Featuring 2013 ACS Surgical Forum Excellence in Research Award Recipient: Nicole Tapia, MD

General Surgery Resident Nicole Tapia, MD was honored a Surgical Forum Excellence in Research Award at the 2013 American College of Surgeons Clinical Congress held in Washington, D.C. Her work entitled "PACT Project: Standardized Resident Hand-off Implementation Improves Hand-off Quality" was also chosen as one of the top three resident presentations at the American College of Surgeons South Texas Chapter Meeting held in Austin, Texas during February 2014. The Association of Women Surgeons is proud to present Dr. Tapia’s work—in her own words—on the blog.

Standardizing Resident Hand-offs to Improve Hand-off Quality

by Nicole Tapia, MD

Morbidity and mortality conferences allow us to review our complications and ask ourselves if it was preventable, how it happened, and what we could have done differently to achieve an alternate outcome. There is usually a lesson to be learned during discussion of the adverse patient event, and a new best practice can develop as a result of such dialogue.

I have come to believe that the question of “what could I have done differently” is applicable to many realms of surgical life – struggling in the operating room with a new task, juggling management of a surgical team as a senior resident with both junior resident and attending expectations, and even balancing home and resident life. Recently, my institution offered an Advancing Clinical Excellence (ACE) in Health Care research grant which challenged residents to propose a study to improve health care delivery. They asked us to approach health care with a unique resident perspective and hypothesize and test our ideas.

Brainstorming with another research colleague and my research mentor, we agreed that a current hot topic which is omnipresent in resident work-life is the unintended consequences of the ACGME work hour requirements. In particular, our residents and staff have noted challenges that come with increased patient handoffs as we transitioned to a night-float system. We all agreed that anecdotally, we thought quality of patient care was likely worsened by this change.

Our research group determined that to test and study our hypothesis and improve handoffs, we needed to focus on verbal communication of patient information, as we work at several hospitals with varied electronic medical records and wanted our approach to be independent of a computer system. We set out to improve patient handoffs using a three-pronged approach: (1) determine current limitations and shortcomings of patient handoffs, (2) develop an ideal handoff, and (3) test the new handoff comparing subjective and objective quality measures.

Utilizing a focus group of residents and surgical staff to determine current limitations as well as the ideal handoff, everyone agreed that patients should be discussed based on acuity -- communication of events and plans of the sickest patients should occur first. This should be followed by in-depth discussion of the newest admissions, then changes to the current patients. Finally, a task review for the on-coming shift would be reviewed in top-down fashion. We developed a mnemonic, PACT (Priority, Admissions, Changes, Task review), to help our residents remember this discussion based on acuity.

Measuring pre- and post-PACT implementation, we found that with PACT implementation, residents had lower incidence of incomplete tasks and lack of patient knowledge on morning rounds, decreased discrepancy between junior and senior handoffs, and senior residents reported junior residents were better able to handle emergencies.

We were encouraged by our findings, but in true reflective fashion, thought we could further improve our handoffs. One limitation we found was that there were considerable interruptions during the handoff process. Additionally, we found that although residents were discussing the PACT content, they preferred to discuss patients based on list order – organized by patient location – rather than true acuity. Achieving complete buy-in to the new process has not been without resistance, even though our outcomes were excellent with improved handoff practices. As a result, we developed a second iteration of the handoff process (PACT 2.0) to address these limitations, and we are testing it head-to-head with our current PACT system, in a randomized controlled trial. We are currently analyzing the results and hope to report soon on our outcomes.

As a previous research resident and now third-year clinical resident, I have witnessed the junior residents transfer care of their patients with improved communication and feel confident that the night float residents have better knowledge of the patients on their census as a result of the work we have done so far. We introduced the PACT handoff system to our interns at orientation this past year and intend to do so again when they show up in late June. I feel privileged that through a unique grant opportunity at my institution, we were able to review our handoff process and ask ourselves not only what we could do differently, but also, were able to institute change.

Our experience has made me curious: How does your program do handoffs? Do you do handoff training?

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Nicole Tapia, MD, is a general surgery resident in the Michael E. DeBakey Department of Surgery at Baylor College of Medicine, currently in her third clinical year. She recently completed two years of research, focusing on trauma and resident education. Nicole hopes to be a trauma surgeon at an affiliated academic center, where she can work with residents and medical students.

A bit of kindness

by Amalia Cochran, MD

The following is an excerpt from an email I recently received from a mentee:

“I love, love, love surgery, but even as someone who has thrived in this environment, I now acknowledge that there are some aspects of the culture of surgery/academics/surgical and medical education that I am deeply unsettled by and wish very much to change. I see fellow students, residents, fellows, young faculty transform from being full of zeal and goodwill into angry, bitter, jaded people, and it’s absolutely disheartening to see. What’s more infuriating (to me because of the wrongness of it all and because I’m such a fixer) is that those who have been negatively affected and are the very ones capable of enacting positive change because they’ve “been there” sadly become the very ones who perpetuate the indignities of the broken culture, and they don’t even recognize that they’re doing so.”

Her important question that she asked me, and one that I found incredibly wise, was, “Did you ever struggle with this during your training or see this among your colleagues? Or even now?”

I asked her if I could answer this on the blog, and she graciously said yes. It was important for me to do so because I feel obliged to make some confessions related to her concerns.

The biggest one? I had many days during my residency when I was so tired, so broken, so frustrated that I wasn’t a nice person. While I was able to focus on doing the right thing for my patients, I could be and often was impatient with students who needed nurturing and staff who were still learning too. I was so Hell-bent on my own survival, on not making mistakes, on not showing any shred of evidence that I might not be able to succeed as a surgeon that I had no qualms about running over people. I nearly quit surgical residency during my PGY2 year because I didn’t like what I was my self becoming (then was nurtured by some VERY kind mentors who managed to help me hang in there).

I attribute a significant portion of my behaviors when they weren’t outstanding to sleep deprivation and not having a functional set of skills for coping with my chronic exhaustion. I also attribute some of my less-than-ideal behaviors to the surgical culture in which we were supposed to prove that we’re tough and don’t have flaws. Reality check: I may be resilient- I far prefer that word to “tough”- but I do have flaws. Sometime around my 40th birthday, I became okay with that.

• I want to believe I was asked about this topic because I’m seen as someone who is generally patient and supportive. A few key lessons have helped me get back to this place, one in which I think I existed prior to my 7 years of complete exhaustion and chronic stress.
• We’re all struggling. Every one of us is, in one way or another. That’s not a source of shame, it’s a source of humanity.
• If those moments in which your lesser self shows up are rare, people believe you when you apologize for your behavior.
• We are all learning, ever hour of every day. That’s what we’re here to do in a teaching environment.
• As someone in a position of leadership, my team and those around my team rely on me to set a tone. I don’t want that tone to be one of nastiness, blaming, and negativity because I want/ need a high-achieving team. Therefore, it’s up to me to be supportive, to be patient, to take a deep breath before reacting, even when my gut wants to say, “WHAT were you thinking?!?”
• When people are intimidated, their ability to think critically is impaired. Working in an ICU, I need everyone around me to be a critical thinker. Kindness does much more towards that end than bullying.
• If all else fails, go for a walk with the dog. Dogs are masters of this moment being the very best moment ever and that influence is contagious- particularly on a snowy day if one has a Siberian Husky in their life (as I do).

If nothing else I wrote tonight resonates with you, it’s my hope that a picture of an incredibly happy husky will help you pause and be a bit kinder.

This post originally appeared March 24, 2014 on Dr. Cochran's website Life in the Wild West

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Dr. Amalia Cochran is Associate Professor of Surgery at the University of Utah.  She is heavily involved in undergraduate medical education, serving as the Surgery Clerkship Director and the Director for the Applied Anatomy track for 4th year medical students at the University of Utah.  Her research interests lie in surgical education and in clinical outcomes in burns.  She is completing her term as Vice President for the Association of Women Surgeons.