We’ve probably done more columns on the problems associated with handoffs in healthcare than any other topic (see the listing and links at the end of today’s column). Handoffs are among the most common transactions in transitions at all levels of the healthcare system and are also among the processes most prone to error. We know that breakdowns in communication are contributing factors in roughly 70% of all Sentinel Events in Joint Commission’s Sentinel Event database and many of those breakdowns occur during handoffs. We had been intending for some time now to do a column on an excellent Australian initiative on improving handoffs. But in just the last couple months several more initiatives on improving handoffs have also been published. Importantly, each points out that the tools and formats used are really situation-dependent. That is, a tool or format used in one setting may not work well in another.
There are a number of key features of to successful handoffs in any situation (adequate time, minimal distraction, adequate allowance for interactive discussion where the recipient is able to review all relevant material and has ample opportunity to ask questions, using language that is clearly understood by all parties, use of “read-back”, “repeat-back” and “hear-back” to ensure that communication is understood by all parties, etc.) The most successful handoffs utilize both a written/computerized component and a verbal component and need to meet confidentiality standards. And don’t forget that during a handoff you are not only passing on information but also passing on responsibility for care of the patient.
But another key feature of handoffs is use of some sort of a tool with a standardized format to remind staff of all the important elements to cover during a handoff. Mnemonics may be very helpful in that regard. Over the course of all those previous columns we’ve covered handoff tools and formats that go by a variety of acronyms and mnemonics: SBAR, ISBAR, iSoBAR, I PASS the BATON, PACE, the 5 P’s, SHARED and others.
An ongoing project by several pediatric organizations, the I-PASS Study, perhaps best puts the issue in perspective (Starmer 2012). This collaborative project is looking at improving the handoff process and reducing errors and improving patient outcomes. But they are going about it in the right way. First, they recognized that the format of some handoff tools may not be optimal for other handoffs. An example they use is SBAR. Don’t get us wrong – SBAR is a great format for many handoffs. We use it frequently in demonstrating how communication across professions may be facilitated. For instance, after an RCA showed that a nurse was reluctant (probably for a variety of reasons) to ask a physician to physically come see a patient, we noted that SBAR could have been very helpful:
Situation – Patient X is becoming increasingly diaphoretic and nauseous.
Background – She was admitted with a non-ST elevation MI.
Assessment – I think she is extending her MI.
Recommendation: I think you should come to see her immediately.
But the leaders of the pediatric collaborative recognized that the SBAR format does not work very well for resident-to-resident handoffs, etc. because the situations are much more complex. They note that SBAR is ideal for situations where a brief summary suffices and less than 5 key points need to be communicated, and is especially suited for communications across hierarchical boundries.
So, even though adoption of SBAR has been shown to reduce adverse events in hospitals, they looked at other formats. They first piloted a tool/format and analyzed both the benefits and the downsides of the tool. The tool/format they started with was the SIGNOUT tool but when they analyzed the handoffs during the pilot they recognized that most did not adhere well to that format. Moreover, the residents involved in that pilot said that a tool/format needed to be short, easy to remember, and not have elements that overlapped each other. They also recognized that it would have to integrate with the increasing use of computerized tools for handoffs and other communication.
So after considering other tools (such as I PASS the BATON from the TeamSTEPPS™ program) and brainstorming, they came up with the I-PASS format (and note that even though it sounds like the I PASS the BATON format it is a totally different format):
I: Illness Severity
P: Patient Summary
A: Action List
S: Situation Awareness and Contingency Planning
S: Synthesis by Receiver
The final “S” emphasizes a key feature of all successful communication: it ensures that the message is fully understood by the person receiving the handoff, including asking questions then summarizing the key steps and restating the key actions/to-do steps.
The Starmer article includes a nice example of use of the I-PASS format in a clinical handoff.
The article also summarizes some of the key elements that make a mnemonic successful. It needs to be “catchy”, symbolic, parsimonious, utilitarian, and somehow link a visual image to a process or subject. The I-PASS mnemonic certainly accomplishes that.
The I-PASS Study collaborative is now ongoing at 10 pediatric institutions, utilizing a “resident handoff bundle” that includes not only the I-PASS format but also team training and a template for the written or computerized portion of handoffs. We look forward to seeing the impact this collaborative has on reducing errors and improving patient safety.
The Australian Commission on Safety and Quality in Health Care (ACSQHC) recently updated its Clinical Handover program that was launched in 2007 to improve handover communication across a range of healthcare settings (ACSQHC 2011).
The ACSQHC Clinical Handover pilot program had numerous lessons learned. Perhaps most surprising was the need to convince clinicians that the current way of doing business was simply not adequate and that change was necessary. So developing a compelling case for change was essential. Potential benefits they considered for clinicians include decreased duplication of effort, concise communication with other staff, clear allocation of staff roles, higher staff morale and more confidence in giving and receiving patient handovers, and a reduction in errors and adverse events caused by miscommunication at handovers.
Their toolkit includes a suggested project plan that includes conventional advice about a change management project (support from top leadership, involvement of strong clinical champions, stakeholder engagement, input from staff at all levels and from patients, adequate allocation of resources, identification of barriers and facilitators of change, etc.). They then describe piloting the project, flowcharting current practices, doing a PDSA style rapid improvement project, and sustaining a project. Establishing clear cut goals and measures is critical in demonstrating that any performance improvement project actually leads to improvement. The tools provided are excellent, not only for a clinical handover project but for almost any improvement project. Links to reference materials are excellent and they even provide a host of presentations for various clinical settings.
They point out that, through use of handover mnemonics such as SBAR, ISBAR, ISOBAR, iSoBAR, SHARED, handovers may be facilitated but that there is no evidence that any mnemonic is better than another in terms of improving patient safety and that the choice of handover mnemonic must be considered in the local context.
An external evaluation found that overall the Pilot Program has:
· raised the profile of clinical handover as a key safety and quality issue and established a national impetus for change
· fostered expertise and clinical handover champions for change
· embedded improved handover in a number of Australian health services
· developed a range of tools for improving different types of handover across different settings
· reinforced the need for effective approaches to change, spread and sustainability
· contributed to jurisdictional handover priorities and policies
· created a body of published work on pilot processes, outcomes and lessons learned
· identified gaps in handover knowledge and practice for further investment and development.
Perhaps the most important lesson from the ACSQHC project is that there is no one handoff mnemonic that is ideal for all handoff situations. There are advantages and disadvantages of each mnemonic in different settings.
The emergency department presents yet another unique situation for handoffs. A UK project came up with “the ABC of handover” tool for ED handoffs (Farhan 2012). They noted that some mnemonics commonly used in the UK, such as JUMP (Jobs outstanding, Unseen patients, Medical contacts, Patients to be aware of) and ANTICipate (Administrative data, New information, Tasks, Illness, Contingency planning), were better suited for ward handovers than for ED handovers. Rather than focusing on just the transfer of information and responsibility for single patients, they focused on the transfer of responsibility of a whole department, the ED, at change of shift. That includes knowledge of all the patients in the ED, prioritization of risks, pending tests and other issues, patient flow and waiting time issues, staffing patterns, equipment issues, planned patient dispositions (admissions, transfers, discharges), and even events taking place in the community that might impact the ED. And, since the project was done at an academic medical center, teaching responsibilities were considered as well. They recognized that poor handovers were not only associated with potentially bad patient outcomes but also added a considerable amount of unnecessary work for ED providers (some estimated they lost 1-3 hours per shift “catching up” after a poor handover). Using direct observation of handoffs, a series of semi-structured interviews with ED participants of all levels, and consensus building they were able to develop a tool called “the ABC of handover” though it really has the elements ABCDE:
A Areas and Allocation
B Beds, Bugs, Breaches
C Colleagues, Consultant on Call
D Deaths, Disasters, Deserters
E Equipment, External Events
Note that the ED practices in the UK allow for a one hour overlap at change of shift that is dedicated for handovers. In addition, they recommend that another brief review of progress take place halfway through a shift.
They have formalized a template for this tool and developed laminated cards and posters to facilitate its use. They also recommend keeping a written record of the handovers. Though the tool might seem to violate the “parsimonious” characteristic desired in the I-PASS collaborative, it does have an easy to use format that clearly reminds all participants to discuss a host of important ED issues at each handover and still takes less than 5 minutes to complete. The article provides some good examples of issues that might be discussed during handovers using the tool.
A follow up study on the impact of “the ABC of handover” tool (Farhan 2011) showed that discussion of the items considered to be essential increased from a mean of 34% at each handover to 86% and staff felt that the tool improved their situational awareness and made them more proactive on operational issues such as staffing and equipment shortages.
Also in February ACOG released its updated committee opinion on “Communication Strategies for Patient Handoffs” (ACOG 2012). Note that they advocate the “I PASS the BATON” format from the TeamSTEPPS™ program as their structured communication tool and also discuss SBAR. But their document also discusses things like barriers to effective handoffs and ways to facilitate good handoffs.
Note that ACOG does consider e-mail to be an appropriate form of handoff as long as receipt of the e-mail can be acknowledged. But they stress that voice mail or other messages for which receipt cannot be acknowledged are not acceptable formats. We personally would discourage use of e-mail as the sole component of handoffs since it limits at least to some degree the ability of the recipient to ask questions, which is a core component of good interactive handoffs, and lacks the “body language” that is such an important part of any communication. The document does, however, have good discussion about the physical environment for handoffs and is quite good in pointing out the language and cultural aspects of communication and “styles” of communication.
We think the information you’ll find in the pediatric I-PASS project, ACSQHC project, the ABC of handover, the ACOG opinion, and the AORN toolkit we noted in our December 2011 What’s New in the Patient Safety World column “AORN Perioperative Handoff Toolkit” will be valuable to help you improve your handoff processes in multiple venues.
Mnemonics and the tools or format that they denote may be very helpful in your handoffs. The key message is that you need to implement tools that address the needs of each particular type of handoff that occurs in your organization.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “ ”
May 22, 2007 “ ”
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “ ”
November 18, 2008 “ ”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “ ”
April 25, 2009 “ ”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
Starmer AJ, Spector ND, Srivastava R, et al. and the I-PASS Study Group. I-PASS, a Mnemonic to Standardize Verbal Handoffs.
Pediatrics 2012; 129(2): 201 -204
ACSQHC (Austrailian Commission on Safety and Quality in Health Care) Clinical Handover. October 25, 2011
Farhan M, Brown R, Woloshynowych M, Vincent C. The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department. Emerg Med J 2012; Published Online First: 3 January 2012 http://emj.bmj.com/content/early/2012/01/03/emermed-2011-200199.full.pdf+html?sid=4b3509fa-c354-42cb-a27c-b80721ddeec5
Farhan M, Brown R, Vincent C, Woloshynowych M. ‘The ABC of Handover’: impact on shift handover in the emergency department. Emerg Med J 2011; published online 28 December 2011
ACOG. Committee on Patient Safety and Quality Improvement. Committee Opnion Number 517. Communication Strategies for Patient Handoffs. February 2012
AORN. Perioperative Patient 'Hand-Off' Tool Kit.