Transition of Care Policy

Effective communication is essential to safe and effective patient care (refer to Supervision and Communication Policy).

  • The faculty and fellows should clarify the communication plan prior to any shared clinical service experience. This clarification of expectations should include:
    • Times of planned communication
    • Ready availability and contact information (pager, cell phone, e-mail, home phone, and preferred method of communication)
    • Expectations concerning when to initiate communication regarding patient care and safety
    • A discussion of how to effectively balance supervision, providing assistant, and resident autonomy
    • Review of “direct supervision” and “indirect supervision”

Care Transitions

  • We use the sign-out feature in EPIC to provide safe, accurate, and up-to-date sign-outs. Sign out occurs from fellow to fellow, fellow to attending, and attending to attending.
  • Each Monday, all inpatients are discussed during our weekly multidisciplinary rounds and the service is turned over from attending to attending. Fellows present patients on our inpatient service when they are on call over the weekend. Fellows also present clinic patients scheduled on their continuity clinic days.
  • We use the I-PASS curriculum to teach and guide our handoff process.
  • Fellows and faculty complete the Institute for Healthcare Improvement (IHI) module found on the GMEC website. This is where they learn about patient safety.  PS 103 is specifically about handoffs.
  • Residents, physician assistants, nurse practitioners, and attending schedules are available in Amion and the Shands/UF online on-call system. This is available in advance on a quarterly basis.
  • Attending and fellows should clarify with each other how they want to be contacted (e.g., cell phone, home phone, or beeper) if the method of contact is going to be different than what is listed in SPOK. SPOK information should be updated for each attending, fellow, and support staff member. All fellows will have a second method of communication (i.e., cell phone and beeper) in case the primary method fails.
  • An email the following morning providing a summary of the patients and any overnight events will be completed by the on-call fellow and sent to everyone who is on-service.

Care Transition and Communication Logistics

Times during the day when communication should occur include:

  • 7:30-8:00 AM – Review with residents previous night’s call issues, identify new admissions to be seen, prioritize patients with urgent issues to be evaluated, discuss discharges and planned admissions
  • 09:00-11:30 AM – Rounds, Patient- and family-centered rounds
  • Rounds are expected to begin in PICU when the critical care team is available to discuss our most critically ill patients
  • 2:00 PM – Follow-up of specific patients
  • 4:30 PM – Sign-out pending issues, new admissions
  • 10:00 PM – Tuck-in Rounds by phone with the on-call attending
  • This is expected in the first 4 months of the Fellowship (and should continue to occur until your performance has been reviewed with you by your attendings)