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.
Whenever feasible, handoff communications should be face-to-face, in a relatively quiet setting, with simultaneous availability of Health Link and PACS. In simple cases (e.g., the night float resident is assuming care for a stable epilepsy monitoring unit patient with whom he’s already familiar), asynchronous communication via secure messaging or the sign-out list is permissible.
In order to promote high-quality handoffs, we use a standardized patient sign out list within our electronic medical record and specific templates to help populate these lists with the following patient information:
I: Identify the patient, service, and attending physician
D: Diagnosis and current condition
E: Events that have recently occurred
A: Anticipated changes in condition or treatment—what to watch out for
L: Leave time for questions and discussion
Following is a summary of our program’s handoffs:
- Resident morning sign-out occurs at ~ 0730 each weekday. 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. This helps ensure that no one, especially consults seen over the weekend, falls through the cracks. On the other days, the night float resident signs out individually to each on-service resident.
- Afternoon sign-out / interdisciplinary rounds occurs each weekday at ~ 1600. The on-service residents and the short call resident meet with a small group of nurses and case managers both to transition the patients’ care and to review the patient census with an eye toward anticipated discharges. The short call resident assumes care from the on-service residents at that time.
- Evening sign-out occurs Sunday-Thursday at ~ 2000. The short call resident transitions the patients’ care to the night float. Importantly, residents may hand off pending consults when these are received at the end of a call shift, putting the resident at risk for a duty hour violation (i.e., not getting out of the hospital at the required time because of the last-minute consult and associated chart work). As a general rule, short-call residents may hand off consults received after ~ 19:30 in order to ensure that they can leave the hospital by 21:00. Of course, a preliminary determination must still be made whether the matter is urgent or not. As always, patient care comes first and so other unfinished work may have to be handed off to the oncoming resident if a late consult is for an urgent matter.
- Weekend rounds are preceded by an 0800 sign-out among the post-call and on-call residents and the stroke and general neurology / consult attendings and fellows. In this way, the attendings and fellows can hear first-hand about any new patients they will be rounding on with the other resident and can also monitor the quality of resident handoffs.
- The vascular neurology fellow will utilize the IDEAL process to handoff patients to an on-call attending if they are leaving a shift or moving on to a different role where they are no longer responsible for the patient. This may be done via telephone, though in-person conversations are favored.
Both in the clinic and the wards, neurology is very much an interprofessional discipline. Nurses, physical therapists, occupational therapists, speech/language pathologists, neuro- and health psychologists, dieticians, respiratory therapists, social workers, and case managers all play crucial roles in our patients’ care. Importantly, optimal patient care depends not just on having members of these various disciplines independently performing their evaluations and treatments, but on actual collaboration among the team members; this is what is meant by the term “interprofessional”. The sine qua non of an interprofessional team is communication; in our residency and fellowship programs, interprofessional communications occur constantly throughout the work day, and formally occur at the following times:
- Morning interdisciplinary rounds—daily at 0900. The stroke and general neurology inpatient teams gather with the nursing staff, PT, OT, speech, swallow, social work, case management, etc. to discuss each patient on service with specific attention to their overall plan of care and anticipated discharge needs.
- Afternoon sign-out / interdisciplinary rounds—as above.
Training and Assessment
The above handoff processes and our program’s emphasis on interprofessional teamwork are introduced in our orientation sessions each July. In the fall, we hold additional conferences with our PT, OT, speech, and social work / case management colleagues to learn about their roles in more detail and to facilitate team-building and communication. Further, interprofessional communication is an important aspect of clinical case reviews. This is especially true in systems of care conference, but also true for morning report, stroke conference, etc.
Assessment and feedback regarding residents and fellows’ handoff and communication skills occurs via a variety of methods:
- Senior residents on night float are expected to provide feedback to the juniors signing patients out to them, either right away or, if a deficiency comes to light through the night, then during the next morning’s handoff.
- Attending physicians are present for the 0900 interdisciplinary rounds and will directly observe and provide feedback regarding the residents and fellows’ communication skills.
- Each end-of-rotation evaluation survey contains at least one question regarding communication skills.
- Twice each year, multi-source (360⁰) evaluation surveys are sent to many members of our interdisciplinary team, and these questions focus specifically on interprofessional communication.
Latest revision: 09/17/2021 Jamie Elliott, MD, PhD