Dropping the Baton at UCSF

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Dropping the Baton at UCSF

• Improving the quality of ED to Medicine patient
  handoffs at Parnassus campus

Christian Okoye, David Stern Levitt, Daniel Perez
and Joseph Tonna PISCES Quality Improvement
assignment UCSF School of Medicine  Class of 2010
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Key QI Concepts
FOCUS
Find a process to improve Organize the team and
its resources Clarify current knowledge about the
process Understand sources of variation and
clarify steps in the process Select an
improvement or intervention Plan how you
will implement the intervention Do it (preferably
on a small scale) Study the process to see
whether your inervention has made an
improvement Act on what you have learned, which
may either mean implementing the change on a
larger scale, tweaking interventions or
refocusing the intervention
PDSA
Coleman M.T., et al    Schwarz M., et al.
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FOCUS

• Find a process to improve

PISCES allowed us to track patients from ED
triage to Medicine and other services    Room
for improvement?
Absolutely
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FOCUS

• Organize the team and resources

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FOCUS

• Clarify current knowledge

Literature Search

• - Most of prior literature on transfer of care
  has focused on intra-department handoffs
• Arora (2005) - Communication failures in pt
  signout
• -Interviewed interns
• Issues w/ content
•    -active problem
•    -medication/treatment
•    -pending or ordered diagn. test or consult
• Issues with communcation
•    -double sign out
•    -no face-to-face
•    -illegible or unclear notes

- "Sentinel Paper" which deals with ED to
Medicine handoff/transition of care Horwitz
(2008) - Dropping the Baton - cross sectional,
qualitative survey all parties involved Identifie
d several contributors to error   
 - Communication     - Environment     - IT   
 - Patient Flow     - Assignment of Patient
Responsibility
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Vulnerabilities in Transfer of Care
FOCUS
Understand sources of variation and clarify steps
in the process
Why Horwitz paper as guide, needs assessment at
UCSF, differences in hospitals
Stakeholders Patients, ED medical and Nursing
staff, consulting/admitting service team,
hospital floor nurses.

•       Overall Themes
• Different cultural expectations and priorities
  re communication
• Disjointed EMR and nursing records
• Amount of Information/Work up
• Interim care after signout

• Medicine Perspective
• -time expectations
• -auxillary information
• -lack of reevaluation
• -Resource utilization / Lack of feedback

• ED Perspective
• -Exclusive Medicine Admitting service?
• -w/u should end
• -ed throughput

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FOCUS

• Understand sources of variation and clarify steps
  in the process

The Problematic Handoff
Plagued by     Failures (less than ideal care,
death)     Frustrations on both sides.   Handoff
failed to include     -Patient Course     -ED
Interventions Handoffs were     -Overly long and
rambling ---gt inaccuracy              -Medicine
c/o insufficient handoff -Emergency Medicine c/o
overly long handoff -Unsure when
patient responsibility switched from ED to Med
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InterDepartment Actions
FOCUS
Understand sources of variation and clarify steps
in the process

• 2007-2008
• Department QI Representatives Meeting
•     -Brad Sharpe, MD (Dept of Medicine)     
•     -Steve Polevoi, MD (Dept of Emergency
  Medicine)
•                                               
                               Goal     Simplify
•                                                 
                       Standardize 
•                                                 
                         Improve
• Transfer of Care Guidelines established
•     "What Info" 
•     "How" 
•     "Time Limits" --gt 30-60 sec suggestion --gt
  infamously known as the
•  "Brad Sharpe Rule"

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"The Brad Sharpe Rule" 
FOCUS
Understand sources of variation and clarify steps
in the process
Where did things go wrong?

• Practice evolved where EM residents would "stop
  talking" at 60 seconds, citing "Well, Brad Sharpe
  says...."
• With time, the "rule" for better or for worse,
  was forgotten.

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Currently...
FOCUS
Understand sources of variation and clarify steps
in the process

• "Brad Sharpe Rule" EFFECTIVE, but
•  
•  Needs to be adjusted to
• Include new information (interventions,
  patient trajectory)
• Taught and explained 
• Refocus on organization    
• Actively disseminated and supported by faculty in
  the departments

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FOCUS

• Understand sources of variation and clarify steps
  in the process

Best practices at other institutions
Emailed 32 schools (academic tertiary care
centers)
30min -- 12 faculty -- 10 schools
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FOCUS

• Understand sources of variation and clarify steps
  in the process

Decision to admit
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FOCUS

• Understand sources of variation and clarify steps
  in the process

The Handoff
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FOCUS

• Understand sources of variation and clarify steps
  in the process

Ownership in ED
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FOCUS

• Understand sources of variation and clarify steps
  in the process

Feedback
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FOCUS

• Understand sources of variation and clarify steps
  in the process

Improving EMR
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Meeting Between Medicine and ED
FOCUS

• Select an improvement or intervention

• - Goal to bring medicine and ED liaisons
  together to speak about the pertinent issues
• Highlights
• -Overview of the state of the handoff at UCSF
• -Open discussion
• Admission decisions
• Handoff protocol
• Ownership in ED
• Feedback
• EMR/IT

• Action plan / Future Goals
• QI team 
• Clarifying/finalizing signout protocol
• other institutions - challenging admissions
• Medicine
• signout protocol
• Clarifying avenues for feedback
• ED
• signout protocol
• access to ED charts

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New EM-IM Rule to Assess UCSF's Current State of
Affairs
FOCUS
Select an improvement or intervention

• Four Categories explored 
•  
• Faith
• Comraderie
• Communication
• Resources

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EM Perspective
FOCUS
Select an improvement or intervention

• Faith in sign out
• whether it helps IM physicians and/or patient
  care
• Believe Filemaker documentation helps IM team
• Camaraderie
• How well received is the signout by IM in the
  opinion of EM
• Feels the IM team in comfortable asking questions
• Communication
• Labs, tests, studies
• working dx
• Resources
• repeat labs, tests, studies
• time to IM handoff--gt verbal and physical

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IM Perspective
FOCUS
Select an improvement or intervention

• Faith in sign out
• does sign out help me in patient care?
• Review Filemaker
• Camaraderie
• ED staff cooperate well with my team
• Feel comfortable asking questions or requesting
  studies
• Communication
• Know who is the attending who saw my patient
• Labs, tests, studies
• working dx
• Resources
• repeat labs, tests, studies
• time to IM handoff--gt verbal and physical

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References

• Schwarz S, Landis M, Rowe JE, A Team Approach to
  Quality Improvement To realize change, rely on
  the knowledge and experience of a team such as
  the authors', which improved the care of patients
  with diabetes. Family Practice Management, March
  1999. 
• Coleman MT, Endsley S, Quality Improvement First
  Steps QI can bring about substantial, lasting,
  positive change in your practice. It all begins
  with identifying the opportunities. Family
  Practice Management. March 1999 23. 
• Thakore S and Morrison W. A survey of the
  perceived quality of patient handover by
  ambulance staff in the resuscitation
  room. Journal of Emergency Medicine, 2001
  18293-296.
• Ye K, Taylor DM, Knott JC, et al. Handover in the
  emergency department Deficiencies and adverse
  effects. Emergency Medicine Australasia, 2007
  19433-441 
• Beach C, Croskerry P, Shapiro M. Profiles in
  Patient Safety Emergency Care Transitions.
  Academic Emergency Medicine, 2003 10364-367
• Perry S. Transitions in Care Studying Safety in
  Emergency Department Signovers. Focus on Patient
  Safety, 200471-3
• Lee R, Woods R, Bullard M, Holroyd B, and Rowe B.
  Consultations in the emergency department a
  systematic review of the literature. Emergency
  Medicine Journal, 2008252-9
• Toncich G, Cameron P, et al. Institute for Health
  Care Improvement Collaborative Trial to improve
  process times in an Australian emergency
  department. J Qual. Clin. Practice 2000 20,
  79-86
• Brandwijk M, Nemeth C, et al.  Distributing
  Cognition ICU Handoffs Conform to Grices
  Maxims. Poster Presentation, University of
  Chicago, 2003
• Leonard M, Graham S, Bonacum D. The human factor
  the critical importance of effective teamwork and
  communication in providing safe care.  Qual. Saf.
  Health Care, 2004 13 i85-i90

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Acknowledgments

• UCSF depts. of Internal Medicine and
• Emergency Medicine at Parnassus
• Alejandra Casillas, Lorie Leard, Steve Polevoi,
  Christina Lee, Rebecca Nessel, Heather Nye, Susan
  Promes, Ralph Wang
• Faculty at other institutions
• Michael Strong, Rebecca Sturges, Jason Krupp,
  Leora Horowitz, Ian Jenkins, Neil Wenger, Debbie
  Craig, Michael Lukela, David Krakaw, Taimur
  Habib, Kathleen Clem, Azita Hamedani, Theodore
  Chan
• Project advisors
• Karen Hauer, Arpana Vidyarthi, Brad Sharpe, Steve
  Polevoi