Browsing by Subject "Patient Handoff"
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Item Assessing the Need for and Developing a Standardized Patient Handover Curriculum for Undergraduate Medical Education(2017-04-03) Gajera, Prakash; Reed, W. Gary; Greilich, Philip; Ambardekar, AditeeBACKGROUND: Improving patient handoff communication is a national patient safety goal; however, few medical schools have standardized handoff training curricula for their medical students. Studies show that a large number of medical students perform handoffs and observe handoff errors during their clerkships [1,2]. This lack of formalized training has a negative impact on medical student perceptions of handoffs [3]. This project assessed the need for handoff education at our institution and developed a curriculum aimed at medical students. IMPLEMENTATION: Clerkship directors were interviewed & preclinical medical students were surveyed for a stakeholder analysis. Prior to starting core clerkships, 200 total students participated in four 1-hour workshops consisting of a 20-minute lecture and three 10-minute handoff scenarios. Trained residents performed the scenarios and led group discussions. Pre- and post-course engagement surveys were used to evaluate the workshop. EVALUATION & OUTCOMES: Clerkship directors desired handoff training before clerkships; however, there was concern that the curriculum would be too advanced. Survey of pre-clinical students showed 71% had heard of standardized patient handoffs, but 94% had no training. 75% believed training should be done prior to core clerkships, and 64% believed handoff simulations were the best method for learning. Students scored 10.7% higher on the post-engagement quiz and 98% of students believed they better understood the elements of a good handoff after the workshop. IMPACT & LESSONS LEARNED: Standardized patient handoff curriculum designed for preclinical medical students improved confidence and knowledge about the handoff process. Concerns about creating handoff curriculum for medical students were addressed by focusing on general concepts rather than specific handoff tools and by creating simple handoff evaluation scenarios. Further work will focus on evaluating the impact of this workshop on the handoff experience during clerkships.Item Designing an Audit and Feedback System to Drive Handoff Redesign and Implementation(2021-03-18) Dao, Anthony Quang; Reed, W. Gary; Greilich, Philip; Lynch, IsaacBACKGROUND: Following the handoff efficacy pilot that was implemented 6 quarters ago at Clements University Hospital, a new measurement system needs to be implemented for preparation of a diffusion pilot to 4-6 additional units. At present there is no such system to monitor and provide feedback to key stakeholders. An Epic based clarity report was identified as a potential measurement system and this project revolved around the feasibility, acceptability, and appropriateness of implementing such a system. A survey was sent out to identify top handoff outcomes to be included in the system and to assess the feasibility of the system. From preliminary results, it was understood that it is possible to successfully implement an acceptable, appropriate, and feasible measurement system. LOCAL PROBLEM: Information loss during care transfers, or "handoffs", can disrupt care coordination and lead to adverse events, especially in high risk, error prone environments like the perioperative setting. Clements University Hospital piloted the redesign and implementation of a structured handoff process to Enhance Communication for Handoffs from the Operating room to the Intensive Care Unit (ECHO-ICU) to improve team-based communication and care. As a result of this successful efficacy pilot, an implementation science-based approach is being taken to prepare for widespread adoption of inpatient handoff redesign. This requires the development of an acceptable and feasible audit and feedback system to support the work led by an inter-professional, unit-based change team guided by institutional subject matter experts. Previous attempts to relay feedback to the original units from the efficacy pilot were unresponsive and slow, leading to disengagement of the stakeholders. This project will attempt to make this process easier, timelier, and scalable. The aim of this project is to reduce the time it takes to perform and Audit and Feedback by 50% by May 2021. METHODS: An initial literature review was performed to identify candidate important outcome measures related to successful handoffs. To assess acceptability, the primary stakeholders were surveyed on what they identified as the most important outcome measures related to handoffs. Feasibility was assessed by determining end users' personal motivation level for entering critical data into the electronic medical record and the complexity of generating an automated report by data specialists from Epic, enterprise, and clinical data registries. Data was collected using multiple methods, including a REDCap survey, small group discussions, and individual interviews. The top three voted upon measures will be added as new data fields into Epic for data collection. RESULTS: The outcomes deemed most important by the survey were all team members present during handoff, the receiving team feeling capable of meeting patient needs, and unanticipated postoperative events. Using these measures of meaning, a prototype dashboard audit and feedback system was designed for use in future efforts. By using participatory design, usability was addressed by focusing on feasibility, acceptability, and fidelity. The guidance team will work with the unit-based change team for handoff redesign and implementation of this audit and feedback. Initially, the feedback will occur quarterly, but each unit will determine their preferred feedback period. CONCLUSIONS: The next steps of this project will be to pilot this prototype with other handoff redesign efforts to collect usability data and assess whether the prototype remains feasible, acceptable, and fidelity. This prototype hopes to align with the University Hospital handoff diffusion pilot within 4 to 6 clinical units. Acceptability and feasibility are leading indicators of successful of widespread adoption, penetration, and sustainability. These latter implementation measure will be applied to future work from this project team.Item Development of the Liang Handover Assessment Tool for Simulation (L-HATS)(2020-05-01T05:00:00.000Z) Liang, Tyler; Greilich, Philip; Phelps, Eleanor; Reed, W. GaryINTRODUCTION: Clinical handovers are critical to patient safety and outcomes. Handover simulation prepares healthcare students for handoffs in the clinical setting upon graduation. UT Southwestern has developed a longitudinal handover educational curriculum in which student handovers will be assessed. Although valid and reliable tools exist for assessing clinical handovers, assessment tools adapted for the undergraduate simulation environment currently do not exist. Our objective was to develop a reliable and valid assessment tool that could be used by scholarly healthcare students to assess undergraduate simulated handovers throughout the longitudinal handover education curriculum. METHODS: A literature review was conducted to identify critical elements of high-quality, effective handovers. Following the tool's creation, we underwent several PDSA cycles to optimize the tool for medical student evaluation and ease of grading. Grader inclusion criteria were students who had completed the transition to clerkship (T2C) handover activity. A training curriculum was developed to train graders on proper use of the tool and to promote reliable grading with the tool. 62 pre-clinical student handovers were conducted in the simulation setting and recorded. The handovers were stratified into three levels (low, intermediate, and high quality), and 10 handovers were selected from each of the three levels for grading (30 handovers total). Each handover was scored by four clerkship medical students "graders". Two-way random effects intra-class correlation coefficients (ICC) were used to establish inter-rater reliability and inter-rater agreement among graders using the tool. Three external handover experts were used to establish the tool's validity using face validity. RESULTS: The product of this project is Liang Handover Assessment Tool for Simulation (L-HATS) which evaluated three domains: handover content, handover process, and language with a maximum score of 28. Two-way random effects ICC for agreement was 0.804, 95% CI [0.601, 0.906]. Two-way random effects ICC for reliability was 0.866, 95% CI [0.765, 0.930]. Three external handover experts have sufficiently validated the tool. CONCLUSIONS: The L-HATS had good to excellent inter-rater reliability and agreement. The L-HATS is the first reliable and valid handover assessment tool used for undergraduate simulation education. By using a two-way random effects model, the results suggest that the tool can be used in settings outside of the T2C handover simulation activity. Having good to excellent absolute agreement suggests that the tool is suitable for assigning grades. Future studies include comparing faculty vs student grading of handovers as well as evaluating the tool in the clinical setting.Item Improving the Reliability of the Clements University Hospital OR to CV-ICU Patient Handover Observer Training Program(2017-04-03) Thangada, Neela D; Reed, W. Gary; Greilich, Philip; Barker, BlakeOR to CV-ICU patient handovers reflect high risk clinical scenarios where providers must transfer patient care responsibilities in the safest possible way. These post-sternotomy handovers are error prone, as providers must exchange patient information in a busy and chaotic environment while simultaneously stabilizing the often tenuous patient who requires hemodynamic and cardiopulmonary support. At UT Southwestern's University hospital, patient handoffs and transitions of care have less than a 50% approval rating per HSOPS data, suggesting a serious need for improving patient handovers. The Clements University Hospital (CUH) OR to CV-ICU observer training program was developed to train a cohort of clinicians who can evaluate post-sternotomy handovers and subsequently make recommendations for improving these handovers. The aim of this project is to improve the reliability and user satisfaction of the existing CUH OR to CV-ICU patient handover observer training program by January 2017. The performance results of the six observers who underwent the first iteration of the observer training program were reviewed. All six observers achieved greater than 80% agreement with the faculty expert, or master key, in their evaluation of handover scenarios from the training videos, suggesting an adequate understanding of how to evaluate a OR to CV-ICU handover. However, observers did not achieve a sufficient inter-rater reliability, with a suboptimal average Fleiss' kappa of 0.65. Since sufficient percent agreement and inter-rater reliability are both required to deem observers appropriately trained, these six observers did not meet the criteria to become 'trained observers.' To understand observers' challenges and overall satisfaction with the training program, a focus group analysis was performed. Elements critical-to-quality for the observer were identified, which included better teaching of handover best practice requirements so observers can more confidently evaluate the handovers.Item Standardizing the Intra-Operative Handover Between Faculty Anesthesiologists Using an EMR-Based Tool(2018-03-29) Sheng, Jim Zhengji; Reed, W. Gary; Bryson, Trenton; Greilich, PhilipSHORT DESCRIPTION: The primary aim of this project is to improve faculty satisfaction with a newly implemented intra-operative handoff tool. The secondary aim is to increase the effectiveness of the intra-operative handoffs by creating a user-friendly electronic medical record (EMR)-based cognitive aid designed to improve the reliability of this process. BACKGROUND: Communication failures during intra-operative handoffs can lead to adverse events and poor patient outcomes [1]. Faculty anesthesiologists frequently perform intra-operative handoffs as a part of their patient care responsibilities. While handoffs have garnered international attention calling for standardization [2,3], there are currently few specific recommendations on how intra-operative handoff should be completed. Checklists in the electronic medical record (EMR) have been shown to be effective in improving relay and retention of critical patient information during intra-operative transfers of care [3]. However, the essential elements and qualities in an intra-operative handoff tool have not been explored. This project identified the attributes in an EMR-based intra-operative handoff tool that are critical to faculty anesthesiologists at UT Southwestern Medical Center (UTSW). METHODS: Faculty anesthesiologists were interviewed for thoughts and comments about the current intra-operative handoff tool implemented at UTSW. Qualitative interview responses were separated into unique comments and analyzed for common themes. Quantitative results on opinions about current process handoff process and tool were determined. Critical-to-quality elements for effective intra-operative handoff tool were extracted from interview responses. EVALUATION AND OUTCOMES: Faculty had mixed opinions about current intra-operative handoff process, and most were unsatisfied about current handoff tool. From one-on-one interviews to explore faculty opinion, a total of 80 unique comments were generated regarding the tool, and 4 main themes were identified: patient information, tool functionality, data organization, and implementation. A total of 17 subtopics were identified based on comments. 15 critical-to-quality in an intra-operative tool was identified. IMPACT AND LESSONS LEARNED: Detailed faculty opinion and feedback regarding current intra-operative handoff process and tool at our institution were collected. Key critical-to-quality elements for an effective intra-operative handoff tool were identified and a proposed tool was created based on feedback. Further work will focus on working with electronic medical record system to develop updated and "ideal" tool based on results of this study. REFERENCES: 1. Commission, J. & Others. Improving America's hospitals: The Joint Commission's annual report on quality and safety. The Joint Commission, Oakbrook Terrace (2007). 2. The Joint Commision. "Sentinel Event Alert 58:Inadequate Hand-off Communication." Jointcommission.org, 11 Sept. 2017, www.jointcommission.org/sentinel_event_alert_58_inadequate_handoff_communications/, Accessed March 8, 2018. 3. World Health Organization Collaborating Center for Patient Safety: Communication during Patient Handovers. Geneva, Switzerland, WHO Press; 2007. Available at: http://www.who.int/patientsafety/solutions/high5s/High5_overview.pdf 4. Agarwala, Aalok V., et al. "An Electronic Checklist Improves Transfer and Retention of Critical Information at Intraoperative Handoff of Care." Anesthesia & Analgesia, vol. 120, no. 1, 2015, pp. 96-104., doi:10.1213/ane.0000000000000506.