemia Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 ---D/C Info--- PMD Dr. Jones 444-2244 [] needs gi appt ---To Do --- [] f/u xxx test [] daily pulm note [] f/u 7pm Na – increae IVF if Na <130 -if looks bad, consider fungal coverage S [H O U] T

28. Approach to verbal handoff Pt InfoHPIProb ListMEDSTo DoCrossCover Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: FULL Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215- 777-7777 Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pna Race, pertinent PMH, presentation to ED, HPI. -relevant ROS -relevant ED issues (vitals, meds given) -relevant things done o/n -important events during hospitalizaton 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Diarrhea – possibly CDIff, cx pending -Prostate ca – resected, cured ---PMH--- -hyperlipidemia -PTSD -chronic anemia Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 ---D/C Info--- PMD Dr. Jones 444-2244 [] needs gi appt ---To Do --- [] f/u xxx test [] daily pulm note [] f/u 7pm Na – increae IVF if Na <130 -if looks bad, consider fungal coverage S = SICK/NOT SICK 30 seconds -Name -Code Status -Culture/Family etc

29. Approach to verbal handoff Pt InfoHPIProb ListMEDSTo DoCrossCover Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: FULL Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215- 777-7777 Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pna Race, pertinent PMH, presentation to ED, HPI. -relevant ROS -relevant ED issues (vitals, meds given) -relevant things done o/n -important events during hospitalizaton 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Diarrhea – possibly CDIff, cx pending -Prostate ca – resected, cured ---PMH--- -hyperlipidemia -PTSD -chronic anemia Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 ---D/C Info--- PMD Dr. Jones 444-2244 [] needs gi appt ---To Do --- [] f/u xxx test [] daily pulm note [] f/u 7pm Na – increae IVF if Na <130 -if looks bad, consider fungal coverage H = History 1-2 sentences (1 minute) What brought the patient to the hospital Similar to your ASSESSMENT statement on your A/P

30. Approach to verbal handoff Pt InfoHPIProb ListMEDSTo DoCrossCover Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: FULL Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215- 777-7777 Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pna Race, pertinent PMH, presentation to ED, HPI. -relevant ROS -relevant ED issues (vitals, meds given) -relevant things done o/n -important events during hospitalizaton 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Diarrhea – possibly CDIff, cx pending -Prostate ca – resected, cured ---PMH--- -hyperlipidemia -PTSD -chronic anemia Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 ---D/C Info--- PMD Dr. Jones 444-2244 [] needs gi appt ---To Do --- [] f/u xxx test [] daily pulm note [] f/u 7pm Na – increae IVF if Na <130 -if looks bad, consider fungal coverage “H O U” Active Problems, Hospital course, Objective data & Plan for each MAIN AREA OF FOCUS

31. Approach to verbal handoff Pt InfoHPIProb ListMEDSTo DoCrossCover Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: FULL Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215- 777-7777 Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pna Race, pertinent PMH, presentation to ED, HPI. -relevant ROS -relevant ED issues (vitals, meds given) -relevant things done o/n -important events during hospitalizaton 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Diarrhea – possibly CDIff, cx pending -Prostate ca – resected, cured ---PMH--- -hyperlipidemia -PTSD -chronic anemia Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 ---D/C Info--- PMD Dr. Jones 444-2244 [] needs gi appt ---To Do --- [] f/u xxx test [] daily pulm note [] f/u 7pm Na – increae IVF if Na <130 -if looks bad, consider fungal coverage T = To Do SECOND AREA OF FOCUS -Go through each cross cover to do item, what needs to be done, rationale & action plan -If/Then statements or other guidance

32. Patient Information Pt InfoHPIProb ListMEDSTo DoCrossCover Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: FULL Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215-777- 7777 Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pna Race, pertinent PMH, presentation to ED, HPI. -relevant ROS -relevant ED issues (vitals, meds given) -relevant things done o/n -important events during hospitalizaton 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD MICRO: 11/2 UA neg, Ur cx neg-final 11/2,3,4,5 bld cx x2 neg-final 11/6 UA neg, cx neg-final 11/6,7,8,9 bld cx x2 ngtd 11/9 sputum cx – normal OP flora **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Hyponatremia – likely 2/2 dehydration **Diarrhea – possibly CDIff, cx pending ---PMH--- -Prostate ca – resected, cured -hyperlipidemia -PTSD -chronic anemia Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 ---D/C Info--- PMD Dr. Jones 444- 2244 [] needs gi appt ---To Do --- [] f/u xxx test [] daily pulm note [] f/u 7pm Na – increae IVF if Na <130 -if looks bad, consider fungal coverage

33. Patient Information Pt Info Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: DNR A Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215-777- 7777 Automatically imported from SCM

34. Patient Information Pt Info Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: DNR A Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215-777- 7777 Start with name & status: If you are worried about the patient, say it now - up front. Write it in the crosscover section. “ John Smith is very sick ” ; “ I ’ m worried about Mrs Jones ” Code Status: If not Full Code, always state this verbally. “ He is DNR A ” Access, Culture Limits, Precautions: mention if relevant Contact information: Emergency contact for patient. “ This family wants to be called with every change or new problem, even if in the middle of the night ” ; “ No contact person has been located yet for this patient with dementia ”

35. History & Relevant Data Pt InfoHPIProb ListMEDSTo DoCrossCover Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: FULL Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215-777- 7777 Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pna Race, pertinent PMH, presentation to ED, HPI. -relevant ROS -relevant ED issues (vitals, meds given) -relevant things done o/n -important events during hospitalizaton 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD MICRO: 11/2 UA neg, Ur cx neg-final 11/2,3,4,5 bld cx x2 neg-final 11/6 UA neg, cx neg-final 11/6,7,8,9 bld cx x2 ngtd 11/9 sputum cx – normal OP flora **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Hyponatremia – likely 2/2 dehydration **Diarrhea – possibly CDIff, cx pending ---PMH--- -Prostate ca – resected, cured -hyperlipidemia -PTSD -chronic anemia Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 ---D/C Info--- PMD Dr. Jones 444- 2244 [] needs gi appt ---To Do --- [] f/u xxx test [] daily pulm note [] f/u 7pm Na – increae IVF if Na <130 -if looks bad, consider fungal coverage

36. History & Relevant Data HPI Age, Gender, CC short of breath CC: aspiration pna Patient w/ shortness of breath for 1 week & 10 pound weight loss. Found to have lung mass & post obstructive pna.Vitals on adm to ED: 100 140/80 30 88% RA 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation MICRO: 11/2 UA neg, Ur cx neg-final 11/6,7,8,9 bld cx x2 ngtd 11/9 sputum cx – normal OP flora Automatically imported from SCM

37. HPI Age, Gender, CC short of breath CC: aspiration pna Patient w/ shortness of breath for 1 week & 10 pound weight loss. Found to have lung mass & post obstructive pna.Vitals on adm to ED: 100 140/80 30 88% RA 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation MICRO: 11/2 UA neg, Ur cx neg-final 11/6,7,8,9 bld cx x2 ngtd 11/9 sputum cx – normal OP flora History & Relevant Data History: State the chief complaint at first – once you know the diagnosis, you should UPDATE it. Short history. Admission vitals if they are relevant. “ 45 y/o female with abdominal pain ” “ 89 y/o male with pneumonia. ” Important Hospital Events: Mention things that could come up overnight “ Desatted last night and responded to IV lasix ” Data and Micro: Summarize findings, do not cut and paste results!!

38. History & Relevant Data HPI 45 y/o F w/ Shortness of breath 45yo female with history of multiple sclerosis, GERD, CAD, DM, hypothyroidism brought in by husband after 5 days h/o confusion, shortness of breath, and fever. Initial CXR negative, however CT from 11/16 showed pna suspicious for aspiration. ROS also notable for 10 pound weight loss, anorexia, and fatigue over past 6 months. Vitals on adm to ED: 100 140/80 30 88% RA Got lasix x 2, Cefepime/Flagyl, and morphine in the ED. Duiresed in the ED to lasix through not thought to be volume overloaded by us. Also has UTI on levo, foley now out DATA: 11/5 Chest CT: Heart, mediastinum, and great vessels are normal. There is mild emphysema throughout the lung fields, there is a left lower lobe consolidation new since prior CT from 1/06. Suspect aspiration MICRO: HPI 45 y/o F w/ Pneumonia 45 yo female admitted with shortness of breath and confusion: suspected aspiration pna. Also has 10 pound weight loss. Vitals on adm to ED: 100 140/80 30 88% RA 11/18 – UTI diagnosed – now on Levo 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation MICRO: 11/2 UA neg, Ur cx neg-final 11/6,7,8,9 bld cx x2 ngtd 11/9 sputum cx – normal OP flora Too Wordy… MUCH BETTER!

39. History HPI Age, Gender, CC short of breath CC: aspiration pna Patient w/ shortness of breath for 1 week & 10 pound weight loss. Found to have lung mass & post obstructive pna.Vitals on adm to ED: 100 140/80 30 88% RA 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation MICRO: 11/2 UA neg, Ur cx neg-final 11/6,7,8,9 bld cx x2 ngtd 11/9 sputum cx – normal OP flora

40. Problem List Pt InfoHPIProb ListMEDSTo DoCrossCover Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: FULL Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215-777- 7777 Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pna Race, pertinent PMH, presentation to ED, HPI. -relevant ROS -relevant ED issues (vitals, meds given) -relevant things done o/n -important events during hospitalizaton 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD MICRO: 11/2 UA neg, Ur cx neg-final 11/2,3,4,5 bld cx x2 neg-final 11/6 UA neg, cx neg-final 11/6,7,8,9 bld cx x2 ngtd 11/9 sputum cx – normal OP flora **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Hyponatremia – likely 2/2 dehydration **Diarrhea – possibly CDIff, cx pending ---PMH--- -Prostate ca – resected, cured -hyperlipidemia -PTSD -chronic anemia Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 ---D/C Info--- PMD Dr. Jones 444- 2244 [] needs gi appt ---To Do --- [] f/u xxx test [] daily pulm note [] f/u 7pm Na – increae IVF if Na <130 -if looks bad, consider fungal coverage

41. Problem List Prob List **Asp Pna – on cefepime, pox 98% 2L **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **Dementia-Ox1 but still able to converse and give a history ---PMH--- -Prostate ca – resected, cured -hyperlipidemia -PTSD -chronic anemia Chronic Problems: place chronic or inactive problems at the bottom of the list List all Active Problems: Include salient points of plan and important results. “ For aspiration pna – patient is on cefepime, 10 day course. He also has renal failure & hyponatremia – likely because of dehydration. Diarrhea is concerning for CDiff ” Document Relevant Physical Exam Findings: “ Mr S. has dementia but is able to converse well and can tell you if he is in pain ” “ Mr J has CHF, her lungs always have rales.. ”

42. Info is nice to have, but too much! Makes the prob list too long to sort through in a rush Summarize study in the Data section. Put relevance for day to day care here

43. Combine related problems to save space

44. Problem List Mention things that on-call interns have been called about every night “ This patient sundowns every evening…and here is the plan should it happen tonight… ” Review important exam findings and always think about including mental status “ Mrs. J has severe asthma flare, lung exam is severe wheezing and little air movement on exam today ” “ Mr S.has dementia and only oriented x 1, but always able to follow commands, tell you if he ’ s in pain, etc ”

45. Medications Pt InfoHPIProb ListMEDSTo DoCrossCover Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: FULL Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215-777- 7777 Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pna Race, pertinent PMH, presentation to ED, HPI. -relevant ROS -relevant ED issues (vitals, meds given) -relevant things done o/n -important events during hospitalizaton 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD MICRO: 11/2 UA neg, Ur cx neg-final 11/2,3,4,5 bld cx x2 neg-final 11/6 UA neg, cx neg-final 11/6,7,8,9 bld cx x2 ngtd 11/9 sputum cx – normal OP flora **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Hyponatremia – likely 2/2 dehydration **Diarrhea – possibly CDIff, cx pending ---PMH--- -Prostate ca – resected, cured -hyperlipidemia -PTSD -chronic anemia Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 ---D/C Info--- PMD Dr. Jones 444- 2244 [] needs gi appt ---To Do --- [] f/u xxx test [] daily pulm note [] f/u 7pm Na – increae IVF if Na <130 -if looks bad, consider fungal coverage

46. Medications MEDS Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 Automatically imported from SCM

47. MEDS Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 Medications Mention any important changes in meds: New meds, Discontinued meds, Dose Changes “ For HTN he is on metoprolol, but we had to decrease his dose today because of bradycardia. So if he is hypertensive, I would use something else. ” Important Meds Should Be Verbally Reviewed & Highlighted: Antimicrobials, Anticoagulants, Narcotics, Benzos “ For pneumonia, patient is on cefepime, plus flagyl for possible CDiff, and warfarin for a low EF. ”

48. MEDS Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 Medications Other med info: Medications dosed by level, ordered daily, recent antibiotics, abnormal reactions For warfarin, use “warfarin dose daily” order

49. D/C Info & To Do List Pt InfoHPIProb ListMEDSTo DoCrossCover Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: FULL Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215-777- 7777 Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pna Race, pertinent PMH, presentation to ED, HPI. -relevant ROS -relevant ED issues (vitals, meds given) -relevant things done o/n -important events during hospitalizaton 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD MICRO: 11/2 UA neg, Ur cx neg-final 11/2,3,4,5 bld cx x2 neg-final 11/6 UA neg, cx neg-final 11/6,7,8,9 bld cx x2 ngtd 11/9 sputum cx – normal OP flora **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Hyponatremia – likely 2/2 dehydration **Diarrhea – possibly CDIff, cx pending ---PMH--- -Prostate ca – resected, cured -hyperlipidemia -PTSD -chronic anemia Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 ---D/C Info--- PMD Dr. Jones 444- 2244 [] needs gi appt ---To Do --- [] f/u xxx test [] daily pulm note [] f/u 7pm Na – increae IVF if Na <130 -if looks bad, consider fungal coverage

50. D/C Info & To Do List To Do ---D/C Info--- PMD Dr. Jones 444-2244 [] needs gi appt ---To Do --- [] f/u xxx test [] check TEN panel weekly [] daily pulm note D/C Info – Outpatient MD information, appointments to be made after discharge, any discharge related item To Do – Items for the primary team to do (today or later in the admission) Crosscover teams will look at this too

51. Crosscover Items Pt InfoHPIProb ListMEDSTo DoCrossCover Smith, John Bob F14 1465A MR: 34520984 DOB: 11/3/38 DOA: 11/2/06 Allergies: NKDA Code: FULL Access: RIJ 3L (11/4) Cx: >101.4 Precautions: MRSA Contact: Wife Mary 215-777- 7777 Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pna Race, pertinent PMH, presentation to ED, HPI. -relevant ROS -relevant ED issues (vitals, meds given) -relevant things done o/n -important events during hospitalizaton 11/20 – desat last night, improved after diuresis DATA: 11/3 CXR: LLL pna 11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD MICRO: 11/2 UA neg, Ur cx neg-final 11/2,3,4,5 bld cx x2 neg-final 11/6 UA neg, cx neg-final 11/6,7,8,9 bld cx x2 ngtd 11/9 sputum cx – normal OP flora **Asp Pna – on cefepime, still borderline **ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Hyponatremia – likely 2/2 dehydration **Diarrhea – possibly CDIff, cx pending ---PMH--- -Prostate ca – resected, cured -hyperlipidemia -PTSD -chronic anemia Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 ---D/C Info--- PMD Dr. Jones 444- 2244 [] needs gi appt ---To Do --- [] f/u xxx test [] daily pulm note [] f/u 7pm Na – increae IVF if Na <130 -if looks bad, consider fungal coverage

52. Crosscover Items BE SPECIFIC Check box for each task you need done Avoid vague statements “ try to keep an eye on… ” If you want vitals followed up on or something “ eyeballed ” – make a separate task for it

53. Crosscover Items CrossCover [] f/u 7pm Na - If <130, then increase IVF to 150cc/hr []if any fever, delta MS, or low BP, then add vorizonazole ***SICK*** For Labs: give specifics “ Follow up on the 7p Na – he has been hyponatremic and we think this is prerenal. Increase his IVF if Na is still lower than 130. ” Write here if your patient is sick or if you are worried about the patient Anticipatory Guidance: use If…then statements “ If he looks worse tonight (any fever, low BP, or called for confusion), evaluate him and add fungal coverage ”

54. Tips for Cross-Cover Items Discuss each crosscover task to be done, why it is being done (rationale), and what to do based on results (anticipatory guidance). Anticipate overnight clinical scenarios, and give the cross-cover intern guidance on what to do if they occur…If/Then statements If the patient has a fever >101.5, then draw blood cultures and consider starting vancomycin. We are worried about a line infection

55. Give specific lab & parameters: [] 1800 Hg – if <7, trf 2u PRBC Give recs for meds to use: -if not, t/c 80mg IV lasix Give antibiotic preferences to start

56. What are you looking for?

57. Don ’ t get “ locked in ” (anchoring bias) Remember if/then statements are for guidance You should still always: EVALUATE the patient first Then CONSIDER what they have recommended on the sign-out. Independent thought is what you get paid the big bucks for!

58. Don ’ t feel bad!! We are all on the same team You will be doing the same thing for your colleague when you are on call Be clear about what needs to be done Avoid phrases like “ If you can… ” Only signout out things that need to get done overnight

59. Responsibility of the Receiver

60. READBACK & RECAP  Reiterate important parts of the plan Take notes as you go You will pay attention to these notes later in the night

61. Responsibility of the Receiver Be gently assertive! Suggest a quiet place, suggest to sit down, if the “ giver ” of the signout does not. Do not be afraid to ask them to slow down Similarly, do not let the receiver RUSH You! Don ’ t be afraid to ask them to pay attention! Do not be afraid to ask questions or repeat If you are uncomfortable with a plan of care that is signed-out to you, get both of your residents involved.

62. Responsibility of the Receiver Eyeball sick patients early in the evening Get a baseline for their clinical status Write down all events overnight to relay the next morning

63. Responsibility of the Receiver MEDS Cefepime 1gm IV q12 Colace 100mg po bid Docusate 5mg po daily Furosemide 20mg po daily Metoprolol 50mg po bid Metronidazole 500mg po bid Morphine SR 30mg po bid Warfarin 5mg po qHS Diet: Cardiac, mech grnd, NS @ 150 ---Other Med Info--- Flagyl 500mg q12 11/2-4 Prob List **Asp Pna – on cefepime, still borderline**ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume **CAD – EF 10%, on coumadin for low EF **DM – on insulin **HTN **Hyponatremia – likely 2/2 dehydration **Diarrhea – possibly CDIff, Circle or Highlight important issues on the sign-out. For Medications: Consider highlighting pressors, antibiotics, anticoagulants, narcotics

64. Morning Handoff When on Call Every call, or order placed should be verbally reviewed Write down all calls/issues/orders placed on handoff while on call to serve as a visual reminder the next morning IMPORTANT: any changes in medications or clinical status, new or pending results

65. When to update? As frequently as possible Less to do at the end of the day Busy days: Take notes on signout Update at the end of the day If cant get to it all, update the most important info, and keep notes to update the next day

66. Summary of “ Best Practices ” in Handoffs Quiet Location Minimize Interruptions Problem based verbal handoff Standardize both written and verbal format as much as possible Use anticipatory guidance Make time for questions and clarifications

67. PRIVACY Handoffs contain many patient identifiers! Do NOT leave the hospital with them Do NOT leave them on tables, counters or anywhere other than your hands Old signouts should be placed in locked containers for shredding

68. Questions?