Handover cognitive aid 활용이 업무교대시 임상추론과 정보전달에 미치는 영향에 대한 기초연구

Handover cognitive aid 활용이 업무교대시 임상추론과 정보전달에 미치는 영향에 대한 기초연구

A preliminary study of the impact of a handover cognitive aid on clinical reasoning and information transfer

Matthew J Weiss, Farhan Bhanji, Patricia S Fontela & Saleem I Razack

목적

인지보조노트(written cognitive aid)의 임상추론 및 레지던트간 업무교대시 정보전달의 양과 정확성에 대한 효과를 평가하고자 하였다.

방법

이 연구는 PICU에서 있었던 20번의 업무교대 사건(그룹당 10회)에 대한 RCT이다. PICU rotation을 처음 도는 레지던트들에게 한 그룹에게는 업무교대시 인지보조노트(written handover cognitive aid)를 사용하게 했고, 다른 그룹은 평소에 하던 대로 하게 놔두었다. 회진에 앞서서 조사자는 업무교대 정보전달의 기준을 정해둔다. 

그 후 어떤 그룹이 어떤 그룹인지 모르는(blinded) 연구보조원이 레지던트간 업무교대 상황을 녹음하고, 녹취록이 작성한다. 이 녹취록의 내용은 blank handover aid에 입력된다. 그 후 blinded 전문가가 사전에 확립된 기준과 information score(IS)에 따라서 이 aid에 적혀있는 정보의 양과 질을 평가한다. 

이 전문가는 임상추론과 그 효과성에 대한 다섯 가지 영역에 대해서도 녹취록을 평가한다. 다섯 가지 영역은 다음과 같다.

(i) effective summary of events; 

(ii) expressed understanding of the care plan; 

(iii) presentation clarity; 

(iv) organisation; 

(v) overall handover effectiveness. 

개입법을 활용한 그룹과 그렇지 않은 그룹간의 차이를 Mann-Whitney test와 다변량 선형 회귀분석으로 분석하였다.

결과

개입법을 활용한 그룹은 81% : 61%로 그렇지 않은 그룹보다 기준에 더 부합하는 IS를 받았다. 또한 임상추론을 평가한 총 점수를 비교했을 때에도 21.1 : 15.9점으로 더 높은 점수를 받았다. 업무교대 정보전달에 걸리는 시간은 양 그룹관 차이가 없었다.

결론 

간단한 handover cognitive aid의 사용만으로도 투자되는 시간을 늘리지 않고서도 정보의 전달과 레지던트의 임상추론 표현 능력을 향상시킬 수 있다.

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Design of cognitive aid

To design the cognitive aid, we engaged in an iterative consensus building process between PICU fellows and attending physicians asking what information they considered essential during resident handover. There was rapid agreement among those surveyed, and we generated a cognitive aid that prompted residents to transmit that information. 

A draft of this cognitive aid was presented to a small group of paediatric residents not enrolled in the study who offered comments that were incorporated into its design. The finished aid included sections for all the relevant information a paediatric resident would be expected to present during rounds. It also included prompts to present the rationale for daily actions as well as the patient care plan (See Appendix S1). The handover aid was not linked to our hospital clinical information system, so residents were expected to complete the aid by hand prior to transfer.

Statistics

We used descriptive statistics, including the mean (standard deviation [SD]) and median (interquartile range), as well as frequency distribution, to describe the characteristics of the study groups. Each handover event was considered independent, as they happened in a specific context and related to different patients. 

Differences in information and educational scores were assessed by Student’s t-test; in the case of violation of the normality assumption (non-parametric data), the Mann–Whitney test was used. We performed multivariate linear regression on both information and educational scores to control for the effect of completed months of residency training and base residency programme. p values < 0.05 were considered significant and the statistical analysis was performed using R version 2.11.0 (R-Development Core Team, Vienna, Austria). The inter-rater reliability of ISs was assessed by calculating intraclass correlations (ICCs) using SPSS Grad Pack 21.0 (SPSS, Inc., Chicago, IL, USA).

Reliability

In order to assess the reliability of our scoring system, we compared the ISs generated by a second PICU staff doctor of the first five study handover events with those generated by MW. We calculated ICCs between these scores and considered scores of 0.4–0.75 to demonstrate fair to good reproducibility and those >0.75 to indicate excellent reproducibility, as described by Rosner.24 

24 Rosner BA. Fundamentals of Biostatistics, 6th edn. Belmont, CA: Duxbury 2006.

The results are shown in Table 5. Excellent reproducibility was found for FEN/GI system (0.99, 95% CI 0.91–0.99), haematology system (0.99, 95% CI 0.92–0.99) and TIS (0.96, 95% CI 0.61–0.99). The ICC for the respiratory domain was noted to be much lower at 0.21 than for the other systems. A review of the scoring by the two observers in the respiratory domain revealed greater variation in the direction of scoring, leading to the lower ICC.

The reliability of educational domain scores from the outside evaluator and MW was also assessed. The ICC calculation revealed a non-significant correlation (data not shown). However, the individual scores from the outside observer were less than or equal to those of MW in 100% of measured values, and were within 0 or 1 point on the Likert scale in 92% (23/25) of the measured values. This suggests that although one observer had a tendency to evaluate subjective resident performance more harshly, the overall trends were closely correlated.

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Med Educ. 2013 Aug;47(8):832-41. doi: 10.1111/medu.12212.

A preliminary study of the impact of a handover cognitive aid on clinical reasoning and information transfer.

Weiss MJ, Bhanji F, Fontela PS, Razack SI.

Source

Division of Pediatric Critical Care, McGill University, Montréal, Québec, Canada.

Abstract

OBJECTIVES:

To assess the impact of a written cognitive aid on expressed clinical reasoning and quantity and the accuracy of information transferduring resident doctor handover.

METHODS:

This study was a randomised controlled trial in an academic paediatric intensive care unit (PICU) of 20 handover events (10 events per group) from residents in their first PICU rotation using a written handover cognitive aid (intervention) or standard practice (control). Before rounds, an investigator generated a reference standard of the handover event by completing a handover aid. Resident handovers were then audio-recorded and transcribed by a blinded research assistant. The content of this transcript was inserted into a blank handover aid. A blinded content expert scored the quantity and accuracy of the information in this aid according to predetermined criteria and these information scores (ISs) were compared with the reference standard. The same expert also blindly scored the transcripts in five domains of clinical reasoning and effectiveness: (i) effective summary of events; (ii) expressed understanding of the care plan; (iii) presentation clarity; (iv) organisation; (v) overall handover effectiveness. Differences between intervention and control groups were assessed using the Mann-Whitney test and multivariate linear regression.

RESULTS:

The intervention group had total ISs that more closely approximated the reference standard (81% versus 61%; p < 0.01). The intervention group had significantly higher clinical reasoning scores when compared by total score (21.1 versus 15.9 points; p = 0.01) and in each of the five domains. No difference was observed in the duration of handover between groups (7.4 versus 7.7 minutes; p = 0.97).

CONCLUSIONS:

Using a novel scoring system, our simple handover cognitive aid was shown to improve information transfer and resident expression of clinical reasoning without prolonging the handover duration.

© 2013 John Wiley & Sons Ltd.

PMID:

 

23837430

 

[PubMed - in process]