Patient and Family Centered I-PASSPCORI Annual Meeting Plenary

November 1, 2018

Christopher P. Landrigan, M.D., M.P.H.Research Director, Inpatient Pediatrics Service, Boston Children’s HospitalDirector, Sleep and Patient Safety Program, Brigham and Women’s HospitalProfessor of Pediatrics , Harvard Medical School Principal Investigator, I-PASS Study Group

Disclosures• Dr. Landrigan has received grant funding from the Patient

Centered Outcomes Research Institute (PCORI), the Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health (NIH), Department of Health and Human Services (DHHS) and the Controlled Risk Insurance Company (CRICO)

• He has consulted with and owns equity in the I-PASS Institute, which seeks to help hospitals implement safer handoff systems

• Dr. Landrigan has served as an expert witness in cases regarding sleep deprivation and safety

• The presentation will not involve discussion of unapproved or off-label, experimental or investigational use

• The presentation will show copyrighted materials for which permission has been obtained from Boston Children’s Hospital and the I-PASS Study Group

Patient Safety in the U.S.: Ongoing Problems

Institute of Medicine, 1999– 44,000-98,000 deaths per year due to adverse events

Office of the Inspector General, 2010– 180,000 deaths per year due to adverse events

Makary et al, BMJ, 2016– 251,000 U.S. deaths per year due to medical error– 3rd leading cause of death

North Carolina Pt Safety Study– 2341 randomly selected

admissions from ten randomly selected hospitalsstatewide

Landrigan et al., NEJM 2010: 363:2124-34

Communication Failures

Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type (2004 - Third Quarter 2011)

The I-PASS MnemonicI Illness Severity • Stable, “watcher,” unstable

P Patient Summary • Summary statement• Events leading up to admission• Hospital course• Ongoing assessment• Plan

A Action List • To do list• Timeline and ownership

S Situation Awareness and Contingency Planning

• Know what’s going on• Plan for what might happen

S Synthesis by Receiver

• Receiver summarizes what was heard• Asks questions• Restates key action/to do items

Starmer. Pediatrics. 2012 Feb;129(2):201-4.

Intervention: More Than Just A MnemonicI-PASS Handoff Bundle Components

I-PASS Handoff Bundle

I-PASS Mnemonic

Introductory WorkshopI-PASS Campaign

Faculty Development

Simulation Exercises

Faculty Observations &

Feedback

TeamSTEPPSTraining

I-PASS Printed Handoff Document

Results – Primary OutcomeMedical Error Rates

Number of errors (rate per 100 patient admissions)

blankPre

(n=5516 admissions)Post

(n=5571 admissions) P value

Overall rate of medical errors 24.5 18.8 <.0001

Preventable adverse events 4.7 3.3 <.0001Near misses / non harmful

medical errors 19.7 14.5 <.0001

Non-preventable Adverse Events 3.0 2.6 0.48

30% reduction 23% reduction

Starmer AJ, et al. Changes in Medical Errors After Implementation of a Handoff Program. NEJM. 2014 Nov 6; 371(19):1803-12

Nursing Handoff Related Care FailuresBigham et al., Pediatrics 2014; 134: e572-579

Communication Interventions

• Interventions to improve intra-professional communication have been shown to improve patient safety

• Communication interventions—including I-PASS—have not typically included families and other members of the inter-professional team

Current State of Rounds

• “Family Proximate Rounds”• Excess medical jargon• Lack of family questions or attempts to ensure

family understanding or engagement

Patient and Family Centered I-PASS Study

We aim to implement Patient and Family Centered I-PASS with an Intervention Bundle to• Reduce serious medical errors• Improve family centered rounds and daily

communication • Improve the shared understanding of care

plans between providers, patients and families• Improve the patient and provider experience

Curriculum Delivered to All Team Members

• Residents• Medical students• Faculty• Nurses• Patients and

families• Separate patient

education materials for patients and families

Family Brochure

Roles of Patients and Families on FCR

• Families need to be included as equal partners

• Patients and families should be the first to speak on FCRs – Sets stage/orients

team to discussionhttp://hipxchange.org/FamilyRounds

Health Literacy Principles“Universal Precautions”

• Use living room language• Avoid medical jargon / explain medical terms

if used• Check for understanding

• Check back

Synthesis by Receiver

• How do you ask a parent to synthesize?– Use open-ended questions– Create a safe and welcoming

environment– Be attuned to non-verbal

cues that you observe in family members

Rounds Report

Study Methods

• Multicenter prospective pre-post study• Inpatient pediatric units at 7 North American hospitals• Staggered implementation and data collection from 2014-

2017• At each participating hospital:

– 3 months baseline data collection– 9 month intervention period with iterative cycles of improvement– 3 months of post-intervention data collection matched by time of year

• Nurses and families engaged in every aspect of study

Communication Process Scores0 20 40 60 80 100

Family engagement

Nurse engagement

Family centered rounds occurred

Family received written updates

Teaching occurred on rounds

Optimal pace of rounds

%

Pre-Intervention

Post-Intervention

*

*

*

*

n=206 rounds encounters pre-intervention; n=278 post-intervention

Medical Error Rates

Per 1000 patient-days Pre- Post- p

value

Medical Errors 41.2 35.8 .21

Harmful errors/ Preventable AEs 20.7 12.9 .01

Nonharmful errors/ Near misses 20.0 22.0 .5

Adverse Event Rates

Per 1000 patient-days Pre- Post- p

value

AEs 34.0 18.5 .002

Preventable AEs/Harmful errors 20.7 12.9 .01

Nonpreventable AEs 12.6 5.2 .003

Aspects of Family Experience that Improved

0 20 40 60 80

Understood what was said on rounds

Understood written updates provided

Shared understanding of medical planwith nurses

Nurses addressed family concerns

Nurses made family feel an important partof healthcare team

% Top-box score

Pre-Intervention

Post-Intervention

*

*

*

*

*

*p<.05

Summary & Future Directions• Communication and handoff errors are

common• Patient and Family Centered I-PASS Bundle Decreased adverse events and improved patient experience

• We recently received PCORI funding to Disseminate and Implement Patient and Family Centered I-PASS in 18 Additional Hospitals

Acknowledgements• PCORI• All 150 Family Members, Nurses and

Physicians of the I-PASS Study Group, without whom this work would not have been possible

Thank you!!

Questions? clandrigan@partners.org