# Presentation: 148362

## Patient Safety ModuletteInpatient Transitions of Care:Improving Safety by Improving Handover 

- Rajesh S. Mangrulkar, MD
- J. Michael Kramer, MD
- Department of Internal Medicine
- University of Michigan Health System

## Outline

- Introduction to the problem
- The proposed solution: structured signout
- Discussion of cases and skill development
- Summary

## Physician discontinuity

## Inpatient signout: scope of the problem of shift change

- Cross-coverage is a way of life for most physicians, especially residents
- Adverse effects of being cared for by a cross-covering physicians include:
- more patients leaving AMA
- higher rates of ordering labs
- increased preventable adverse events

## Inpatient signout: targeted interventions

- Information management crucial to caring for patients not your own
- Residents have expressed desire to improve the signout process1
- Use of automated signout forms may reduce preventable adverse events2
- 1Parker J, et al. *JAMIA*. 2000; 7(5): 453-61
- 2Petersen LA, et al. *JCJQI*. 1998; 24(2): 77-87.

## Goals of signout: an intern’s perspective

- Patient Care

- Don’t burden
- your co-intern

- -Unnecessary work
- -Sick patients, no info
- -Inaccurate info

## Proposed solution: structured signout

**DATA**

**TASKS**

**JUDGEMENT**

## Structured signout: data

- Appropriate
- relevant to the current clinical condition(s)
- Accurate
- recent and precise
- Complete
- Labs, X-rays, code status, allergies, relevant meds, recent important events
- Include anticipated information

## Structured signout: tasks

- Limits unnecessary work, yet promotes care for the sickest patients
- Focus on minimizing the “to do” list to the necessary
- Minimize procedures where possible (including blood draws, ABG’s)
- Minimize information seeking as a “task”: anticipate the information needs

## Structured signout: judgement

- Capitalize on the opportunity to guide your colleague’s DDx and plan for your patient:     ***S I P S***
***S***tatus: mention clinical condition
***I****nterpret**** P***otential events
- Anticipate likely events
- Give best judgement as to what is going on.
- Suggest actions to take if these events occur.
***S***urveillance: encourage “checking” on the very ill

## Illustrative cases

## Case Discussion: Principles

- For each case, reflect on the following:
- Is the case description appropriately reflected in the signout document? If not, what are the big discrepancies?
- What is missing information that should be present?
- What is present in the document that should not be there?
- What other aspects of the signout are inappropriate?

## Case 1

- On short call, the GI Liver team admits Ms. Williams, a 49 yo woman with end-stage liver disease and cirrhosis secondary to autoimmune hepatitis.  At baseline, she is on spironolactone, lactulose, and lasix.  She was placed on the transplant list and has had frequent bouts of hepatic encephalopathy.  She presented to clinic today with worsened ascites, and was subsequently admitted to the short call team. She has had multiple paracentesis in the past in clinic, all successfully, but this time she is admitted to improve her status on the transplant list. On further questioning the patient’s family, it seems that the patient’s clinical status is truly at baseline, except for worsened ascites. Her mental status is fine. The short call team draws labs (shown below) without significant abnormality (including UA, CXR – all normal).  Her aldactone dose is increased, and plans are made for a therapeutic paracentesis.  The team elects to get an ultrasound-guided tap.  However, the ultrasound is scheduled for 9:00 PM and the intern has the day off tomorrow.

## Case 2

- Mr. Paulette is a 60 yo man with a long standing history of type II DM, chronic renal failure secondary to DM and HTN (baseline Cr 3.0), currently he presents with a worsening diabetic foot ulcer.  He was admitted from clinic yesterday. On presentation, he is afebrile, but he has a large right heel ulcer with surrounding erythema, probing through to bone.  His foot is asensate and has poor distal pulses. WBC on admission was 8.6; his ESR was 63.  His wound was debrided in clinic, and he was started on vancomycin and merepenem on the day of admission, because of a penicillin allergy.  Blood cultures are negative, and he is scheduled to undergo an MRI of his foot. Unfortunately, Mr. Paulette loses his intravenous access the next day, and numerous attempts to place a peripheral line are unsuccessful.  The PICC nurse is called who refers him to angio for placement, scheduled for tomorrow.  Today, however, the team places a right subclavian line without event.  The post-call intern placed the line at Noon, and orders the CXR.  She’s quite tired and needs to leave the hospital by 1PM, as mandated by her schedule.

## Case 3

- Mrs. Jones is a 72yo woman with a history significant for CAD (2 vessel, s/p RCA stent 4 years ago, normal ejection fraction), osteoarthritis of both knees and left hip, and history of a TAHBSO. She presented to the hospital 1 day ago with a 1-week history of a fever, productive cough, worsening dyspnea on exertion, accompanied by pleuritic chest pain.  On presenting physical examination, she was found to be febrile to 101.9F, tachycardic and tachypneic.  Her O2 sat was 86% on RA.  She was euvolemic, and had rhonchi and egophony at both lung bases. Her creatinine is elevated at 1.4 (baseline 1.1). ABG was 7.41/34/60/23 on RA.  She was diagnosed with a LLL and RML pneumonia by CXR, and was also found to have a moderate left sided pleural effusion.  The team attempted to drain this effusion without success.  Post-procedural CXR showed no pneumothorax. Blood cultures are unrevealing.  The team began her on ceftriaxone and azithromycin.  She improves over the next day.

## Case 4

- Mr. Stevens is a 68 yo man with a history of smoking, COPD (FEV1 1.2 l), intermittent atrial fibrillation and osteoarthritis.  He presented to the service 3 days ago with a 2 week history of progressive dyspnea, wheezing and a productive cough.  He is admitted (as he has been several times in the past) with the diagnosis of a COPD exacerbation with probable bronchitis.  His exam reveals wheezes, no egophony, some tachycardia and tachypnea. His O2sat is 90% on RA. His WBC is 15.2K, his CXR is clear on presentation.  The team begins around-the-clock albuterol and atrovent nebulizer treatments, as well as solumedrol.  On the admission day, the patient’s tachycardia progresses, with an irregular HR of 175.  EKG reveals afib with RVR. At the same time he becomes hypotensive and thus receives DC cardioversion, resulting in a normal sinus rhythm and normal bp.  On day 2, his hypoxia worsens and he develops a fever with a significant productive cough.  CXR shows a new LLL infiltrate and he is begun on ceftriaxone and azithro.  Today is day 3, and he is stable with regards to O2 requirements and dyspnea.  His rate is better controlled and remains in normal sinus rhythm.