From the 2022 HVPA National Conference
Alison Koransky MD (Lewis Katz School of Medicine at Temple University), Dharmini Shah Pandya MD
Background
Inpatient transitions of care of patients between providers occurs twice a day in systems with night coverage. Communication failures, including omission of key information, during the sign out process can result in unintended harm or suboptimal care to patients (1,2). Additionally, it has been shown that cross coverage is an independent risk factor for preventable adverse events (4). In our Internal Medicine (IM) Residency Program, the “IPASS” format of hand offs was implemented two years ago, but no feedback or assessment mechanism for trainees has existed.
Objective
The primary objectives of this project were to evaluate current transitions of care between day and night times and subsequently address the deficiencies
Methods
IM Interns at a large academic medical center were observed by third year residents giving sign out to night coverage team. A validated CEX (clinical evaluation exercise) was completed for 19 interns which included organization, communication skills, content and clinical judgement, patient focus, setting and overall quality (3). Educational curriculum was subsequently designed to address findings from evaluations.
Results
This CEX was performed approximately 4-6 months after intern hand offs workshop. The lowest average scores on the CEX were in the organizational efficiency (4.9/9), content (5.4/9) and overall quality (5.3/9). Within content, a score of 1 means information omitted or irrelevant, clinic condition omitted, lack of plan, whereas a 9 correlated with all essential information included, clinical conditional described, plans provided for to do list with rationale explained. The best scores were observed in the patient focused category (7.5/9) and setting (8.1/9).
The transitions of care (TOC) curriculum has evolved but is traditionally targeted at interns early in the year to discuss expectations of TOC skills. Based on our needs assessment and outcomes of this hand off assessment, an educational workshop was developed for rising second year medicine residents entitled “How To Teach Your Intern IPASS.” The workshop consisted of an introduction which reviewed the IPASS format for sign out and multiple role play scenarios. Residents were assigned various roles including an observer, whose job was to provide feedback and demonstrate how they would coach their team members. Each case was followed by discussion points that focused on situational awareness and the quality of the sign out. The focus of this workshop shifts from performing skills to teaching the skill and providing new learners feedback in real time.
Conclusions
High quality sign out is essential in providing safe care to patients. To improve the quality of sign out at our institution, explicit feedback and assessment is crucial to improve the quality of the sign out process. To engage residents a workshop was created with the focus on these skills and a secondary focus on how to subsequently teach the skill. Next steps include repeat CEXs to be completed in the fall of next academic year to assess if a workshop focused on teaching sign out helps improve the quality of sign out given.
Clinical Implications
Transitions of care are a time prone to medical error (1,2,4) and giving a quality sign out often requires practice and coaching. By designing a curriculum that helps others teach the skill and uniquely focuses on common deficiencies noted in this specific residency program, we hope to improve provide safer care to our patients even in cross coverage situations.
