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Transitions of Care

Procedures

In the inpatient setting, rising patient volume and acuity, coupled with work hour restrictions, has required an increase in the number of transitions of patient care from one physician to another (handoffs). It is therefore of paramount importance that handoffs be conducted in a high quality manner.

For our primary admitting services (epilepsy/EMU, stroke, and general neurology), handoff communications should be face-to-face, in a relatively quiet setting, with simultaneous availability of Health Link and PACS. For consult-based services, an in-person or telephone conversation for handoff communication is expected for any neurologically complex or sick patients (for example, patients on video EEG needing frequent medication adjustment, patients with acutely evolving exams, or patients with pending diagnostic studies likely to change management). For neurologically stable consult patients, asynchronous communication via secure messaging or the sign-out list is permissible. No matter which method is used, the residents giving and receiving the handoff must leave time for questions and clarifications.

In order to promote high-quality handoffs, we use a standardized patient signout list within our electronic medical record and specific templates to help populate these lists with the following patient information:

  • Indentity, location, and clinical service
  • Diagnosis and current condition
  • Resuscitation (code) and isolation statuses
  • Recent events/changes in condition or treatment
  • Anticipated changes in condition or treatment
  • Behavioral contracts, Power of Attorney (POA), family dynamics, etc.

Following is a summary of our program’s handoff times:

  • Morning sign-out occurs at 0700 or 0800 each weekday (depending on whether there is an 0800 conference). All of the on-service residents gather each Monday morning to review the patient lists and make sure that all patients appear on the appropriate list (stroke, general, consult, epilepsy, peds) and have the proper attending. On the other days, the night float resident signs out individually to each on-service resident.
     
  • Afternoon sign-out occurs each weekday at ~ 4:00 pm. The on-service residents and the night float meet for face-to-face signout.
     
  • Weekend rounds are preceded by an 8:00 am sign-out among the post-call and on-call residents and the stroke and general neurology / consult attendings. In this way, the attendings can hear first-hand about any new patients they’ll be rounding on with the other resident and can also monitor the quality of resident handoffs.

Training and Assessment

The above handoff processes are introduced to new residents in our orientation sessions each July. They are reviewed with the teaching faculty at least annually during the faculty development segment of the monthly department meeting. Assessment and feedback regarding residents’ handoff and communication skills occurs via a variety of methods:

  • The night float residents are surveyed regarding the quality of the signouts they receive from the junior on-service residents.
     
  • Attending physicians evaluate the signout quality, both verbal and written, for each junior resident at least once during the PGY2 year.
     
  • Attending physicians are present for the 0900 interdisciplinary rounds and will directly observe and provide feedback regarding the residents’ communication skills.
     
  • Each end-of-rotation evaluation survey contains at least one question regarding communication skills.
     
  • Twice each year, multi-source (360) evaluation surveys are sent to many members of our interdisciplinary team, and these questions focus specifically on interprofessional communication.

Latest revision: 05-22-2019