Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety.

PURPOSE: Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff. METHOD: In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes. RESULTS: Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P<.01), more verbal handoffs (80% versus 38%, P<.01), more patients aware of the handoff (100% versus 74%, P=.01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P=.03), and more ownership of patients before the first visit (56% versus 26%, P=.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P<.01), and more tests were followed up appropriately (67% versus 46%, P=.02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P=.06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P=.06). CONCLUSIONS: Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.

Improving identification and documentation of pressure ulcers at an urban academic hospital.

BACKGROUND: A two-year quality improvement campaign at a teaching hospital was launched to improve the identification and accurate documentation of pressure ulcers (PUs) after the Centers for Medicare & Medicaid Services (CMS) changed reimbursement regarding hospital-acquired PUs. METHOD: The campaign consisted of (1) reference materials, (2) new documentation templates, (3) staff education, and (4) hospitalwide mattress replacement. RESULTS: The campaign significantly increased the proportion of PUs completely documented by nurses from 27% to 55% following mattress replacement and resident education (odds ratio [OR] 3.68; p = .001; 95% confidence interval [CI]:1.68-8.08). A similar improvement was observed for physician documentation, increasing from 12% to 36% following the same interventions; however, this change was not statistically significant (OR 2.11; p = .12; 95% CI:0.82-5.39). These improvements were short-lived because of the implementation of electronic medical records (EMRs) for nursing notes. Although the percentage of PUs completely documented by nurses decreased following EMR implementation, it increased in the following months to above the precampaign baseline as nurses adapted to the new documentation system. However, after EMR implementation, complete PU documentation by physicians decreased to a nadir of 0% and did not recover. CONCLUSIONS: A multicomponent campaign to improve the quality of PU documentation by both physicians and nurses can yield positive gains. However, these improvements were short-lived because of EMR implementation, which acutely worsened documentation of PUs. This emphasizes the importance of frequent and repeated interventions to sustain quality improvement successes.