Implementation of a handoff improvement program was associated with improvements in handoff quality and a significant reduction in reported rates of handoff-related adverse events, a prospective study found.
Researchers enrolled residents at 32 hospitals (12 community, 20 academic) to determine if I-PASS would be associated with improvements in patient safety and communication across diverse settings. I-PASS (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver) is a multifaceted verbal and written handoff communication improvement program for residents that includes handoff training, process improvements, faculty development and observations, and a sustainability campaign. In a prior nine-center study, I-PASS was associated with a decrease in harmful medical errors in pediatric academic hospitals.
As part of the expanded intervention, external teams provided longitudinal coaching to facilitate I-PASS implementation and monthly metric reviews. The project was implemented in two 17-month waves (16 hospitals in each wave) between 2015 and 2017. Systematic surveillance surveys assessed rates of resident-reported adverse events, while validated direct observation tools measured verbal and written handoff quality. Results were published Nov. 3 by the Journal of Hospital Medicine.
Overall, 2,735 residents and 760 faculty champions from multiple specialties participated (16 internal medicine, 13 pediatric, 3 other). A total of 1,942 error surveillance reports were collected from the resident end-of-rotation survey (response rate, 58.6%). Across all sites, major handoff-related reported adverse events fell 47.1% following implementation, decreasing from 1.7 to 0.9 major events per person-year (P<0.05). Minor harm events decreased from 17.5 to 9.3 per person-year (P<0.001), a 46.9% reduction across hospitals. Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20.0% [95% CI, 15.0% to 26.2%] vs. 66.3% [95% CI, 59.8% to 72.1%]; P<0.001) and written (10.4% [95% CI, 5.8% to 17.7%] vs. 73.5% [95% CI, 63.8% to 81.4%]; P<0.001) handoffs. I-PASS implementation was also associated with increased frequency of handoffs with high-quality verbal (38.7% vs. 80.9%; P<0.001) and written (29.1% vs. 78.1%; P<0.001) patient summaries, verbal (28.9% vs. 77.8%; P<0.001) and written (24.1% vs. 72.6%; P<0.001) contingency plans, and verbal syntheses by the receiving physician (31.4% vs. 83.1%; P<0.001).
The extent to which the I-PASS approach is generalizable to handoffs occurring at times other than the end of the residents' shifts or to clinicians other than those on general pediatric and internal medicine units is unclear, the study authors noted. Another limitation was that those measuring handoff documentation quality or reporting adverse event frequency could not be blinded to intervention status, they added.
“Importantly, across provider types (adult vs. pediatric), settings (community vs. academic), and level of training (PGY1 vs. PGY2+), similarly high levels of handoff quality and reported adverse event reduction rates were achieved post-implementation,” the authors wrote. “Taken together, these findings indicate that the I-PASS Handoff Program can be successfully implemented in diverse specialties and hospitals, and could potentially promote widespread improvements in patient safety.”