In the late 1980’s New York State adopted recommendations of the Bell Commission to limit the number of hours housestaff could work in a week. The Bell Commission was convened after the Libby Zion case had highlighted issues related to fatigue and supervision of physicians in training. At the time we actually asked Dr. Bell what the evidence base was that the change in housestaff hours would have a beneficial effect on patient outcomes. His response was that incidents reported in NYS were more frequent on evenings and weekends. We pointed out that those were also the times where cross-coverage occurred most frequently and that important information was often suboptimally transmitted during handoffs. We suspected that benefits from reduced housestaff fatigue might be balanced by detrimental effects of an increased number of handoffs that would occur after the change in housestaff hours.
Subsequently other states and ACGME have adopted significant restrictions in housestaff hours. As you all probably know, the evidence of an impact of restricted housestaff hours on patient outcomes and patient safety has been mixed and contradictory. The most recent study (Sen 2013) found that although interns report working fewer hours under the new duty hour restrictions, this decrease has not been accompanied by an increase in hours of sleep or an improvement in depressive symptoms or well-being but has been accompanied by an unanticipated increase in self-reported medical errors.
So, while the new restricted housestaff hours are likely here to stay, we have subsequently focused our attention on improving handoffs and transitions of care and responsibility.
In our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and June 2012 What’s New in the Patient Safety World column “I-PASS Results and Resources Now Available” we highlighted the good work on handoffs done by researchers and clinicians at Boston Children’s Hospital (Starmer 2012, Boston Children’s Hospital 2012). Now a new study from Boston Children’s Hospital (Starmer 2013) found that implementation of a resident handoff bundle was associated with a significant reduction in medical errors and preventable adverse events. There were also improvements in multiple process measures pertaining to handoffs. Importantly, there were no untoward effects on resident workflow and time spent with patients actually increased post-intervention.
The resident handoff bundle included an educational/training component (that included TeamSTEPPS™), standardization of the verbal handoff, and restructuring of the handoff format (eg. team handoffs instead of separate intern-to-intern resident-to-resident handoffs, use of quiet private locations for handoffs, etc.). A printed handoff template that had been in use prior to the intervention continued to be used. However, one unit in the intervention also used a computerized handoff tool that automatically imported a number of data elements from the electronic medical record.
The standardized format used for the verbal handoff used the mnemonic “SIGNOUT?” (Horwitz 2007):
S Sick or DNR (highlight sickest or unstable patients and those that are DNR)
I Identifying data (name, age, gender, diagnosis)
G General hospital course
N New events of day
O Overall health status/clinical condition
U Upcoming possibilities with plan, rationale
T Tasks to complete overnight with plan, rationale
? Any questions
The overall medical error rate improved from 33.8 to 18.3 per 100 admissions after implementation. Preventable adverse events improved from 3.3 to 1.5 per 100 admissions. Nonpreventable adverse events did not change.
Process measures that improved included comprehensiveness of the written handoffs and an increase in verbal handoffs done in quiet, private locations. As you might expect, the unit that also used the computerized handoff tool had fewer key omissions of data on the written handoff documentation. Despite the more frequent use of quiet private locations for handoffs, the mean number of interruptions per handoff session did not change (though the mean number of interruptions per patient did decrease after the intervention).
Time spent on verbal handoffs did not change, and time spent at the computer did not increase. And time spent by residents in bedside patient care actually increased from 8.3% in a 24-hour period to 10.6% after the intervention.
One thing lacking in almost all prior studies on handoffs in healthcare settings has been objective measures of errors and adverse events. Most published studies linking patient outcome improvement to improved handoffs have used subjective measures. The current Starmer study (Starmer 2013) used pre-defined objective measures. It’s really the first study to demonstrate that improved handoffs translate into improved clinical outcomes.
The study did have some limitations, as noted by both the study authors and the author of the accompanying editorial (Horwitz 2013). Perhaps most importantly, the pre-intervention period included the summer and autumn following housestaff change whereas the “after” period was during the subsequent winter, so an experience effect cannot be excluded as a confounding variable. Also, because the intervention was a “bundle” of interventions, it is impossible to determine whether one or more of the individual interventions was more responsible than others for the observed improvements. Also, because the study was done at a single pediatric hospital the generalizability of the findings is unknown.
The accompanying editorial (Horwitz 2013) was written by Leora Horwitz, who was coauthor of the “SIGNOUT?” structured format (Horwitz 2007) and coauthor of previous work demonstrating adverse consequences of poorly done handoffs (Horwitz 2008). She also points out that results of the mutli-instituional I-PASS study (see our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and our June 2012 What’s New in the Patient Safety World column “I-PASS Results and Resources Now Available”) are expected to be published soon (check the I-PASS Study website for updates).
As we noted in our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” 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. Key to good handoffs is discipline in performing them, doing them in a setting conducive to uninterrupted communication, and ensuring communication is two-way (i.e. that the recipient has adequate opportunity to ask questions and get clarification).
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”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving Handoffs”
August 2012 “Review of Postoperative Handoffs”
January 29, 2013 “A Flurry of Activity on Handoffs”
Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 Duty Hour Reforms on Interns and Their PatientsA Prospective Longitudinal Cohort Study. JAMA Intern Med. 2013; 173(8): 657-662
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
Boston Children’s Hospital. I-PASS: Standardizing patient "handoffs" to reduce medical errors. News Release April 29, 2012
Starmer AJ, Sectish TC, Simon DW, et al. Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle. JAMA 2013; 310(21): 2262-2270
Horwitz LI, Moin T, Green ML. Development and Implementation of an Oral Sign-out Skills Curriculum. J Gen Intern Med. 2007 October; 22(10): 1470–1474
Horwitz LI. Does Improving Handoffs Reduce Medical Error Rates? JAMA 2013; 310(21): 2255-2256
Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of Inadequate Sign-out for Patient Care. Arch Intern Med 2008; 168(16): 1755-1760
I-PASS Study website.
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