We’ve written many columns highlighting issues related to handoffs in healthcare (see the listing and links at the end of today’s column). But there have been several good new articles on handoffs recently that deserve mention.
Two systematic reviews on both nursing handoffs and physician handoffs (Riesenberg 2010; Riesenberg 2009) found a dearth of high quality research studies showing what features of handoffs are responsible for desirable outcomes. So we’ll admit right up front that most of the recommendations on handoffs are largely based on anecdotal evidence. The Riesenberg paper on nursing handoffs nicely summarizes the barriers to effective handoffs identified in the literature, plus recommendations from the literature.
In the past few years there has been a movement to doing face-to-face nursing handoffs right at the patient bedside at change-of-shift. This gives patients (and families) both the opportunity to be updated on their plans of care but also to have input. From a patient satisfaction standpoint these handoffs have been very positive. But it is not yet known whether they result in better clinical outcomes. Again anecdotally, there are many examples where a patient or family member were able to change incorrect information or add additional information during these bedside handoffs that did impact on their care.
Among several articles on handoffs appearing in the February 2010 Joint Commission Journal on Quality and Patient Safety was one on measuring effectiveness of handoffs (Patterson & Wears 2010). Though the article gets somewhat ethereal at times, it does highlight the difficulties in assessing the effectiveness of handoffs. Perhaps most importantly it really makes you realize that there is more to a handoff than simply transmission of information. It also involves, in most cases, transfer of authority and responsibility and in most cases requires not only that the two parties directly involved understand what change of responsibility has occurred but also that all other pertinent parties understand that change. Moreover, they point out that the handoff also involves social aspects, and those may be interdisciplinary.
Several good articles on handoffs related to the emergency department (ED) appeared in the February 2010 issue of the Annals of Emergency Medicine. Cheung et al (Cheung et al 2010) discuss some of the same conceptual frameworks as in the above article (one of the authors participated in both publications) but also discuss concerns that are unique to the ED. They begin with the statistics about ED’s as high risk areas and that communication issues commonly contribute to both adverse outcomes and delays in care. Up to 62% of delays in care related to communication issues are associated with shift changes. Up to 24% of ED malpractice claims involve faulty handoffs. They highlight the difficulty of communicating in an environment that is loud and disruptive with numerous interruptions, ongoing patient concerns, phone and radio calls, etc. They even note that poorly performed handoffs actually add to the distractions.
They note one particularly unique occurrence in the ED: the “departing physician” sometimes stays in the ED to complete charts, etc. Nurses and other staff often then go to that physician for decision making, often resulting in the receiving physician (who now officially is responsible and accountable for the patient) not knowing vital information.
Another problem that may occur in any situation where the care of a patient is temporary (so especially in the ED) is “cognitive bias” or “diagnosis momentum” where the receiving physician relies too heavily on the judgement of the departing physician.
Though the article admits that there is no “standard” ED handoff (and that there may in fact be no “one size fits all” handoff model for each setting), they discuss the various pros and cons of some handoff models such as single vs. multidisciplinary handoff, central vs. bedside handoff, verbal vs. written vs. computerized handoff, etc. Note that a previous study on nursing handoffs (Pothier et al 2005) showed that pure verbal handoffs and note-taking style handoffs had high rates of data loss but that when a typed sheet was included with the verbal handoff, data loss was minimal. Many programs have been utilizing computerized tools that extract data electronically from multiple computer sources to populate templates that can then be supplemented and used during physician handoffs (see Flanagan et al 2009).
Cheung et al have some good advice regarding strategies to improve ED handoffs. Firstly, reduce the number of unnecessary handoffs. That can often be done by scheduling overlapping shifts or protecting the departing physician from new patients toward the end of a shift (but beware of the unintended consequence of pushing the patient through the system too rapidly). Do the handoffs in a quiet, dedicated space to minimize distractions, leaving adequate time for discussion and questions. Balance completeness with succinctness in the handoff (if too much information is conveyed, the critical elements are often lost among the irrelevant ones). Prioritize patients who need to be seen first and communicate all outstanding issues (labs, radiology, consultations, etc.). Be sure to spell out authority issues (eg. when a consultant will be determining disposition of the patient) and let all the ED staff know that a transition of care has occurred.
The second paper (Apker et al 2010) used an assessment tool developed for the express purpose of evaluating handoffs and then used it to evaluate handoffs between ED physicians and hospitalists that were recorded. They found that most handoffs were predominantly “one-way”. The bulk of the handoffs were spent with the ED physician speaking and seldom did the hospitalists ask questions or seek verification. And in most cases the hospitalists acceptance of the admission was indirect. They did comment, however, on the use of silence, “uh-huhs”, and “okays” by hospitalists as communication tools.
Despite the trend toward using more standardized tools for handoffs using formats such as SBAR, we continue to see many incidents in which poorly done handoffs have played major roles. During the economic downturn we have seen many hospitals either cutting back on staff or cutting back on staff hours. The “7 ½ hour day (shift)” has appeared. And even where hospitals have been able to change scheduling to create overlapping shifts, that 7 ½ hour shift inevitably results in fewer face-to-face handoffs. So even though most hospitals are now using structured handoff tools, the ability of the “recipient” of the handoff to ask questions and get clarifications is impaired.
Hospital cutbacks may have also created new, unique need for handoffs. For example, in some small hospitals nursing will now perform some respiratory therapy treatments during night or evening shifts that were formerly done by respiratory therapists. So there now needs to be a handoff from respiratory therapy to nursing (and then a handoff in the reverse direction in the morning).
The biggest problem we see with handoffs is failure to allow adequate time. One party is often delayed in arriving at the site where the handoff will take place and there is often pressure on the oncoming party to cut the handoff short to attend to some urgent need. Ensuring adequate time for exchange of information is critical to effective handoffs. Yet we wonder if our failure to ensure adequate time may be a reflection that our “safety culture” is not yet mature enough to give the handoff the priority it is due.
Part of the problem in ensuring adequate time is that interruptions remain a major barrier to effective handoffs. Back to our aviation analogies, the handoff should be done under “sterile cockpit” conditions where all parties must be focused on the task at hand. So the handoff should be done in an environment where nothing but the most serious emergencies should be allowed to interrupt.
All too often we realize that our handoffs are suboptimal only after we review an incident that has already occurred. We believe that recording handoffs can be a valuable educational and performance improvement tool that may help your organization identify problematic communication before adverse events occur. Video recording is preferable to audio since so much communication is nonverbal. When you play back the handoffs to those staff members who were involved, they usually readily recognize opportunities for improvement. As long as this is done in a constructive, nonpunative and nonderogatory fashion it helps staff at all levels of the organization improve their communication skills.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
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 “Hot Topic: Handoffs”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”
April 25, 2009 “ ”
Riesenberg LA, Leisch J, Cunningham JM. Nursing Handoffs: A Systematic Review of the Literature. AJN The American Journal of Nursing. 110(4):24-34, April 2010.
Riesenberg LA, Leitzsch J, Massucci JL et al. Residents' and Attending Physicians' Handoffs: A Systematic Review of the Literature. Academic Medicine 2009; 84(12): 1775-1787, December 2009.
Patterson ES, Wears RL. Patient Handoffs: Standardized and
Reliable Measurement Tools Remain Elusive. Joint Commission Journal on
Quality and Patient Safety 2010;
36(2): 52-61 February 2010
Cheung DS, Kelly JJ, Beach C, et al for the American College of Emergency Physicians Section of Quality Improvement and Patient Safety. Improving Handoffs in the Emergency Department. Annals of Emergency Medicine 2010; 55(2): 171-180 February 2010
Pothier D, Monteiro P, Mooktiar M, Shaw A. Pilot study to show the loss of important data in nursing handover. British Journal of Nursing 2005; 14(20): 1090 - 1093
Mindy E. Flanagan, Emily S. Patterson, Richard M. Frankel,
and Bradley N. Doebbeling
Evaluation of a Physician Informatics Tool to Improve Patient Handoffs
J Am Med Inform Assoc 2009; 16: 509-515.
Apker J, Mallak LA, Applegate EB, et al. Street. Exploring Emergency Physician–Hospitalist Handoff Interactions: Development of the Handoff Communication Assessment. Annals of Emergency Medicine 2010; 55(2):161-170 February 2010