Handout # 4

Transitions of Care
Hand-overs are a common cause of errors in medicine, thus a standardized approach
can help decrease some of these errors. Minimizing the number of hand-overs is also
important to facilitate both continuity of care and patient safety. The family medicine
residency, after study, has determined to optimize patient safety, that the optimal
number of hand-over’s should, when practical occur twice daily (generally approximately
12 hours apart) on its hospital inpatient medicine and obstetrics team-based care. This
frequency minimizes the number of transitions of care for patient safety and balances
this with appropriate rest for residents and compliance with duty hours. Additionally,
hand-overs of patients to a different resident team member will occur at least one day in
seven when averaged over a four week period to allow residents adequate rest and
compliance with duty hours. Residency team-based care should include the residents
taking care of the same patient until discharged unless patient requests to be
transferred to a different resident or physician (rather than changing resident physicians
throughout the patient’s hospital stay – except during times of resident being off-duty).
To clarify, this means generally the same daytime resident sees the patient each day
and the same night float resident is responsible for the patient, except when they are
not on duty at the hospital. The FMC is team-based to decrease the number of
transitions. (See FPC policies). Each resident is responsible for their own continuity
patient. When off duty, the resident’s team members are the primary residents to
address patient care needs. To preserve continuity and decrease the number of
transitions, the patient’s primary FMC resident, if they are not providing the hospital care
when patient requires hospitalization, is to converse with the resident on the inpatient
team or hospitalist (depending on where patient is admitted) and discuss the patient
with the resident/physician provider at time of admission (optimally within 24 hours),
discharge and during any significant event during the admission.

Program Director and faculty are to ensure the availability of schedules which inform all
members of the health care team of supervising physicians and residents currently
responsible for each patient’s care.

Residents are required to perform patient care transitions (hand-overs) using a

standardized protocol. This includes the DRAW technique.

D= Diagnosis and current condition of the patient- given by transferring resident

R= Recent Changes - this includes patient condition, exam findings, labs, diagnostics,
etc. - given by transferring resident

A= Anticipated Changes-This is divided in half. The first part is provided by the

transferring resident – it includes any pending labs, imaging and consultations. The
receiving resident then finishes the second half of the “A”. They are to predict the
normal course/trajectory/anticipated changes of the patient….i.e.….what one normally
would expect the clinical course of the patient should be from here forward and
especially over the next duty period of time. The second half of the “A” confirms that the
 Handout # 4

transferring resident articulated/communicated the case adequately and that the

receiving resident was engaged, not distracted, and perceived the patient scenario well
enough. This also tests the receiving resident’s knowledge-base and experience to
assure resident is capable of taking care of this patient and whether supplemental
education is needed during the hand-over process to enable/optimize resident care of
the patient.

W= What to watch for in the next interval of care- this is performed by the receiving
resident. They articulate what other possible trajectories the patient’s course could take
and what signs/symptoms they should observe for, if the patient started to follow one of
these alternative paths. (Example: The anticipated course of the patient with
pyelonephritis, who was placed on antibiotics, becomes afebrile, decreasing flank pain,
and overall improvement. The alternatives could be worsening/non-responsiveness
associated with resistant bacteria, or complicated with obstruction, or development of
urosepsis, etc. The resident would describe signs to watch out for with these alternative
scenarios (development of hypotension, febrile beyond 2-3 days, increasing flank pain,
etc). This also tests the receiving resident’s knowledge-base and experience to assure
resident is capable of taking care of this patient and whether supplemental education is
needed during the hand-over process to enable/optimize resident care of the patient.

Additionally, to help support patient safety efforts, the receiving resident is to articulate,
“What may cause harm to the patient”. Examples could be indwelling urinary catheters,
central lines, pressure ulcers, prolonged use of antibiotics, etc.

The A & W may be done individually (one resident with another resident) or as a small
group (residents and/or faculty and/or healthcare team) in order to develop team
situational awareness, for efficiency, and developing Resident as Teacher and Leader
skills.

A Handover must also include:

 Exam Findings/ Labs( part of the DRAW)
 Clinical changes/status
 Family Contact ( POA)
 Active Supervising Physician ( also any changes if expected in the
next shift)
This process will be evaluated by Faculty and Senior Residents and monitored by
FWMEP (as the institution) and the Program Director (Evaluation form). This process
requires three (3) evaluations per resident at the beginning of the resident team
rotations (Lutheran IMFM and NHC). These hand-over evaluations are to be turned in
to the Program Coordinator, who reviews and submits to FWMEP CFO, who generates
a report for the GMEC and Program Director for their monitoring requirements. The
hand-overs are to documented on the patient rounding list which is structured to include
the hand-over elements.

Residents will be required to update the White Board in the call rooms with any change
in Supervising Attending Physician. (weekends, vacation, illness, etc.)
 Handout # 4

Residents and Faculty must demonstrate responsiveness to patient care needs which
supersede self-interest. Sometimes this means hand-overs to another provider.

Source: Seton Family of Hospitals, Austin, TX 2010; Methodist Medical Center of Illinois, Peoria, Ill; Joint
Commission: Handoff Communications: Toolkit for Implementing the National Patient Safety Goal.

Doctor/ Patient Communication

Good communication with a patient is vital. A patient has the right to know who is
taking care of them. With multiple Residents taking care of a patient and frequent
changes in the Attending Physician, the patient can get confused.

To improve this communication in the Family Medicine Clinic, the names of the
Attending Physicians will be broadcast every 15 minutes on the televisions in the
waiting rooms.

For inpatient (Lutheran/ St. Joseph Hospital) the Attending and Resident Physicians will
identify themselves and update the whiteboard in the patient’s room with this
information.