MULTIDISCIPLINARY PERCEPTIONS OF THE EFFICACY OF PHYSICIAN TO PHYSICIAN TRANSITION OF CARE: CURRENT PRACTICE AND CHANGES IN PERCEPTIONS POST POLICY INTERVENTION. Dana Eilen MD, Joan Viksjo M.Ed., Darshana Shah PhD

BACKGROUND  This transfer of information is crucial for patient safety and successful care. There are substantial risks of failing to be told, forgetting or misunderstanding information that has been communicated during any patient care handoff.  Communication problems are judged to be the most common cause of preventable inhospital disability or death, and more than 60% of root causes of sentinel events reported to the Joint Council on Accreditation of Healthcare Organizations (JCAHO) are judged to be due to failures of communication between healthcare personnel.

BACKGROUND  According to estimates from the Institute of Medicine, 44,000 to 98,000 patients die in U.S. hospitals annually because of injuries in their care due to errors (Institute of Medicine (2000). "To Err Is Human: Building a Safer Health System (2000)". The National Academies Press. Retrieved ).  An Australian study involving 28 hospitals reviewed the causes of adverse events and found that communication errors were the leading underlying cause, associated with twice as many deaths as was clinical inadequacy (Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust. 1995;163:458-71).  Researchers at the University of Virginia collected 158 of 196 surveys assessing the effectiveness of their sign-out process. On 49/158 surveys, resident indicated something happened while on call they were not adequately prepared for. In 40/49 instances, residents did not receive information during sign-out that would have been helpful, and in 33/40 the situation could have been anticipated and discussed during sign-out (Borowitz SM, Waggoner-Fountain LA, Bass EJ, Sledd RM. Adequacy of information transferred at resident sign-out (in- hospital handover of care): a prospective survey. Qual Saf Health Care Feb;17(1):6-10).

CARDIAC FELLOWS’ UNIQUE CHALLENGES  A single fellow covers three hospitals (SMMC, CHH, and VAMC) on call  Can cover upwards of established patients and see 10 – 15 new patients  There are at least 4 – 5 fellows covering inpatients at these hospitals during the daytime hours.  Some days can continue in the cath lab till 9 – 10pm depending on urgent/emergent cases  Face to face signout not technically feasible.  Patient load has mixture of primary and consultative services, ICU and floor patients, acute emergencies and stable admissions

 We conducted an anonymous survey of the cardiology fellows, attendings, and nurses throughout our teaching system. The survey was different for each of these three cohorts and designed to obtain a view of the system from each of their unique vantage points.  We involved all of the cardiology fellows and attendings. The nurses from the telemetry, stepdown, and intensive care units were invited to participate online if they desire. They were given a slip of paper with the web link on it that took them directly to the survey.  Numbers too low for statistical significance.  Step 1: Use subjective perceptions from multiple disciplines to define a baseline status of the efficacy of fellow to fellow sign out.  Step 2: Devise and institute a formal, online, and detailed sign out system  Step 3: Study the changes in perceptions over time. STUDY Plan Step 1

HIGHLIGHTS  1. Sign out is poor. 90% of fellows says they never get a formal written patient list.  2. >90% of fellows, attendings, and nurses believe that all information the fellows use at night to cross cover a patient is either from the nurse or the chart. 75% of fellows says that “very often” the nurses call at night is the first introduction they have to the patient they are cross covering.  3. 88% of fellows say that they “very often” or “frequently” feel underprepared to provide cross coverage due to this.  % of fellows admit to “occasionally” committing a medical error due to lack of information, 62.5% have “occasionally” seen someone else commit these errors. Only 12.5% have “never” seen these errors. Attendings don’t appear to notice this, which may be the reason this has gone unresolved.  You committed, personally?  Noticed another fellow commit?

SIGN-OUT POLICY  Fellows are required to maintain an up-to-date list of active consultative and service patients for each hospital.  Updated both by the day and night fellows  Must include both demographic and relevant clinical data  At each handoff, the fellow responsible for each population of patients will call the oncoming fellow and give verbal, if not face to face, sign out.  Relevent information given with instructions to reference the list.  Oncoming fellows will sign in and print out the list at the start of their shift.

CONCLUSIONS  Fellow to Fellow sign-out within the Cardiology fellowship appears to be woefully inadequate.  There is evidence that poor communication may lead to medical errors.  A new formal, detailed, and online sign-out system along with formal aggressive policies have been instated to try and address this issue.  A planned follow up study should be done in 6-12 months to assess if any positive changes have been achieved.

BIBLIOGRAPHY 1. (Institute of Medicine (2000). "To Err Is Human: Building a Safer Health System (2000)". The National Academies Press. Retrieved ). 2. (Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust. 1995;163:458-71). 3. (Borowitz SM, Waggoner-Fountain LA, Bass EJ, Sledd RM. Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey. Qual Saf Health Care Feb;17(1):6-10). 4. (Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care Dec;14(6):401-7).