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
Make an action plan using I-PASS...
If the window below is not working, CLICK Here.
Same scenario as before!
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.
1. In the box below, create an action plan for Problem #3 Thrombocytopenia. You can devise your own criteria, but try to include all of the essential elements of an action plan. Then, add your thoughts about "situation awareness" for this particular problem.
Show/Hide the Answer and Discussion for Question 1
Example: "We have increased her corticosteroids to prednisone 40 mg/day. I have ordered a platelet count to be drawn at 2100 tonight. Please check as soon as result is back. If the platelet count is less than 20K, transfuse a unit of platelets. Order a repeat platelet count for 2 hours after the infusion (because we want to know if platelet transfusion is effective). If the platelet count is >20K, then we will wait to see what the count is in the AM."
Situation Awareness: "We are concerned because we don't know whether the thrombocytopenia is related to ITP or DIC or something else (drug reaction?). Because she is already on corticosteroids and has a splenectomy, the next therapeutic choices are more limited. Most importantly, if she has a platelet destruction process ongoing, she may not respond to platelet transfusion. She is likely to be at high risk of bleeding (intra-cranial, for example) at platelet counts this low."
2. Which of the following would be examples of appropriate patient handoff "action plans"?
A. If the patient has a fever (T>101.4), then don't do anything.
B. Check the hemoglobin later, and, if it's low, transfuse.
C. At 2000, the patient will get another dose of furosemide. Check the urine output at 2200; if less than 150 ml of urine, order another 40 mg of furosemide IV.
D. Check the serum K at 2200.
E. There is nothing to do for this patient tonight.
Show/Hide the Answer and Discussion for Question 2
A, C, and E are most correct.
Indicating that the patient does not need anything done for fever is an acceptable action plan, but it would be helpful to tell the handoff receiver the rationale for your plan. Perhaps you have enough cultures and just recently changed antibiotics, etc.
C specifies the timeframe for action and gives a specific goal and action to take. You could possibly add more about what to do after the second dose of furosemide. As for E, you don't anticipate needing anything specific tonight.
What are wrong with B and D?
3. What should the patient handoff "receiver" do after receiving a handoff?
A. Repeat all information on all patients to show adequate understanding
B. Eat dinner before the cafeteria closes.
C. Provide a brief re-statement of the essential information.
D. Maintain an "active role" in the handoff process.
E. Demonstrate that he/she understands priorities for each patient
Show/Hide the Answer and Discussion for Question 3
B, C, D, and E are most correct.
It is inefficient and unnecessary to repeat all information about the patient!
The patient handoff receiver should be "active" during the handoff, asking for clarification and completeness if necessary. This often provides sufficient feedback to indicate that the receiver understands the patients' conditions and priorities. In addition, a brief re-statement of essential information is warranted. Both the reporter and the receiver must be aware of the clinical experience and expertise of receiver. The patient handoff may be very brief if both are very experienced and very familiar with the patients. In contrast, a completely new patient handed off to a less experienced receiver may need more time and detail to be acceptable.
Eating (B) is always correct!
4. What other issues might be important to "situation awareness" in this patient? What do you need to know compared to what should you handoff to your colleague? Spend some time thinking about this!
Show/Hide the Answer and Discussion for Question 4
Situation Awareness is the most difficult and subjective part of a patient handoff because you have to make decisions about what is/what is not important in your "thinking" about the patient. Do you have to convey all of your current thinking about what is happening or what might happen? What concerns are foremost or most likely compared to everything that could happen? Here are some ideas and issues that might or might not be relevant:
1. She has a chronic underlying disease (SLE) that is relatively inactive, but she is (mildly) immunosuppressed--May still be worried about an opportunistic infection or SLE flare.
2. She is now (only) 4 days post-admission for CAP, septic shock, and hypoxemic respiratory failure--Could she relapse because of insufficient or inadequate treatment? She just left the ICU earlier today.
3. Thrombocytopenia is new and the cause is not yet elucidated-She has no overt bleeding, but her platelet count is very low and may drop further. Will she need platelet or PRBC transfusion? When?
4. She doesn't have a spleen because it was removed surgically--Could this make her at increased risk for certain infections.
5. The family is worried because she hasn't had anything to eat for 5 days.
6. The patient's nurse tells you that there is a lot of bruising where the patient gets her injections.
7. The patient is worried about her pet cats and wants to go home as soon as possible.
