Facilitator
Packet
General Instructions:
•
You will be divided into groups of three.
•
Each packet includes three handoff scenarios, each with three roles to be divided. You will get
the chance to play each of these roles.
•
The roles are the Front-line Provider giving the handoff, the Front-line Provider receiving the
handoff, and an observer (each is denoted by a separate color). In each scenario, there may be
unique challenges to be acted out and overcome. Follow the instructions for your role. You
should treat the patient information as real.
•
Additional information is provided in the printed handoff documents; these should be used as a
resource for completing focused verbal handoffs. Please do not attempt to handoff all the
information in the printed handoff document.
•
Apply the techniques you learned today; you are welcome to use the pocket card as a refresher.
The I-PASS Mnemonic:
I
Illness Severity
Stable, “watcher,” unstable
P
Patient Summary
Summary statement; events leading up to admission;
hospital course; ongoing assessment; plan
A
Action List
To do list; timeline and ownership
S
Situation Awareness and
Contingency Planning
Know what’s going on; plan for what might happen
S
Synthesis by Receiver
Receiver summarizes what was heard, asks questions;
restates key action/to do items © 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Faculty Debrief Guide Scenario 1
•
•
•
•
•
•
During scenario encourage residents to actively embrace roles and ensure that the
observer fills out verbal tool.
Monitor use of mnemonic.
Observe the handoff carefully. Were they able to communicate that Richard Smith
was the sickest patient?
Were contingency plans adequate?
o Did they mention that Richard Smith was DNR/DNI and what to do if
he developed worsening respiratory distress?
o Did they discuss that the family does not want Richard Smith
transferred to the ICU?
Did they demonstrate synthesis of the plan (e.g. being able to check-back and ask
appropriate clarifying questions)?
While facilitating, evaluate the handoff using the “I-PASS Handoff
Assessment Tool.” Discuss your score compared to the resident observer.
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Scenario 1: Person delivering the handoff
You are a senior resident taking care of a busy general Internal Medicine inpatient service that you need
to handoff so you can go to clinic. You are very worried about Richard Smith, a 93 year old male with
stage IV squamous cell lung cancer who was admitted from his hospice facility with pneumonia and
sepsis. The nurses just came to tell you that he has not had any urine output into his foley bag. He
received 2 one liter normal saline boluses in the ED, and you placed him on maintenance fluids. His heart
rates are in the 80s and blood pressures have been stable. You need to leave for clinic and want to make
sure the resident receiving handoff fully understands your concerns. There are also 3 admissions coming
and a discharge that still has not gone home. Other patients on the ward include Betty, a 43 year old
female with a large right sided pulmonary embolus and DVT. She has been hemodynamically stable
since admission, and Jim. Jim is a 62 year old male with a history of heavy alcohol abuse presently
admitted with acute alcoholic pancreatitis. You expect he will have not issues this afternoon, though you
are leaving some very detailed contingency plans for your colleagues that you want to be sure they
understand.
Deliver the above information in a clear handoff using the IPASS mnemonic.
•
o
Use communication techniques (clarifying questions, feedback, closed-loop
communication) to ensure that you and the person receiving the handoff achieve a
shared mental model.
You may elaborate on the clinical information as needed.
•
The I-PASS Mnemonic:
I
Illness Severity
Stable, “watcher,” unstable
P
Patient Summary
Summary statement; events leading up to admission;
hospital course; ongoing assessment; plan
A
Action List
To do list; timeline and ownership
S
Situation Awareness and
Contingency Planning
Know what’s going on; plan for what might happen
S
Synthesis by Receiver
Receiver summarizes what was heard, asks questions;
restates key action/to do items
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Handoff Sim #1
M765 Jones,Betty
DOA: 1/13/13
DOB: 2/21/70
MRN: 12345678
Attending: Brown, Jack
Code Status: FULL
Allergies: NKDA
Wt: 95 kg
Access: PIV
Resident: Smith, Michael
Medications:
Lovenox
Coumadin
HCTZ/Triamterene
Levothyroxine
Morphine PRN
M789 Smith, Richard
DOA: 1/13/13
DOB: 3/1/20
MRN: 87654321
Attending: Brown, Jack
Code Status: DNR/DNI
Allergies: Bactrim
Wt: 57 kg
Access: PIV
Resident: Smith, Michael
Medications:
Vancomycin
Cefepime
Lovenox prophylaxis
Morphine PRN
M731 Benett, Jim
DOA: 1/10/13
DOB: 6/4/51
MRN: 24681012
Attending: Brown, Jack
Code Status: FULL
Allergies: NKDA
Wt: 85 kg
Access: Subclavian CVL
Resident: Smith,Michael
Medications:
Dilaudid
D5 ½ Normal Saline
Ativan drip
Lovenox prophylaxis
Ranitidine
Rally Pack x 3 days
I
P
Illness
Severity
Patient Summary
43 year old with a history of obesity, hypertension, and hypothyroidism who presented with
chest pain, dyspnea and leg pain following a 14 hour car trip. Diagnosed with right lower
extremity deep venous thrombosis and large right pulmonary artery embolism (via CT
angiogram) in the ED. Tachycardic and hypoxic on arrival to the ED. Admitted on
telemetry and supplemental oxygen.
A
Action
List
! Nothing
to do this
evening
! If she develops a drop in her
blood pressures need to worry
about repeat PE causing
hemodynamic compromise. If
this occurs will need to transfer
to ICU for possible
thrombolytic therapy.
! Check
patient’s
urine output
at 1am. If
output has
been
minimal
(<200 mL
in Foley bag)
can give
another 1
liter normal
saline bolus.
! If he develops worsening
respiratory distress can increase
oxygen or consider noninvasive positive pressure
ventilation, however family
does NOT want intubation.
! If should develop hypotension
can give additional fluids
however family does NOT
want transfer to ICU for
aggressive vasopressor support.
! Check with
nurses at
9pm to
follow-up
withdrawl
symptoms.
If CIWA
scores
remain high
can increase
drip rate to
4 mg per
hour.
! If pain worsens can increase
dilaudid to 3 mg every four
hours.
1.
Pulmonary Embolism/DVT:
Receiving lovenox and Coumadin.
No evidence of hemodynamic compromise.
Thrombophilia workup sent in ED before anticoagulation started.
2. Hypertension:
•
BPs stable since admission.
•
Plan to continue home anti-hypertensives titrating as needed.
3. Hypothyroidism:
•
No acute issues; continue home levothyroxine dose.
•
•
•
93 year old male with stage IV squamous cell lung carcinoma and tobacco abuse currently in
hospice and receiving palliative therapy who presented with cough, purulent sputum, fever,
and dyspnea. Diagnosed with a right lower lobe pneumonia and sepsis in the ED. Hypoxic
with a HR of 110 on arrival. Temperature of 102 and WBC 24K in the ED. Receiving
hospice care at a skilled nursing facility; admitted two months ago for pneumonia.
1.
Pneumonia, healthcare associated :
Continue Vancomycin and Cefepime; PICC line ordered.
Continue supplemental oxygen therapy; remains DNR/DNI comfort care.
2. Sepsis:
•
2 liters of normal saline in the ED and HR improved to 80s. Maintaining BPs
•
On maintenance IVF and broad spectrum antibiotics.
3. Squamous cell lung carcinoma:
•
Currently in hospice and receiving comfort care only; family does not want him
transferred to ICU for intubation or aggressive vasopressor support if he should
worsen.
•
•
62 year old male with a history of alcohol dependence, tobacco abuse, and depression who
presented with epigastric abdominal pain and emesis secondary to acute alcoholic
pancreatitis. Lipase 10,000 on arrival, other labs otherwise within normal limits.
1.
•
•
•
2.
•
•
•
3.
•
Pancreatitis:
NPO and on IVF. Pain control with dilaudid Q4hours.
Abdominal CT showed evidence of pancreatitis without necrosis or
pseudocyst.
Daily lipase levels and may consider transition to clears tomorrow if pain and
lipase improves.
Alcohol dependence:
At risk for delirium tremens given significant alcohol use. CIWA scores
ordered.
Currently on Ativan drip at 2mg per hour. Plan to wean tomorrow if he tolerates
and transition to scheduled diazepam and Ativan PRN.
Thaimine/Folic acid/MVI replacement solution administered.
Tobacco dependence:
Nicotine patch ordered.
S
Situation Awareness &
Contingency Planning
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
S
Synthesis by
Receiver
SYNTHESIS
BY
RECEIVER
SYNTHESIS
BY
RECEIVER
SYNTHESIS
BY
RECEIVER
Scenario 1: Person receiving the handoff
You are relieving your fellow senior resident, who is late for clinic. On your way to the
handoff, you heard the nurses talking about a patient named Richard Smith that they are really
worried about. You wonder if there is the need for an ICU evaluation.
•
You will receive handoff on all 3 patients.
•
Listen carefully to the handoff and ask clarifying questions to check-back about key
features of the patient.
•
Please make an effort to ensure that you are given adequate contingency plans on
Mr. Smith given the conversation you overheard The I-PASS Mnemonic:
I
Illness Severity
Stable, “watcher,” unstable
P
Patient Summary
Summary statement; events leading up to admission;
hospital course; ongoing assessment; plan
A
Action List
To do list; timeline and ownership
S
Situation Awareness and
Contingency Planning
Know what’s going on; plan for what might happen
S
Synthesis by Receiver
Receiver summarizes what was heard, asks questions;
restates key action/to do items
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Scenario #1: Observer of the handoff
•
Listen carefully to the information in the handoff on all 3 patients.
•
Complete the I-PASS Handoff Assessment Tool.
•
Be prepared to give feedback to your colleagues:
o Did they follow the guidelines for using the IPASS mnemonic?
o Who was the sickest patient?
o Were there admissions or discharges?
o Did they achieve a shared mental model?
The I-PASS Mnemonic:
I
Illness Severity
Stable, “watcher,” unstable
P
Patient Summary
Summary statement; events le ading up to admission;
hospital course; ongoing asse ssment; plan
A
Action List
To do list; timeline and owner ship
S
Situation Awareness and Contingency
Planning
Synthesis by Receiver
Know what’s going on; plan f or what might happen
S
Receiver summarizes what wa s heard, asks questions;
restates key action/to do items
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Handoff Sim #1
I-­‐PASS Handoff Assessment Tool: GIVER
Observation Start: hh:mm ___:___ AM/PM Observation End: hh:mm ___:___ AM/PM Specialty (circle): Pediatrics / Medicine / Surgery / Other: ______________ Date: ____/____/____(mm/dd/yy) Specific Service /Unit Name: ___________________ Type of service: ICU / general inpatient ward / specialty inpatient ward / other (specify): _____________ Learner (Receiver) Information: Provider/Resident ID number:__________ PGY Level:____ Observer Information: I-­‐PASS Champion / Faculty ID number: _________ Number of individual patient handoffs observed: _______
Situational Overview: Was a situational overview provided by the provider giving the handoff (e.g. description of the “big 1 picture” of what will need to be prioritized by the receivers of the handoff): YES NO Frequency of I-­‐PASS Mnemonic Elements (Items 2-­‐6): Indicate the frequency that each element of the mnemonic is present Some-­‐
I-­‐PASS Mnemonic Description Never Rarely Usually Always times Identification as stable, “watcher”, or unstable; must 2 Illness Severity occur at beginning of each patient handoff Might include summary statement, e vents leading up to 3 Patient Summary admission, hospital course, ongoing assessment, plan 4 Action List To do list (must be separated from patient summary) Situation Awareness/ 5 Know what’s going on; plan for what might happen
Contingency Planning Ensures receiver verbally summarizes what he/she 6 Synthesis by Receiver heard Indicate the frequency with which the provider who gave the handoff did the following: Actively engages receiver to ensure shared understanding of patients (e.g. 7 encouraged questions, asked questions, considers learning style of receiver) 8 Never Rarely Some-­‐
times Usually Always Appropriately prioritizes key information, concerns, o r actions Quality of Handoff Information Transferred (Items 9-­‐17): Only complete if sufficient clinical knowledge of patients to evaluate Rate the frequency with which the provider who gave the Unable to Some-­‐
Never Rarely Usually Always handoff included the following: evaluate times 9 Patient summary includes clearly specified plan for remainder of admission 10 To-­‐do items with clear if/then format when appropriate 11 To-­‐do list restricted to items that should be accomplished on next shift 12 High quality contingency plans with clear if/then format 13 Miscommunications or transfer of erroneous information 14 Omissions of important information 15 Tangential or unrelated information Rate the following: 16 Accuracy of Illness Severity Assessments 17 Quality of Patient Summaries Unable to evaluate Poor 18. Circle the phrase that BEST describes the pace of the handoff (circle one):
Very slow pace / Slow pace / Inefficient
Optimally paced / Very inefficient Efficient 19. What was especially effective about the handoff?
Fair Good Fast / Pressured pace 20. What aspect(s) of the handoff could be improved?
Very Good Excellent Very fast / Very pressured pace 21. Additional comments:
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact ipass.institute@childrens.harvard.edu.
Faculty Debrief Guide Scenario 2
•
•
•
•
•
•
During scenario, encourage residents to actively embrace roles and ensure
observer fills out verbal tool.
Monitor use of mnemonic.
Observe handoff carefully
o Were contingency plans adequate?
o Did they demonstrate synthesis of the plan?
o How did it compare to prior handoff?
o Was the receiver able to redirect the sender? Did the receiver get the
information on Mr. Barton that he/she needed?
Encourage discussion of the barriers to effective handoff in this scenario
(e.g. distracted resident delivering, dismissive, irrelevant information
given).
Discuss what might have helped improve the handoff (e.g. asking giver to
take a minute, validating concerns).
While facilitating, evaluate the handoff using the “I-PASS Handoff
Assessment Tool.” Discuss your score compared to the resident
observer.
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Scenario #2: Person delivering the handoff
You have had a very busy day on the general Internal Medicine wards, and you haven’t even finished your
notes yet. You need to handoff three patients (Barton, Smith, and Diamond – see attached) as well as what
you know about a pending admission. You are trying to be efficient so that you can get your work done
and leave sometime tonight. Mr. Barton is pretty sick and you know that you really need to make sure the
resident receiving handoff understands that. Of note, the resident receiving the handoff was just called in
to cover another resident who called in sick.
•
Give handoff on all 3 patients using the I-PASS mnemonic.
•
Engage effectively the “sick call” resident using the communication skills you learned today
to develop a shared mental model.
The I-PASS Mnemonic:
I
Illness Severity
Stable, “watcher,” unstable
P
Patient Summary
Summary statement; events leading up to admission;
hospital course; ongoing assessment; plan
A
Action List
To do list; timeline and ownership
S
Situation Awareness and
Contingency Planning
Know what’s going on; plan for what might happen
S
Synthesis by Receiver
Receiver summarizes what was heard, asks questions;
restates key action/to do items
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Handoff Sim #2
M605 Barton,James
DOA: 1/13/13
DOB: 3/17/1946
MRN: 12345678
Adm Date:3/18/11
Attending: Brown, Jack
Code Status: FULL
Allergies: NKDA
Wt: 75 kg
Access: PIV
Resident: Smith, Michael
Medications:
Azithromycin
Prednisone
Albuterol
Hydrocholorothiazide/Triamterene
Lisinopril
Atorvastatin
M606 Smith,Jack
DOA: 1/13/13
DOB: 4/29/75
MRN: 87654321
Attending: Brown, Jack
Code Status: FULL
Allergies: NKDA
Wt: 89 kg
Access: PIV
Resident: Smith, Michael
Medications:
Vancomycin
M607 Diamond, Lucy
DOA: 1/10/13
DOB: 3/1/22
MRN: 24681012
Attending: Brown, Jack
Code Status: FULL
Allergies: NKDA
Wt: 60 kg
Access: Subclavian CVL
Resident: Smith, Michael
Medications:
Enoxaparin
Ciprofloxacin
Oxycodone PRN
Atorvastatin
Amlodipine
Acetaminophen PRN
Bisacodyl
Senna
I
P
Illness
Severity
Patient Summary
67 year old male with a history of COPD (FEV1 of 40% predicted), hypertension, hyperlipidemia, and
peripheral arterial disease who came to the ED today with increasing dyspnea, cough, sputum
production, and hypoxia consistent with a COPD exacerbation.
ABG shows an acute on chronic respiratory acidosis and CXR showed clear lung fields.
1.
•
•
2.
•
3.
4.
•
•
•
Moderate COPD Exacerbation:
Plan to continue steroids, bronchodilators, azithromycin, and supplemental oxygen.
Goal oxygen saturations 88-92%. Presently on 4L oxygen.
Hypertension:
BPs mildly elevated at the time of admission, likely due to respiratory distress, though
improved on arrival to the floor.
Plan to continue home anti-hypertensives titrating as needed.
Peripheral arterial disease:
No acute issues at this time.
Hyperlipidemia
Continue atorvastatin.
37 year old male, otherwise healthy, admitted with an abscess and cellulitis of the right lower extremity
following an insect bite.
Failed outpatient antibiotic therapy with trimethoprim/sulfamethoxazole and cephalexin. In ED was
febrile and large abscess noted on right medial calf. Incision and drainage of abscess done in the ED.
1.
•
•
•
•
Underwent ORIF (open reduction, internal fixation) two days ago. Post-op course complicated by
urinary tract infection and sun downing (delirium).
•
•
2.
•
•
3.
•
4.
•
•
•
! At 11pm
check in on
patient and
monitor lung
exam, oxygen
requirement,
and
respiratory
rate.
S
Synthesis by
Receiver
! If he develops increasing
dyspnea, oxygen
requirement > 4L, or
change in mental status
order stat nebulizers and
obtain ABG and CXR.
SYNTHESIS
BY
RECEIVER
! If ABG reveals
worsening acute
respiratory acidosis
contact attending for
transfer to progressive
care unit for initiation of
BiPAP therapy
! If he develops fever
please go to bedside
and examine leg.
! If erythema should
extend outside of
marked borders order
ultrasound and consult
surgery. May need
further surgical
exploration of abscess
cavity.
! Check with
nurses at 9pm
to follow-up
on delirium.
! If delirium worsens and
reorientation not
effective may give small
dose of haloperidol
(0.25mg PO or IV)
! If fever develops please
obtain blood culture,
urinalysis, and urine
culture.
! If pain increases may give a
dose of IV morphine (2mg
IV)
Urinary Tract Infection:
Urine culture grew pansensitive E.coli.
Presently on Ciprofloxacin, Foley catheter has been removed.
Delirium (sun downing) and dementia:
Attempting to avoid sedating meds if possible.
Nursing staff providing reorientation and calm environment; family will try to stay in
evenings to provide additional supervision.
Left Femoral Neck Fracture S/P ORIF:
Receiving daily PT and allowed to ambulate with assistance. Orthopedics continues to
follow. Wound healing well.
Acetaminophen and oxycodone as needed for pain.
Low molecular heparin ordered and post-op hemoglobin stable.
Hypertension:
Blood pressures well controlled since surgery on outpatient dose of amlodipine. Received
beta-blocker peri-operatively.
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
S
Situation Awareness &
Contingency Planning
! Nothing to
do this
evening
Right leg abscess and cellulitis:
Plan to continue IV Vancomycin and observe clinical response.
Packing will be changed tomorrow.
Repeat CBC and CRP ordered for the morning.
Blood and wound cultures pending.
90 year old female with a history of hyperlipidemia, hypertension, and dementia admitted following
fall at her facility 1/7 during which she had a fracture of the left femoral neck.
1.
A
Action
List
SYNTHESIS
BY
RECEIVER
SYNTHESIS
BY
RECEIVER
Scenario #2: Person receiving the handoff
You had plans for the evening that have been ruined by being called in to cover for a fellow resident that
is ill. Your spouse keeps texting you because he/she is angry that your plans have been ruined. You are
texting back, since your marriage is more important to you than handoff at this point. You’ll figure it all
out anyway based on the printed handoff document.
•
You will receive handoff on 3 patients.
•
Text during handoff and vent your frustration unless redirected by your colleague.
•
During check-back, continue being distracted and omit key information.
The I-PASS Mnemonic:
I
Illness Severity
Stable, “watcher,” unstable
P
Patient Summary
Summary statement; events le ading up to admission;
hospital course; ongoing asse ssment; plan
A
Action List
To do list; timeline and owner ship
S
Situation Awareness and Contingency
Planning
Synthesis by Receiver
Know what’s going on; plan f or what might happen
S
Receiver summarizes what wa s heard, asks questions;
restates key action/to do items
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Scenario #2: Observer of the handoff
Your colleagues are attempting to handoff, but one is extremely distracted.
•
Listen carefully to the information in the handoff on all 3 patients.
•
Complete the I-PASS Handoff Assessment Tool.
•
Be prepared to give feedback to your colleagues
o Did they follow the guidelines for using the I-PASS mnemonic?
o Who was the sickest patient?
o Did they achieve a shared mental model?
o What advice would you have as an observer to redirect a colleague who is
disengaged?
The I-PASS Mnemonic:
I
Illness Severity
Stable, “watcher,” unstable
P
Patient Summary
Summary statement; events leading up to admission;
hospital course; ongoing assessment; plan
A
Action List
To do list; timeline and ownership
S
Situation Awareness and
Contingency Planning
Know what’s going on; plan for what might happen
S
Synthesis by Receiver
Receiver summarizes what was heard, asks questions;
restates key action/to do items
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
I-­‐PASS Handoff Assessment Tool: GIVER
Observation Start: hh:mm ___:___ AM/PM Observation End: hh:mm ___:___ AM/PM Specialty (circle): Pediatrics / Medicine / Surgery / Other: ______________ Date: ____/____/____(mm/dd/yy) Specific Service /Unit Name: ___________________ Type of service: ICU / general inpatient ward / specialty inpatient ward / other (specify): _____________ Learner (Receiver) Information: Provider/Resident ID number:__________ PGY Level:____ Observer Information: I-­‐PASS Champion / Faculty ID number: _________ Number of individual patient handoffs observed: _______
Situational Overview: Was a situational overview provided by the provider giving the handoff (e.g. description of the “big 1 picture” of what will need to be prioritized by the receivers of the handoff): YES NO Frequency of I-­‐PASS Mnemonic Elements (Items 2-­‐6): Indicate the frequency that each element of the mnemonic is present Some-­‐
I-­‐PASS Mnemonic Description Never Rarely Usually Always times Identification as stable, “watcher”, or unstable; must 2 Illness Severity occur at beginning of each patient handoff Might include summary statement, e vents leading up to 3 Patient Summary admission, hospital course, ongoing assessment, plan 4 Action List To do list (must be separated from patient summary) Situation Awareness/ 5 Know what’s going on; plan for what might happen
Contingency Planning Ensures receiver verbally summarizes what he/she 6 Synthesis by Receiver heard Indicate the frequency with which the provider who gave the handoff did the following: Actively engages receiver to ensure shared understanding of patients (e.g. 7 encouraged questions, asked questions, considers learning style of receiver) 8 Never Rarely Some-­‐
times Usually Always Appropriately prioritizes key information, concerns, o r actions Quality of Handoff Information Transferred (Items 9-­‐17): Only complete if sufficient clinical knowledge of patients to evaluate Rate the frequency with which the provider who gave the Unable to Some-­‐
Never Rarely Usually Always handoff included the following: evaluate times 9 Patient summary includes clearly specified plan for remainder of admission 10 To-­‐do items with clear if/then format when appropriate 11 To-­‐do list restricted to items that should be accomplished on next shift 12 High quality contingency plans with clear if/then format 13 Miscommunications or transfer of erroneous information 14 Omissions of important information 15 Tangential or unrelated information Rate the following: 16 Accuracy of Illness Severity Assessments 17 Quality of Patient Summaries Unable to evaluate Poor 18. Circle the phrase that BEST describes the pace of the handoff (circle one):
Very slow pace / Slow pace / Inefficient
Optimally paced / Very inefficient Efficient 19. What was especially effective about the handoff?
Fair Good Fast / Pressured pace 20. What aspect(s) of the handoff could be improved?
Very Good Excellent Very fast / Very pressured pace 21. Additional comments:
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact ipass.institute@childrens.harvard.edu.
Faculty Debrief Guide Scenario 3
•
•
•
•
•
•
During scenario, encourage residents to actively embrace roles and ensure
observer fills out Direct Observation Tool.
Monitor use of mnemonic.
Observe handoff carefully:
o Were contingency plans adequate?
o Did they demonstrate synthesis of the plan?
o How did it compare to prior handoffs?
Encourage discussion of the barriers to effective handoff in this scenario
(e.g. distracted resident delivering, receiver not focused or engaged).
Discuss what might have helped improve handoff (e.g. validating concerns,
asking receiver to take a minute, requesting that receiver stop texting).
While facilitating, evaluate the handoff using the “I-PASS Handoff
Assessment Tool.” Discuss your score compared to the resident
observer.
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Scenario #3 – Person delivering the handoff
You are a very frustrated intern signing out for the evening. You are angry because the person
receiving the handoff is late. You need to handoff three patients as listed on the printed
handoff documents (attached). Mr. Grant is a 24 year old with asthma and a pneumonia who
you have been wondering if he should go to the ICU and maybe start on BiPAP. To add to
your frustration, Mr. Grant’s wife was angry with you because she was tired of her husband
being cared for by a “resident who “wasn’t even a real doctor.” She thinks he’s just fine and
wants to see a doctor in charge” now. In addition, she smoked in the bathroom, which
prompted security to come to the room. Nothing you said could change anything and that’s all
you find yourself talking about at handoff.
•
Give handoff on all 3 patients using the I-PASS mnemonic.
•
Handoff the information on the printed handoff document.
•
Discuss your bad day at length unless redirected successfully by your
colleague. You can decide what success is.
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Handoff Sim #3 I
P
Illness
Severity
Patient Summary
Action
List
A
S
45 y/o female with Type 1 Diabetes, who was admitted yesterday for DKA and sepsis
secondary to a UTI. She was initially admitted to the ICU, where she received an insulin drip,
aggressive hydration, and was started on ceftriaxone for her UTI. Insulin drip was stopped
overnight when gap closed, started on subcutaneous insulin prior to stopping drip. She was
transferred to the medicine floor this AM in stable condition.
! Make sure
Glargine is
started
! Follow up
8PM BMP
! Monitor her
respiratory
status Q4h
! Monitor
fever curve
! Replete her electrolytes if
K<4, Phos<2, and Mg <2.
! If anion gap increases insulin
drip may need to restart
! For resp distress get a CXR
and consider Lasix 40 mg IV
! If she develops a fever
>101F, please re-culture
urine and blood and broaden
antibiotics to Zosyn.
Situation Awareness &
Contingency Planning
M822
Jones,Rhoda
DOA: 1/13/13
DOB: 2/21/68
MRN: 12984678
Attending: Brown, Jack
Code Status: FULL
Allergies: NKDA
Wt: 75 kg
Access: PIV
Resident: Smith, Michael
Medications:
Ceftriaxone
Aspart QAC
Glargine QHS
1. Glycemic control:
•
Continue subcutaneous insulin— 15U Aspart QAC and 40U Glargine tonight.
•
Last fingerstick glucose 1hr ago was 233.
M834 Grant, Clark
DOA: 1/13/13
DOB: 3/1/89
MRN: 82354908
Attending: Brown, Jack
Code Status: FULL
Allergies: Shrimp
Wt: 62 kg
Access: PIV
Resident: Smith, Michael
Medications:
Fluticasone
Albuterol PRN,
Montelukast
24 year Electrolyte
old male with
a history
of asthma who
presented
the ED
a 2 day
history
Finally,
issues:
Her electrolytes
are stable
at thistotime
withwith
Na 138,
K 4.3,
Phosof3.0,
Mg 2.1, andintermittent,
an anion gap
of 12, down
from
24high
on admission.
She’s
getting
q4hhe
BMPs, with
worsening
productive
cough
and
fevers (Tmax
103°).
Today
the next at acute
8pm. worsening of his respiratory effort and his breathing became fast and
developed
labored. No other complaints CXR showed LLL pneumonia. In ED 2L of supplemental
oxygen
therapy,
1 liter
normal
and levofloxacin
weretransitioned
administered
admitted
2: (Interjects)
Before
youofget
to thesaline
actionbolus
list, when
was the patient
from
IV to SQ
with
pneumonia, respiratory distress and hypoxia. In ED labs significant for a sodium of
insulin?
130, likely due to volume depletion
1: Good question, thank you. She was transitioned this morning at 7 prior to breakfast.
1. Pneumonia
•
.
• Oxygen increased to 3lpm on admission
• Continues on Levofloxacin
• Still with increased work of breathing
2. Hyponatremia
• Given another bolus of NS on admission for tachycardia and hypovolemia,
! Monitor resp
status after
handoff and
Q3h
! Monitor fever
curve
! Follow up
BMP at 8PM
! Follow I+O
every 6h
! If he develops worsening
respiratory distress call the
ICU as he may need NIPPV
! If febrile, reculture and
consider adding Vancomycin
! If hyponatremic or decreased
urine output repeat NS bolus
and send urine lytes to rule
out SIADH
M731 Fine, Dan
DOA: 1/10/13
DOB: 6/4/51
MRN: 29746382
Attending: Brown, Jack
Code Status: FULL
Allergies: NKDA
Wt: 85 kg
Access: Subclavian CVL
Resident: Smith,Michael
Medications:
Amlodipine
Pantoprazole gtt
62 year old male with a history of hypertension who presents with epigastric abdominal pain,
hematemesis and hypotension secondary to bleeding duodenal ulcer. Endoscopy revealed
active bleeding, hemostasis achieved endoscopically. Received 2 units PRBC, pantoprazole,
with resolution of bleeding.
! CBC Q6h
! Check I+O for
emesis,
adequate urine
output
! BMP in AM
! Monitor BP
! If Hgb<8 consider
transfusion, call GI
! If hematemesis resumes
may need repeat endoscopy,
call GI
! If hypertensive restart
amlodipine tonight.
S
Synthesis by
Receiver
SYNTHESIS
BY
RECEIVER
2. Urosepsis:
•
Afebrile, leukocytosis is down from 24K on admission to 15K today.
•
Hypotension has resolved, but she is still on NS at 200cc/hr.
•
Received 8L total over the course of her hospital stay
•
Exam is unremarkable for signs of volume overload.
•
Blood and urine cultures are pending
1. Duodenal Ulcer:
•
NPO and on IVF D5NS at 140 ml/hr
•
On pantoprazole infusion
2. Hypertension:
•
Amlodipine held secondary to hypotension in ED
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
SYNTHESIS
BY
RECEIVER
SYNTHESIS
BY
RECEIVER
Scenario #3 – Person receiving the handoff
You are reviewing the printed handoff document (attached) and see that there are three patients to
handoff. Mr. Grant seems like he might be sick just looking at the document. You are already late
getting back from clinic to receive handoff and your colleague looks frazzled. Sometimes your
colleague’s handoff can be very disorganized after a bad day. But it sounds like you really need to get
a good handoff and contingency plan on Mr. Grant.
•
You will receive handoff on all 3 patients.
•
Listen closely to the handoff and be able to check-back key features to ensure
adequate contingency planning.
•
Use communication techniques discussed today (feedback, focusing on relevant
information) to redirect your frustrated colleague. It’s not your fault you were late!
The I-PASS Mnemonic:
I
Illness Severity
Stable, “watcher,” unstable
P
Patient Summary
Summary statement; events leading up to admission;
hospital course; ongoing assessment; plan
A
Action List
To do list; timeline and ownership
S
Situation Awareness and
Contingency Planning
Know what’s going on; plan for what might happen
S
Synthesis by Receiver
Receiver summarizes what was heard, asks questions;
restates key action/to do items
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Scenario #3: Observer of the handoff
•
Listen carefully to the information in the handoff on all 3 patients.
•
Complete the I-PASS Handoff Assessment Toold.
•
Be prepared to give feedback to your colleagues:
o Did they follow the guidelines for using the IPASS mnemonic?
o Who was the sickest patient?
o Were there admissions or discharges?
o Did they achieve a shared mental model?
The I-PASS Mnemonic:
I
Illness Severity
Stable, “watcher,” unstable
P
Patient Summary
Summary statement; events leading up to admission;
hospital course; ongoing assessment; plan
A
Action List
To do list; timeline and ownership
S
Situation Awareness and
Contingency Planning
Know what’s going on; plan for what might happen
S
Synthesis by Receiver
Receiver summarizes what was heard, asks questions;
restates key action/to do items
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact
ipass.institute@childrens.harvard.edu.
Handoff Simulation #3
I-­‐PASS Handoff Assessment Tool: GIVER
Observation Start: hh:mm ___:___ AM/PM Observation End: hh:mm ___:___ AM/PM Specialty (circle): Pediatrics / Medicine / Surgery / Other: ______________ Date: ____/____/____(mm/dd/yy) Specific Service /Unit Name: ___________________ Type of service: ICU / general inpatient ward / specialty inpatient ward / other (specify): _____________ Learner (Receiver) Information: Provider/Resident ID number:__________ PGY Level:____ Observer Information: I-­‐PASS Champion / Faculty ID number: _________ Number of individual patient handoffs observed: _______
Situational Overview: Was a situational overview provided by the provider giving the handoff (e.g. description of the “big 1 picture” of what will need to be prioritized by the receivers of the handoff): YES NO Frequency of I-­‐PASS Mnemonic Elements (Items 2-­‐6): Indicate the frequency that each element of the mnemonic is present Some-­‐
I-­‐PASS Mnemonic Description Never Rarely Usually Always times Identification as stable, “watcher”, or unstable; must 2 Illness Severity occur at beginning of each patient handoff Might include summary statement, e vents leading up to 3 Patient Summary admission, hospital course, ongoing assessment, plan 4 Action List To do list (must be separated from patient summary) Situation Awareness/ 5 Know what’s going on; plan for what might happen
Contingency Planning Ensures receiver verbally summarizes what he/she 6 Synthesis by Receiver heard Indicate the frequency with which the provider who gave the handoff did the following: Actively engages receiver to ensure shared understanding of patients (e.g. 7 encouraged questions, asked questions, considers learning style of receiver) 8 Never Rarely Some-­‐
times Usually Always Appropriately prioritizes key information, concerns, o r actions Quality of Handoff Information Transferred (Items 9-­‐17): Only complete if sufficient clinical knowledge of patients to evaluate Rate the frequency with which the provider who gave the Unable to Some-­‐
Never Rarely Usually Always handoff included the following: evaluate times 9 Patient summary includes clearly specified plan for remainder of admission 10 To-­‐do items with clear if/then format when appropriate 11 To-­‐do list restricted to items that should be accomplished on next shift 12 High quality contingency plans with clear if/then format 13 Miscommunications or transfer of erroneous information 14 Omissions of important information 15 Tangential or unrelated information Rate the following: 16 Accuracy of Illness Severity Assessments 17 Quality of Patient Summaries Unable to evaluate Poor 18. Circle the phrase that BEST describes the pace of the handoff (circle one):
Very slow pace / Slow pace / Inefficient
Optimally paced / Very inefficient Efficient 19. What was especially effective about the handoff?
Fair Good Fast / Pressured pace 20. What aspect(s) of the handoff could be improved?
Very Good Excellent Very fast / Very pressured pace 21. Additional comments:
© 2015 I-PASS Institute/Boston Children’s Hospital. All rights reserved. For permissions, contact ipass.institute@childrens.harvard.edu.