552671
letter2014
AJMXXX10.1177/1062860614552671American Journal of Medical QualityMiller et al
Letter to the Editor
House Staff Perceptions of How Handoff Quality Influences Code Blue and Rapid Response Team Events To the Editor: Implementation of the 80-hour workweek and limitation of intern shifts to 16 hours have increased the number of resident shift-to-shift handovers and the proportion of a patient’s care overseen by “cross-covering” teams.1,2 Code Blue (code) and Rapid Response Team (RRT) events often occur during periods of cross-coverage, and miscommunication between providers may contribute to this.3 The verbal and written quality of the handoff may play an important role in the prevention and management of these situations. To better understand the relationship between handoffs and cross-coverage medical emergencies, we explored house staff perceptions of handoff quality preceding code/RRT events during periods of cross-coverage. This study was conducted by Duke University’s Patient Safety and Quality Council Task Force on Handoffs.4 Between May 1 and November 30, 2013, the primary resident responding to each code/RRT event at Duke University Medical Center was identified. These individuals received an e-mail survey exploring their perceptions of the adequacy of the preceding handoff. Survey questions included whether a verbal and/or written handoff had occurred, whether the handoff was appropriate and sufficient, whether it had prepared the resident to understand and handle the patient’s emergency, and whether the event could have been avoided or would have “gone better” if there had been a better handoff. Survey responses used a 4-point Likert-type scale, and were counted as agreeing with a statement if the respondent selected agree or agree strongly and as disagreeing with a statement if disagree or disagree strongly was chosen. Duke University Institutional Review Board approval was obtained (Pro00032334). In total, 188 code/RRT events occurred during the study period. Seventy-five house staff responded to the survey (40% response rate); 38 of the 75 responses occurred during cross-coverage. Four responses were removed as they had been completed by providers other than the cross-covering team, leaving 34 events for analysis. All respondents had received at least one form of handoff. Although 94% of respondents described the handoff as “appropriate or sufficient,” only 44% of respondents agreed that the handoff had prepared them to manage the acute medical situation. No respondent agreed that the event would have been prevented by a more complete handoff, and only 12% agreed that the event could have “gone better” with a more complete handoff.
American Journal of Medical Quality 2015, Vol. 30(3) 292–293 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614552671 ajmq.sagepub.com
Overall, the vast majority of residents felt the preceding handoff was appropriate and sufficient and indicated that the event was unavoidable. This indicates that house staff are largely satisfied with the quality and quantity of information provided during transitions of care and that educational efforts regarding effective handoffs have been successful. In a prior pilot study, we found that 95% of Duke medical and surgical residents surveyed after a night shift felt that the evening handoff they had received would have enabled them to respond to an acute change in patient status. However, in the current study only 44% of house staff who actually did experience a patient status decline felt prepared to handle the code/RRT event based on the handoff received. This suggests that emergent patient needs often will be unanticipated and that additional educational resources may need to be devoted to familiarize house staff with the management of code/RRT events more generally. This study had several limitations. The sample size was small, but did represent all adult events at our institution over 7 months. Second, the response rate was low (40%), although comparable to other surveys of residents.5 Third, this survey was not validated; however, we are unaware of any validated survey for this topic. Deana Miller, MD Duke University Medical Center, Durham, NC Aaron Mitchell, MD Durham VA Medical Center, Durham, NC Duke University Medical Center, Durham, NC Rebecca Sadun, MD, PhD Judy Milne, MSN, RN, CPHQ Duke University Medical Center, Durham, NC Joel Boggan, MD, MPH Durham VA Medical Center, Durham, NC Duke University Medical Center, Durham, NC References 1. Vidyarthi A, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1:257-266.
Downloaded from ajm.sagepub.com at UNIV TORONTO on November 16, 2015
293
Miller et al 2. Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166:1173-1177. 3. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121: 866-872.
4. Boggan JC, Zhang T, Derienzo C, Frush K, Andolsek K. Standardizing and evaluating transitions of care in the era of duty hour reform: one institution’s resident-led effort. J Grad Med Educ. 2013;5:652-657. 5. Yarger JB, James TA, Ashikaga T, et al. Characteristics in response rates for surveys administered to surgery residents. Surgery. 2013;154:38-45.
Downloaded from ajm.sagepub.com at UNIV TORONTO on November 16, 2015
letter2014
AJMXXX10.1177/1062860614552671American Journal of Medical QualityMiller et al
Letter to the Editor
House Staff Perceptions of How Handoff Quality Influences Code Blue and Rapid Response Team Events To the Editor: Implementation of the 80-hour workweek and limitation of intern shifts to 16 hours have increased the number of resident shift-to-shift handovers and the proportion of a patient’s care overseen by “cross-covering” teams.1,2 Code Blue (code) and Rapid Response Team (RRT) events often occur during periods of cross-coverage, and miscommunication between providers may contribute to this.3 The verbal and written quality of the handoff may play an important role in the prevention and management of these situations. To better understand the relationship between handoffs and cross-coverage medical emergencies, we explored house staff perceptions of handoff quality preceding code/RRT events during periods of cross-coverage. This study was conducted by Duke University’s Patient Safety and Quality Council Task Force on Handoffs.4 Between May 1 and November 30, 2013, the primary resident responding to each code/RRT event at Duke University Medical Center was identified. These individuals received an e-mail survey exploring their perceptions of the adequacy of the preceding handoff. Survey questions included whether a verbal and/or written handoff had occurred, whether the handoff was appropriate and sufficient, whether it had prepared the resident to understand and handle the patient’s emergency, and whether the event could have been avoided or would have “gone better” if there had been a better handoff. Survey responses used a 4-point Likert-type scale, and were counted as agreeing with a statement if the respondent selected agree or agree strongly and as disagreeing with a statement if disagree or disagree strongly was chosen. Duke University Institutional Review Board approval was obtained (Pro00032334). In total, 188 code/RRT events occurred during the study period. Seventy-five house staff responded to the survey (40% response rate); 38 of the 75 responses occurred during cross-coverage. Four responses were removed as they had been completed by providers other than the cross-covering team, leaving 34 events for analysis. All respondents had received at least one form of handoff. Although 94% of respondents described the handoff as “appropriate or sufficient,” only 44% of respondents agreed that the handoff had prepared them to manage the acute medical situation. No respondent agreed that the event would have been prevented by a more complete handoff, and only 12% agreed that the event could have “gone better” with a more complete handoff.
American Journal of Medical Quality 2015, Vol. 30(3) 292–293 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614552671 ajmq.sagepub.com
Overall, the vast majority of residents felt the preceding handoff was appropriate and sufficient and indicated that the event was unavoidable. This indicates that house staff are largely satisfied with the quality and quantity of information provided during transitions of care and that educational efforts regarding effective handoffs have been successful. In a prior pilot study, we found that 95% of Duke medical and surgical residents surveyed after a night shift felt that the evening handoff they had received would have enabled them to respond to an acute change in patient status. However, in the current study only 44% of house staff who actually did experience a patient status decline felt prepared to handle the code/RRT event based on the handoff received. This suggests that emergent patient needs often will be unanticipated and that additional educational resources may need to be devoted to familiarize house staff with the management of code/RRT events more generally. This study had several limitations. The sample size was small, but did represent all adult events at our institution over 7 months. Second, the response rate was low (40%), although comparable to other surveys of residents.5 Third, this survey was not validated; however, we are unaware of any validated survey for this topic. Deana Miller, MD Duke University Medical Center, Durham, NC Aaron Mitchell, MD Durham VA Medical Center, Durham, NC Duke University Medical Center, Durham, NC Rebecca Sadun, MD, PhD Judy Milne, MSN, RN, CPHQ Duke University Medical Center, Durham, NC Joel Boggan, MD, MPH Durham VA Medical Center, Durham, NC Duke University Medical Center, Durham, NC References 1. Vidyarthi A, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1:257-266.
Downloaded from ajm.sagepub.com at UNIV TORONTO on November 16, 2015
293
Miller et al 2. Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166:1173-1177. 3. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121: 866-872.
4. Boggan JC, Zhang T, Derienzo C, Frush K, Andolsek K. Standardizing and evaluating transitions of care in the era of duty hour reform: one institution’s resident-led effort. J Grad Med Educ. 2013;5:652-657. 5. Yarger JB, James TA, Ashikaga T, et al. Characteristics in response rates for surveys administered to surgery residents. Surgery. 2013;154:38-45.
Downloaded from ajm.sagepub.com at UNIV TORONTO on November 16, 2015
