Transitions
of Care
Patient Handoffs/Harbor-UCLA
Home
Tutorial
Home/Start/Intro
Page 2: Case Example
Page 3: SBAR
Page 4: I-PASS Patient Summary
Page 5: I-PASS Action Plan
Print Certificate
Tutorial launched
March 2014
Department of Medicine
Darryl Y. Sue, M.D.
Patient Handoff Tutorial: I-PASS
Now, learn about I-PASS for patient summaries...
If the window below is not working, CLICK Here.
The patient responds well to therapy and by Day #4 is transferred out of the ICU to the PCU. She remains on antibiotics for CAP in a hospitalized patient (ceftriaxone and azithromycin). The AKI resolves and she remains only on 2 L O2 by nasal cannula. There are no manifestations of active SLE and no changes are made to her immunosuppression.
On the morning of Day #4, the following laboratory results return: WBC 6.7K, Hgb 12.1 g/dL, platelets 47K. Na 140, K 4.8, Cl 100, HCO3 27, Cr 0.81, BUN 22. ANA + 1:20, anti-dsDNA negative, C3, C4 normal, CRP normal. PT is 15.6 sec, PTT 51 sec, INR 1.8. Peripheral smear shows Howell-Jolly bodies and few large platelets.
The patient has mild shortness of breath when she gets out of bed but not at rest and no other complaints. BP 129/77, HR 88, T 37.1, SpO2 99% on 2 L O2. Lungs are clear and heart examination is normal. She has a few petechiae on her hard palate but none on her skin anywhere, and there are no bruises or other signs of bleeding.
Before you leave, you order a platelet count to be drawn at 2000 tonight.
1. Classify your patient under I-PASS for "I" (Illness Severity) by clicking the button.
Show/Hide the Answer and Discussion for Question 1
Although the patient has improved with regards to septic shock and acute hypoxemic respiratory failure, the new problem of worsening thrombocytopenia at least makes this a patient a
watcher.
You could make a strong argument that this patient should be classified as
unstable.
2. In the box below, design the Patient Summary ("P") part of the I-PASS system for your patient. You are handing off care of your patient to a co-resident. Think about what you want to emphasize/de-emphasize tonight. Hint: Is there anything new with your patient?
Show/Hide our Patient Summary for today.
The "One-Liner"
> 46-year old woman admitted 4 days ago for fever, sore throat and weakness for 4 days.
> Admitted with pneumonia, then developed acute hypoxemic respiratory failure.
> SLE, stable activity, on low dose corticosteroids.
> ITP, s/p splenectomy, platelet count 102K on admission.
> Acute kidney injury, Cr 2.1, BUN 84 on admission.
Hospital Course
> Started on ceftriaxone and azithromycin for CAP.
> Developed hypotension/septic shock on Day 1, transferred to ICU for IV fluids, required pressors for 2 days.
> Needed O2 by non-rebreather mask, but not intubated.
> Blood cultures negative; sputum cultures negative.
> Transferred out of ICU today.
> Today noted to have drop in platelets to 47K but no evident bleeding.
Assessment
Re-Prioritized Problem List
#1 CAP due to
#2 Septic shock (resolved).
#3 Thrombocytopenia, possibly ITP vs. DIC. Patient's platelet count dropped from 102K to 47K over the last three days. She had some petechiae noted on her hard palate, but none elsewhere and she didn't have any bruises or other signs of bleeding. Hgb is stable at 12 g/dL. We are worried about her platelet count and the possibility of bleeding. It's probably ITP but DIC is possible, too. We stopped her enoxaparin (DVT prophylaxis) and gave her some vitamin K. A repeat platelet count will be drawn at 2000.
#4 Acute hypoxemic respiratory failure, resolving.
#5 SLE, currently inactive by clinical and laboratory.
#6 Acute kidney injury, resolved.
#7 H/o hypothyroidism, on replacement.
#8 H/o antiphospholipid syndrome, inactive.
#9 Allergy to amoxicillin.
Note that the problem list has changed from admission, with some additions (CAP has now become the clear cause of septic shock), some re-ordering (thrombocytopenia is "new"/worsening and has moved up), and some clarification (SLE is deemed inactive, AKI is resolved, and respiratory failure is resolving).
3. What important things you should do when "updating" your problem list for a patient handoff?
A. Social history should always be included on the handoff problem list.
B. Some acute problems may have become less important.
C. Be sure that the reason for admission is Problem #1.
D. New problems may have been identified since the last update.
E. You should never re-order your problem list because it confuses the handoff receiver.
Show/Hide the Answer and Discussion for Question 3
B and D are most correct.
Social history may be highly relevant for some patients, but may be extraneous information for handoff purposes. Remember that social and family history will still be part of the medical record and can be looked up if necessary.
Both newly identified problems, especially if they are the most relevant and critical, and existing problems should rise to the top of your problem list for updated written handoffs. Similarly, some problems are resolved and are no longer active. Therefore, "reordering" of problems can be very important.
The reason for admission may no longer be important (think about a patient who has been hospitalized for several weeks!). For example, if the patient's initial problems were fever and shortness of breath, but this has been changed to a diagnosis of community-acquired pneumonia, the problem list is updated to reflect this. If complications unrelated to CAP become the key issues, then CAP should drop lower on the problem list at that time.
