Handoffs/handovers have been our single most frequent individual topic over the years (see the list of prior columns at the end of today’s column). However, almost everything written about handoffs/handovers has been about the transfer of information (and responsibility) either to someone who will be covering patients for a specified time or to someone on another service who will be receiving the patient in transfer. Almost nothing appears in the literature about what we like to call the “handback”. This refers to the transfer of information (and responsibility) back from the covering physician to the original physician or team.
This month a great study was published on issues arising with the most common form of handback – morning rounds on an academic service (Devlin 2014). But don’t stop reading if you are not at an academic or training institution! We strongly suspect that the same issues identified by Devlin and colleagues apply equally well to non-training settings, such as a night hospitalist reporting back to the daytime hospitalists in a community hospital or physicians in a rural hospital cross-covering for a long weekend.
The authors studied the morning handovers on general internal medicine services at two academic medical centers in Toronto. A researcher was present for the morning rounds and documented how and where the handovers were conducted, what information was transferred, and whether there were interruptions or distractions during the handover process. In addition, the researchers did extensive review of those patients being “covered” the night before (reviewing the charts, progress notes, orders, nurses’ notes, lab results, etc.). The study was not focused on new patients admitted during the previous night shift but rather solely on those previously admitted patients who had been “signed out” to the covering physician and were now being reported back to the daytime medical team. Hence, these patients were being “handed back”.
Out of 453 individual medical records reviewed the researchers identified 141 clinically important overnight issues (change in patient’s clinical status 47.5%, abnormal lab test result 15.6%, review/response to a consultant’s recommendations 12.8%). Significantly, 40% of the clinically important overnight issues were not included in the verbal handover and not documented in a progress note in 85% (overall 37% were not passed on in either the verbal handover or the medical record). An internet-based written sign-out tool available at these centers was used to document only 7.8% of the clinically important overnight issues. Extrapolating, the researchers note that hundreds of clinically important issues might not be handed over every month at their institutions. And these were not trivial issues that were overlooked. They were issues like patients with chest discomfort on whom cardiac enzymes and EKG’s were ordered, or patients in whom consultants recommended holding off on anticoagulation.
Teams in the Toronto study spent the bulk of their morning rounds discussing newly admitted patients and spent only 11 minutes on average discussing overnight issues on previously admitted patients.
Devlin and colleagues also kept track of the interruptions and distractions occurring during the morning rounds handback. The teams experienced an average of 6.2 distractions per hour resulting in 2.6 interruptions per hour during the morning rounds handover. Over half the interruptions were due to pagers or overhead speakers and announcements. Interruptions by other physicians, nurses, and other members of the healthcare team were also frequent.
The researchers identified certain features that promoted appropriate discussion of clinical important overnight issues. Foremost was “running the list”, i.e. discussing every patient on the list of overnight patients (as opposed to the on-call resident just discussing patients he/she felt needed discussion or handing over to a third party who would update the rest of the team). Distractions correlated negatively with handover of overnight issues.
The researchers note that the preferred method of “running the list” is also a good interruption-handling strategy (i.e. you are more likely to return to the correct point of discussion if you are running the list of patients and less likely to skip over something because of the interruption).
Another extremely important point Devlin and colleagues make is that the handover format for morning rounds (or the handback) may need to be different from the format used for the handover that occurs from the daytime team to the covering physician. We’ve made that point in many of our prior columns, that is the format of the handoff or handover should be tailored to the type of transfer of responsibility and “one size does not fit all” (see our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics”). Specifically, Devlin and colleagues suggest that the SBAR format may be preferable to the I-PASS format in this scenario because it focuses discussion on specific situations and emphasizes the on-call physician’s assessment and response.
The authors had recommendations for improvement of these handovers at the individual, team, training program, and training environment levels. Probably the most important recommendation is to set aside enough dedicated time (while minimizing interruptions) to “run the list” of patients in the presence of the physician who had been on-call.
Though not specifically addressing the “handback”, a recent collaboration among 23 pediatric hospitals (Bigham 2014) demonstrated a significant decrease in handoff-related care failures for multiple different handoff types. The improvement project was guided by evidence-based recommendations regarding handoff intent and content, standardized handoff tools/methods, and clear transition of responsibility. Hospitals tailored handoff elements to locally important handoff types. Examples of the handoff types included shift-to-shift handoffs, emergency department to inpatient handoffs, and perioperative to inpatient handoffs. Handoff-related care failures decreased from 25.8% at baseline to 7.9% in the final intervention period.
Compliance to critical components of the handoff process improved, as did provider satisfaction. Key elements required, regardless of the handoff type, were that active participation by both the sending and receiving teams were required, discrete times
and mechanisms set aside for the receiving team to ask questions, a proscribed script of important handoff elements was available, and a “read back” summary of basic issues and next steps was accessible. One very interesting finding was that even where baseline compliance with individual elements was pretty good at baseline, relatively small incremental improvements in those individual elements collectively led to very good reductions in overall handoff failures.
Though restrictions on hours that residents may work have increased the number and complexity of handoffs/handovers, most of the same issues apply to other physician coverage arrangements. Yes, one resident just finishing a 24-hour shift may have to leave immediately after morning rounds. But a physician in a community or rural hospital who is covering for another physician also has competing requirements for his/her time (eg. office hours, scheduled surgery, etc.). And the same types of interruptions and distractions (phone calls, pages, nurses or colleagues or families requesting information, etc.) apply equally well to morning rounds or the physician cross-coverage handback.
Though neither the Toronto study nor the pediatric collaborative looked at the impact of the missed handoff issues on patient harm or actual patient outcomes, we would certainly predict that improvement in the handback process would likely prevent many adverse events and outcomes. Both are very good studies and have implications for all healthcare organizations, not just academic ones.
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”
December 10, 2013 “Better Handoffs, Better Results”
February 11, 2014 “Another Perioperative Handoff Tool: SWITCH”
March 2014 “The “Reverse” Perioperative Handoff: ICU to OR”
Devlin MK, Kozij NK, Kiss A, et al. Morning Handover of On-Call IssuesOpportunities for Improvement. JAMA Intern Med 2014; 174(9): 1479-1485
Bigham MT, Logsdon TR, Manicone PE, et al. Decreasing Handoff-Related Care Failures in Children’s Hospitals. Pediatrics 2014; 134:2 e572-e579; published ahead of print July 7, 2014,
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