Transition of care between physicians remains a vulnerability in providing optimal patient care. The Clinical Learning Environment Review (CLER) program identifies Care Transitions as a core pathway for evaluation. Specifically, they assess a program’s educational process for handoff training and implementing standardized assessments to allow residents to move from direct to indirect faculty supervision. Hospitalists continue to lead initiatives about care transitions and have expertise to develop an educational structure to promote this important skill amongst trainees in Internal Medicine.Methods:
The Internal Medicine program at Baylor College of Medicine adopted the IPASS process as the universal handoff structure. Starting in the 2014, all incoming interns participated in a Care Transitions workshop during Internal Medicine Bootcamp at orientation. The workshop was divided into three sections: 1. Large group session – Introduction/videos of handoffs, 2. Small group session – discussion of videos/case scenarios, and 3. Handoff simulation – one-on-one session with hospitalist to practice handoffs with immediate feedback and opportunity to incorporate the feedback in another simulated handoff. During the session, each intern was assessed using a milestone-based format for care transitions. For this study, we focused on prior training with handoffs and evaluating how their comfort and confidence with handoffs changed using a survey before and after Internal Medicine Bootcamp.
Response rates to the pre and post surveys were 100% and 89% (2014, n=73), 100% and 77% (2015, n=73), 95% and 83% (2016, n=83) respectively. Since 2014, the proportion of incoming interns reporting prior formal training in handoffs during medical school steadily increased from 45% (2014) to 59% (2015) to 63% (2016) and prior experience in performing handoffs increased from 79% (2014) to 88% (2015) to 90% (2016).
The interns reported increased comfort for providing effective checkout [Likert scale 1=very uncomfortable, 5=very comfortable] consistently each year: 3.58 (pre-bootcamp) vs. 4.08 (post-bootcamp) in 2014, 3.51 vs. 4.25 in 2015, and 3.42 vs. 4.02 in 2016 (p<0.05 for all years).
Self-reported confidence levels in identifying factors essential to an effective verbal handoff improved [Likert scale 1=not at all confident, 5=very confident]: 3.07 vs 4.26 (2014), 3.21 vs. 4.30 (2015), and 3.24 vs. 4.15 (2016). In addition, the simulated session consistently boosted confidence in using the IPASS tool for handoffs: 3.34 vs. 4.32 (2014), 3.69 vs. 4.35 (2015), and 3.56 vs. 4.16 (2016) (p<0.05 for all years). When asked how likely the interns would change their patient handoffs, the majority answered very likely or somewhat likely: 100% in 2014, 100% in 2015, and 91% in 2016.
With increased attention to transitions of care, medical schools are increasingly including training and practice of handoffs for students. Despite these interventions, interns lack comfort and confidence with these skills. Instituting a formal handoff training workshop led by hospitalists during intern orientation consistently improved comfort and confidence of trainees in performing handoffs. Using formal assessments at the simulated sessions, residency programs can satisfy requirements by CLER and allow patient handoffs to move from direct to indirect supervision.
To cite this abstract:Shah, C; Stewart, DE; Hubenthal, E . IMPROVING TRANSITIONS OF CARE: IMPLEMENTING A TRAINING PROGRAM FOR INCOMING RESIDENTS. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 267. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/improving-transitions-of-care-implementing-a-training-program-for-incoming-residents/. Accessed July 20, 2019.