Published in the November 2007 issue of Today’s Hospitalist
In July 2005, the educators at Denver Health Medical Center were frustrated. Two years had gone by since new work-hour regulations for housestaff had taken effect, and the housestaff schedules were a mess.
Housestaff hours were being dictated not by patient care, but by the work-hour rules. On some days, housestaff could work as long as they needed; on other days, they had to up and leave in the middle of their duties to make sure they didn’t violate the rules.
That’s when the educators at the medical center decided to take a relatively radical approach. Instead of working longer hours on some days and shorter hours on other days, all housestaff would work the same predefined shifts. Housestaff might end up working fewer hours overall, but they would be working consistent schedule.
“We didn’t want a mixed model where they were a shift worker one day and on another day they weren’t,” says Eugene S. Chu, MD, head of the center’s division of hospital medicine. “We decided to embrace the shift work mentality instead of trying to fight it to the bitter end.”
While that decision streamlined housestaff schedules, it also paved the way to change how interns do handoffs.
A standardized approach
Handoffs among housestaff were an issue because like in many other training programs “more than 30%, according to a 2006 study “the interns at Denver Health did handoffs without any supervision or input from attendings.’
While the medical center had encountered no errors with intern handoffs, educators thought it was an area ripe for action. “You have two very inexperienced people handing off patients,” Dr. Chu says, “doing perhaps the most important communication process in patient care, with no supervision.”
Beginning in July 2005, the training program required interns to do their handoffs at 6 p.m. Dr. Chu says the move was an important first step to standardizing handoffs.
“If you go to a shift system,” he explains, “you can standardize when handoffs occur, how they occur, under what circumstances they occur and what the expectations are.”
To introduce even more standardization, the training program at Denver Health then developed templates to guide both written and verbal handoffs.
Dr. Chu, who is also assistant professor of medicine at the University of Colorado Health Sciences Center, says that the written templates his program uses resemble those used at many academic centers. Physicians use a word processing document that prompts them to include pertinent information “a summary statement, medications, active issues and follow-up “in the handoff.
To introduce a similar level of standardization to verbal handoffs, the training program developed similar tools. A key was a mnemonic designed to help physicians hit the basics. (Dr. Chu plans to release more details on the mnemonic by publishing his research in a medical journal.)
Teaching the teachers
Initially, he recalls, the program sent eight attendings out on the wards with the following guidance: “Supervise handoffs.” It quickly became obvious that like housestaff, the attendings could benefit from a little standardization.
The problem? No one really knew how to teach a handoff. “None of our attendings was explicitly taught this information in medical school or residency,” Dr. Chu says. “We had an idea of what was good and what was bad, but everyone was teaching something different.”
Some attendings, for example, reverted to delivering didactic lectures about medical topics that came up during the handoffs, because that’s what they knew. That approach wasn’t always well-suited to a handoff, particularly when interns were anxious to go home and sleep after a long shift.
In an effort to standardize how handoffs are taught, the training program streamlined the group of attendings charged with that task, reducing it to four.
Those attendings decided that it was important to stress both efficiency and effectiveness in the handoff process. To do so, they taught residents to do the following: give a quick summary or background statement; discuss the active issues, with contingency plans for situations that might crop up in the next shift; and go over pending diagnostics or therapeutics that would require follow up. The incoming resident would be encouraged to ask questions for clarification and repeat or read back information to confirm understanding.
And after surveying housestaff, the training program decided it made the most sense to focus on teaching handoffs during the first few months of the year.
For the first four months of the academic year, two attendings worked with the incoming and outgoing intern the first two nights each intern performed handoffs. Dr. Chu says that typically, three of the four attendings would work 6-8:30 p.m. four nights a month for three months.
He says the goal was not only to supervise the interns who were handing off patients, but also to work with the interns who were receiving patients “and be available for a consult on any issues that came up.
Problems with contingency plans
What did the attendings witness as they worked with interns on handoffs? While Dr. Chu says there were some things that caught their attention, most of the issues were relatively minor.
Initially, for instance, interns found it hard to formulate contingency plans. They often could think of things that might go awry with their patients, but they weren’t sure of what they would do, or they would suggest a course of action that the attending would modify.
“There were times where obviously there was some misunderstanding about what was going on, a natural part of the learning process,” he says. “They are just out of medical school and they are bombarded with information, so every once in a while, they don’t process something correctly.”
In one case, an attending told the resident to start a patient on insulin. As one of the attendings teaching handoffs on that shift, Dr. Chu received a call from the intern. The problem? The intern had never started a patient on insulin. “I just briefly went over how to start insulin,” Dr. Chu says, and the intern did fine.
While Dr. Chu says he can’t definitively say whether care was improved, he is quick to add that attendings and interns alike think that it has. “The interns said they felt that care was safer,” he explains, “which usually translates into better patient care.”
So far, feedback from both interns and attendings has been encouraging. In a survey, 85% of the interns said they thought attending supervision during handoffs was extremely or very useful.
“Every once in a while, there would be a little clinical question that we could help troubleshoot,” Dr. Chu points out. “They liked the fact that there was someone with more experience to help them out.”
He notes that what interns liked least was the monthly lectures that are part of the focus on handoffs. He says he’s not surprised and compares teaching handoffs in a lecture format to teaching someone to drive a car with lectures.
Perhaps the biggest sign of the program’s success is the fact that it has been rolled out to all four hospitals that are part of the University of Colorado Health Sciences Center system. While the other facilities have made changes to the way they teach handoffs, Dr. Chu says the basic approach “and reception by interns and attendings alike “is the same.
“One of the reasons that most of our attendings are in academics is that they enjoy the satisfaction of providing good education and fulfilling a need in a trainee’s educational progression,” Dr. Chu says.
Edward Doyle is Editor of Today’s Hospitalist.