2014 Practice Changers and Important Topics in Hospital Medicine

Larry Beresford


December 26, 2014

Standardization of Care: The I-PASS Handoff

Changes in Medical Errors After Implementation of a Handoff Program
Starmer AJ, Spector ND, Srivastava R, et al; I-PASS Study Group
N Engl J Med. 2014;371:1803-1812

An illustration of the possibilities for standardization of hospital care is the I-PASS patient handoff study (named for a continuity-of-care mnemonic). Dr Li pointed to an article about I-PASS[1] in the New England Journal of Medicine, which confirmed how a standardized resident handoff program implemented in nine hospitals led to safer overall care.

Outcomes included a 23% decrease in medical errors, a 30% decrease in preventable adverse events, and improved staff communication, all without negatively affecting workflow. The intervention included a mnemonic to help residents standardize patient handoffs, communication training, faculty observation, and a campaign to promote sustainability.

"It raises the question, why don't we all do this?" Dr Li said.

Safety of Thrombolysis in PE

Thrombolysis for Pulmonary Embolism and Risk of All-cause Mortality, Major Bleeding, and Intracranial Hemorrhage: A Meta-analysis
Chatterjee S, Chakraborty A, Weinberg I, et al
JAMA. 2014;311:2414-2421.

In a "Year in Review" session at the Management of the Hospitalized Patient conference in San Francisco this past October, Michelle Mourad, MD, associate professor of medicine and director of quality and safety for the Division of Hospital Medicine at UCSF, highlighted several studies from the previous 12 months with significant implications for hospitalist practice.

Among those highlighted was an analysis of 16 clinical trials of thrombolysis with conventional anticoagulation therapies for patients with pulmonary embolism.

For patients aged 65 years and under, the increased risk of bleeding was not significant, while the treatment was associated with lower all-cause mortality, Dr Mourad said.

"This is more of a confirmation of practice—you should feel reassured to consider thrombolysis, particularly in patients under 65," she explained. "We've probably been so scared of thrombolytics and the risk of major bleeding such as intracranial hemorrhage that we don't use them enough except for high-risk patients."

Dr Mourad added that questions remain as to what to do about patients over age 65 years and that caution should be used with this population.


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