The University of Florida has had a prize football team since 1906. The bronze statues of our Heisman trophy winners outside of the Swamp are a tribute to our best. John Heisman’s famous quotes talk about how a football should never be fumbled. When we talk about fumbled handoffs in the healthcare setting, the connotation is very different. Perhaps comparing healthcare to football is not a fair comparison. While they are two very different settings, it is clear that fumbled handoffs are high stakes.
What are Handoffs?
Handoffs or handovers are the process for transferring responsibility for the care of patient: “a transfer of care involving a transfer of information, responsibility, and authority between clinicians.”
A transition occurs when 2 or more workers exchange mission-specific information, responsibility, and authority for an operation.1
There are multiple handoffs that take place every day in the healthcare setting. Anytime a patient comes from an outpatient setting to an inpatient setting there is a handoff. Within the hospital setting there are multiple handoffs between care-givers. A very important handoff occurs at discharge from the hospital. This is a vulnerable time for a patient as responsibility transitions from the inpatient team to the outpatient team.
Handoffs in the Hospital Setting:
Multiple care providers take care of a patient in the hospital. There are transitions of care from the emergency room to the inpatient ward. While the patient is on the ward, there are multiple nurses and physicians taking care of the patient. If the patient needs to go to an ICU or to a different service, there are further transitions in care. Discontinuity amongst caregivers in the hospital is inevitable. No single care provider can work 24 hours a day and 7 days a week. Nurses typically work 8-12 hour shifts. A study showed that when nurses worked greater than 12 hours, the number of errors doubled.2 In a teaching hospital, there are many handoffs on the physician team to accommodate for the ACGME duty hours. On a hospitalist service, there are many handoffs as different physicians cover patients to provide 24 hour care. Handoffs are an inevitable reality of taking care of patients in the hospital.
How do Handoffs in the hospital contribute to adverse events?
We know that handoffs in the hospital are inevitable. We also know that communication errors and discontinuity of care can contribute to adverse patient events. A study out of Australia analyzed 25,000-30,000 preventable adverse events that led to permanent disability. In this study it was noted that 11% of preventable adverse events were due to communication issues, in contrast to 6% due to inadequate skill levels of practitioners.3 Retrospective reviews of malpractice claims in the ambulatory setting4 and
emergency department5 showed that handoffs were a contributing factor in 20% and 24% of medical errors respectively. With frequent transitions in care, there is potential harm if key portions of the clinical data are omitted during handoffs.
What are some recommendations for effective Handoffs?
The key to effective handoffs is standardization. If each healthcare provider chooses his or her own format there is bias in terms of what information is relayed. Additionally, in general conversation, we tend to overestimate peer comprehension of the information relayed.6 Without a standard process and an opportunity for two-way communication, key clinical details are likely to be omitted.
The Joint Commission requires all health care providers to “implement a standardized approach to handoff communications including an opportunity to ask and respond to questions” (2006 National Patient Safety Goal 2E). The Joint Commission National Patient Safety Goal also contains specific guidelines for the handoff process, many drawn from other high-risk industries:
In 2010, the Accreditation Council for Graduate Medical Education released its resident duty hours restrictions, requiring that faculty monitor their residents’ patient handoffs to ensure that residents are competent in handoff communications. Standardized formats allow faculty to monitor information being relayed and assess clarity and comprehension.
While some may argue that the progress notes in the Electronic Medical Rrecord (EMR) are sufficient to utilize for information, this is not always the case. Often, the notes are updated later or not entered in the EMR (i.e. events that happen overnight). The other major thing that is lacking in daily progress notes is anticipatory guidance. That is the crucial information of “if this happens, do that” or “look out to make sure that this does not happen”. In using only the progress notes, there is no ability to ask questions or clarify issues.
There are various tools that have been implemented in the EMR to guide handoffs such as checklists and standardized formats. However, these tools need to be used in the context of interactive communication.
What are strategies to improve Handoffs?
The topic of standardized handoffs has been studied and a variety of mnemonics have been used. SBAR (Situation, Background, Assessment, Recommendation) is a standardized communication tool. This was originally developed by the United States Navy as a communication technique to be used on a nuclear submarine. It has been used in the healthcare setting since the late 1990s. SBAR is a useful tool that is easy to remember. SBAR can be modified for a variety of settings. It can also be used across disciplines. It is used in both nursing and physician communication.
Another mnemonic that has been implemented and studied is the IPASS format. This study was published in the NEJM in November 20147. The IPASS group conducted a multicenter prospective intervention study looking at resident handoffs. The intervention included a mnemonic to standardize oral and written handoffs. There were also structured handoff trainings. In 10,740 patient admissions, the medical-error rate decreased by 23% from the pre-intervention period to the post-intervention period. The rate of preventable adverse events decreased by 30%.
The mean duration of in-person oral handoff sessions did not change significantly after the intervention (duration before and after the intervention, 2.4 and 2.5 minutes per patient, respectively).
What this study showed is that structured handoffs can be done in a timely manner. Additionally, they can decrease preventable adverse events.
Handoffs from Inpatient to Outpatient
The handoff from the inpatient team to the outpatient team is perhaps the most important handoff of all. Complexities in the medical system, busy inpatient and outpatient providers and a lack of a standardized approach have made this a challenging handoff to achieve effectively. The American College of Physicians proposes standards of communication between the hospital team at the primary care team.8 These include contacting and communicating with the primary care team at admission and during the hospitalization. At discharge a follow up appointment is to be made, additionally a discharge summary is to be sent in 24-48 hours. At the time of discharge the following information is recommended to be relayed to the primary care provider:
A recent editorial in the NEJM suggested that hospitalist and primary care physicians work together in a collaborative care model. In this model, the primary care physician is a consultant on the inpatient team.9 Care transitions are extremely challenging and the primary care physician needs to have involvement, at the minimum, upon admission, at discharge and post-discharge. The challenge is to find a way to standardize this process which takes into account the primary care providers’ and inpatient team’s schedules and work flow.
Standardized handoffs reduce preventable adverse events and improve communication. Each institution should take steps to standardize handoffs in a way to provide clear communication and an opportunity for two way communication. There are a variety of tools in the published literature which can be modified, as needed, to meet institutional needs. Since faculty need to monitor resident handoffs, there are also tools to teach and evaluate effective handoffs.10 The transition from inpatient care to outpatient care remains an extremely important handoff. This is a vulnerable time for the patient and more work needs to be done to standardize this handoff.
Handoffs are inevitable. A standardized approach presents an opportunity to decrease adverse events. We can all work together to avoid fumbled handoffs!
1. Cheung DS, Kelly JJ, Beach C, et al. Improving handoffs in the emergency department. Ann Emerg Med 2009;55:171–80.
2. Scott LD, Rogers AE, Hwang WT, Zhang Y. Effects of critical care nurses’ work hours on vigilance and patients’ safety. Am J Crit Care. 2006;15:30-37
3. Zinn C. 14,000 preventable deaths in Australian hospitals. BMJ. 1995;310:1487.
4. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Ann Intern Med. 2006; 145:488–496
5. Kachalia A, Gandhi TK, Puopolo AL, et al.Missed and delayed diagnoses in the emergency department: A study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196 –205.
6. Chang VY, Arora VM, Lev-Ari S, D’Arcy M, Keysar B. Interns overestimate the effectiveness of their hand-off communication. Pediatrics. 2010;125(3):491–496
7. Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803-1812.
9. Goroll and Hunt N Engl J Med 2015; 372:308-309 January 22, 2015DOI 10.1056/NEJMp1411416
10. The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. Wohlauer MV1, Arora VM, Horwitz LI, Bass EJ, Mahar SE, Philibert I; Handoff Education and Assessment for Residents (HEAR) Computer Supported Cooperative Workgroup
11. Abraham J, Kannampallil T, Patel VL. A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. J Am Med Inform Assoc 2014;21:154–162