Increasing emphasis has been placed in recent years on the importance of high-quality resident handoffs in the inpatient setting, particularly in the form of I-PASS.1 However, there has been much less focus on resident handoffs in the outpatient setting, particularly as it relates to year-end handoffs between graduating residents and the residents who will assume care of these patients in their respective patient panel. Previous studies have demonstrated that the implementation of a standardized handoff process in the ambulatory setting during this critical period of year-end transition improves resident confidence and satisfaction and can improve patient outcomes.2, 3
Prior to our intervention, the year-end ambulatory handoff system at our institution consisted of asking graduating residents to identify patients in their panel whom the resident believed to be “high-risk” and write a short handoff for each of them. These patients were considered the most complex in the panel, and thus were preferentially transitioned to a rising PGY-2 resident who would ideally receive this handoff. PGY-3 residents had previously not been provided guidance on which patients to identify as high-risk or specific instructions on how to conduct the handoff process.
A needs assessment was conducted in the form of a survey sent to all PGY-2 and PGY-3 residents (n=62) prior to the implementation of a new standardized handoff process with a response rate of 45%. This survey found that only 41% (11/27) of residents reported receiving any form of handoff when they were inheriting their new patient panel. Additionally, 67% (18/27) of residents reported feeling worried about missing something on a patient they had newly inherited.
Implementation of a New Handoff System
We sought to develop an enhanced, standardized approach to year-end resident handoffs in the ambulatory setting that could be viewed by any provider seeing the patient in clinic. To do so, we implemented use of the Specialty Comments Sticky Note feature in our Electronic Medical Record (EMR), Epic (Epic Systems Corporation).4 The Specialty Comments Sticky Note (i.e., “blue sticky note”) is a feature in Epic that allows a provider to write notes in a patient’s chart that is specific to the user’s specialty and can only been seen by other users across the login department specialty. Notes in this field are not part of the permanent medical record. Utilizing this easily visible feature for resident handoffs allows residents to access handoff information more readily and prevent key tasks from getting lost in the oftentimes expansive electronic medical record.
We began our intervention by leading a workshop on our enhanced and standardized handoff process for the PGY-3 residents as part of our standard noon conference educational series. We introduced the blue sticky note feature and provided residents with a specific framework by which patients should be identified as high risk. Recommended categories that classified patients as high risk included significant medical complexity, complex social history (housing insecurity, substance use), frequent acute care utilizer, or complex medical workup ongoing. We also provided residents with a template handoff that could be copy-and-pasted into the sticky note and then modified for each individual patient.
Evaluation of Resident Satisfaction and Clinical Outcomes
A post-intervention analysis after the handoff workshop in August 2022 showed that 79% (22/28) of graduating residents utilized the blue sticky note for their year-end resident handoffs. A follow-up survey was sent to all PGY-2 and PGY-3 residents in October of 2022 regarding their experiences with the blue sticky note feature with a response rate of 47% (33/70). Approximately 30% of residents (10/33) reported already seeing patients in clinic who had handoff information written in the blue sticky note field. All these residents reported that the handoff they received improved their ability to provide optimal clinical care for patients. Of those who had not yet seen patients with a blue sticky note handoff, 91% (20/22) reported that this type of handoff, if provided, would improve their care of complex or challenging patients. Residents were also asked what aspects of the handoff template provided to them would be most helpful when seeing complex or challenging patients. 85% of residents (28/33) felt that a “short description of any complex social issues” would be helpful, while 61% felt that “pending tests to follow up” would be helpful.
In addition to an evaluation of resident satisfaction, we also sought to evaluate the impact on clinical outcomes because of this handoff process. Pre-intervention analysis showed that at the beginning of the 2020 academic year, 137 patients were identified as high risk by 31 graduating PGY-3 resident PCPs and were transitioned to a rising PGY-2. Following complete implementation of the handoff system in 2022, 28 residents identified 167 high-risk patients for transition to a PGY-2 resident. Outcomes among these two patient populations such as number of ED visits, admissions, overdue colonoscopies, and overdue mammograms were quantified in the first four months of the academic year, both pre- and post-intervention. Notably, there was a statistically significant decrease in the number of patients with overdue mammograms in the post intervention period (62% vs 31%, p=.000962). However, a mammography machine was installed on site at the clinic during the time between pre- and post-intervention analyses, which may bias results. The difference in ED visits, admissions, and overdue colonoscopies did not achieve statistical significance.
Lessons Learned and Future Directions
A 2014 survey of Internal Medicine Program Directors found that only 34% of respondents reported having a year-end ambulatory handoff program.5 While our residency program did previously have a year-end ambulatory handoff program, a needs assessment demonstrated that a majority of residents never received handoff on new, high-risk patients. Even in instances where a handoff was completed, the resident who received the handoff may not have seen a given patient in clinic for many months. Ease of handoff access to anyone within the department is important, as analysis of patient handoffs prior to our intervention showed that only 43% of high-risk patients had a visit with their new PCP in the four months following the transition.
This highlights a significant challenge that permeates the resident clinic experience: balancing provider-patient continuity and access to care. This challenge was also unfortunately reflected in our post-intervention survey four months into the academic year, as most PGY-2 residents reported they had not yet seen a patient within their panel with a blue sticky note handoff, although most PGY-3 residents completed a handoff and patients were assigned to the PGY-2 resident at the start of the academic year. This can possibly be attributed to difficulty in promptly scheduling these high risks patients with their new PCP. However, embedding this handoff within the EMR may bridge the gap that exists in resident clinic continuity by making the handoff visible to any resident or faculty member that may see the patient in clinic, while developing a standardized template improves clinical usefulness and resident participation.
Future directions for this project may be to re-evaluate our scheduling protocols to improve timely access to PCP visits for our high-risk patients, as well as to further evaluate and optimize how residents select high-risk patients. Additionally, we would like to see this handoff tool distributed to other clinics and residency programs, like implementation of I-PASS and other handoff tools in the inpatient setting.
- Starmer AJ, Landrigan CP, I-PASS Study Group. Changes in medical errors with a handoff program. N Engl J Med. 2015 Jan 29;372(5):490-1. doi:10.1056/NEJMc1414788.
- Young JQ, Pringle Z, Wachter RM. Improving follow-up of high-risk psychiatry patients at residency year-end transfer. Jt Comm J Qual Patient Saf. 2011 Jul;37(7):300-308. doi:10.1016/s1553-7250(11)37038-9.
- Pincavage AT, Prochaska M, Dahlstrom M, et al. Patient safety outcomes after two years of an enhanced internal medicine residency clinic handoff. Am J Med. 2014 Jan;127(1):96-9. doi:10.1016/j.amjmed.2013.09.024. Epub 2013 Oct 8.
- Epic Systems. About us. Epic. https://www.epic.com/about. Accessed August 15, 2023.
- Phillips E, Harris C, Lee WW, et al. Year-end clinic handoffs: A national survey of academic internal medicine programs. J Gen Intern Med. 2017 Jun;32(6):667-672. doi:10.1007/s11606-017- 4005-2. Epub 2017 Feb 14.
Clinical Care Redesign, Medical Education, SGIM
Dr. Rabinovich (firstname.lastname@example.org) is a chief resident in the department of medicine at Wake Forest School of Medicine. Dr. Valente (email@example.com) is an assistant professor in the department of medicine at Wake Forest School of Medicine and associate program director of the internal medicine residency program. Dr. Williams (firstname.lastname@example.org) is an associate professor in the department of medicine at Wake Forest School of Medicine and program director of the internal medicine residency program. Dr. Denizard-Thompson (email@example.com) is an associate professor in the department of medicine at Wake Forest School of Medicine and vice chair of faculty development.
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