IPASS Training

Created by Dr. Raeanna Simcoe - Updated Aug 20, 2018

Evernote Link: https://www.evernote.com/shard/s33/sh/45916cce-9a8d-4fd1-a042-c1d48627bb5f/c9945d12622ee5f3d9b46979e67efab7

INTRODUCTION

Why Standardize Handoffs?

  • Miscommunication during handoff is a leading cause of serious medical errors
    • 100,000 people die each year in US hospitals as a result of preventable medical errors
    • 2/3 of these deaths are due to errors in communication -- often during handoffs
    • Duty hour restrictions led to more handoffs, multiplying the risk of error
  • Standardized handoff is now a requirement for all ACGME residencies
  • Teaching handoffs is easier if there is a standard model


There are Options -- Why IPASS?

  • It has lots of supportive data
  • It was developed at UCSF and is in use at many institutions including UW and Harborview
  • It has been proven to: (Amy Starmer, NEJM 2014)
    • Increase efficiency
    • Decrease time spent during handoffs
    • Decrease medical errors by 23% and ‘near misses’ by 30%

THE IPASS METHOD

A verbal handoff supported by a written tool.

The Mnemonic

  • Illness Severity
  • Patient Summary
  • Action List
  • Situational Awareness/Contingency Planning
  • Synthesis by Receiver

Prepare/Print your Written Tool

  • Include relevant but concise information
  • Middle and right column should be updated before every printing
  • Night team should take advantage of their extra opportunity to "clean up"! It is especially helpful to synthesize the current A&P in the middle column to frame the case for the morning team when they come back in.
  • More details about what should be in each column are below, correlated with their respective parts of the verbal handoff

Set the Scene

  • Quiet in the room
  • Pagers go to the call person who is not delivering handoff (so if the night senior is giving handoff to the day team, then the night intern should hold the pagers and triage the messages)
  • The person delivering the handoff should lead with an impression of the entire service:
    • # of patients, including # of IMCU and ICU
    • # of pending admissions and their locations
    • Names of goat and attendings (if different from yesterday)
    • Afternoon plans for all team members
    • Any other important notes for the day
  • If there is an unstable patient, the intern for that patient should be signed out first so that they can leave Gumby if needed. Otherwise, follow the typical order with call intern first, then interns with afternoon commitments, then the rest.
  • For each intern, sign out the sickest patients first. The receiver's attention is best at the beginning!
  • The team should not interrupt. Allow the person signing out to finish with the patient and then allow the receiver to respond first.

Illness Severity

  • Options: Stable, watcher, unstable
  • Watcher = a patient who any clinician has a "gut feeling" is at risk for deterioration or is on the verge of deterioration
  • Unstable = actively transferring to the IMCU/ICU, code or rapid recently called
  • This part of the verbal handoff isn't in the written tool because it changes too frequently

Patient Summary (“Middle column”)

  • Includes
    • Summary statement:
      • One liner with age, sex, reason they presented, leading diagnosis, and current status.
      • "68 year old female presented with abdominal pain likely pancreatitis, improving with plan to advance diet today."
    • Then go by problem, including for each problem:
      • Pertinent hospital course, including relevant objective data
      • Plan by bullet point
    • Only need to talk about active problems! There may be less active problems in the written tool which are useful to keep as FYI for cross coverage.
  • Avoid specific medication dosages (they're automatically printed in the left column)
  • Avoid to-dos (these should be under Action List)
  • Example

Action List (“Right column”)

  • Specific tasks that need to be done
  • Should be assigned to a person or team
  • Should be sorted in chronological order, with soonest at the top
  • Example

             [ ] AM: f/u lipase

             [ ] Noc: resp check

             [ ] 12/8: repeat ESR/CRP

             [ ] Dispo: schedule f/u with cards

Situational Awareness/Contingency Planning (“Right column”)

  • Held home meds and if/then’s
  • Also a good place to include other context like family issues, code concerns, etc.
  • Example
summary2.JPG

Synthesis by Receiver

  • Opportunity for the person who received handoff to express understanding, clarify confusion, and make a plan for the shift
  • Doesn’t have to be redundant! Don't repeat age or sex.
  • Wait until the person delivering handoff is done before starting synthesis.
  • Start with a one-line summary for old patients. For new patients the summary can be more detailed and problem-focused.
  • Then ask questions.
  • Then assign to-do’s (“I’ll call the consult, senior please call Evergreen, then we can discuss the med change at rounds…”).
  • AFTER ALL THIS, then the rest of the team can chime in.

SUMMARY

Handoff Improvement...

  • Happens in a Protected setting
  • With the Appropriate support (written tool)
  • Start by Discussing the sickest patients first
  • And give a Structured delivery
  • With the opportunity for Summarizing back what is heard

RESOURCES

Demo Video (13 minutes)

This one from a group of emergency medicine docs shows a bad example, then reviews the tenets of a IPASS, then demonstrates a good handoff. Note: We don't do the "Final Summary" at the end.

Print your own ID card sized IPASS here