Print
E-mail
Reprint

Creating a better hand-off means scrapping questionable mnemonics and embracing flexible yet standardized checklists.

A few years ago, on a busy night in my small ED, I had an encounter with a toxic-appearing lung cancer patient with increasing shortness of breath. It didn’t require years of medical training for me to quickly decide that this gentleman required intubation. However, in the spirit of our patient-centered care model, I restrained myself from whipping out my belted laryngoscope on the spot and actually took the time to speak to him and his family. Our conversation informed me, much to the dismay of my medical student, that this particular patient had no desire to be on a ventilator for any period of time. I commended our staff for their excellent efforts elucidating his true wishes. Feeling pretty good about myself for sparing this gentleman and the U.S. Healthcare system a long and expensive ICU visit, I signed out to my partner and headed to Burger King for my 5:00 AM Whopper.

When I returned for my next shift the following night, I was stunned to hear that my patient was currently intubated in the ICU. I immediately ran up to find out what happened. The ICU team shared with me the frustrating truth: the patient was admitted upstairs, decompensated and was intubated by the on-call overnight team. Where did the communication of this patient’s needs fall short? My subsequent frustration compelled me to get the heart of the matter through a personal journey exploring transitions of care, or the lack thereof.

 

In conceptualizing the current state of transitions of medical care, I refer back to Atul Gawande’s Checklist Manifesto and all the other volumes of work focusing on standardizing medical care. Despite the leaps and bounds we’ve made in bringing transitions of care to the forefront of discussions of health care quality, medical professionals still need to step up to the plate when it comes to getting consultations and hand-offs right. If consulting a checklist is the first thing a flight crew does in the event of a crashing plane, a potential disaster for 300+ people, why can’t medical teams look to the checklist to save one crashing patient, one handoff at a time? In reality, we can’t afford not to do so!

In order to more effectively discuss this topic, let me give you some more background on transitions of care. A transition of care occurs any time a new provider assumes the care of a patient. More specifically, it can be defined as a transfer of information, responsibility, and authority as patients move between health care practitioners, settings, and home, allowing the new provider to act safely in the best interest of the patient. Common synonyms include “hand-off,” “changeover,” and ‘hand-over,” “sign out,” “sign over.”

Multiple transition points occur for each patient being evaluated and treated in the emergency department. The first handoff may take place as EMS providers present the patient to the emergency physician (EP) or when the EP receives a telephone report from a referring physician. Within the ED itself, hand-offs occur between EPs at shift changes and during provider breaks, and between EPs and consultants. Hand-offs occurring at routine shift changes have recently increased due to the new ACGME resident work-hour mandates.

The next transition point occurs when the patient leaves the emergency department. A handoff may occur between the EP and the admitting team, an accepting physician at a transfer institution, or with a primary care physician or home healthcare provider (personal or professional) at the time of discharge. When a patient’s acute medical needs have been fully addressed, the EP may decide that the patient has further needs that can be better addressed by a social worker, case manager, home health nurse, or other member of the medical team. For hospitalized patients, hand-offs occur during transfer between medical services and between levels of care (ICU to ward), as well as between consulting and primary team members. Although in-hospital transitions in care are often considered together, these examples demonstrate that they may take many different forms. Providers involved in these hand-offs will have unique goals and needs depending on their role and on the patient’s acuity, complexity, acute and long-term care needs.

Why do effective transitions of care matter so much? The Joint Commission Center for Transforming Healthcare estimates that poorly communicated hand-offs lead to 80% of serious preventable medical errors and are the leading cause of sentinel events reported to the Joint Commission [1,2]. Poor transitions of care can lead to critical errors if providers receive incomplete, inaccurate, or poorly communicated patient information, and if issues of responsibility and authority are confused. One retrospective analysis of incident reports related to hand-offs demonstrated that the most frequently reported error was when a needed handoff failed to occur entirely. For example, a patient arrives to a ward bed before the accepting physician receives a handoff from the ED. Other examples of common errors during hand-offs include omitting essential information relevant to the patient’s care such as a patient’s MRSA status, thereby placing other patients on the floor at risk [3]. Incidents may also occur where an action appropriate to a patient’s need did not take place despite the hand-over of outstanding jobs. For instance, a septic patient misses their second dose of antibiotics. Hand-offs that fail to signify a clear moment of responsibility transfer are also vulnerable to error. For instance, a patient from the ED is admitted and accepted by the receiving ICU team but remains in the ED awaiting a bed. A lack of close monitoring in the ED due to the patient’s impending transfer to the floor and confusion over the most appropriate person to evaluate the patient may lead to delays in necessary treatment as the patient’s clinical status deteriorates. Sometimes, the wrong action may be taken following a hand-over despite clear instructions, such as the resuscitation of a DNR patient. Occasionally, information transferred during a hand-over may be incorrect or not reflective of the patient’s current condition [3]. Faulty hand-overs can even lead to patients getting “lost” during the transfer within the hospital and not being physically found in the admitting department or ward!

National organizations have taken note of the relationship between ineffective hand-offs and poor patient outcomes. The Joint Commission lists “improving effective communication throughout the hospital” as a lead patient safety goal in the United States [2]. The World Health Organization also recognizes “communication during patient care handovers” as one of its “high 5 patient safety initiatives [4].” The ACGME recognizes the ability to conduct an effective transition of care as a key competency for all graduating emergency medicine residents.

So how do we actually improve the way transitions of care occur, a task that is admittedly much easier said than done? It turns out that a lot of different, very bright folks are working on this very issue, including the leaders of major EM organizations such as ACEP, SAEM, CORD, and many other bodies outside of EM and the house of medicine. The ACGME has published a position paper urging residency programs to teach handoff skills and standardize their handoff processes. An in-progress ACEP task force is compiling a white paper in an attempt to define best practices to inform current standards of care and future research.

Several aspects of the emergency department setting make the task of improving transitions of care inherently more difficult to achieve. For one, interruptions and noise are impossible to avoid in a typical emergency department. Additionally, EPs hand off patients of varying complexity to providers in multiple specialties, and occasionally to non-physician care providers such as social workers. This variability makes it difficult to determine a standard set of information to include in each specific handoff. Achieving an appropriate amount of detail during the handoff process is also challenging, as providing too much information about a patient may de-emphasize the most critical facts. ED patients are also more likely to display characteristics placing them at higher risk for errors during hand-offs. Other common challenges combating efforts to improve transitions of care include cognitive bias, failure to transfer authority and communication breakdown. Educating medical students and residents on how to deal with these challenges and improving the curriculum for effective communication skills is one integral way of improving handoff quality. However, few residences currently offer formal education in changeover and communication skills.

Various mnemonics, forms, and templates have also been proposed to unify handoff protocol between institutions in an effort to improve transitions of care. In fact, I have a difficult time deciding what is more dangerous: my kid choking on the popcorn we got at Finding Nemo 3D, or the 38 different acronyms you can use to handoff a patient. While many of these mnemonics subjectively improve users’ perceptions of the hand-offs quality and efficacy, authors of a systematic review of 24 mnemonics concluded that available literature was “not of sufficient quality or quantity to synthesize into evidence-based recommendations [5].” A systematic review published in the Journal of Academic Medicine found that the efficacy of templates was mixed at best [6].

Despite the several attempts to standardize transitions of care, analyses of medical hand-offs have not supported any single method of standardization as being effective [7,8,9]. A potential reason for the failure of previous methods of standardization is the fact that hand-offs are not “one size fits all,” but rather are both discipline and organization specific. Hand-offs must also be tailored to their end users’ needs in order to be effective, especially in the ED setting where patients vary widely in complexity and acuity.

Most experts do agree on a few key points. Although it is nearly impossible in the ED setting, a provider should make attempt to find a dedicated time and space for hand-offs with minimal interruptions. The handoff should include the signaling and documentation of a clear moment of responsibility and authority. Although the level of detail and structure of a handoff will vary by institution and clinical scenario, critical information such as the patient’s code status, active medical problems, baseline status and relevant medical history, unresolved tasks and pending clinical data, a contingency plan for acute status change, and the patient’s condition at time of handoff should always be included. Accepting providers should read back to confirm understanding, and should have the opportunity to ask questions and clarify any information before the handoff concludes.

In sum, despite the advances that have been made in recognizing the critical role that effective transitions of care plays in ensuring high quality health care, in identifying barriers to effective communication during transitions of care, and in pursuing methods of standardizing handoff protocols, the bulk of the work remains to be done. We still need to develop, study and impart a standardized approach to transitions of care that actually works. Given that hand-offs are not “one size fits all,” we will need a common approach, or “checklist,” that is standardized enough to be validated and safe, yet flexible enough to be adapted to the variety of patients under our care. Achieving this will continue to require the brainpower and collaboration of leaders within our field, not another falsely reassuring mnemonic that is unlikely to improve outcomes. Once a protocol has been established, leaders in academic medicine must share the approach with their medical students and residents, so that the future generation of physicians can stand on our shoulders.

References

  1. Solet, D.J., et al., Lost in translation: challenges and opportunities in physician-to-physician communication during patient hand-offs. Acad Med, 2005. 80(12): p. 1094-9.
  2. Improving Transitions of Care: Hand-off Communications. http://www.centerfortransforminghealthcare.org/assets/4/6/CTH_Hand-off_commun_set_final_2010.pdf 2010 [cited 2012 August 30].
  3. Pezzolesi, C., et al., Clinical hand-over incident reporting in one UK general hospital. Int J Qual Health Care, 2010. 22(5): p. 396-401.
  4. Action on Patient Safety- High 5s. http://www.who.int/patientsafety/implementation/solutions/high5s/en/index.html 2012 [cited 2012 August 30].
  5. Improving Transitions of Care: Hand-off Communications. http://www.centerfortransforminghealthcare.org/assets/4/6/CTH_Hand-off_commun_set_final_2010.pdf 2010 [cited 2012 August 30].
  6. Foster, S. and T. Manser, The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research. Acad Med, 2012. 87(8): p. 1105-24.
  7. Patterson, E.S., Communication strategies from high-reliability organizations: translation is hard work. Annals of surgery, 2007. 245(2): p. 170-2.
  8. Patterson, E.S., et al., Handoff strategies in settings with high consequences for failure: lessons for health care operations. International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua, 2004. 16(2): p. 125-32.
  9. Foster, S. and T. Manser, The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research. Acad Med, 2012. 87(8): p. 1105-24.

Add comment

Security code
Refresh

Popular Authors

  • Greg Henry
  • Rick Bukata
  • Mark Plaster
  • Kevin Klauer
  • Jesse Pines
  • David Newman
  • Rich Levitan
  • Ghazala Sharieff
  • Nicholas Genes
  • Jeannette Wolfe
  • William Sullivan
  • Michael Silverman

Earn CME Credit