— Mnemonic machine helps for oral and also written handoffs.

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by J. Duncan Moore, Jr., Contributing Writer, MedPage now November 25, 2014


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A rigorous clinical handoff protocol taught to medical citizens for usage at hospital shift changes led to a 23% diminish in medical errors and also a 30% diminish in avoidable adverse events, a study has actually concluded.

The handoff innovation plan associated a mnemonic come standardize oral and also written handoffs, a faculty breakthrough program, training because that the residents, and also a sustainability campaign.

The examine was conducted at nine pediatric residency training programs in the U.S. And Canada. The total study period was 18 months, consists of 6 months every of pre-intervention outcomes assessment (to develop a baseline), implementing the intervention, and post-intervention data collection. The outcomes covered 10,740 patient admissions.


Note the a large, multicenter study of pediatrics residents discovered that a structured "handoff" curriculum was associated with a reduction in medical errors.Be conscious that the trial was no randomized; thus origin can no be inferred.

The researchers "have excellent an amazing task of arising a very well designed study, with big sample size, with multiple centers, and geographically diverse," said Lee Ann Riesenberg, PhD, RN, a clinical educator in ~ the college of Alabama in ~ Birmingham, that was not connected in the program. Until now, researches of handoff improvements have actually been smaller in scale, generally at one institution, pertaining come a single discipline, she claimed -- naught as huge as this project.

Although the research was limited to pediatric programs, Riesenberg claimed the outcomes are probably applicable to various other kinds of inpatient settings and a variety of care transitions.

The study was led through Amy J. Starmer, MD, MPH, a doctor in medicine at Boston Children"s Hospital, and had 36 co-authors native children"s organizations in places like Honolulu, St. Louis, Salt Lake City, and Toronto. It showed up in The brand-new England newspaper of Medicine.


"We recognize that handoffs are a leading resource of miscommunication and medical errors, and also a major cause of mortality in the U.S.," Starmer called MedPage Today. "There is definitely a heightened feeling of awareness around this subject now."

The institute of medicine highlighted the duty of insufficient handoffs in clinical errors in a 2001 report, "Crossing the quality Chasm." The joint Commission has approximated that "80% the serious medical errors show off miscommunication between caregivers once patients are transferred or handed-off." The accrediting company has contained improved handoff techniques among its patient safety goals, and in 2009 it started working ~ above a device for better handoff communications.


Oddly, Starmer told MedPage Today, doctors in training have actually never got much particular instruction on just how to happen along info to one another, particularly at a change in shift. Nor has actually such training to be mandated through agencies the regulate physician education. Typically, trainees have learned top top the task by city hall other world do it, yet without any formal didactic instruction.


Over last 10 years, there has actually been raising interest in knowledge how fatigue affects medical decision-making. The Accreditation council on Graduate Medical education has limited the variety of hours that medical residents may work. With shorter shifts, an ext handoffs occur.

Starmer"s examine group emerged a mnemonic, or storage aid, to help doctors remember all the piece of information they room expected to gather at the moment of handoff. Your mnemonic is dubbed I-PASS, and also was published in Pediatrics 3 years ago. The stands for:

I: illness severityP: patience summaryA: activity listS: case awareness and contingency planningS: synthesis by receiver

The I-PASS memory help is modeled ~ the SBAR acronym (Situation, Background, Assessment, Recommendation) occurred in the Kaiser Permanente mechanism a few years ago to facilitate handoffs there.

Beyond indict on the mnemonic device, the I-PASS Handoff Bundle contained six more elements: a 2-hour workshop come teach teamwork and communication; a 1-hour function play and also simulation exercise; a computer module because that independent learning; a faculty development program; straight observation devices for faculty to offer feedback come residents; and a process-change and culture-change campaign.


Errors were assessed by having a research nurse translate in weekly perform of potential events from many sources, v two blinded doctors then reviewing the list to recognize whether cases represented medical errors or avoidable adverse events.

"A Skill"

"Handoffs room a skill. They room not miscellaneous you can teach in a didactic lecture," Riesenberg said. Girlfriend may have the ability to give the citizens data ~ above the prominence of the handoff, she said, "but in bespeak to carry out a really an excellent handoff, you need practice, you need feedback, and also they walk that. Lock also provided a computer module, which to be helpful. They listed faculty development. Climate they likewise included a item on society change, i beg your pardon is hard to implement.

"They did some amazing things that all connect together as a well-constructed bundle, that on the confront of it do a lot of great sense." It"s not really feasible to to speak which aspect of the bundle made the difference, she noted. "Intuitively, I would certainly say they space all important," Riesenberg said.


Medical inhabitants are for this reason busy during their shifts that they would certainly be unlikely to take on any carry protocol that expense them extra time or psychological energy. For that factor the study team payment close fist to just how much time the handoffs actually took. They carried out time-motion monitorings at all the examine sites through assigning research aides to monitor doctors around with a stopwatch for 8 come 12 hours, and then carried out an end-of-rotation survey to evaluate residents" perception of the handoff training. The investigators were particularly interested in just how much time physicians spent top top the computer system or in the handoff, and also whether they were diverted from direct patient care.

The handoff protocol go not rise the work load or take it the physician away from patience care, the group reported.

The text of the NEJM short article notes that there is one association between implementation the the protocol and also a 23% family member reduction in all clinical errors and also a 30% relative reduction in avoidable adverse events, yet it walk not claim the treatment caused the changes.


"The only means we could absolutely prove causality," Starmer said, "would it is in if us did a randomized, regulated trial, wherein a details group that residents acquired the intervention and others didn"t, prefer a brand-new drug trial." It would certainly not be helpful or possible to blind medical professionals or patients to even if it is they were participating in the study, she added. "We tried to do the study design so that the combination is quite strong."

The research is a "landmark," she said. "It is exceptional to have actually this durable educational intervention developed with together a multidisciplinary team and also a rigorous curricular design. The clinical study whereby we assessed the influence of the intervention was same rigorous and also robust, through a direct patient outcome measure, a meaningful measure of reduction in errors. Those two things together space an amazing measure of the job for us."

Significantly, the high quality metric is not a proxy measure up or a process-of-care measure; that is a actual patient outcome. The strategy the study group took to measuring medical errors is considered to be "the gold typical methodology in the hospital setting," Starmer said. "We obtained a the majority of things the go unreported by classic hospital security systems."


The study included three different species of data, Riesenberg said: self-report, procedure change, and also patient outcomes. Other previously studies never quite accomplished all three: "What"s been absent is good, strong evidence native a huge geographically diverse sample that consists of patient outcomes," she said.

The following step in the study on handoffs will be to recognize whether this techniques deserve to be adjusted to various other provider settings. Massachusetts basic Hospital is rolling out I-PASS for every providers, v a most success, Starmer said. "The ideas themselves space not that specific to pediatrics, which is one of the encouraging outcomes here."

However, outcomes in the regimen were uneven across the study sites. The the nine organizations participating, 3 did not achieve a palliation in avoidable adverse events or clinical errors.

"There is other unique around those three sites. One have the right to only speculate what could have happened," Riesenberg said. Possibly the protocol wasn"t adopted as strongly at those sites together at the other six, she suggested.


"There is something called the hidden curriculum," she said. It"s the difference between "what we teach the occupants to do and what we in reality do. If the medical professionals at those sites room doing handoffs a various way, or pooh-pooh the idea, climate the hidden curriculum may over-ride these innovations." In the case, a human determinants inquiry might be important to uncover why the curriculum didn"t job-related at those sites.


The study was sustained by sponsor from the department of Health and Human Services, the company for medical care Research and Quality, the medical Research structure of Oregon, the doctor Services Incorporated structure (of Ontario, Canada), and by an unrestricted medical education grant native Pfizer.

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Primary Source

New England journal of Medicine

Source Reference: Starmer AJ, et al "Changes in medical errors after ~ implementation of a handoff program" N Engl J Med 2014; DOI: 10.1056/NEJMsa1405556


Secondary Source

Pediatrics

Source Reference: Starmer, AJ, et al "I-PASS, a mnemonic come standardize linguistic handoffs" Pediatrics 2012; 129: 201-204.