#KeyLIMEPodcast 81: An Education Bundle Improves Handover

I would struggle as a health care administrator. For many reasons. (Please don’t include your comments below.) One of the obvious reasons is that I recognize – and I’m also guilty – that physicians prioritize professional autonomy and resist regulations that are perceived to be prescriptive or that limit the individual.  For example, as a trauma physician, it has been a very long time since I have strictly followed the ATLS guidelines. Thankfully, the emerging patient safety movement in health care is improving adoption of standardized best practices by physicians. For example, I routinely use a central venous catheter insertion bundle to minimize complications and improve patient outcomes.

This leads to today’s KeyLIME article on
clinical practice bundles, specifically, a standardized protocol to hand over patient care between physicians.  We have covered the IPASS clinical education bundle previously on KeyLIME (See here).

This week, we return to the original pilot data that informed the larger generalizability study.  (Hat tip to the authors for achieving both a JAMA and NEJM publication, among others, from their research program.)

So, as a Clinician Educator, should you promote a standardized framework for patient handover that decreases preventable medical error?  For details, keep reading.  For a more in-depth take on this topic, check out the podcast.  If you like what you hear, please consider giving us a 5 star rating on iTunes.

– Jonathan (@sherbino)


KeyLIME Session 81 – Article under review:

Listen to the podcast

View/download the abstract here.

Starmer AJ, Sectish TC, Simon DW, Keohane C, McSweeney ME, Chung EY, Yoon CS, Lipsitz SR, Wassner AJ, Harper MB, Landrigan CP. Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle. JAMA, Dec 2013; 310 (21): 2262-70

Reviewer: Linda Snell

Work-hour regulation means more frequent change of residents and teams caring for patients, thus more hand over of cases. Signover (handoff) skills are an important competency to improve patient safety, are highlighted in recent competency frameworks, and formal instruction in this area is required by the ACGME.

Strategies suggested to improve handoffs include:

  • Communication training
  • Standardized mnemonics
  • Minimizing interruptions during verbal handoffs
  • Involving all team members
  • Using written or computerized tools.

The authors combined these into a ‘resident handoff bundle’, introduced on 2 general pediatrics inpatient services, and assessed the association of this intervention with changes in medical error rates, miscommunications, and resident workflow.

‘To determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow.’

Type of paper
Research: pre-post and comparative, multiple outcomes, prospective, single-blind

Key Points on the Methods
Prospective intervention study of 1255 patient admissions involving 84 intern and senior resident physicians, 3 months pre and 3 months post the intervention of the ‘Resident handoff bundle’ (standardized communication & handoff training, a verbal mnemonic, a new team handoff structure, and on one unit, a computerized handoff tool linked to the electronic medical record).

Primary outcomes – the rates of medical errors and preventable adverse events measured by daily systematic surveillance with document review. Secondary outcomes – omissions in the printed handoff document and resident time-motion activity.

Key Conclusions
The authors conclude that ‘implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events… Improvements in verbal and written handoff processes occurred, and resident workflow did not change adversely. There were no adverse effects on resident workflow: time spent on verbal handoffs did not change, and time spent at the computer did not increase; residents spent more time in the post intervention period in direct contact with patients. Given the increasing frequency of handoffs in hospitals following resident work hour reductions and the high frequency with which miscommunications lead to serious medical errors, disseminating high-quality handoff improvement programs has the potential for benefit.’

Spare Keys – other take home points for clinician educators

  • Combining education interventions is perhaps more effective to produce behavior change (cf CPD/CME literature)
  • Combining education and systems interventions may help facilitate behavior change
  • Think of novel sources of funding ….from an insurance company!

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