Patient handoffs: standardized and reliable measurement tools remain elusive.

With changes in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements related to transitions in care effective July 1, 2011, sponsoring institutions and training programs must develop a common structure for transitions in care as well as comprehensive curricula to teach and evaluate patient handoffs. In response to these changes, within the Duke University Health System, the resident-led Graduate Medical Education Patient Safety and Quality Council performed a focused review of the handoffs literature and developed a plan for comprehensive handoff education and evaluation for residents and fellows at Duke. The authors present the results of their focused review, concentrating on the three areas of new ACGME expectations--structure, education, and evaluation--and describe how their findings informed the broader initiative to comprehensively address transitions in care managed by residents and fellows. The process of developing both institution-level and program-level initiatives is reviewed, including the development of an interdisciplinary minimal data set for handoff core content, training and education programs, and an evaluation strategy. The authors believe the final plan fully addresses both Duke's internal goals and the revised ACGME Common Program Requirements and may serve as a model for other institutions to comprehensively address transitions in care and to incorporate resident and fellow leadership into a broad, health-system-level quality improvement initiative.

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements

Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.

Can We Make Postoperative Patient Handovers Safer? A Systematic Review of the Literature

Effective handover communication: An overview of research and improvement efforts

Medical Education 2011: 45: 1081–1089

Context  Effective handover within the health care setting is vital to patient safety. Despite published literature discussing strategies to improve handover, the extent to which educational interventions have been used and how such interventions relate to the published theoretical models of handover remain unclear. These issues were investigated through a systematic review of the literature.

Methods  Any studies involving educational interventions to improve handover amongst undergraduate or postgraduate doctors or nurses were considered. A standardised search of online databases was carried out independently by both authors and consensus reached on the inclusion of studies. Data extraction and quality assessment were also completed independently, after which a content analysis of interventions was conducted and key themes extracted.

Results  Ten studies met the inclusion criteria. Nine studies reported outcomes demonstrating improved attitudes or knowledge and skills, and one demonstrated transfer of skills to the workplace. Amongst the included studies, the strength of conclusions was variable. Poor reporting of interventions impeded replication. Analysis of available content revealed themes in three major areas: teamwork and leadership; professional responsibility with regard to error prevention, and information management systems. Methods used included exercises based on simulation and role-play, and group discussions or lectures focused on errors and patient safety.

Conclusions  There is a paucity of research describing educational interventions to improve handover and assessing their effectiveness. The quality of published studies is generally poor. Some evidence exists to demonstrate that skills can be transferred to the workplace, but none was found to demonstrate that interventions improve patient safety.

Educational interventions to improve handover in health care: a systematic review.

INTRODUCTION With the increase in shift pattern work for junior doctors in the NHS, accurate handover of patient clinical information is of great importance. There is no published method that forms the gold standard of handover and there are large variations in practice. This study aims to compare the reliability of three different handover methods. PATIENTS AND METHODS We observed the handover of 12 simulated patients over five consecutive handover cycles between SHOs on a one-to-one basis. Three handover styles were used and a numerical scoring system assessed clinical information lost per handover cycle. RESULTS After five handover cycles, only 2.5% of patient information was retained using the verbal-only handover method, 85.5% was retained when using the using the verbal with note taking method and 99% was retained when a printed handout containing all patient information was used. CONCLUSIONS When patient information is handed over by the verbal only method, very few facts are retained; therefore, this method should be avoided whenever possible. Verbal handover with note taking is shown to be an effective method of handover in our study, although we accept that this is an artificial scenario and may not reflect the reality of a busy hospital. Nearly all information is retained by the printed handout method but this relies on the handout being regularly updated.

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An experimental comparison of handover methods.

Objectives:To measure the thermal properties of operative endoscopes used in otorhinolaryngological practice.Methods:A series of endoscopes of varying diameters and angulations were attached to a light source and temperature measurements taken of their shaft and tip; a measurement was also taken 5 mm in front of the endoscope tip.Results:Temperature changes took place rapidly. The amount of heat produced by the endoscopes was maximal at the tip, with larger diameter endoscopes attaining a higher temperature. Temperatures on the shaft and in front of the tip reached relatively constant temperatures independent of the type of endoscope. The maximum temperature achieved was 104.6°C for the 4 mm, 0° endoscope. Cooling occurred rapidly after the light source was switched off.Conclusion:The heat produced by some endoscopes is sufficiently great to cause thermal injury to tissues. Awareness of the temperatures produced by these endoscopes should prompt clinicians to actively cool their endoscopes during a procedure, before any thermal injury is caused.

Thermal properties of operative endoscopes used in otorhinolaryngology.

ObjectivePrevious studies of computed tomography (CT) and magnetic resonance imaging (MRI) before cochlear implantation have been of limited sample size, lacked statistical analysis, and been inconsistent in their conclusions. We aim to quantify the utility of CT, MRI, and their combination in order to rationalize their selection.MethodsClinical records and radiological findings were correlated retrospectively in 158 adults and children. All underwent both CT and MRI.ResultsA total of 27.9% (95% confidence interval (CI): 21.0–35.5) of patients had a significant radiological abnormality, but these were considered critical to subsequent management in only 12.7% (7.9–18.9). All these were detected by MRI. They were missed by CT in 6.3% (3.1–11.3). In all, 6.3% also had non-critical abnormalities that were reported only on CT. Cochlear dysmorphisms were more common in children but the overall frequency of abnormalities and their detection rates did not depend on age. Omitting CT and using MRI alone ar...

Pre-operative imaging for cochlear implantation: magnetic resonance imaging, computed tomography, or both?

Epistaxis is a common problem. Most patients presenting to hospital will stop bleeding with simple first-aid measures or with nasal packing. Those who do not stop will usually require surgical management. For persistent posterior epistaxis, the sphenopalatine artery may be ligated as the artery leaves the sphenopalatine foramen to enter the nasal mucosa of the lateral wall of the nose. This may be performed endoscopically. We describe the anatomy of the area and the surgical technique. We also present a brief review of the literature on this technique.

Sphenopalatine artery ligation: technical note.

OBJECTIVES/HYPOTHESIS To determine if aspirin intake is associated with reduced growth of vestibular schwannomas (VS). To determine the prevalence of contraindications to regular aspirin in patients with VS. STUDY DESIGN Retrospective, observational case-control study. METHODS The study utilized a postal questionnaire and telephone interviews to determine aspirin exposure. Propensity score matching was used to control for age, sex, and tumor size. Cases were defined as patients with VS proven to have grown on serial magnetic resonance imaging (MRI). Controls were defined as patient with VS stable on serial MRI. Prevalence of regular aspirin use was compared in patients with growing VS versus stable VS. Absolute and relative contraindications to aspirin intake were recorded. RESULTS Six hundred fifty-three patients with VS were contacted, and responses were received by 67% (220 cases and 217 controls). The mean tumor size was 11.3 mm (9.0 mm and 13.3 mm in controls and cases, respectively). Aspirin exposure was more common in stable VS than growing VS (22.1% vs. 17.3%). However, following matching to control for covariates, aspirin was not found to be associated with VS stability (P = .475). Multiple logistic regression (analysis of variance) found tumor size to be the only factor strongly associated with tumor growth (P < .0001). Ninety-two percent of patients were able to take aspirin, with the majority being at low risk of complications from regular use. CONCLUSIONS This study aimed to examine the relationship between aspirin intake and VS stability. In contrast to previous reports, after controlling for covariates, the findings do not demonstrate an association. Only tumor size at diagnosis appears predictive of risk of VS growth. LEVEL OF EVIDENCE 3b. Laryngoscope, 128:2139-2144, 2018.

Samuel Mackeith

Papers

An experimental comparison of handover methods.

Thermal properties of operative endoscopes used in otorhinolaryngology.

Pre-operative imaging for cochlear implantation: magnetic resonance imaging, computed tomography, or both?

Sphenopalatine artery ligation: technical note.

Aspirin does not prevent growth of vestibular schwannomas: A case-control study.