We’ve done many columns on the problems associated with handoffs in healthcare (see the listing and links at the end of today’s column). And we’ve discussed the fact that our efforts to minimize errors due to fatigue of long working hours (for not only physicians but also nurses and others) must always be balanced against the errors that occur due to fumbled handoffs that increase when work hours are restricted.
When the Bell Commission in New York State first recommended restriction of housestaff hours in 1989, we queried what the evidence was that patient outcomes were improved when such restrictions were imposed. The answer was “incidents reported to the Department of Health are more frequent at night and on weekends”. Of course, those are also times when continuity of care is reduced because you may have physicians “covering” patients with whom they are less familiar. So even then it was not clear whether tired physicians or lack of familiarity and continuity were more problematic.
And we still don’t have the answer as to the net impact on patient outcomes of such restrictions in housestaff hours. There are some small studies showing worse outcomes (Laine 1993) and some showing improved outcomes (Horwitz 2007) but two systematic reviews (Fletcher2004, Moonesinghe 2011) have basically found no consistent impact on patient outcomes, either beneficial or harmful.
But that doesn’t mean we should not be doing everything possible to improve the handoff process and minimize errors arising from handoffs. A new study (Helms 2011) combined surveys of housestaff attitudes regarding handoffs with direct observations of handoffs to identify some best practices. They found considerable variation in handoffs, differences between “day” and “night” handoffs, and overall degradation of information across consecutive sign-outs. But they did identify 5 residents deemed by their peers to be superior at the handoff process and then identified 5 key strategies used by those ‘best performers”. These included:
· Discussing sickest patients first
· Minimizing discussion on the more straightforward patients
· Limiting plans to active issues
· Using a systematic approach
· Limiting error-prone chart duplication
The limitations of the study are that it included only a single institution, looked at only weekday handoffs, had some subjective variables, and most importantly did not assess impact on patient outcomes.
We’ve always stressed to our residents the following regarding handoffs:
· Allow sufficient time
· Do them where interruptions are less likely (the “sterile cockpit” analogy with aviation)
· Ensure the handoff is a 2-way communication (i.e. ensure the person receiving the handoff understands and has the opportunity to ask questions)
· Use structured communications formats and tools (eg. SBAR)
· Paper vs. verbal: use both (literature says outcomes better when both used)
· Involve the patient when you can
Ensuring that both parties agree on the important issues of a handoff is not so clear-cut. A study last year (Chang 2010) showed that the most important piece of information about a patient was not communicated about 60% of the time! To-do items (65%) and items related to anticipatory guidance (69%) were more likely to be adequately communicated compared with a knowledge items (38%).
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. And it reinforces to all staff the critical importance of handoffs.
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 “ ”
November 18, 2008 “ ”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “ ”
April 25, 2009 “ ”
April 13, 2010 “Update on 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”
Laine C, Goldman L, Soukup JR, et al. The Impact of a Regulation Restricting Medical House Staff Working Hours on the Quality of Patient Care. JAMA 1993; 269(3): 374-378
Fletcher KE, Davis SQ, Underwood W. Systematic Review: Effects of Resident Work Hours on Patient Safety. Ann Intern Med 2004; 141(11): 851-857
Horwitz LI, Kosiborod M, Lin Z, et al. Changes in Outcomes for Internal Medicine Inpatients after Work-Hour Regulations. Ann Intern Med 2007; 147(2): 97-103
Moonesinghe SR, Lowery J, Shahi N, Millen A, Beard JD. Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review. BMJ 2011; 342:d1580
Helms AS, Perez TE, Baltz J, et al. Use of an appreciative-inquiry approach to improve resident sign-out in an era of multiple shift changes. Journal of General Internal Medicine 2011. DOI 10.1007/s11606-011-1885-4
Springer Press Release. Hospital patients suffer in shift shuffle. Shorter hours for residents and multiple patient care handovers result in poorer continuity of care.
Chang VY, Arora VM, Lev-Ari S, et al. Interns Overestimate the Effectiveness of Their Hand-off Communication. Pediatrics 2010; 125(3): 491 -496