RESUMO
BACKGROUND: The majority of adverse events in healthcare involve communication breakdown. Physician-to-physician handoffs are particularly prone to communication errors, yet have been shown to be more complete when systematised according to a standardised bundle. Interventions that improve thoroughness of handoffs have not been widely studied. AIM: To measure the effect of an electronic medical record (EMR)-based handoff tool on handoff completeness. INTERVENTION: This EMR-based handoff tool included a radio button prompting users to classify patients as stable, a 'watcher' or unstable. It automatically pulled in EMR data on the patient's 24-hour vitals, common lab tests and code status. Finally, it provided text boxes labelled 'Active Issues', 'Action List (To-Dos)' and 'If/Then' to fill in. IMPLEMENTATION AND EVALUATION: Written handoffs from general and specialty (haematology, oncology, cardiology) Internal Medicine resident-run inpatient wards were evaluated on a randomly chosen representative sample of days in April and May 2015 at Stanford University Medical Center, focusing on a predefined set of content elements. The intervention was then implemented in June 2015 with postintervention data collected in an identical fashion in August to September 2016. RESULTS: Handoff completeness improved significantly (p<0.0001). Improvement in inclusion of illness severity was notable for its magnitude and its importance in establishing a consistent mental model of a patient. Elements that automatically pulled in data and those prompting users to actively fill in data both improved. CONCLUSION: A simple EMR-based handoff tool providing a mix of frameworks for completion and automatic pull-in of objective data improved handoff completeness. This suggests that EMR-based interventions may be effective at improving handoffs, possibly leading to fewer medical errors and better patient care.
RESUMO
BACKGROUND: Resident work hour restrictions have led to the creation of the 'night float' to care for the patients of multiple primary teams after hours. These residents are often inundated with acute issues in the numerous patients they cover and are less able to address non-urgent issues that arise at night. Further, non-urgent pages may contribute to physician alarm fatigue and negatively impact patient outcomes. OBJECTIVE: To delineate the burden of non-urgent paging at night and propose solutions. METHODS: We performed a resident review and categorisation of 1820 pages to night floats between September 2014 and December 2014. Both attending and nursing review of 10% of pages was done and compared. RESULTS: Of reviewed pages, 62.1% were urgent and 27.7% were non-urgent. Attending review of random page samples correlated well with resident review. Common reasons for non-urgent pages were non-urgent patient status updates, low-priority order requests and non-critical lab values. CONCLUSIONS: A significant number of non-urgent pages are sent at night. These pages likely distract from acute issues that arise at night and place an unnecessary burden on night floats. Both behavioural and systemic adjustments are needed to address this issue. Possible interventions include integrating low-priority messaging into the electronic health record system and use of charge nurses to help determine urgency of issues and batch non-urgent pages.