Association for Academic Surgery
Description of Web-Enhanced Virtual Character Simulation System to Standardize Patient Hand-Offs

https://doi.org/10.1016/j.jss.2010.04.052Get rights and content

Introduction

The 80-h work week has increased discontinuity of patient care resulting in reports of increased medication errors and preventable adverse events. Graduate medical programs are addressing these shortcomings in a number of ways.

Methods

We have developed a computer simulation platform called the Virtual People Factory (VPF), which allows us to capture and simulate the dialogue between a real user and a virtual character. We have converted the system to reflect a physician in the process of “checking-out” a patient to a covering physician. The responses are tracked and matched to educator-defined information termed “discoveries.” Our proof of concept represented a typical post-operative patient with tachycardia. The system is web enabled.

Results

So far, 26 resident users at two institutions have completed the module. The critical discovery of tachycardia was identified by 62% of users. Residents spend 85% of the time asking intraoperative, postoperative, and past medical history questions. The system improves over time such that there is a near-doubling of questions that yield appropriate answers between users 13 and 22. Users who identified the virtual patient's underlying tachycardia expressed more concern and were more likely to order further testing for the patient in a post-module questionnaire (P = 0.13 and 0.08, respectively, NS).

Conclusions

The VPF system can capture unique details about the hand-off interchange. The system improves with sequential users such that better matching of questions and answers occurs within the initial 25 users allowing rapid development of new modules. A catalog of hand-off modules could be easily developed. Wide-scale web-based deployment was uncomplicated. Identification of the critical findings appropriately translated to user concern for the patient though our series was too small to reach significance. Performance metrics based on the identification of critical discoveries could be used to assess readiness of the user to carry off a successful hand-off.

Introduction

Since the ACGME introduced the 80-h work week in July 2003 residency programs rely on a model where multiple teams of residents are responsible for a given patient's care. “Night-float” residents or teams take care of patients overnight and on weekends, increasing the need for patient “hand-offs” to transfer the care of patients from one resident team to another [1]. Individual residents and groups of residents often transition patient care between one another using a process commonly referred to as a “sign-out” or a patient “hand-off” [2].

A hand-off is the transfer of information and professional responsibility from one provider to another while patient is in hospital. This type of transfer of patient care information has been most commonly performed and studied in the nursing profession, however, more recently, attention is being shifted toward hospitalist and resident physician hand-offs 2, 3, 4. With the shift away from the traditional surgical residency structure of in-house call every second to every third night, which provided excellent continuity of care, to the paradigm of multiple teams of residents taking care of a single patient, the discontinuity of patient care is greater than ever before. To this end the Joint Commission has developed expectations that hospital systems would “implement standardized approaches to ‘hand-off’ communications” in their National Patient Safety Goals, 2009 [5].

Suboptimal communication between physicians during sign-out has the potential to increase the incidence of preventable adverse events [6]. A case-control study performed at Brigham and Women's Hospital found that preventable adverse events were strongly associated with coverage by a physician from a team other than the patient's primary team, which nearly doubled when the cross-covering physician was an intern [7].

A literature review on the subject of physician patient handoffs reveals that most reports were performed at single institutions and there were few controlled interventions. These papers most often utilized subjective data such as observations and/or participant surveys 2, 3, 4. At the conclusion of these reports, there are recommendations for improvements in the process of patient hand-off; however, little has been done to systematize an educational curriculum or series of metrics in order to prepare residents for this responsibility 3, 5. Many programs are currently addressing the issue of patient hand-offs, and this was one of the primary focus points at the 2009 AAMC Annual Congress.

Section snippets

Methods

Our team has developed a web-based computer application called the Virtual People Factory (VPF) for creating modeled conversations between real and virtual humans. This system allows us to capture a dialogue between a real user and a virtual character; the system then learns from each user interaction thereby improving the virtual character's “intelligence.” We have developed a hand-off case scenario between two resident physicians in the process of “checking-out” a patient. For proof of

Results

Phase 1 included the development of a scenario of a resident checking out a post-operative patient who had a laparoscopic gastric band placed the same morning. Tachycardia was chosen as a frequent but concerning presentation. We began the initial script development and testing using surgical residents at the University of Florida. When the script was adequate, it was distributed to a group of surgical residents at Tulane University for feedback. We then analyzed the transcripts and tabulated

Discussion

As many residency programs have to switch to a “cross-cover” system of patient coverage in order to comply with resident work hour restrictions, there has been an increasing focus on improving patient hand-offs between residents. Common conclusions that are drawn throughout the literature are that in addition to providing written or computerized sign-out information on the patients, verbal communication between practitioners, preferably a face-to-face, interactive hand-off process is essential 3

References (10)

  • E.G. Van Eaton et al.

    Organizing the transfer of patient care information: The development of a computerized resident sign out system

    Surgery

    (2004)
  • S. Okie

    An elusive balance: Residents'work hours and the continuity of care

    N EnglJ Med

    (2007)
  • D.J. Solet et al.

    Lost in translation: Challenges and opportunities in physician to physician communication during patient handoffs

    Acad Med

    (2005)
  • A.R. Vidyarthi et al.

    Managing discontinuity in academic medical centers: Strategies for a safe and effective resident sign-out

    J Hosp Med

    (2006)
  • J. Sharit et al.

    Examining links between sign-out reporting during shift changeovers and patient management risks

    Risk Anal

    (2008)
There are more references available in the full text version of this article.

Cited by (14)

  • Handover in Intensive Care

    2018, Medicina Intensiva
  • Trauma morning report is the ideal environment to teach and evaluate resident communication and sign-outs in the 80 hour work week

    2017, Injury
    Citation Excerpt :

    Communication in surgery has been paralleled to fields with “high consequences for failure” [23] such as the airline industry, nuclear power plants, and space shuttle mission control [23]. Simulation has often been advocated as a viable method for teaching and evaluating communication skills among physicians [24]. However, simulation does not accurately capture the subtleties of communication that are essential to effective sign-out.

  • Establishing a conceptual framework for handoffs using communication theory

    2015, Journal of Surgical Education
    Citation Excerpt :

    Devoge et al.16 and DeRienzo et al.17 separately investigated whether web learning was a viable option for handoff education. Filichia et al.18 developed a handoff computer simulation program that was both web-based and interactive. In studies where handoff quality was measured, researchers overwhelmingly found improvement after educational intervention.

  • Receiving care providers' role during patient handover

    2012, Trends in Anaesthesia and Critical Care
    Citation Excerpt :

    These improvement efforts have largely viewed patient handover as a one-way information transfer,7–9 focusing on the correctness and completeness of the information transmitted during handover.10 The roles and perspectives of receiving care providers, however, have rarely been addressed explicitly.11 This is surprising, as receiving care providers are the ones who have to assume responsibility for patient care after handover and hence the ones who should be the beneficiaries of handover.

  • Handing over patient care: Is it just the old broken telephone game?

    2011, Journal of Surgical Education
    Citation Excerpt :

    So far, the evidence seems to be contradictory; while some studies have favored electronic or tech-enhanced hand offs,20,21,23 others favor direct in person transfer of information.24-26 Furthermore, a paucity of research exists on how to teach the skills necessary to deliver an effective hand off;27 in fact it is still unclear whether such training is even needed in the setting of a clinical practice with a “standard” approach to handing over patient care. In an effort to better understand the hand off process and to help answer these unresolved questions, we sought to examine how the information delivery method (direct or tech-enhanced communication) affects hand off quality, and whether improvement in hand off quality occurs over time through clinical practice without formal hand off training.

  • Effect of handoff training on resident communication quality: An observational study

    2018, Proceedings of the Annual Hawaii International Conference on System Sciences
View all citing articles on Scopus
View full text