1. A Survey of Patient Care Handoff and Sign-out Practices Among Podiatric Surgical Residency Programs Laura E. Sansosti, DPMa, Amanda Crowell, DPMa, Whitney Ellis-McConnell, DPMa, and Andrew J. Meyr, DPM FACFASb aResident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, Pennsylvania bClinical Associate Professor and Residency Program Director, Department of Podiatric Surgery, Temple University School of Podiatric Medicine and Temple University Hospital, Philadelphia, Pennsylvania *Please don’t hesitate to contact AJM with any questions/concerns. He’s happy to provide you with a .pdf of this poster if you him.
Survey Questions and Results
-Contacted/Participating Programs: 50/40 (80.0% Response Rate)
-On-call Practices
-Which most appropriately describes your in-patient and on-call service…..during the day/at night/on weekends (multiple answers permitted)?:
-A single resident is primarily responsible for in-patient rounding and consults at a single health care institution: 47.5% / 52.5% / 45.0%
-A single resident is primarily responsible for in-patient rounding and consults at multiple health care institutions: 17.5% / 45.0% / 42.5%
-Multiple residents are primarily responsible for in-patient rounding and consults at a single health care institution: 17.5% / 2.5% / 7.5%
-Multiple residents are primarily responsible for in-patient rounding and consults at multiple health care institutions: 22.5% / 0.0% / 5.0%
-A single resident is primarily responsible for consults at a single emergency department:: % / 47.5% / 42.5%
-A single resident is primarily responsible for consults at multiple emergency departments: 25.0% / 50.0% / 45.0%
-Multiple residents are primarily responsible for consults at a single emergency department: 17.5% / 2.5% / 7.5%
-Multiple residents are primarily responsible for consults at multiple emergency departments: 22.5% / 0.0% / 5.0%
-Which best describes your in-patient and on-call service at night and on weekends?: % call from home; 10.0% in-house hospital call
-Does your service have a specific “night float” resident?: % “yes”
-Patient Care Handoff Protocols and Practices
-In which situations does your service regularly encounter patient care handoffs (multiple answers permitted)?:
-Between multiple residents during a given day: 30.0%
-From an “on-call” resident during the day to an “on-call” resident at night: 47.5%
-From an “on-call” resident at night to an “on-call” resident during the day: 45.0%
-From an “on-call” resident during the week to an “on-call” resident on weekends: 70.0%
-From an “on-call” resident on weekends to an “on-call” resident during the week: 70.0%
-Between multiple residents during a weekend: 17.5%
-Which of the following patient care handoff situations are commonly encountered on your service (multiple answers permitted)?:
-From one single resident to another single resident: 90.0%
-From one single resident to a group of residents: 47.5%
-From a group of residents to one single resident: 17.5%
-From a group of residents to another group of residents: 15.0%
-Which of the following best describes your patient care handoff practices (multiple answers permitted)?:
-Sign-out takes place in person: 60.0%
-Sign-out takes place over the phone: 52.5%
-No direct communication takes place between residents other than an electronic passing of information: 50.0%
-27.5% reported that the electronic passage of information without direct resident communication was their primary or sole means
-For sign-outs that take place in person, which of the following best describes your handoff practices?:
-Sign-out takes place at the patient’s bedside: 2.5%
-Sign-out takes place with a computer available to review labs and imaging studies: 50.0%
-During a sign-out, what is the average time spent discussing each patient?:
-Approximately 1-2 minutes: 37.5%
-Approximately 3-5 minutes: 32.5%
-Approximately 5-10 minutes: 12.5%
-Approximately >10 minutes: 0.0%
-Which of the following best describes your service’s patient care handoff practices (“Yes” or “No” questions)?:
-Our service utilizes a designated time for handoffs and sign-out: 42.5% Yes
-Our service performs handoffs and sign-outs at differing times of convenience: 67.5% Yes
-Our service utilizes an electronic sign-out that is regularly updated: 85.0% Yes
-An electronic sign-out is ed to residents and/or attendings: 67.6% Yes
-An electronic sign-out is available on a secure hospital network: 76.5% Yes
-An electronic sign-out contains personal protected patient information: 79.4% Yes
-An electronic sign-out is only distributed via secured % Yes
-Attendings regularly take part in the sign-out process: 5.0% Yes
-Our hospital and/or residency program provides formal handoff education during resident orientation: 42.5% Yes
-Our hospital and/or residency program has a standard handoff protocol: 25.0% Yes
-If yes, our service regularly utilizes this standard protocol: 70.0% Yes
-Our hospital and/or residency program provides residents with an assessment or feedback of their handoff proficiency: 17.5% Yes
-I feel as though my service’s handoff/sign-out practices are safe: 87.5% Yes
-I feel as though my service’s handoff/sign-out practices are effective: 90.0% Yes
-I feel as though my service’s handoff/sign-out practices could be improved: 67.5% Yes
Statement of Purpose and Literature Review
Methodology
An electronic survey was developed and administered to participating chief residents of podiatric surgical residency programs. Participation was voluntary and residents were told that individual program results would be kept anonymous. The survey attempted to elucidate on-call practices of the programs, as well as patient care handoff protocols and procedures.
Some questions were single answer while other questions allowed for multiple responses. A free text portion was also available for residents to clarify/supplement any answers as well as provide any comment on individual or general topics.
The chief residents of 50 programs were initially contacted with 40 programs responding for a survey response rate of 80.0%. Basic descriptive statistics of responses were calculated.
A patient “handoff” or the “sign-out” process is an episode during which the responsibility of a patient passes from one health care professional to another. These are important events in the care of patients, and unfortunately, communication failures during this process contribute to as many as 67% of adverse events occurring within hospitals. The surgical patient has been specifically identified as being most at risk for handoff communication errors because of the multiple transitions that occur in the pre-operative, intra-operative and post-operative phases [1-5].
Because of this potential for contributing to adverse effects, the Joint Commission added to its National Patient Safety Goals a recent requirement for hospitals to “implement a standardized approach to handoff communications.” In response to this, the Accreditation Council of Graduate Medical Education (ACGME) amended their policies and now requires that residents be proficient in communication skills that “result in efficient information exchange and teaming with patients, their patients’ families, and professional associates.”
Despite this, a consensus has yet to be developed of the definition or essential components of an effective handoff and studies have consistently identified gaps and deficits in the process. These studies have primarily been conducted among emergency departments and internal medicine services however [1-5]. Further, podiatric residency programs do not fall under the direct purview of the ACGME, but rather the Council of Podiatric Medical Education (CPME), who have no specific requirement with respect to patient handoff skills other than the CPME 320 Program Standard 6.1.D competency: “Communicate effectively and function in a multi-disciplinary setting.”
The objective of this investigation was to conduct a survey among podiatric surgical residency programs with respect to patient care handoff and sign-out practices.
Results
Results are displayed in the admittedly large accompanying Table. It was most common for a single resident to be primarily responsible for in-patient rounding and consults as opposed to a shared responsibility among a multiple resident team. It was most common for a single resident to be responsible for a single health care institution and emergency department, but on nights and weekends it became increasingly common for a single resident to cover multiple hospitals and emergency departments. Most residency programs (90.0%) had residents take call from home on the nights and weekends, and for those that didn’t there was usually a specific “night float” resident. It was most common for one single resident to sign-out to either another single resident (90.0%) or to a group of residents (47.5%).
There was significant variety in terms of sign-out practices and protocols. It was common for sign-outs to take place in person, over the phone, and even without direct communication between residents (instead relying only on the electronic transfer of information). In fact, 27.5% of programs reported that their primary or sole sign-out procedure was electronic without any direct physician-to-physician communication. We found that sign-outs overwhelmingly took place away from the patient’s bedside, with a computer being available to review lab results and radiographs only 50.0% of the time. It was most common to spend 1-2 minutes discussing each patient, and no program routinely discussed patients for >10 minutes.
Most programs (85.0%) utilized some type of electronic sign-out to organize their in-patient service, with 67.6% reporting that this patient list was ed to residents and attendings. Only a small minority of programs (5%) reported that attendings took part in the sign-out process and/or provided feedback on handoff/sign-out proficiency (17.5%). Most residents (57.5%) reported not receiving formal handoff education from their program or hospital during orientation and were not encouraged to utilize a specific patient care handoff protocol.
Although most residents felt as though their handoff/sign-out practices were safe (87.5%) and effective (90.0%), most also thought that the process could be improved (67.5%).
Discussion
The results of this investigation provide original evidence on patient care handoff and sign-out practices among podiatric surgical residency programs. We believe these results point to some common deficiencies within our profession during this process and during our training of residents with respect to the development of interprofessional communication. These results have encouraged our program to re-evaluate our patient care handoff policies and we would encourage other residency programs to do the same. This is particularly true with respect to resident assessment and the use of standard patient care handoff protocols. Finally, based on these results, we conclude that the CPME might want to consider specific requirements with respect to assessment of proficiency in handoff practices and communication skills similar to the Joint Commission and the ACGME.
References
[1] Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care 2010, 19:
[2] Horwitz LI, Moin T, Green ML. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med Oct; 22(10):
[3] Kessler C, Shakeel F, Hern HG, Jones JS, Comes J, Kulstad C, Galladue FA, Burns BD, Knapp BJ, Gang M, Davenport M, Osborne B, Velez LI. A survey of handoff practices in emergency medicine. Am J Med Qual Sep-Oct; 29(5):
[4] Kessler C, Shakeel F, Hern HG, Jones JS, Comes J, Kulstad C, Gallahue FA, Burns BD, Knapp BJ, Gang M, Davenport M, Osborne B, Velez LI. An algorithm for transition of care in the emergency department. Acad Emerg Med Jun; 20(6):
[5] Nagpal K, Abboudi M, Fischler L, Schmidt T, Vats A, Manchanda C, Sevdalis N, Scheidegger D, Vincent C, Moorthy K. Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Ann Surg Apr; 253(4):