Published in the November 2006 issue of Today’s Hospitalist
When the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) added patient handoffs to its patient safety goals for 2006, hospitalist groups everywhere were left wondering how they could improve handoffs. One of them was the nine-physician hospitalist group at Methodist Hospital in Omaha, Neb.
Eric Rice, MD, the group’s medical director, says that while face-to-face hand-off meetings between doctors may be the gold standard, it’s simply not a practical approach much of the time. “It’s too hard,” he explains, “to get all the physicians to show up in one room at the same time.”
Complicating matters was the fact that the group was preparing to switch from a call-based schedule to a 24/7 shift-based schedule. (The switch took place in August.)
“With the shift-based model, we now have four different physicians checking on as many as 65 patients every night,” Dr. Rice says. “When someone comes on at 5 o’clock in the afternoon but the day hospitalist has left at 2, how are they supposed to communicate?”
One potential solution was to have the day-shift doctor sign out verbally to the physician on day call, who in turn would sign out to the hospitalist coming in on the night shift. But that chain of communication might pose big problems for accuracy and patient safety.
“The more people you have in the chain for the check-off,” Dr. Rice notes, “the more likely you’re going to drop information.”
Tailoring another system
After struggling with the issue, the hospitalists at Methodist found an ideal solution, one that was right under their nose. The group’s care manager, Mary Hamilton, RN, took a basic tool that was already being used by the hospital’s nurses and made it the group’s own.
For years, the nurses at Methodist had used the VoiceCare telephone system marketed by Integrated Voice Solutions to record hand-off reports at the end of each shift. Each nurse would dictate patient reports that the nurses coming on the next shift could phone in for and listen to.
But the system required some significant changes because hospitalists’ shifts are so different from nurses’. Hospitalists tend to see more patients and to treat patients throughout the hospital, not just in one ward or on one floor, Dr. Rice explains. And the way the nurses’ recording system was set up “to identify patients by bed number “wasn’t practical for the physicians to use. The system’s vendor had to work with the hospitalists to change some of the system’s identifiers.
As a result of those changes, the hospitalists could begin recording their hand-off reports at the end of each shift, standardizing the hand-off process. “Now it flows more like a normal conversation, with ‘Here are my patients today and here’s what you need to know,’ ” says Dr. Rice.
For each report, the physician signing off records the following information: the patient’s name and room number; admitting diagnosis; pertinent history; consulting physicians; pending tests for follow-up; potential problems; and discharge plan.
Physicians do all their dictation at the end of their shift, pressing one number on the phone keypad to separate the reports of various patients and other numbers to re-record, pause and resume, or add an addendum. (The addendum function is very helpful, Dr. Rice says, when the night physician wants to leave messages for the day doctors about their patients.)
When listening to the reports at the beginning of their shift, physicians likewise manipulate the keypad to listen to an addendum or to skip to the end of each report, skip back or ahead among patients, or pause and resume.
Reactions then and now
When the new recording system was first introduced in February of this year, Dr. Rice recalls, “Physicians hated it.” While part of that reaction was due to bugs in the system, he adds, “Part of that was just not wanting to do something new and different.”
Ironing out the glitches made the system more physician-friendly, as did giving each doctor a laminated pocket card with all the keypad prompts. The fact that the service fulfilled the new JCAHO patient safety requirement was another key motivator.
But what really won physicians over was the fact that they saved time both creating and listening to recorded hand-offs.
“All you have to do is talk, which is very liberating,” says Dr. Rice. Physicians appreciated not having to sit down to write or type. Even more important, they realized they were now relaying more pertinent information than previously, when they’d relied on written notes.
“In one minute, I can tell you a lot more than I can write,” Dr. Rice points out. Far from having to remind the hospitalists to use the system, the group has now had to impose a 15-minute time limit on each physician’s recorded hand-off.
Another big selling point: Physicians can listen to the reports at their own pace. “You can sit down, listen to the whole report and take notes,” he says. “You don’t have to worry about trying to get physicians together in one place at the same time.”
The exception to the rule
That said, the hospitalist group at Methodist makes a major exception to recording their hand-offs.
“For a patient who is unstable or having a major problem,” Dr. Rice points out, “the physician signing off must relay that information in person to the physician on call. For those cases, we did not replace the person-to-person interaction.”
Because they use the VoiceCare system for hand-offs of stable patients, however, that face time has become much more efficient. “You record all the routine detail,” he says, “so you can limit the amount that you have to talk about in person to very critical, essential information.”
Physicians also make sure they sign off their reports by saying they can be reached day or night to discuss any of the patients. “It’s not optimal,” says Dr. Rice, “but it meets the JCAHO requirement that you be available to answer questions.”
Fixing a key deficiency
The physicians did find one flaw in the new system: It doesn’t allow them to archive or access previously recorded reports. That’s a big problem, particularly with complex patients who are hospitalized for weeks at a time.
The solution? Have a physician dictate an interim discharge summary every seven days that a patient is in the hospital, then enter those summaries in the hospital’s computer system.
“If physicians take over care of a patient who’s been in the hospital for 45 days, they’ll have six interim discharge summaries outlining the entire hospitalization,” says Dr. Rice. “They’ll sit down and read them in a row.”
Because the hospitalist program has undergone so many changes this year, Dr. Rice says he’s not yet able to tease out the impact of the recording system on issues like length of stay and patient safety. Anecdotally, case manager Ms. Hamilton points out that physicians appreciate having recorded reminders to, for instance, restart anticoagulation medications stopped for surgical patients. Hospitalists also have been more prompt discharging patients over the weekend.
Dr. Rice plans to track outcomes associated with the recording system, once all the rough edges of the new shift model have been smoothed out. In the meantime, he’s convinced the system has had a real impact on continuity of care.
“It gives you a great outline of what needs to be done that day,” he says. By making it so easy to organize priorities for each patient’s care, “it helps you continue the care for that patient.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.