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Conversations key to patients’ health in handover processes

Doctor examining patient in hospital room

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In a bid to minimize medical error, leading academic hospitals are developing tools to improve handover communication – timely initiatives considering the Royal College of Physicians and Surgeons of Canada is set to roll out new standards that include patient handover as a mandatory part of medical residency programs by 2015.

The key to a safe handover? A good conversation.

At the forefront, a collaborative of nine North American pediatric hospitals, including the Hospital for Sick Children in Toronto, has developed a five-step handover process called I-PASS to help doctors remember the critical components of a successful handover. I-PASS stands for Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver. That means doctors are expected to convey information about the sickest patients first, summarize the patient's condition, share an action plan for the patient's care and explain what might happen to the patient in the future. In the last step, the incoming doctor reiterates all the information to make sure it was understood.

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The concept isn't complicated – but that's exactly what makes it valuable, especially for medical institutions without standardized handover plans, says Trey Coffey, medical safety officer at Sick Kids and I-PASS researcher.

"Any hospital can format their handover tool in I-PASS," Dr. Coffey says. A pilot study, published last year in the Journal of the American Medical Association, found that use of an early iteration of I-PASS cut the rate of medical errors from 33.8 per cent to 18.3 per cent.

"I-PASS is the hot one that everyone is talking about right now," says Jason Frank, an emergency physician at Ottawa Hospital who is also director of specialty education, strategy and standards at the Royal College of Physicians and Surgeons.

But it's not the only strategy for improving dialogue during handover being used in Canada.

Ed Etchells, medical director of information services at Sunnybrook Health Sciences Center in Toronto, developed an app called SunnyCare that gathers all the information about a patient in one place so that health-care professionals can access it from a smartphone, tablet or computer.

The technology has advanced information sharing. "Seven years ago, if I was going to get signout [information] on a team of patients on a weekend, someone might tape a piece of paper to a door on a call room, or they might not," Dr. Etchells said.

"[SunnyCare] doesn't replace conversation, it doesn't replace teamwork – it just augments it," he says.

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Nurses at the University Health Network in Toronto have started sharing information at shift change by meeting at the patient's bedside and including the patient in the conversation about care.

"It is becoming best practice and the gold standard" in nursing, says Mary Jane McNally, a registered nurse and senior director of professional practice at the University Health Network.

Ms. McNally is teaching other health-care professionals at the University Health Network how to adopt these verbal, face-to-face handovers. It may encounter resistance from doctors who often have the handover conversation in a private, interruption-free environment.

A train-the-trainer program devised by Canadian Patient Safety Institute and the Royal College has medical faculty (and some residents) learning how to teach patient safety to others, including better techniques for handover communication.

"We may see that our residents are better equipped to handle some of these things than our faculty are," says Brian Wong, a Sunnybrook physician and organizer of the Advancing Safety for Patients in Residency Education program.

Though this program will help academic hospitals, Dr. Wong points out that it won't extend to veteran doctors at community hospitals where there are no residency programs.

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Editor's note: The original version of this story incorrectly said the Canadian Patient Safety Institute and the Royal College have devised a role-reversing program in which residents teach more experienced medical professions new strategies for patient safety. In fact, the program is a train-the-trainer model, in which medical faculty (and some residents) learn how to teach patient safety to others. This version has been corrected.

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