I-PASS, a Mnemonic to Standardize Verbal Handoffs

1 CONTRIBUTORS: Amy J. Starmer, MD, MPH,a,b Nancy D. Spector, MD,c Rajendu Srivastava, MD, MPH,d April D. Allen, MPA, MA,b,e Christopher P. Landrigan, MD, MPH,b,f Theodore C. Sectish, MDb and the I-PASS Study Group a Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon; bDivision of General Pediatrics, Department of Medicine, Children's Hospital Boston, and fDivision of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; cSection of General Pediatrics, St. Christopher's Hospital for Children, Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania; dDepartment of Pediatrics, Primary Children's Medical Center, Salt Lake City, Utah; and eHeller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. The opinions and conclusions expressed herein are solely those of the authors and should not be constructed as representing the opinions or policy of any agency of the Federal Government.

2 Address correspondence to Amy J. Starmer, MD, MPH, Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health and Science University, Mail code: CDRCP, 707 SW Gaines St, Portland, OR 97239-2998. E-mail: edu Accepted for publication Nov 22, 2011. I-PASS, a Mnemonic to Standardize Verbal Handoffs The rst cohort of IIPE projects from The resident handoff bun- of the I-PASS Mnemonic will be de ned 2009 are beginning to realize some early dle includes 3 major elements: team in this article. successes. We bring you this article in training by using focused TeamSTEPPS Mnemonics are memory aids. Effective the spirit of sharing what works and communication strategies,2 implementa- mnemonics are catchy, symbolic, par- what doesn't. The lesson about the tion of a standardized template for simonious, utilitarian, and may conjure importance of context is critical in the written or printed computerized up a visual image linked to a process or adopting and adapting innovations to handoff document, and introduction of subject.

3 In this report, we emphasize your own learning environment. several evidence-based Verbal handoff the importance of structured commu- Carol Carraccio, MD, MA processes, which are referred to by nication strategies to enhance patient Section Editor using a novel Verbal Mnemonic . This safety, review literature pertinent to the New duty hours standards have in- multisite collaborative education and handoff process, including the use of creased the frequency of transitions in research project was launched with Verbal mnemonics, and describe the care or Handoffs for resident physi- the support of the Initiative for In- creation of the I-PASS Mnemonic , a core cians. Because miscommunications are novation in Pediatric Education (IIPE) element of our resident handoff bundle. a leading cause of adverse events in and the Pediatric Research in Inpa- tient Settings (PRIS) network. The title Background hospitals, optimizing the handoff pro- cess is essential for patient safety.

4 The I-PASS is an acronym that not only Communication errors are a contribut- I-PASS Study aims to determine the denotes the title and purpose of our ing cause of approximately two-thirds effectiveness of implementing a resi- research study IIPE-PRIS Accelerat- of sentinel events,3 over half of which dent handoff bundle to Standardize ing Safe Sign-outs but also serves as involve handoff In health inpatient transitions in care and de- the Verbal Mnemonic for the standard- care, the magnitude of the patient crease medical errors in 10 pediatric ized handoff itself. Individual elements safety epidemic rst became widely PEDIATRICS Volume 129, Number 2, February 2012 201. Downloaded from by guest on May 24, 2016. recognized with the publication of To days) and adverse drug events (from including regular faculty and chief res- Err Is Human in 1999, which concluded 30 to 18 per 1000 patient days).9 ident observations and feedback re- that medical errors cause up to 98 000 SBAR was developed to facilitate the garding the Verbal handoff process.

5 Preventable deaths annually in the ef cient transmission of information. It However, we found that a majority of United Subsequently, calls for is most effective when time is limited Verbal Handoffs did not adhere to the action emerged from the federal gov- and a quick decision is needed, as this structure of the SIGNOUT Mnemonic . ernment and many private and pro- tool is suited to situations when a brief As part of the process for curriculum fessional organizations, including the summary is suf cient and fewer than development for the I-PASS study, we recommendation that principles from 5 key points need to be communicated. re ected on the successes and chal- High Reliability Organizations (HROs) Further, this Mnemonic should be used lenges of SIGNOUT, and considered use be applied to the health care system. as a situational brie ng tool, as intended, of the Mnemonic , IPASSTHEBATON from HROs are organizations in high-risk, and is appropriate for use across hi- Feedback from chief high-impact industries that consis- erarchical Although use residents who had been involved in the tently achieve high quality outcomes of SBAR has been extended to Handoffs pilot curriculum, however, expressed despite experiencing many unexpected of patient care at change of shift or the need for a Mnemonic that was events where the potential for error is patient location, there are limitations shorter, easier to remember, and had very These organizations em- in its applicability, particularly in sit- discrete elements without overlap.

6 Ploy team training and reliability sci- uations that include transmission of in- They felt strongly that elements of the ence to improve their performance, formation about complex patients who Mnemonic needed to be fully integrated the roots of which arose from the require broader information and context. into computerized handoff tools. military and civilian aviation commu- Modeling the process used to design nities. Programs such as Crew Re- Development of the I-PASS. the original SBAR Mnemonic , we (Drs source Management have led to major Mnemonic Starmer, Spector, Landrigan, and Sect- advances in team training and may Given the limitations of SBAR, alterna- ish) conducted a brainstorming session result in dramatic improvements in tive mnemonics have been developed, and identi ed the essential elements of fatalities, accident related costs, and implemented, and tested for use in a Verbal handoff. We focused on ele- human factor based mishaps.

7 Handoffs of care. A recent systematic ments that pilot study faculty observers A speci c application of HRO principles review of published handoff mnemon- noted were most commonly absent is the use of explicit Verbal mnemonics ics identi ed 46 articles describing from resident Handoffs (illness severity to Standardize communication. One of 24 different handoff Most assessment, contingency planning, and the most commonly used communication have not been rigorously studied, how- read-back by the receiving resident). tools, SBAR, an acronym for situation, ever, and descriptions of their deriva- and incorporated best practices for background, assessment, recommenda- tion are lacking. A notable exception Verbal Handoffs from our review of tion, was developed by Doug Bonacum, includes an article describing the use existing literature. vice president of Kaiser Permanente and of the SIGNOUT Mnemonic , which was shown to increase the consistency and The results of this session led to the former safety of cer on a nuclear sub- con dence with which residents perform development of a novel Mnemonic , I-PASS.

8 During a patient safety Verbal sign-outs, as compared with an (Fig 1), which serves as the cornerstone workgroup meeting, Bonacum de- implicit, informally structured for the resident handoff bundle that scribed expectations when handing off is currently being implemented and a situation to an of cer on deck. These Drawing from the apparent evidence- tested in the I-PASS study. key concepts were translated into core based success of the SIGNOUT mnemo- elements of the SBAR Mnemonic . Suc- nic, we included the SIGNOUT Mnemonic The I-PASS Mnemonic provides a frame- cess of a pilot study investigating the in a pilot resident handoff bundle work for the patient handoff process as use of SBAR as a communication tool intervention study at the Children's follows: led to rapid spread across hospitals Hospital Boston that preceded the I: Illness severity nationwide and studies examining its ongoing multicenter I-PASS study. P: Patient summary Implementation of SBAR Resident input was a key factor in this A: Action list in 1 hospital was associated with sub- selection.

9 Efforts were made to re- S: Situation awareness and contin- stantial drops in the rates of adverse inforce use of the Mnemonic dur- gency planning events (from 90 to 40 per 1000 patient ing the postintervention study period, S: Synthesis by receiver 202 STARMER et al Downloaded from by guest on May 24, 2016. PEDIATRICS PERSPECTIVES. Conclusions and the Agency for Health Care Research and Quality, grant 1K12HS019456-01. The novel Mnemonic , I-PASS, was de- Developed with input from the IIPE. veloped from best handoff practices and the PRIS Network. cited in the literature, resident feed- back from a pilot study, and obser- IIPE is the Initiative for Innovation in Pe- vations made by faculty of the handoff diatric Education and is the entity that process. Structured communication, recognizes innovative educational pro- especially at the time of transitions in posals for pediatric residency training care, is essential to promote patient programs.)

10 More can be found on the safety. The multisite I-PASS study will Web site, test the effectiveness of the resident PRIS is a collaborative hospitalist re- handoff bundle, including the I-PASS search network sponsored by the Mnemonic , on medical errors in 10 American Academy of Pediatrics, the Ac- pediatric institutions. Lessons learned ademic Pediatric Association, the Soci- may apply to other settings where the ety of Hospital Medicine, and the Child opportunities to improve the handoff Health Corporation of America. Details FIGURE 1 process remain a challenge. are available at Elements of the I-PASS Mnemonic . org. ACKNOWLEDGMENTS Members of the I-PASS Study Group in- An example of a Verbal I-PASS handoff This project was supported with a grant clude coinvestigators from the follow- communication is provided in Fig 2. from the US Department of Health and ing institutions as follows: Children's As we began implementing the I-PASS Human Services, Of ce of the Assistant Hospital Boston (primary site): April Mnemonic , we received widespread in- Secretary for Planning and Evaluation, D.