Hern H Gene, Gallahue Fiona E, Burns Boyd D, Druck Jeffrey, Jones Jonathan, Kessler Chad, Knapp Barry, Williams Sarah
Department of Emergency Medicine, Alameda Health System - Highland Hospital, Oakland, CA.
Division of Emergency Medicine, University of Washington, Seattle, WA.
Acad Emerg Med. 2016 Feb;23(2):197-201. doi: 10.1111/acem.12867. Epub 2016 Jan 14.
Transitions of care present a risk for communication error and may adversely affect patient care. This study addresses the scope of current handoff practices amongst U.S. emergency medicine (EM) residents. In addition, it evaluates current educational and evaluation practices related to handoffs. Given the ever-increasing emphasis on transitions of care in medicine, we sought to determine if interval changes in resident transition of care education, assessment, and proficiency have occurred.
This was a cross-sectional survey study guided by the Kern model for medical curriculum development. The Council of Residency Directors Listserv provided access to 175 programs. The survey focused on elucidating current practices of handoffs from emergency physicians (EPs) to EPs, including handoff location and duration, use of any assistive tools, and handoff documentation in the emergency department (ED) patient's medical record. Multiple-choice questions were the primary vehicle for the response process. A four-point Likert-type scale was used in questions regarding perceived satisfaction and competency. Respondents were not required to answer all questions. Responses were compared to results from a similar 2011 study for interval changes.
A total of 127 of 175 programs responded to the survey, making the overall response rate 72.6%. Over half of respondents (72 of 125, 57.6%) indicated that their ED uses a standardized handoff protocol, which is a significant increase from 43.2% in 2011 (p = 0.018). Of the programs that do have a standardized system, a majority (72 of 113, 63.7%) of resident physicians use it regularly. Significant increases were noted in the number of programs offering formal training during orientation (73.2% from 59.2%; p = 0.015), decreases in the number of programs offering no training (2.4% from 10.2%; p = 0.013), and no assessment of proficiency (51.5% from 69.8%; p = 0.006). No significant interval changes were noted in handoffs being documented in the patient's medical record (57.4%), the percentage of computer/electronic signouts, or the level of dissatisfaction with handoff tools (54.1%). Less than two-thirds of respondents (80 of 126, 63.5%) indicated that their residents were "competent" or "extremely competent" in delivering and receiving handoffs.
An insufficient level of handoff training is currently mandated or available for EM residents, and their handoff skills appear to be developed mostly informally throughout residency training with varying results. Programs that have created a standardized protocol are not ensuring that the protocol is actually being employed in the clinical arena. Handoff proficiency most often goes unevaluated, although it is improved from 2011.
医疗护理转接存在沟通错误风险，可能对患者护理产生不利影响。本研究探讨了美国急诊医学（EM）住院医师当前转接实践的范围。此外，还评估了与转接相关的当前教育和评估实践。鉴于医学领域对医疗护理转接的重视日益增加，我们试图确定住院医师在护理转接教育、评估和熟练程度方面是否发生了阶段性变化。
这是一项以Kern医学课程开发模型为指导的横断面调查研究。住院医师主任委员会邮件列表提供了175个项目的联系方式。该调查重点在于阐明急诊医师（EP）之间转接的当前实践，包括转接地点和时长、是否使用任何辅助工具以及在急诊科（ED）患者病历中的转接记录。多项选择题是主要的作答方式。在关于感知满意度和能力的问题中使用了四点李克特量表。受访者无需回答所有问题。将回答结果与2011年一项类似研究的结果进行比较，以找出阶段性变化。
175个项目中共有127个回复了调查，总体回复率为72.6%。超过一半的受访者（125人中的72人，57.6%）表示他们所在的急诊科使用标准化转接协议，这比2011年的43.2%有显著提高（p = 0.018）。在拥有标准化系统的项目中，大多数（113人中的72人，63.7%）住院医师会经常使用。在入职培训期间提供正式培训的项目数量显著增加（从59.2%增至73.2%；p = 0.015），不提供培训的项目数量减少（从10.2%降至2.4%；p = 0.013），且不进行熟练程度评估的项目数量减少（从69.8%降至51.5%；p = 0.006）。在患者病历中记录转接情况（57.4%）、计算机/电子签出的百分比或对接转工具的不满意程度（54.1%）方面，未发现显著的阶段性变化。不到三分之二的受访者（126人中的80人，63.5%）表示他们的住院医师在进行和接收转接方面“胜任”或“极其胜任”。
目前，针对EM住院医师的转接培训要求不足或培训机会有限，他们的转接技能似乎大多是在住院医师培训期间通过非正式方式培养的，结果各不相同。制定了标准化协议的项目并未确保该协议在临床实际中得到应用。转接熟练程度大多未得到评估，不过与2011年相比已有改善。
