The Handoff Culture: Can we change how an ICU to floor transfer works?

Handoffs between providers have increased following the implementation of the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions. Properly structured and timed handoffs are essential to patient safety.1 Despite this, studies have shown that errors in code status, medication allergies, and important updates to the problem list are common, all of which can lead to adverse outcomes to patients.2 At Thomas Jefferson University Hospital (TJUH) the 2016 Safety Culture Survey revealed that across all specialties, 37% of residents felt that things “fall through the cracks” when transferring patients from one unit to another. Our interdepartmental Housestaff Quality and Safety Leadership Council (HQSLC) sought to evaluate and modify the TJUH ICU to floor handoff process. Through engaging our diverse membership, we realized that the ICU to floor handoff process at TJUH lacks standardization. The following areas demonstrated a high degree of variation, and were seen as targets for improvement: ● Timing of handoff: Some departments give the handoff at the time of transfer order, and others at bed assignment. ● Incorporation of best practices: Both verbal and written handoffs should be performed with time for follow up questions by the receiving team ● Closed loop communication: Both sending and receiving teams should clearly communicate the plan of care, and the receiving team should clearly indicate when they have taken over primary responsibility. Poster presented at: House Staff Quality and Safety Leadership Council conference at Thomas Jefferson University.https://jdc.jefferson.edu/patientsafetyposters/1073/thumbnail.jp

Case Report: Diagnosis of Dual-Biopsy Negative Severe Cardiac Amyloidosis

INTRODUCTION Amyloidosis is a rare disorder that involves the deposition of misfolded protein in extracellular tissue. Disease manifestations vary depending on the affected organs. Areas most often involved include the kidneys, gastrointestinal tract, heart, nervous system, and musculoskeletal system. The most common type is AL amyloidosis, in which plasma cells produce an abundance of a monoclonal proteins that affect numerous organ systems. A second variety, AA amyloidosis, is associated with inflammatory diseases such as rheumatoid arthritis and inflammatory bowel disease. Finally, a heritable version of amyloidosis mediated by mutations in the transthyretin protein (TTR) has a predilection for deposition in peripheral nerves and cardiac tissue1

Lost in Translation: A Standardized, Interdepartmental Approach to Improve the Safety of Inpatient Transitions of Care

AIM: During the 2016-2017 academic year physician perception of favorability regarding inpatient interunit handoffs will meet the national HSOPS benchmark without negatively impacting patient bed flow. All ACGME training programs at Thomas Jefferson University Hospital will expose their new trainees to standardized handoff training during orientation in June 2017 as well as adapt a framework for monitoring trainee compliance and proficiency.https://jdc.jefferson.edu/patientsafetyposters/1028/thumbnail.jp

VKORC1 Common Variation and Bone Mineral Density in the Third National Health and Nutrition Examination Survey

Osteoporosis, defined by low bone mineral density (BMD), is common among postmenopausal women. The distribution of BMD varies across populations and is shaped by both environmental and genetic factors. Because the candidate gene vitamin K epoxide reductase complex subunit 1 (VKORC1) generates vitamin K quinone, a cofactor for the gamma-carboxylation of bone-related proteins such as osteocalcin, we hypothesized that VKORC1 genetic variants may be associated with BMD and osteoporosis in the general population. To test this hypothesis, we genotyped six VKORC1 SNPs in 7,159 individuals from the Third National Health and Nutrition Examination Survey (NHANES III). NHANES III is a nationally representative sample linked to health and lifestyle variables including BMD, which was measured using dual energy x-ray absorptiometry (DEXA) on four regions of the proximal femur. In adjusted models stratified by race/ethnicity and sex, SNPs rs9923231 and rs9934438 were associated with increased BMD (p = 0.039 and 0.024, respectively) while rs8050894 was associated with decreased BMD (p = 0.016) among non-Hispanic black males (n = 619). VKORC1 rs2884737 was associated with decreased BMD among Mexican-American males (n = 795; p = 0.004). We then tested for associations between VKORC1 SNPs and osteoporosis, but the results did not mirror the associations observed between VKORC1 and BMD, possibly due to small numbers of cases. This is the first report of VKORC1 common genetic variation associated with BMD, and one of the few reports available that investigate the genetics of BMD and osteoporosis in diverse populations

Improving Management of Chest Pain with a High Sensitivity Troponin Based Prootocol

Chest pain is one of the most common presenting complaints to emergency departments in the United States. Management typically centers on ruling in or out myocardial infarction, or other forms of major adverse cardiac events which are overall rare diagnoses. The high sensitivity troponin assay can detect abnormal troponin elevations at 10-to-100-fold lower levels compared to traditional troponin assays, and thus can allow faster time to disposition and diagnosis. This has implications for improving length of stay in the emergency department, and earlier and more accurate identification of those presenting with myocardial infarction. The aim of this study was to evaluate the effect that a high sensitivity troponin assay combined with a chest pain clinical management protocol based on the HEART score would have on emergency department length of stay and disposition for patients presenting for evaluation of chest pain across Main Line Health acute care hospitals. This intervention was able to achieve a reduction in emergency department length of stay, increase the number of patients discharged home from the emergency department, and reduce the number of patients admitted to observation and inpatient status. A $1 million cost savings was noted after one year related to reduction in unnecessary observation admissions. The intervention was additionally associated with reduction in use of stress testing, echocardiograms and cardiology consultations for patients admitted to observation status

White Paper: Improving Handoff Culture in Intensive Care Unit to Floor Handoffs

The frequency of handoffs between providers has increased since the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions, generating concerns over the quality of these handoffs and their impact on patient safety. At Thomas Jefferson University Hospital (TJUH), the 2016 Safety Culture Survey revealed that across all specialties, many residents felt that “things fall through the cracks” when transferring patients from one unit to another. The interdepartmental Housestaff Quality and Safety Leadership Council (HQSLC) at TJUH sought to improve handoffs at our institution and identified two areas of focus: (1) standardizing the language of handoffs with a commonly accepted handoff technique (IPASS), and (2) standardizing the process of handoffs from the ICU to the floor. Qualitatively, resident comfort with handoffs improved with no adverse impact on time to patient movement between units. This project demonstrated the difficulty of changing the handoff culture at an institution, establishing lasting change via a new EMR system, and training housestaff of a new handoff method. Future directions include monitoring compliance with the new standardized handof f curriculum, and determining whether these efforts and interventions translate to improved patient safety at our institution

Utilizing feedback as a mechanism to improve resident event reporting rates

Objectives Provide feedback to 100% of residents entering a report between December 2017 and March 2018 Evaluate the degree to which residents value the feedback we were able to provide Assess a pilot process for sustainability on a larger scalehttps://jdc.jefferson.edu/patientsafetyposters/1099/thumbnail.jp

Adaptation of a Standardized Handoff System for a Radiology Residency Program

Background/Objectives: The Joint Commission has linked communication failure as a root cause for a majority of sentinel events. The “I-PASS” system is a hand-off mnemonic that has been shown to decrease medical errors, prevent adverse events, and improve communication. Multiple Jefferson residency programs have adopted I-PASS training over the last year to standardize sign-outs between treatment teams and departments. Radiology residents also participate in hand-offs with other departments, especially in cases of adverse patient reactions that occur within radiology (ie: allergic reaction, seizure, contrast extravasation). In addition, radiology residents also participate in hand offs between daytime and overnight teams, including sign out of pertinent protocols, studies, and clinician communications. The aim of this study was to assess the adaptability of I-PASS training to the needs of a diagnostic radiology residency program.https://jdc.jefferson.edu/patientsafetyposters/1098/thumbnail.jp

Improving Bedside Procedural Safety through Optimizing Timeout Documentation and a Pre-procedure Checklist

Aim GOAL: Improve the safety of patients undergoing bedside procedures while maintaining the full spectrum of graduated autonomy in procedure training for residents. SMART Aim: Increase the rate of timeouts documented for bedside procedures from 29% to 50% by June 2018.https://jdc.jefferson.edu/medposters/1014/thumbnail.jp