Espresso: Sign Out

Read on with ACOG Committee Opinion: Sign Out

Sign Out: A Critical Moment

• Sign out or hand off – transferring of patient knowledge and plan between two physicians or care teams. 

• Patient care transitions represent a potential challenge to all of us:

• Communication is challenging - different styles and preferences

• External dynamics (interruptions, emergencies, home-life demands)

• Internal dynamics (power differential, hierarchy, fatigue)

• Interpersonal characteristics (defensiveness, minimizing, conflict-averse or conflict-prone)

• Communication errors are frequently identified as pain points or root causes of safety events.

• Three primary focuses to improve sign out:

• Setting the stage

• Being a good (and thorough) “giver” of sign out.

• Being a good (and vigilant) “receiver” of sign out.

Setting The Stage for Effective Handoff

• Preparation

• The “giver” of signout should organize and update information to be prepared for handoff.

• Updating any signout template or process used at your institution.

• Reviewing daily updates to ensure most salient points are reviewed during verbal discussion.

• Identify any tasks or specific guidance for the receiving team to complete.

• Consider organizing sign out order by acuity/urgency or timely completion of these tasks.

• Physical Environment

• The environment should be set appropriately. Ideal physical environments are:

• Quiet, and ideally away from distractions; i.e., a quiet conference room vs at nursing station.

• Areas where patient confidentiality is preserved.

• “Warm hand off” in a patient room as appropriate for particularly significant cases. 

• Paper forms for hand-off should be legible and organized.

• Fortunately many EMRs are incorporating sign-out templates, but don’t be afraid to ask your institution to modify things if needed to apply to your environment.

• Sufficient time should be set aside to protect effective handoff.

• Consider assigning someone specifically to address acute patient concerns during sign out - this keeps a significant amount of the team intact to focus on information exchange. 

• This requires redundancy in those who are aware of patients on the service - sign out is a team responsibility, not an individual one!

• Communication Environment

• Use of medical terminology

• Try to stick to understood medical language: i.e., “Category II for repetitive variable decelerations” instead of “this baby’s been a little naughty.” 

• Standardized terminology allows for conveyance of the appropriate message and plan of care; colloquialisms may leave significant room for error due to being inexact.

• Also consider language importance with respect to professional communication - attention to terms that may be culturally or personally insensitive, or the use of judgment statements rather than objective facts.

• Culture and Hierarchy

• Many times in OB/GYN residency, sign out is predicated on a structural hierarchy. 

• Certainly, all patients should have a primary individual or team responsible for them, but a back-up system should be in place in case the primary contact is unavailable.

• These hierarchies may lead to communication challenges in patient care:

• I.e.,A student, first year resident, or RN should all be as comfortable to communicate in sign out as the senior resident or attending regarding a concern. 

• Senior residents and attendings should role model effective communication and elicit team member concerns.

• Senior residents sign out should strive to serve as a role model for junior team members to demonstrate communication style, active listening, and prioritization.

• At the same time, sign out should be recognized as a patient safety event and treated the same:

• Unique learning points for safety may be raised

• However, sign-out is not a time to do an in-depth review on basic topics - lengthy interruptions should be avoided.

Sign Out Time: The Verbal Discussion

• “Giver” of signout should ideally follow a standardized presentation strategy for each patient.

• Common frameworks:

• IPASS - Illness severity, Patient summary, Action list, Situational awareness, Synthesis by receiver.

• SBAR - Situation, Background, Assessment, Recommendation

• Use of a structure for sign out has been shown in some studies to reduce preventable adverse event rates by as much as 30%.

• Verbal hand-off should focus on the most important items, and ensure your communication is structured to make those points stick for the receiver.

• Even in optimal conditions, studies have shown that in those not using structured communication strategies, the receiver fails to identify the main concern 60% of the time! 

• You as a giver of hand-off should prioritize issues to help the receiver, who is new to the patient - don’t make them prioritize and learn the patient simultaneously!

• Critical to relay tasks to be done, and anticipatory guidance for events that may occur:

• I.e., “The tracing was previously category II for some variable decelerations. If it occurs again, I would recommend an IUPC and amnioinfusion.” or 

• “She is known to have CHF and received 2L IVF intraoperatively. If she is short of breath, she should be evaluated for pulmonary edema and if suspected, start with 60mg IV lasix per cardiology.” 

• Giver should likewise use strategies to check receiver understanding, like read-back and interactive questioning. More on those momentarily!

• “Receiver” of sign out has an equally important role in comprehending sign out and actively listening:

• Read-back communication allows the sender to check that information is received by a recipient. It is rarely employed in hand-offs, but it is one of the most effective strategies to effective communication.

• I.e., last example – “Got it. She’s at high risk for pulmonary edema. If I suspect it, I will give 60mg IV lasix.” 

• Active listening should also be employed - that’s more than just head-nodding or uh-huh-ing!

• Take notes

• Ask questions

• Clarify the plan when needed

• If for a patient you do not hear any “critical events” or “tasks” - take that as a signal to ask!

• Giver and receiver should both be aware that there are high risk scenarios for sign-out failure:

• When a patient is physically moving locations

• When a patient is clinically unstable

• If the hand off is permanent, i.e., a service change, transfer to another facility, or a patient who is newly being admitted at sign out.

• In these scenarios, there is evidence for higher risk of a patient safety event due to hand-off concerns.

• Both should be acutely aware of importance of thorough sign-out in these scenarios.

Espresso: Debriefing

What is a debrief?

• Conversation involving frontline workers taking part in a patient’s care that occurs shortly after the event takes place.

• Can be used for a number of purposes:

• Knowledge or skill attainment (individual learning)

• Describe threats to patient or worker safety, or threats to team dynamics (systems learning)

• Provide closure for individuals involved in a clinical situation (therapeutic)

• Debriefing is not the same as a true “root cause analysis” (RCA) but may be a first-step in performing RCA.

• Cornerstone of clinical and simulation-based education.

When should a debrief occur?

• Defining set triggers in which debriefs should occur has been identified as best practice to:

• Set expectations amongst staff when they should occur, and how frequently

• Increase frequency of debriefs

• Promote system-wide goals

• In OB/GYN, there’s not a standard list of what should generate a debrief; but you might imagine there’s a few major events that we commonly think of as emergencies:

• Shoulder dystocia, or difficult extraction at cesarean

• Significant postpartum or surgical hemorrhage events

• Unexpected newborn complication

• Unexpected surgical complications or unexpected intraoperative findings

• Patient injury or serious complication, unanticipated ICU admission, or death

• Many of these events may be defined locally; and if you don’t have a list defined at your institution, it is worth asking about it and starting one!

• In general, it is good practice to also have a “staff member request” as a trigger for considering a debriefing to empower any person on the team to review events that may be unusual or uncomfortable.

• Best practice has identified that the “hot debrief” (i.e., shortly after the event) is helpful to staff immediately involved and provides opportunity to get a very clear clinical picture.

• “Cold debrief” (i.e., one done much later) will allow for more data to be collected, but worsens recall of participants and also removes some of the other advantages that a hot debrief may enable - i.e., finding time for staff to attend, identifying learning points immediately after event, etc.

• A cold debrief can certainly be performed later on - in some institutions, this is performed through the “M&M” process with which all residents are likely familiar!

How should a “hot debrief” be done?

• Three general stages of debriefing:

• Preparation

• Delivery

• Post-Debrief

• Preparation

• If a debrief is requested/triggered, all staff should be invited.

• A time and location should be identified, ideally soon after the event occurred.

• A facilitator should be named, and a second person can serve as a scribe for documentation (more on that later)

• Ideally, the facilitator should be a designated person who was not the team leader or heavily involved in the events. 

• At UW L&D, this is often our charge nurse or another senior nurse who serves to facilitate.

• This helps to eliminate any issues of hierarchy/power and encourages all voices to speak up.

• Any other concerns to allow for optimal debrief should be addressed - short time period for cross-coverage by other personnel, for instance. 

• Delivery

• Facilitator should set expectations at the start:

• Aim for brevity of debrief (5-10 minutes ideal)

• Establish psychological safety - not to blame or punish, but to review and characterize event.

• Invite the team leader to provide a summary of the case.

• The facilitator should encourage the team leader to provide an objective case overview at this point - the focus should be on the “actions” that occurred. 

• Provide reassurance that the next step of the debrief will be to focus on reflection and judgements.

• After the event summary, the Facilitator should then start conversation according to a specific structure to review the event:

• Many possible structures, but broadly fall into:

• Review things that went well.

• Review opportunities to improve.

• Identify points for action and “take home” learning points.

• Your institution likely has a “debrief form” that helps to guide these conversations. However, some of the more significant ones described include:

• TALK - Target, Analysis, Learning Points, Key Actions

• INFO - Immediate, not For personal assessment, Fast facilitated feedback, Opportunity to ask questions

• STOP5 - Summarize, Things that went well, Opportunities to improve, Points to action, Responsibilities

• Seven Step After Action Review - US Army tool which has been adapted to QI.

• And many more exist!

• Post-Debrief

• Facilitator and scribe can review that action points are recorded.

• If appropriate, can assign action items to specific individuals for follow up.

• Documentation should be completed at this time.

• Again, debrief forms are often present in hospitals for these purposes as part of QI review. Sometimes this may be incorporated into your patient safety reporting system.

• Medico-legally, debrief processes and forms are most frequently considered protected information through quality and safety structures. 

• Your legal department can help ensure all pieces are structured to meet this standard.

Additional Info: 

AHRQ https://psnet.ahrq.gov/primer/debriefing-clinical-learning 

Contemporary OB/GYN: https://www.contemporaryobgyn.net/view/debriefing-after-adverse-outcomes-opportunity-improve-quality-and-patient-safety  

Telehealth for the Ob/Gyn

Reading for this podcast:
Committee Opinion 798: Implementing Telehealth in Practice 

What is Telehealth? 

• Definition

• Collection of means or methods for enhancing the health care, public health, and health education delivery and support using telecommunications technologies

• Term of “telehealth” is often used to refer to traditional clinical diagnosis and monitoring that are delivered by technology (ie. doing a visit on Zoom) 

• Connected health and digital health are also terms that broadly describe similar technology applications in health care 

• But remember that telehealth can refer to a broad list of healthcare topics, such as diagnosis and management, education (ie. podcasts!), and other related fields of health care 

• Can include remote monitoring, mobile health care (ie. text messages, apps) 

• These services can be real time (synchronous) or “store-and-forward” (ie. asynchronous) 

The Data Behind TH 

• A lot of this data is recent due to the COVID-19 pandemic 

• This has especially been true in OB care given the need for multiple prenatal visits in a short period of time 

• One great study that came out in February 2020 (right before COVID!) in the green: 

  • Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes, by Dr. Denicola et al 

  • The looked at 47 total studies, which included 31,967 patients 

  • Telehealth improved obstetric outcomes via: 

  • Increased smoking cessation and increased breastfeeding 

  • Also decreased need for high-risk obstetric monitoring office visits, but did not lead to worse maternal and fetal outcomes 

  • Also effective for continuation of oral and injectable contraception 

  • TH provision of medication abortion services had similar outcomes compared with in-person care and improved access to early abortions 

Providing Equitable Telehealth Care 

• Just like in any time of health care, there will always be barriers to equity 

• To read more about this, check out a great article by Dr. Ukoha in the green from March 2021 called “Ensuring Equitable Implementation of Telemedicine in Perinatal Care” 

• Healthcare practitioner factors 

• Includes attitudes and perceptions, inherent biases and assumptions 

• Studies have shown that when looking at patient portal use, Latino, Black and individuals with low income were less likely to be offered patient portal access and had significantly lower uptake 

• Health system factors 

• Safety net health systems and community health centers often lag behind in offering telemedicine 

• Possibly due to lack of supportive infrastructure 

• Patient factors 

• Absence of technology or reliable internet coverage

• Low health and digital literacy 

• Non-English speakers can also have a barrier to telemed use 

• Disproportionately affect those in rural areas, those identify as BIPOC, and those living on low incomes 

• Payor and Policy Factors 

• State Medicaid programs continue to restrict coverage of telemedicine and other remote management services 

• Before COVID-19, only 19 state Medicaid programs explicitly recognized patient’s home as an eligible originating site for telemedicine 

• States also require practitioners to be licensed within the state where the patient was receiving their care, so this limits patients from accessing telehealth services from out of state practitioners 

• Also there is limited coverage for audio-only services 

• Recommendations to mitigate these barriers 

• Individual practitioners to acknowledge and mitigate implicit biases 

• Systems should ensure that telehealth platforms are secure and widely usable 

• Provide technological and clinical infrastructure including patient-centered education tools 

• Allow for telephone visits when video visits are not feasible or desired

• Conduct rigorous quality assurance efforts  

• Payers should make telemedicine a standard coverage benefit and cover at-home monitoring equipment 

• Payers can also provide mobile devices with data plan or Wi-Fi 

• Require reimbursement of audio-only visit 

• Ensure payment parity across sites and types of visits 

• Expand ability to practice telemedicine across state lines and remove existing barriers to multi-state licensure

Biostatistics Part III: Statistical Analyses

We did biostats once upon a time in two previous episodes around the beginning of our podcast series. If you’d like to take a listen, here are the links: Part I and Part II.

Let’s do a quick review and discuss the different types of studies that we could do:

• Exposure (or intervention): risk factor whose effect is being studied 

  • Also can be referred to as the “independent” or “predictor” variable 

• Outcome: something that develops as a consequence of exposure (or intervention)

  • Also referred to as the predicted or dependent variable (or variables) 

• First study category: temporality: 

  • Retrospective studies 

    • Means that the outcomes or the dependent variables (and likely independent variables!) have already occurred, or you have that data already  

  • Prospective studies 

    • Means that the outcomes or dependent variables (or even independent variables) have not yet been measured 

• Second category: descriptive vs analytical

  • Descriptive studies - where you’re merely trying to describe data on one or more characteristics of a group of individuals; these types of studies don’t usually try to answer a question or establish a relationship between variables:

    • Case report

    • Case series 

    • Cross-sectional studies 

  • Analytical - attempt to test a hypothesis and establish causal relationships between variables:

    • Observational - studies where a researcher is documenting a naturally occurring relationship between exposure and outcome 

      • Case Control studies - first determine if the outcome is present (ie. cases of lung cancer vs. cases where there is no lung cancer) and then traces the presence of prior exposure to a risk factor (ie. tobacco use)

      • Cohort studies - first determine the exposure to a risk factor and then assesses whether the outcome occurs a future time point 

    • Experimental - research actively performs an intervention in some or all members of a group 

      • Remember: only experimental studies can establish a causal relationship; observational studies can show correlation, but not reliably show causation! 

• It is important to know that you can have both retrospective and prospective observational studies, but experimental studies are all prospective.

(c) CREOGS OVER COFFEE, 2022

The next step is, let’s say you have your study and you’ve collected your data… now… HOW DO I ANALYZE IT ALL? Dr. Rebecca Hamm at UPenn has shared with us this crazy but excellent flow chart to figure it out. While we won’t hit everything in the podcast, we’ll hit some of the more common tests and the first few questions of the flowchart.

Courtesy of rebecca hamm, md

First question: What type of data do you have? 

• Continuous (example: age, BMI, weight, etc.)

  • See second question  

• Categorical (Gender; Yes/No; Category 1, 2, or 3)

  • You can use a Chi-Square test!

    • In simple terms, a Chi-Square (or Pearson’s Chi Square test) is going to determine if there is a statistically significant difference between expected frequencies and the observed frequencies in one or more categories of a contingency table

    • In your contingency table, if any category has <5 observations, then you have to use a Fisher’s exact test

• Second question: If you have a continuous variable, do you have parametric or nonparametric data? 

  • Parametric basically means: 

    • You have independent, unbiased samples 

      • Independence (in statistics terms) basically means the occurrence of one thing does not affect the probability of the occurrence of another thing 

    • The data is normally distributed 

      • How do you figure that out? Easiest way - create a histogram to check 

    • Harder way: there are many statistical tests of skewness that we won’t describe here! 

    • Equal variances 

      • Basically, variance is a statistical measurement of the spread between numbers in a data set, or how far each number in the set is from the mean (average) 

      • The square root of variance is standard deviation (you’ve probably heard of that!) 

      • Therefore, equal variance means that in order for us to consider data parametric, we have to assume that the variance is the same for both populations we are comparing 

    • Third question: If you have a continuous variable, what type of question are you asking? 

      • I want to know about relationships:

        • If you have a true independent variable, you can use a regression analysis

          • Example: a linear regression, where you actually have an equation and an R^2 value

          • Doesn’t have to be linear relationship - other forms of regression exist.

        • If you don’t have a true independent variable, then we have to do a correlation analysis  

        1. If parametric: Pearsons’ r test  

        2. Nonparametric: Spearman’s Rank Correlation 

      • I want to know about differences between the means of my groups: 

        • How many treatment groups do you have? 

          • If two: 

            1. If parametric, can use student’s t-test (paired or unpaired) 

            2. If nonparametric, then can use Mann-Whitney U or Wilcoxon Rank sum test 

          • If more than two: 

            1. If parametric, can use an ANOVA 

            2. If nonparametric, can use Kruskal-Wallis test 

Examples

•  Let’s try and figure out what the best statistical test is for the following situations! 

  • What is the frequency of repeat hypertensive disease of pregnancy in patients who took low dose aspirin vs. those that did not take low dose aspirin?

    • Questions you’ll want to ask: is this categorical or continuous? 

      • Categorical! Hypertensive disease is a “yes” or “no” in this case 

      • Therefore, we will want to use a Chi-Square test.

  • What is the gestational age at which patients with short cervix delivered if they got a cerclage or not? 

    • Question you want to ask: is gestational age at delivery categorical or continuous? 

      • Continuous! 

    • Now… is gestational age at delivery going to give us a parametric data set? Let’s see!

      • Is it independent: yes – the gestational age at which one person delivers should not affect the gestational age at which another person delivers in this data set.

      • Is it normal? Nope! – just going to give this one to you, but gestational age at delivery is not normally distributed (lots of people will delivery right around 39-40 weeks, and then there is a long, skewed tail of those that delivery very early, like 24 weeks etc) 

      • So we have a continuous, non-parametric set of data 

      • Next question: do we want to know relationship or difference of means? Difference of means!

        • So we can use a Wilcoxon Rank Sum test  

  • Is there a difference in admission hemoglobin between patients who received iron supplementation during pregnancy or not?

    • Question: is Hgb a continuous or categorical variable - continuous

    • Question: Is Hgb a parametric data set - for our purposes, let’s say yes! 

    • Question: Do we want to know a relationship or a difference of means? Difference of means 

      • So we can use Student’s t-test  

Surgical Essentials: Scalpel Blades and Handles

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It’s been a while since we did a surgically-focused episode - we’ve previously done a series on laparoscopy and hysteroscopy, as well as on sutures and needles. Today, let’s focus in on an essential surgical instrument - the scalpel!

Additional reading: British Journal of Surgery Oct. 2022 review (also, the author Dr. Ron Barbosa is on Twitter and does some great surgical tweetorials!) 

History of the modern scalpel

• Morgan Parker, a 22 year old engineer at the time, patented a locking scalpel handle and blade system in 1915 to replace what previously were often single-piece instruments without a replaceable blade.

  • His original design (slightly modified) is still what we use today!

• Parker initially numbered handles 1-9 and blades 10-20; while this has been somewhat modified/expanded, the nomenclature largely remains the same.

  • We’ll talk about the most common handles and blade types today.

Scalpel handles

• You’ve probably never had to ask for these in a surgical tray – so let’s review!

• The number three handle is most commonly used in surgical specialties:

  • Flat shape

  • Some serrations near the blade attachment area to provide better grip for surgeon

  • Fits blade numbers 10-19

  • Modifications include the 3L (long-handle scalpel) and 3L angled (long-handle with a slight angulation).

• The number four handle fits larger blades (#20 and above), but otherwise is very similar to the #3. 

• The number seven handle is very narrow and meant for precise, fine work – not typically used in OB/GYN or subsepcialties – more common in head/neck/ENT, plastics, neurosurgery, and dentistry.

Barbosa, BJS, 10/2022

Scalpel blades

• You may be more familiar with these, but likewise may not have had to ask for them before!

• The number ten blade is used to make longer skin incisions for laparotomy, or for shorter cuts where a wide blade is ideal (i.e., hysterotomy). 

  • This is probably what you’re most familiar with in OB/GYN applications. 

  • You may also encounter a number 22 blade, which is essentially a larger version of the #10.

• The number eleven blade is triangular, long, and has a sharp point with an edge on one side. 

  • Its shape is best suited for a stab incision - for instance, for laparoscopic port incisions, Bartholin’s gland cruciate incisions, and the like.

  • Its shape is not great though for excising anything - it’s really pointy!

• The number fifteen has a small, curved cutting surface as well as a pointed tip.

  • You can use this for a stab incision at the point, and a more controlled incision for excising tissue with the curved portion.

  • Great for working in tight spaces versus a 10 blade for excision (i.e., oncology cases or urogyn cases – think about sharply cutting on your cardinal ligament bites – a 15 blade on a 3L handle is great for this!)

  • Also great for stab incisions, and many folks may prefer a 15 to an 11 blade for Bartholin’s or laparoscopy incisions.

10 blade (top), 11 blade (middle), 15 blade (bottom)

Scalpel blade materials, and disposables versus regular blade/handles

• Disposables are great and often very available for outpatient procedures or for emergencies

• The blades between disposable and regular blades are the same shape/size/nomenclature, so there’s no difference in that regard.

  • However, the regular blades tend to be a bit thicker on the back, non-cutting surface of the blade, which gives a bit more structure and may feel sturdier when cutting.

• In terms of materials, the vast majority of scalpels we use will be made of carbon steel or stainless steel.

  • Steel blades can also have other compositions or coatings that can help with retaining sharpness and/or resisting rusting/corrosion.

• Other materials used in modern blades include ceramic, titanium, diamond, sapphire, and obsidian.

  • Many of these - especially ceramic and obsidian - are extremely sharp, and can be chosen because they are non-magnetic – so for MRI-guided procedures, they are preferred. However, they are so sharp that they can be very dangerous in poorly trained hands - so we wouldn’t use these unless you have a great reason to do so! 

How do I hold a scalpel?

• Intern struggle – and the truth is that it depends!!! 

  • For larger blades - i.e., a #10 blade or a #20 or above - the best grip is a “palmar” or “violin grip,” in which you have your index finger atop the handle, and use your other fingers to hold the body of the handle, with the back part of the handle under your palm.

    • This allows for precision with the long, wide cuts you would typically make with this blade.

  • For smaller, pointier blades – a #11 or #15 - the “pencil grip” is preferred.

    • This allows for precision with your “stab” incision or for those tight/deeper spaces. 

Barbosa, BJS 10/22: Palmar/”Violin” grip, for larger blades (#10, #20 and above)

Barbosa, BJS 10/22: Pencil grip, for smaller blades (#11, #15)