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Clinical Trial Details — Status: Completed

Administrative data

NCT number NCT02403466
Other study ID # X10-08-0392
Secondary ID R18AE000029
Status Completed
Phase N/A
First received August 1, 2011
Last updated March 30, 2015
Start date September 2010
Est. completion date August 2013

Study information

Verified date March 2015
Source Children's Hospital Boston
Contact n/a
Is FDA regulated No
Health authority United States: Institutional Review Board
Study type Interventional

Clinical Trial Summary

Because communication and handoff failures are a root cause of two-thirds of "sentinel events"- serious, often fatal preventable adverse events in hospitals improving handoffs has been identified by AHRQ and the Joint Commission as a priority in nationwide efforts to improve patient safety. Comparative Effectiveness Research on handoff tools and processes has identified specific strategies to improve handoffs and reduce medical errors: 1) team training; 2) verbal mnemonics; and 3) use of written/computerized tools to supplement verbal sign-outs. To accelerate residents' use of CER-based handoff practices and improve patient safety, the investigators are implementing the three inventions above as a Resident Handoff Bundle (RHB) in eight pediatric hospitals in the United States and Canada.


Description:

The I-PASS Study was initiated in response to mounting evidence that communication and handoff failures are a root cause of two-thirds of "sentinel events" - serious, often fatal, preventable adverse events in hospitals. The Agency on Healthcare Research and Quality (AHRQ) and Joint Commission have identified improving handoffs in care as a priority in nationwide efforts to improve patient safety. Research on handoff tools and processes has identified team training, introduction of verbal mnemonics, and use of written or computerized tools as strategies to improve handoffs and reduce medical errors. This study was designed to evaluate the effect of a resident handoff bundle (RHB) comprised of these three strategies in addressing medical errors, verbal and written miscommunications, and resident workflow and satisfaction.

The US Department of Health and Human Services granted $3 million in funding, with additional support provided by member institutional and private foundations. A total of nine hospitals in the United States and Canada will serve as data collection sites for the study (see list below). Staggered six-month waves of baseline data collection of medical errors and resident workflow, satisfaction, and miscommunications began in January 2010. Each site has a six-month wash-in period to implement the RHB intervention before embarking upon an additional six months of post-intervention data collection. Analysis and dissemination will begin upon completion of data collection at the last wave of sites in April 2013.

Study Sites:

Children's Hospital Boston (Boston, MA) - Coordinating Site Brigham and Women's Hospital (Boston, MA) - Data Coordinating Center

Lucile Packard Children's Hospital (Palo Alto, CA) UCSF Benioff Children's Hospital (San Francisco, CA) OHSU Doernbecher Children's Hospital (Portland, OR) Primary Children's Medical Center (Salt Lake City, UT) St. Louis Children's Hospital (St. Louis, MO) Cincinnati Children's Hospital Medical Center (Cincinnati, OH) Hospital for Sick Children (Toronto, ON) National Capital Consortium (Washington, DC) St. Christopher's Hospital for Children (Philadelphia, PA)

Study Leadership:

Principal Investigator: Christopher Landrigan, MD, MPH Project Leader: Amy Starmer, MD, MPH


Recruitment information / eligibility

Status Completed
Enrollment 875
Est. completion date August 2013
Est. primary completion date May 2013
Accepts healthy volunteers Accepts Healthy Volunteers
Gender Both
Age group N/A and older
Eligibility Inclusion Criteria:

- The study will also include direct observation of house staff residents on the medical service. While implementation of the RHB itself is a QI protocol, the observation and collection of data from residents is research. We will therefore obtain informed consent from residents for participation in the research related to the effects on their care processes and experiences of implementation of the RHB. Participation will be voluntary.

- All resident physicians rotating through study teams during the two 6 month periods of data collection will be included in the study if informed consent is granted. No resident physicians will be excluded on the basis of age, gender, ethnicity, race, or other demographic features. We anticipate enrolling a maximum of 70 resident physicians per site. This number may be significantly less due to the fact that certain residents may rotate through data collection study units more than once during the study period.

Exclusion Criteria:

- The only exclusion criteria will be residents who do not rotate through study units during the data collection periods

Study Design

Endpoint Classification: Safety/Efficacy Study, Intervention Model: Single Group Assignment, Masking: Single Blind (Outcomes Assessor), Primary Purpose: Health Services Research


Related Conditions & MeSH terms


Intervention

Behavioral:
Resident Handoff Bundle
1) team training, 2) verbal mnemonics, and 3) standardization of written/computerized handoff tools

Locations

Country Name City State
Canada Hospital for Sick Children Toronto Ontario
United States Walter Reed National Military Medical Center Bethesda Maryland
United States Brigham and Women's Hospital Boston Massachusetts
United States Children's Hospital Boston Boston Massachusetts
United States Cincinnati Children's Hospital Medical Center Cincinnati Ohio
United States Lucile Packard Children's Hospital Palo Alto California
United States St. Christopher's Hospital for Children Philadelphia Pennsylvania
United States Primary Children's Medical Center Salt Lake City Utah
United States UCSF Benioff Children's Hospital San Francisco California
United States St. Louis Children's Hospital St. Louis Missouri

Sponsors (10)

Lead Sponsor Collaborator
Children's Hospital Boston Children's Hospital Medical Center, Cincinnati, Lucile Packard Children's Hospital, OHSU Doernbecher Children's Hospital, Primary Children's Hospital, St. Christopher's Hospital for Children, St. Louis Children's Hospital, The Hospital for Sick Children, University of California, San Francisco, Walter Reed National Military Medical Center

Countries where clinical trial is conducted

United States,  Canada, 

Outcome

Type Measure Description Time frame Safety issue
Primary Rates of serious medical errors Continuous collection during data collection phase of study (total of 12 months over an 18 month period matched by time of year (i.e., 6 months pre, 6 months wash-in with no data collection, 6 months post-intervention data collection) Yes
Secondary Verbal and written miscommunications Residents will be assessed for 1 month periods at a time, both before and after implementing the intervention. This information will be collected in staggered 18-month intervals across all study sites over the course of a 28 month period. up to 28 months Yes
Secondary Time spent by residents gathering and signing out data Residents will be assessed for 1 month periods at a time, both before and after implementing the intervention. This information will be collected in staggered 18-month intervals across all study sites over the course of a 28 month period. up to 28 months No
Secondary Resident satisfaction with sign-out Residents will be assessed for 1 month periods at a time, both before and after implementing the intervention. This information will be collected in staggered 18-month intervals across all study sites over the course of a 28 month period. up to 28 months No
Secondary Hospital- and patient-level predictors of implementation success analysis of all outcomes above, cross-referenced with hospital indicator codes and patient severity of illness codes up to 28 months No