Having learned many lessons their first year of training the trainers and the trainees, the Colorado hospitalists regrouped the next year. Because there were two interns coming on duty each evening, both taking cross cover, one attending could supervise only one of the interns. And, those hospitalists were getting called away to handle their clinical responsibilities.
“We felt it was important that attendings were available to guide the process safely,” says Dr. Chu. Therefore, because the evening hand-offs were conducted at 6 p.m. and a hospitalist was in house daily at that time, they began having the evening person, who was on each night until about 11, supervise the interns.
To improve the quality and consistency of the teaching, only four of the Division of Hospital Medicine’s eight attendings focused on supervising intern hand-offs. Also, in a series of focus-group meetings with attendings and house staff, they discussed supervision and identified several structures and standards for teaching hand-offs.
In addition to determining a consistent time and place for hand-off exchanges, they developed a consistent written template and a standard for verbal communication that provides an order of thinking and presenting, just as they use for presenting patient history and physical or daily patient progress updates. “The written template and the verbal are not necessarily the same thing,” says Dr. Chu. “We distinguished them as being two separate standards, just as they are with the written and verbal of morning rounds.”
With these protocols in place, attendings now had distinctions to watch for and a clear-cut means by which to supervise. In the third year of training at UCHSC, the hospitalist attendings provided training and feedback on the first night of call for the first four months beginning in July and in small-group sessions during the first week of the ward month.
The Reviews Are In
In response to a survey, the vast majority of UCHSC internal medicine residents said the new protocols were useful or extremely useful. Responses also revealed that training increased interns’ self-perceived hand-off skills and knowledge. The common denominator of a same time and place for hand-offs was judged the most useful element of the program; lectures were considered the least useful element.
Word got around of the program’s success. Eva Aagaard, MD, associate chair for education in the department of medicine, approached the originators to incorporate the program into the medical school’s interclinical curriculum, given to students between the third and fourth years as additional skills they would need in their sub-internships. Originally offered as an elective, demand for the course exceeded the class limit. Plans are under way to make this course mandatory.
“This past year, for the first time, we specifically taught our medical students hand-offs,” says Dr. Chu. He and his colleagues presented an abstract at SHM’s annual meeting in Dallas and are preparing a manuscript for publication.
Until now, all physicians have managed to do hand-offs without formal training. “Most residents figure out their own way of doing things after a while, but what we’re trying to do is not let it be a random evolution of learning,” says Dr. Chu. “It’s like learning to drive or ski with no lesson s: If you point your skis downhill, eventually you’ll learn how to ski, but you’ll have a lot of crashes. In hand-offs, that means communication failures, and a patient may suffer morbidity. We want to train and supervise [residents] so they learn in a progressive fashion and have fewer crashes.” TH
Andrea Sattinger is a frequent contributor to The Hospitalist.