C. Clarke1, S. Patel1, R. Day2, M. Ait Aiss1, G. Avaloa Monetes De Oca1, S. George1, C. Sweeney1, E. Grubbs1, B. Bednarski1, J. Lee1, J. Skibber1, T. Aloia1 1University Of Texas MD Anderson Cancer Center,Surgical Oncology, TX USA 2Mayo Clinic In Arizona,Surgery, AZ USA
Introduction: Following recent changes in work hour regulations, trainee-to-trainee patient care handoffs have become increasingly frequent. Each handoff creates a potential source for communication errors that can lead to near-miss and patient harm events, particularly after complex operations. The purpose of this project was to determine the utility and efficacy of a standardized electronic handoff system.
Methods: At a single cancer center, a task-force of attending surgeons, trainees, and quality improvement personnel was established to improve the trainee-to-trainee patient care handoff process. Root cause analysis and process mapping of the current state was performed to identify specific deficiencies and to document handoff compliance, accuracy, and efficiency. The I-PASS (Illness severity, Patient summary, Action List, Situational awareness and contingency planning, and Synthesis by receiver) methodology was then used to create a standardized electronic program within the REDCap (Research Electronic Data Capture) database frame work. Each on-service trainee was provided a daily email link to the database for structured entry of patient identifiers, acuity, ongoing issues, on-call tasks, and attending preferences. The system was programed to automatically aggregate these data into a single structured worklist for the on-call fellow. Patients identified as higher risk for complications required either a phone call (‘watcher’ designation) or a face-to-face sign out (‘unstable’ designation) in addition to the electronic patient handoff. Pre versus post-implementation handoff compliance (% of patients handed-off and % of night of surgery postoperative checks completed), accuracy (correct data transferred) and efficiency (on-call trainee time to complete worklist) were then compared.
Results: Baseline compliance with handoffs was 72% of patients. Errors in handoff data were found in 12% of unstructured handoffs and the mean on-call trainee time to compile the worklist was 15±11 minutes. During the pilot implementation of the structured electronic tool, 48 handoffs were performed on 49 patients admitted to high acuity surgical floors, increasing the compliance rate to 98%. Post-operative checks were documented in the chart on 27 of 29 eligible patients for 94% compliance. The data error rate dropped slightly to 10%, with most errors related to non-medical data that did not impair the trainee’s ability to care for patients. The mean on-call trainee time to compile the worklist reduced to only 5±3 minutes (p=0.023).
Conclusion: These data suggest that a standardized electronic tool can be used to improve compliance, accuracy and efficiency of handoff communication between surgical trainees. The electronic tool created allows for patient illness stratification and, when used with appropriate face-to-face or phone communication, has helped create a safer environment for patients undergoing complex surgical oncology procedures.