Bundled Approach to Handoff Communication Delivers Significant Safety Dividends
With an estimated 80% of the most serious medical errors linked to communication failures, handoff processes are a rich target for improvement. There are numerous tools designed to help providers remember to convey the most important information when transitioning a patient to another provider, but one approach in particular has demonstrated in multiple studies that it can reduce medical errors and preventable adverse events substantially.
Called the I-PASS bundle, the approach originally was devised for use in pediatric hospitals, but has been adapted and modified since for use in many different types of hospital units, including both pediatric and adult EDs. In fact, such efforts have been so successful and widespread that the I-PASS Study Group has been awarded this year’s John M. Eisenberg Award, an honor bestowed annually by The Joint Commission to recognize national-level innovation in improving patient safety and quality.
“I-PASS” stands for: illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by receiver. However, the bundle includes several other elements, too, including a handoff document, training, faculty observations and feedback, faculty development, and an awareness campaign. Although the approach has delivered impressive results, reducing handoff-related errors by as much as 30%, proponents acknowledge that reaping such gains requires considerable effort and ongoing commitment.
Christopher Landrigan, MD, MPH, the research director of inpatient pediatrics at Boston Children’s Hospital, the principal investigator for numerous I-PASS studies, and co-founder of the I-PASS Institute, a group formed to help guide institutions interested in implementing the I-PASS approach, explains that while the tool was developed and used in children’s hospitals first, there are themes that carry across all healthcare settings.
“There are some common principles in structuring and organizing handoffs,” he explains. “The reason we started at Boston Children’s Hospital is because that is where I am, and it is a place where, from my own clinical experience, I could see there was a problem, and we began to try to design a solution.”
In fact, initially in 2008, I-PASS was just a resident physician initiative that focused specifically on change-of-shift transitions as residents began to work shorter shifts, resulting in more handoffs, Landrigan says. “When we put the I-PASS bundle into effect, there was a very substantial reduction in medical errors,” he observes.1 “And that initial effort served as a foundation for the multicenter I-PASS study where we were in nine children’s hospitals, and again focused primarily on that transition between residents and interns at the change of shift.”2
Beginning in 2010, the study group began to make adaptations to the bundle for nurses, finding that they could achieve similar levels of improvement in the quality of communication during transitions.
“Since 2013, we have really been focused on wide-scale dissemination across different settings, including internal medicine services, the ED, surgical perioperative handoffs, and all kinds of transitions involving doctors and nurses,” Landrigan says. “This includes transitions within services at change of shift as well as between services when patients are moving around in the hospital.”
The I-PASS bundle has continued to deliver good results. For instance, Landrigan notes that one study nearing completion involves 32 hospitals that have begun to adapt the bundle for different settings. “We are seeing similar results to what we saw in the original I-PASS studies where we saw reductions in both medical errors and injuries due to medical errors,” he says.
Prioritize Training, Feedback
Landrigan acknowledges that there are all kinds of mnemonic-based tools published in the literature that provide reasonable organizational frameworks for the information that needs to be conveyed in a handoff.
“What makes the I-PASS bundle unique is that it is not just about the mnemonic,” he says. “We have bundled together a training program for residents and later for nurses and others, with discrete changes to the handoff process.” For instance, there is a written handoff tool that is integrated into the electronic medical record (EMR), and investigators have expended considerable effort thinking through how hospital administrators can achieve the cultural changes needed to sustain the I-PASS approach, Landrigan explains.
“A critical piece of this is workplace-based learning and assessment so that when clinicians are using this, they are getting feedback on what they are doing and constant reinforcement on what a good handoff looks like,” he says. “That requires really building a core of faculty that can provide this feedback.”
Further, when making modifications to the I-PASS bundle, individual units must account for how it is going to integrate with their EMR systems as well as the workflow of physicians and nurses. “It has to be something that is easy for them to use, and ideally is sitting on the same [EMR] system or is accessible from that system so that it feels natural for them,” Landrigan notes. Working with IT specialists, hospitals often can arrange for the electronic handoff form that is part of the I-PASS bundle to be populated automatically with information that exists elsewhere in the EMR, which saves time and effort, Landrigan says.
In fact, Landrigan relates that investigators have taken pains to accurately measure the time required to use the I-PASS bundle when transitioning patients, and they have found that it does not add any time at all to the process.
“It does lead to some reorganization in the way that handoffs are handled ... but in the aggregate, it does not add any time,” he says.
For the past several months, Catherine Perron, MD, the director of physician quality assurance and compliance in the department of emergency medicine at Boston Children’s Hospital, has been focused on implementing I-PASS in the ED after an earlier attempt failed.
“We had an experience back in 2011 where we did a lot of I-PASS training because the hospital was promoting it, but it went still in the water because we never backed it up with any real-time observation,” she explains.
This time, Perron made implementation a top priority, first modifying aspects of the I-PASS bundle so that they integrate well within the emergency setting. For example, she developed her own I-PASS training videos, using patients more representative of those treated in the ED.
“We quickly created five or six patient [examples] so that when we went to do training, it looked like an ED sign out and not an [inpatient] floor sign out,” she explains.
Perron explains that she turned to the most vocal naysayers in the department to prepare video examples of both poor handoffs and good handoffs, using the I-PASS approach. This helped to get buy-in from some of the most resistant staff, she explains. The videos then were sent to all the staff so they could see examples of how the approach works with typical emergency patients.
Another modification of the I-PASS approach involved the written handoff tool because while handoff paperwork for inpatients often involves hefty documents, the ED sees a wide variety of patients, some of whom require very little documentation.
“We as a group troubleshooted what we were going to do about the written handoffs and we left that fairly loose,” she explains. “We provided people with a template they could use in our charting area, but we didn’t actually require people to use a certain template for the handoff. That was probably our quickest modification.”
Identify Champions
With the kickoff for the implementation slated for Jan. 1, 2017, Perron spent much of the fall leading up to that date holding workshops and focus groups and identifying I-PASS champions who would conduct observations and provide feedback to staff once the rollout began.
“We made a plan to get to every provider with two observations, so all attending physicians and nurses, which for us was about 300 observations,” Perron notes. “We were going to do that within six months. We were going to be a presence in the department so that people felt like their behavior was being reinforced, and if we got to everybody, people would reinforce each other.”
The department also launched a marketing campaign so that the I-PASS method was reinforced constantly as a priority.
“The amount of information that providers got — I am sure they are seeing I-PASS in their dreams,” Perron notes. “There was signage, emails, staff meetings, safety stories — this has been a constant presence.”
Prior to the I-PASS rollout, administrators collected data showing that the department would handle a handoff-related safety issue every two to three days. That was the baseline, Perron says.
“Our intent was to reduce our handoff-related safety events by at least 20% at the six-month mark following the start of the initiative,” she explains. “We just ran our numbers; we are down by roughly 30% in handoff-related and reported safety events.”
Going forward, Perron is hopeful that with other units in the hospital also implementing I-PASS, there will be added reinforcement to keep the practice in place. “We have already started to notice that if you call [another unit that is using I-PASS], you don’t have to prompt them to synthesize,” she explains. “They will actually say ‘let me synthesize back to you,’” she says.
Certainly, implementing I-PASS is a big lift, and you have to keep at it, Perron shares.
“You really have to have a multidisciplinary group take this on and make it happen,” she adds. “What we learned a few years ago is you can train everybody, but if you don’t reinforce the behavior, you can’t make it stick.”
Intrigued with the potential and the published results of the I-PASS approach, James Heilman, MD, medical director of the transfer center, telemedicine, and continuous quality improvement for the department of emergency medicine at Oregon Health & Science University (OHSU) Hospital in Portland, led the effort to study, modify, and implement the I-PASS bundle in the ED.3
“We started investigating and did focus groups [on the I-PASS approach] in the fall of 2014,” he explains. “The major modification we made was to the patient summary ... because it is a lot different in the ED than in an inpatient setting.” The main issue is time, Heilman observes. “On the inpatient side, oftentimes there are more things to follow up, but they are not as time-sensitive,” he says. “There may be multiple consultants managing a lot of different things over a longer period of time, whereas in the ED it is a matter of managing fewer things, but in a much more condensed time period.”
To accommodate for this difference, the patient summary must be brief and to the point, Heilman observes.
“It has to be tailored to how much work the oncoming team is going to have to do with that patient,” he says. “It is a challenge with emergency medicine handoffs because of the time pressures that we have. It takes experience to be able to know when you need to talk more or less, so the I-PASS tool helps with this, but it doesn’t solve all the problems.”
Before adopting the I-PASS bundle, the ED used the standard SBAR (situation, background, assessment, recommendation) mnemonic, but the department did not have a standardized EMR template.
“It was loosely used by people to organize their handoff, and that was helpful, but I think the advantage of I-PASS is that it has ‘illness severity’ first,” Heilman notes. “Having that at the beginning is helpful because it really cues the oncoming team if there is someone that they need to worry about ... if you are receiving someone who is unstable, then you are going to want to know more information.”
With SBAR, the stability of the patient is not always communicated, says Heilman, so being prompted to identify whether the patient is stable or unstable helps because it cues the oncoming team to any high-risk patients up front. “It is surprising how [illness severity] can get missed sometimes with handoffs because there are so many other details,” he adds.
The OHSU team also modified the instructions for the second “S” in I-PASS, which stands for synthesize. “In the ED, it is different from an inpatient ward where clinicians have more time to be able to repeat everything back, so we modified it for the ED,” he explains.
Instead, this synthesis is shortened to one sentence on each patient. “It achieves the same thing. It is still a synthesis by the receiver,” Heilman notes. “It is not the whole presentation back, but rather a one-liner so everyone is on the same page.”
It is tough to quantify the effect the I-PASS bundle has made on the ED because other changes were integrated at the same time, says Heilman, but he believes it has made a difference.
“I think the important thing is to have a standardized process and a standardized tool to help guide that process,” he says. “Having a standardized EMR template was critical ... and it was important to the way our work flows here.”
Also key to the successful adoption of the approach was empowering residents to take a leadership role in driving the implementation.
“Different academic programs have different ways that they do sign outs and handoffs. Ours is resident-directed, so having them buy into the idea ... and getting them interested in it was important to our culture here,” Heilman notes.
The I-PASS bundle offers structure to the handoff process as well as to the process for implementing the approach, but putting in the required resources and time is important, Heilman observes.
“Putting the investment up front solves a lot of problems downstream,” he says. “It is a way your department can demonstrate that you are staying up with the current times and the safety literature.”
REFERENCES
- Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA 2013;310:2262-2270.
- Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014;371:1803-1812.
- Heilman JA, Flanigan M, Nelson A, et al. Adapting the I-PASS handoff program for emergency department inter-shift handoffs. West J Emerg Med 2016;17:756-761.
With an estimated 80% of the most serious medical errors linked to communication failures, handoff processes are a rich target for improvement. There are numerous tools designed to help providers remember to convey the most important information when transitioning a patient to another provider, but one approach in particular has demonstrated in multiple studies that it can reduce medical errors and preventable adverse events substantially.
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