Executive Summary
A new approach to hospital handoffs has shown it can significantly reduce medical errors as well as preventable adverse events. The approach, dubbed the I-PASS bundle, uses a mnemonic to alert providers to all the issues that need to be covered during a handoff, but also includes a written handoff tool, communication training, a sustainability campaign, and a process for feedback.
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In a study of the I-PASS bundle conducted at nine pediatric hospitals, investigators found that the approach reduced medical errors by 23%, and the rate of preventable adverse events by 30%.
Investigators say I-PASS did not increase the amount of time required to conduct a handoff. On average, handoffs in the study took 2.5 minutes per patient.
Several medical centers are now implementing the approach hospital-wide, and additional studies into the approach are planned.
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Developers advise hospitals interested in the approach to first gather data and survey providers to make a case for the intervention.
In perhaps the largest study of a handoff protocol ever conducted, investigators have found that a unique, mnemonic-driven approach has the potential to significantly improve care — and not just in particular units or specialties, but in every unit of a hospital setting, including the ED. The study, which took place over a period of 18 months at nine pediatric residency programs in the United States and Canada, found that what developers refer to as the I-PASS handoff bundle effectively slashed medical errors by 23% and produced a 30% reduction in preventable adverse events.1
Already, a number of hospitals are moving to adopt the approach, and follow-up studies of the I-PASS bundle are in the works, including one project in which researchers are evaluating the effectiveness of the handoff method when it is used with both health care team participants and family members.
Developers of the approach note that health care leaders have long recognized a need for improvement in the way patients are handed over from clinician to clinician or team to team during shift changes. "It turns out that 100 different people have 100 different ways of handing off patients, and the bigger issue is that isn't working," explains Colonel Clifton Yu, MD, the chief of graduate medical education at Walter Reed National Military Medical Center in Bethesda, MD, and one of the investigators on the I-PASS study. "Two-thirds of all the medical errors that lead to sentinel events and adverse outcomes in this country are due to miscommunication, and when you stare at that data, no one can really deny that handoffs are an extremely vulnerable area of patient care."
Take steps to sustain protocol
When people first hear about I-PASS, they tend to think that it is just a nifty mnemonic, intended to help clinicians remember all the areas that need to be covered when handing off a patient to the next clinician or team, explains Yu. These include illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by receiver. However, Yu stresses that there are several other components to the process, which is why the protocol is referred to as the I-PASS bundle.
For instance, there is a standard-ized written handoff tool that reflects the mnemonic, and there is team communication training that is derived from the well-established TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) curriculum, which was originally piloted by the Department of Defense a decade ago and is now jointly sponsored by the Agency for Healthcare Research and Quality (AHRQ). "We took parts of TeamSTEPPS and used that in our [I-PASS] curriculum to further promote team communication skills, not just in the context of handoffs and patient care, but all the way around," says Yu.
Recognizing that any new process needs to be sustained, the bundle also includes a sustainability campaign intended to help remind people to continue to use the approach. This consists of posters, screen savers, and other tools that can give the approach repeated visibility in the health care setting.
The final piece of the bundle is a mandate that attending physicians need to observe residents when they conduct their handoffs and utilize a standardized evaluation tool to provide them with feedback. "That's five different things that we incorporated into the study that made up the I-PASS bundle," notes Yu. "It was not just a nifty mnemonic we were going to use; it was going to be coupled with all these other things: the written handoff tool, the abbreviated TeamSTEPPS training, the sustainability campaign, and the feedback from supervisors."
Use simulation techniques
Training sessions for I-PASS make full use of simulation techniques such as role-playing, according to Joseph Lopreiato, MD, MPH, a co-investigator on the I-PASS study and the associate dean for simulation education at the Uniformed Services University of Health Sciences (USUHS) in Bethesda, MD. "In a classroom we gave a group of learners a series of [simulated] patients on paper which they read through and got familiar with, and when they were ready, they orally handed over those patients to another group of residents while several of us involved with I-PASS observed and gave them feedback," he explains. "We were able to practice these simulations several times until the residents were sure and we were sure that they were ready to go, and then we let them go forth on the ward and try it with real patients."
Simulation was also used in the creation of instructional videos to show residents and faculty how I-PASS handovers should ideally be conducted. "We used a series of simulations where we went on the ward, and with actors we went through how a team would behave using TeamSTEPPS concepts," notes Lopreiato. "Most faculty and residents get it. They see it is pretty simple and it makes sense."
Include nurses, allied professionals
Of particular importance to emergency clinicians is the time any intervention takes to perform. Army Major Jennifer Hepps, MD, a co-investigator on the I-PASS study and an assistant professor of pediatrics at the USUHS, suggests that this does not appear to be a problem in the I-PASS protocol. "The study results showed that there was no change from the pre-intervention period to the post-intervention period in the duration of handoffs," she explains. "On average they took 2.5 minutes per patient."
Hepps notes that surgeons have also expressed concerns about the time required to perform the I-PASS bundle, and there is some flexibility built into the process. "We showed them that you can do I-PASS in a very detailed fashion for a very complicated patient who has multi-organ-system issues, and you can also do it in a more rapid-fire fashion for patients who may have a single organ issue, or for patients who are familiar to most people [in the unit or department]," she observes. "I already have physicians who have started to roll it out at Walter Reed, and I think they have found that the I-PASS paradigm can work in their setting just as easily as it worked in the pediatric setting."
In fact, the director at Walter Reed, Brigadier General Jeffrey Clark, MD, MPH, put a policy in place this past summer to implement the I-PASS bundle hospital-wide, notes Yu. "It is coming along very well. Pediatrics has been doing it for three years now. The biggest clinical service in our hospital is internal medicine, and then surgery, and both of those services are now doing it as well, and some of our ICUs are doing it," he explains.
Yu adds the I-Pass bundle is not just for physicians; it should be adopted by nurses and allied health professionals at Walter Reed as well, he says. "There are a number of nursing services in our hospital right now that are using it, and we have just developed a follow-up video demonstrating how it might be used in the nursing setting," he says.
While the ED at Walter Reed has not yet fully implemented the protocol, some of the nurses in that setting have begun to use it. "I can think of no better place to utilize I-PASS than in the ED setting," observes Yu.
Lopreiato agrees, noting that the emergency setting is the perfect context for I-PASS because of the continuous shift work that takes place. "Often times a new shift comes on and has to have patients handed over to them from the old shift," he says. "Heretofore there hasn't been a structured, well-studied method for those handovers to occur so that errors are minimized, and I-PASS is the perfect vehicle for that because it is structured, it seems to work, and it reduces medical errors."
Survey providers
In addition to Walter Reed, other hospitals have signaled their intention to adopt I-PASS hospital-wide, including Massachusetts General in Boston, MA, New York Presbyterian Hospital in New York City, and MD Anderson Cancer Center in Houston, TX, notes Yu.
Further, the Society for Hospital Medicine (SHM) has made grant funding available to a number of hospitals for "mentored implementation" of the approach. What this involves is having an I-PASS expert interface with hospital leadership and conduct faculty development sessions to get the implementation started; the expert then conducts monthly follow-up sessions to look at issues of sustainability, explains Yu, noting that the SHM effort is called the I-PASS Metric Implementation Project.
However, Yu points out that hospitals don't need to be part of that project to implement I-PASS on their own. All of the study information and instructional materials are available at no cost on the I-PASS study website at www.ipasshandoffstudy.org.
Before launching the intervention, though, Yu advises colleagues to first gather feedback from providers on where they see safety vulnerabilities in their own settings. When 700 residents at Walter Reed were surveyed on this issue, the number one problem area they cited was poor transitions of care, observes Yu. These survey data proved helpful in convincing higher-ups that an intervention like I-PASS was needed.
Once people are convinced of the need for action on this issue, making use of the resource materials and getting everyone trained are easier tasks, says Yu. "The meat of the curriculum is a two and a half hour workshop which we are actively working on in our group to try to shorten," he explains. "The key is getting people to actually interact, use the materials, and practice."
- Starmer A, Spector N, Srivastava R, et al. Changes in medical errors after implementation of a handoff rogram. N Engl J Med 2014;371:1803-1812.
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, MD, Assistant Professor of Pediatrics, Uniformed Services University of Health Sciences, Bethesda, MD. E-mail:
[email protected]
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, MD, MPH, Associate Dean, Simulation Education, Uniformed Services University of Health Sciences (USUHS) in Bethesda, MD. E-mail:
[email protected].
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Colonel Clifton Yu, MD, Chief, Graduate Medical Education, Walter Reed National Military Medical Center, Bethesda, MD. E-mail:
[email protected].
