The department was packed and I was counting down the seconds until I would board a plane for the Ivory Coast. I snapped back out of my haze to realize that I had 18 patients on the board. It was a pretty good day, all in all, yet somehow after admitting and discharging scores of patients, the board was still overflowing. With a plane to catch and Dr. Talk-a-Lot on the receiving end of these patients, I thought to myself, “I wish we had an efficient and effective tool to handoff 18 patients in just minutes while not compromising patient care.”
Good communication is critical in any transition of care, which we alternately call the “handoff,” “sign out,” or “handover.” Whatever your ED calls it, it’s “the exchange between health professionals of information about a patient accompanying either a transfer of control over, or of responsibility for, the patient.” In emergency care, these transitions occur in three sectors: incoming (EMS to the ED), in the ED (provider to provider), and outgoing (ED to inpatient services, PCP for outpatient follow-up, skilled care facilities and to home). These “nodes of interface” can act as a nidus for communication failure that can lead to many adverse patient outcomes.
The ongoing Joint Commision Center for Transforming Healthcare’s Handoff Communication project found that more than 37% of handoffs were defective, and 21% of those initiating the handoff felt a sense of dissatisfaction regarding the quality of the handoff (JCCTH, 2010). Communication failure was the primary root cause of 65% of reported sentinel events in 2006. Additionally, duty hour restrictions imposed upon residents increase transfers of care and introduce new opportunities for error. The new guidelines limiting resident shifts to 16 hours have increased frequency of handoffs by 40% (JCCTH, 2010).
Errors may occur at any point during the patient’s hospital stay, and errors may exponentially accrue, even becoming perpetuated in a patient’s chart. The attending physician who is preparing to hand off 20 patients can make any number of the following errors: passing incomplete information, passing incorrect information, or most commonly, relaying information with poor flow such that the receiving physician cannot follow and loses information in the process of piecing information together. The physician may fail to provide his diagnosis or differential, which is often not fully documented in the patient’s chart, thereby leaving the departing physician the decision-maker without the wisdom of the original physician who is familiar with the patient. Lastly, the rushed, departing physician may forget to include other members of the patient’s care team, including residents, medical students, pharmacists, nurses, etc.
Errors in handoffs result not only in missed information, but in poor resource utilization and greater hospital lengths of stay. In a study conducted at the Minneapolis Veterans Affairs Medical center, patients were admitted either to the care of a senior resident providing continuous coverage within a team, or to a senior resident who transferred the patient to a different service the next day. Patients in the cross-cover group had significantly more tests performed and a median of two days longer hospital stay.
Variables of handoffs
The format of the handoff can greatly affect the thoroughness and accuracy of information passed. The narrative-based discussion of the patient’s history, physical exam, and assessment and plan is the most common format for verbal handoffs. This practice has the advantage of being universally accepted and proven effective over time. However, this practice has the drawbacks of incompleteness and inconsistency. Most physicians shorten the patient’s history and assessment for efficiency, or incorrectly deem certain information non-contributory. One alternative model is the multidisciplinary handoff. This model involves physicians (residents/students), nurses, pharmacists, social workers, and other mid-level providers. Although more commonly used in the inpatient setting, it can be quite effective in the ED. This approach promotes teamwork and enables team members to chime in with their viewpoint and gives each an opportunity to ask questions.
Written aids are controversial. A universal template that is intuitive, quick to learn, quick to reference, and utilizes universally-accepted mnemonics may increase efficiency. However, although written aids can assist in retaining information, a rigid structure may hinder its use or confuse and slow down users. An electronic hand-off aid offers the benefit of updated laboratory and imaging results, but is more complicated to set up and maintain. Since any one handoff medium has advantages and disadvantages, multiple media should be assessed in your own setting to identify the best practice in your shop.
One aspect of handoff effectiveness that may come as a surprise to physicians is location. Where and when you sign out matters; an uninterrupted place and time for exchanging information is crucial to prevent unnecessary medical errors. A centralized station outside of the patient’s room is an excellent meeting location as the environment includes easy access to computers and a whiteboard, offers privacy, and allows enough room for the entire interdisciplinary team. A handoff performed in or outside the patient’s room allows providers to witness and verify findings first-hand, but carries the disadvantages of being embarrassing for the patient, and potentially breaching confidentiality if the patient has a roommate. For high-risk patients, strong consideration should be given to seeing these patients first hand. In addition, note-taking is difficult while standing and paying attention to the patient, so information may not all be retained as readily as when concentrating in a meeting room.
The key to the success of any business is consistency, and this applies to handoffs as well. The Joint Commission has recognized this fact, stating that a standardized approach should govern who all should be involved in the handoff, and what information needs to be communicated.
Formula One pit crews are considered by many to be the gold standard “handoff” experts in the world. Any delay or error can cost a driver a victory, or worse, his life. We need to look further into different arenas to better our knowledge and practice of transitions of care, so that we can raise the bar and give patients the best possible medical care.
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3. Joint Commission. Improving America’s hospitals: the Joint Commission’s annual report on quality and safety, 2007. Available at: www.jointcommissionreport.org/pdf/JC_2006_Annual_Report.pdf. Accessed May 9, 2008
4. Lofgren, RP, Gottlieb, D, Williams, RA, et al Post-call transfer of resident responsibility: its effect on patient care. J Gen Intern Med 1990;5,501-505
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6. Arora, Vineet, MD, MA and Johnson, Julie, MSPH, PhD. A Model for Building a Standardized Hand-off Protocol. Joint Commission Journal on Quality and Patient Safety, Volume 32 Number 11 Nov 2006
7. Cohen, Michael D., and Hilligoss, Brian P. Handoffs in Hospitals: A review of the literature on information exchange while transferring patient responsibility of control.
8. Montgomery Hunter K. Doctors’ Stories: The Narrative Structure of Medical Knowledge. Princeton University Press; 1991.
9. Horwitz, LI, Moin, T, Green, ML Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med 2007;22,1470-1474