Patient Handoff Among General Surgery Residents in Saudi Arabia: A Cross-Sectional Study

Background Communication failure is a common cause of adverse events. An essential element of communication among healthcare providers is patient handoffs. To explore this practice, we assessed patient handoffs among general surgery residents in Saudi Arabia. Methods A cross-sectional survey was conducted with individuals in accredited general surgery residency programs in Saudi Arabia between 2020 to 2021. Results Participants comprised 118 general surgery residents—66 (57.3%) were females; 67 (72.8%) did not receive any formal training on patient handoff; 35 (38.8%) reported that they were sometimes interrupted during the patient handoff process. The most common reason for such interruptions was medical personnel paging. Further, 60 (68.1%) general surgery residents stated that such interruptions led to a decreased quality of effective communication, 39 (44.3%) believed it led to decreased quality of patient care, 63(71.5%) believed it led to the loss of some information related to patient handoff, and 16 (18.1%) believed it led to patient harm. Finally, 31 (34.4%) general surgery residents believed that the existing handoff system at their institutions neither adequately protected the patient’s safety nor allowed for continuity of care; and 51 (68%) reported that they did not have a standardized protocol for patients’ verbal handoff process at their institution. There were higher proportion of patients with minor harm in residents who did not, rare or some time received verbal or written hand off (67% vs 33%). Conclusion The patient handoff process among general surgery residents in Saudi Arabia is subjective, not standardized, and can contribute to patient harm. Standardizing it is paramount to improve patient safety.

“Friction by Definition”: Conflict at Patient Handover Between Emergency and Internal Medicine Physicians at an Academic Medical Center

Introduction: Patient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context. Methods: We performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method. Results: From May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow). Conclusions: Causes of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.

The effect of distraction on the quality of patient handoff: a randomized study*

Objective The number of patient handoffs has increased in recent years. In addition, technology has advanced in the medical field, leading to most providers carrying smartphones at work. Little is known about the effect of mobile devices and quality of patient handoffs. The objective of this study was to determine whether distraction affects the quality of sign-out among obstetrical providers. Design A randomized, prospective study was conducted. Setting Hospital. Participants Intervention Obstetrical providers listened to a recorded sign-out vignette. Provider groups either were or were not exposed to a distraction while listening to the vignette. All providers had been told that they would be participating in a trial of two methods of sign-out, although in actuality they were all assigned to a single method. In the distraction arm, the participants were exposed to a ‘distracting event’ (a phone ring, which was answered by the proctor and followed by a brief conversation) that occurred midway through the vignette. Main Outcome Measure Providers answered a 14-question survey testing recall of facts included in the vignette. The results of each group were analyzed using Fisher’s exact test and Student’s t-test. Results Eighty-eight providers were randomized, 44 in the distraction group and 44 in the non-distracted group. The average scores on the survey were similar between groups (11.0 and 10.8, P = 0.57). In addition, the average scores for questions that occurred after the distraction did not differ between the distracted and non-distracted groups (6.4 vs 6.2, P = 0.42). Conclusions We observed that a phone ring and brief response did not affect the obstetrical providers’ recall of details of a standardized sign-out. More studies are warranted to determine if more frequent or longer distractions would change results.

Avoiding Fumbles: Online Patient Handoff Training

Introduction: The COVID-19 pandemic required rapid curriculum adaptation to online delivery. Given the importance of accurate clinical patient handoffs, we adapted simulation-based medical student training in clinical patient handoffs. We scored the accuracy of the information students presented. We also elicited student feedback to determine their perceptions of the event and their evaluations of the effectiveness of the training. Methods: Twenty-six third-year medical students participated online via Zoom. Students participated in groups of three or four students. They sequentially encountered a standardized patient. Clinical information and physical exam findings were handed off from student to student until the encounter was complete. The student group then debriefed with faculty. Students were evaluated based on the proportion of clinical information handed off to the following student. Students also evaluated the training session. Results: The first student handoff included 73.4% of the available information. In subsequent handoffs, the percentage fell to 43%. All students said they felt the training was helpful in practicing patient handoffs and interactions with colleagues. Negative student comments focused on perceived deficiencies in session planning and standardized patient training. Conclusions: This rapidly developed simulation session demonstrated that clinical training in patient handoffs can be adapted to an online environment. In order to ensure success, faculty should carefully consider logistical adjustments required to transition from a patient contact setting to an online environment. Meticulous preparation and attention to detail will ensure that training is successful.

I-PASS Illness Severity Identifies Patients at Risk for Overnight Clinical Deterioration

ABSTRACT Background The I-PASS framework is increasingly being adopted for patient handoffs after a recent study reported a decrease in medical errors and preventable adverse events. A key component of the I-PASS handoff included assignment of illness severity. Objective We evaluated whether illness severity categories can identify patients at higher risk of overnight clinical deterioration as defined by activation of the rapid response team (RRT). Methods The I-PASS handoff documentation created by internal medicine residents and patient charts with overnight RRT activations from April 2016 through March 2017 were reviewed retrospectively. The RRT activations, illness severity categories, vital signs prior to resident handoff, and patient outcomes were evaluated. Results Of the 28 235 written patient handoffs reviewed, 1.3% were categorized as star (sickest patients at risk for higher level of care), 18.8% as watcher (unsure of illness trajectory), and 79.9% as stable (improving clinical status). Of the 98 RRT activations meeting the inclusion criteria, 5.1% were labeled as star, 35.7% as watcher, and 59.2% as stable. Patients listed as watcher had an odds ratio of 2.6 (95% confidence interval 1.7–3.9), and patients listed as star had an odds ratio of 5.2 (95% confidence interval 2.1–13.1) of an overnight RRT activation compared with patients listed as stable. The overall in-hospital mortality of patients with an overnight RRT was 29.6%. Conclusions The illness severity component of the I-PASS handoff can identify patients at higher risk of overnight clinical deterioration and has the potential to help the overnight residents prioritize patient care.