Effective Handoffs Research Articles

Empowering Interprofessional Teams to Perform Effective Handoffs Through Online Hybrid Simulation Education

In recent years, the health care field has recognized the importance of handoff communications, as these crucial events may have serious implications for patient safety if not completed properly. To perform these handoffs correctly, patient information and responsibility must be exchanged accurately and thoroughly between health care providers despite any distractions, interruptions, and/or cultural issues that may exist. To overcome any such obstacles, institutions have experimented with various approaches over the years to determine the best method to ensure the highest probability of effective exchanges. This article describes major barriers that exist to efficient handoff communications and proposes an online, hybrid simulation course as a primary solution to many of the interpersonal obstacles. This highly accessible course uses the dynamic approach of teaching handoff communication with pretests/posttests, videos, a PowerPoint presentation, and interactive exercises. This course emphasizes the importance of teamwork and the SBAR standardization method and has been well received by residents, fellows, and employees of a large health system.

Teaching Video and Workshop Exercises: “Putting the Patient First: Engineering Patient-Oriented Clinic Handoffs (EPOCH)”

Abstract Clinic handoffs occur when residents graduate and patients are transitioned to another primary care physician. Numerous patients are at risk for poor outcomes and face many barriers to eff...

Characterizing Information Decay in Patient Handoffs

The purpose of this study was to analyze the decay of information with multiple sequential patient handoff reports given by third-year medical students who have not had standardized patient handoff training. We examine the information decay of quantitative parameters included in 2 different simulated patient history and physical handoffs conducted among third-year medical students. Both student self-surveys and third party observer surveys tracked accuracy of information. A total of 93 students were surveyed for the first patient scenario and 103 students were surveyed for second patient scenario. Survey data were aggregated into 2 separate spreadsheets, one for each patient scenario tested. A total of 16 data points pertaining to the checklist were analyzed for common trends in handoff accuracy and information decay. Quantitative analysis of information passed between handoffs showed that between the 2 case scenarios, there was a consistent loss of information between one presenter to the next. Overall, 33% of information was lost between the first and third handoffs. Within the progression of individual handoffs, a narrative decay was demonstrated. There was a regression in handoff accuracy, trending down to an average of only 45% of information being passed on successfully by the time each presenter reached the last piece of information in their patient presentation. When examining the survey data points that had greater than an 80% success rate of being included in the handoffs, there appeared to be no correlation between their inherent qualities. This study showed there is a significant decrease in accuracy of information during sequential patient handoff exercises. The information decay may be a result of time, memory, or relevance of the information to the student. Future studies incorporating teaching effective handoffs early in the clinical curriculum would be an area of future research.

Board 259 Program Innovations Abstract A Novel Simulation Program to Train Paramedic Students in Safe EMS Patient Handoff (Submission #411)

Introduction/Background Emergency medical services (EMS) patient handoffs are a critical step in patient care and safety. Approximately 28 million such handoffs occur every year in the United States.1 Despite the importance of safe handoff to patient care, very little exists in formally accredited EMS or paramedic science education regarding the appropriate information to convey to hospital based patient care teams. While the effective use of simulation in paramedic education has been previously described,2,3 the essential step of patient handoff has been largely ignored. We developed and successfully implemented an interprofessional simulation program focused on safe patient handoff. Methods A focus group of emergency medicine faculty, nursing faculty and paramedic science educators came together to develop a program for teaching paramedic science students safe and effective handoffs. The selected educational tool for patient handoff was previously validated and contains the following information: Identification, Mechanism/medical complaint, Injuries/information relative to complaint, Signs/vitals including GCS, Treatment and trends, Allergies, Medications, Background history, and Other (IMIST-AMBO).4 Paramedic students received a didactic session on IMIST-AMBO and were then brought to the simulation center to practice communication and other patient management skills. The simulation began in the center’s Transport Room, featuring a decommissioned ambulance with a manikin representing a patient who had been in a high speed motor vehicle collision. After receiving initial “on scene” information from a confederate first-responder, teams of two paramedic students assumed care of the manikin for a 10 minute transport period. Upon arrival at the hospital, the students had to successfully unload the patient and transport him down the hall to a simulated emergency department room. Emergency medicine residents and nursing students, who until that point were blind to the use of paramedic students, were waiting in the room. The paramedic students transferred care to the team, communicating what they believed was pertinent information. The remainder of the case was completed with paramedic students providing additional assistance to the emergency department team. Following each case a structured debrief session was conducted featuring all members of the patient care team. The debriefing focused on communication issues as part of the patient handoff. All participants completed pre-session and post-session surveys regarding attitudes toward interprofessional communication and overall satisfaction with the simulation. Results: Conclusion A total of 12 paramedic students, 19 emergency medicine residents and 16 nursing students participated in the simulation. In the post-session survey, 44/47 participants (93.6%) agreed or strongly agreed that the in room experience was valuable for preparing them to work with other healthcare providers and 43/47 participants (91.5%) agreed or strongly agreed that the debriefing was valuable. Importantly, 44/47 participants (93.6%) agreed or strongly agreed that the experience enhanced their understanding of the importance of “clear, concise, and respectful” communication during paramedic-physician handoffs. Amongst the primary target audience of paramedic students, 100% agreed or strongly agreed with that statement. In open-ended feedback, paramedic students described the experience as “very beneficial” and noted that it seemed realistic. This model demonstrates an effective educational method for teaching safe patient handoff. Further studies more accurately quantifying the educational benefit will likely follow and have the potential to impact paramedic science education at other institutions. With the clear importance of safe and effective handoff in overall patient care, this could benefit our patients. Furthermore, safe patient transitions are not limited to paramedic-physician handoff in the emergency department and this simulation-based educational model could be easily adapted to provide training for multiple healthcare providers.

Board 277 - Program Innovations Abstract b-SAFER

Introduction/Background Breakdowns in communication are the leading cause of sentinel events according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Arguably, patient handoffs, defined by the JCAHO as "the process of passing information from one person (or team) to another (along with authority and responsibility) for the purpose of ensuring continuity and safety of a patient’s care," are the most prevalent points of communication and information transfer in healthcare. Studies show that ineffective handoffs lead to delays in treatment, increased length of stay, severe adverse events and patient dissatisfaction.1 Additional studies suggest that strictly verbal handoffs result in nearly 100% data loss.2 In response to recognized gaps, JCAHO implemented National Safety Goal 2E, which required a "standardized approach to handoffs including the opportunity to ask and respond to questions. Despite Goal 2E, no uniform mechanism exists for delivering or teaching handoffs and they continue to present deficits in practice for adequate transfer of patient information. Methods As part of a semester-long Interprofessional Teamwork and Communication (IPT) Course, focused on patient safety and effective communication, we developed a module for teaching effective handoffs. The elective course is offered to medical, nursing and pharmacy students and focuses on medical error and effective communication using TeamSTEPPS. As part of the module, we included a unique handoff mnemonic, b-SAFER, to assist learners in organizing their thoughts and delivering efficient patient handoffs interprofessionally. For this module, learners began with a two station simulated series of handoffs in mock shift changes while handing off five patients, reviewed from paper-based vignettes, to a classmate. Students were permitted three minutes to review the patient vignettes and take notes before having five minutes to hand off to the next student. Students receiving the patients completed a brief checklist with questions about their new patients before rotating to a new room and handing off a new set of five patients that included a mix of progressed versions of the previous patients and new patients. The conveyed information was captured in the checklist and the loss of any information was shown statistically to the class to begin the 45-minute didactic lecture on patient handoffs, barriers to effective handoffs and to introduce b-SAFER as a model for safer handoffs. The mnemonic represents: brief Background, Situation, Active Issues, Future Plan, Ensuring Understanding, Repeat for Clarity. A small group breakout during the lecture provided opportunity for the students to practice additional handoffs using b-SAFER. Following the didactic session, students rotated again through another round of two simulated shift changes with a new set of patients. Results: Conclusion Although the data collected from the simulated shift changes was limited, it did provide an opportunity to recognize communication gaps from the first round of handoffs. From the second round of handoffs following the lecture and while using b-SAFER, students (N=17) improved (mean score 43% pre and 77% post) and provided more relevant information during the handoffs. There was also less data loss. The mnemonic b-SAFER is designed as a simpler format to deliver information on multiple patients more efficiently than other existing mnemonics. It showed to be very useful as a teaching and assessment tool and may prove useful as a template for real handoffs.

Standardizing and Evaluating Transitions of Care in the Era of Duty Hour Reform: One Institution's Resident-Led Effort

Compliance with the Accreditation Council for Graduate Medical Education duty hour standards may necessitate more frequent transitions of patient responsibility. We created a multidisciplinary Patient Safety and Quality Council with a Task Force on Handoffs (TFH), engaging residents at a large, university-based institution. The TFH identified core content of effective handoffs and patterned institutional content on the SIGNOUTT mnemonic. A web-based module highlighting core content was developed for institutional orientation of all trainees beginning summer 2011 to standardize handoff education. The TFH distributed handoff material and catalogued additional program initiatives in teaching and evaluating handoffs. A standard handoff evaluation tool, assessing content, culture, and communication, was developed and "preloaded" into the institution-wide electronic evaluation system to standardize evaluation. The TFH developed questions pertaining to handoffs for an annual institutional survey in 2011 and 2012. Acceptability of efforts was measured by program participation, and feasibility was measured by estimating time and financial costs. Programs found the TFH's efforts to improve handoffs acceptable; to date, 13 program-specific teaching initiatives have been implemented, and the evaluation tool is being used by 5 programs. Time requirements for TFH participants average 2 to 3h/mo, and financial costs are minimal. More residents reported having education on handoffs (58% [388 of 668] versus 42% [263 of 625], P < .001) and receiving adequate signouts (69% [469 of 680] versus 61% [384 of 625], P = .004) in the 2012 survey, compared with 2011. Use of a multispecialty resident leadership group to address content, education, and evaluation of handoffs was feasible and acceptable to most programs at a large, university-based institution.

I-PASS Handoff Curriculum: Computer Module

Abstract The I-PASS Computer Module provides a unique platform for asynchronous, individualized learning of key elements of the I-PASS curriculum. It features embedded knowledge questions which pro...

How breast cancer care is coordinated in hospitals serving predominantly minority women.

e17592 Background: Underuse of adjuvant breast cancer treatment results from system failures and occurs more commonly in minority women. We assessed organizational processes associated with care coordination prior to implementing an intervention. Methods: We interviewed 29 clinical and 20 administrative key informants from 6 hospitals with high volumes of minority breast cancer patients. We analyzed qualitative interview data using the constant comparative method. Results: Hospitals varied in approaches to coordinate adjuvant therapy delivery. All hospitals made a “basic” effort to follow up with patients who missed appointments (e.g., certified letters), but some sites included “extra” efforts such as clinician calls. Processes to coordinate handoffs among providers involved use of clerical staff to reach out across specialties in most sites; several sites also explicitly involved clinicians. Effective tracking and handoffs were hindered where electronic health record (EHR) systems were not fully integrated. A critical distinction was whether breast cancer care delivery was integrated within the hospital. Better integration appeared to facilitate communication among clinicians, as well as promote service coordination. Accountability was an important factor contributing to integration, particularly in sites that were less integrated. Conclusions: Appropriate delivery of adjuvant therapies to breast cancer patients appears to be facilitated by better integration of care and services within the hospitals we studied. A fully integrated EHR and enhanced processes for tracking no shows and supporting handoffs seemed to increase integration in these hospitals. Integration was further facilitated when there was accountability for results. Strong clinical leadership can promote integration, but its impact may be lessened if hospitals’ processes are integrated. [Table: see text]

Assessment and standardization of resident handoff practices: PACT project

BackgroundAccreditation Council for Graduate Medical Education duty hour guidelines have resulted in increased patient care transfers. Although structured hand-over processes are required in the guidelines, how to implement these processes is not defined. The purpose of this study is to investigate current handoff methods at our center in order to develop an effective structured handoff process. Materials and methodsThis is a prospective study conducted at two hospitals with large in-house patient censuses. Resident focus groups were used to define current practices and future directions. Based on this input, we developed a direct observation handoff analysis tool to study time spent in handoffs, content, quality, and number of interruptions. ResultsTrained medical students observed 86 handoffs. Survey response rates among junior and senior residents were 63% and 54%, respectively. Average daily patient census was 36 ± 10 patients with an average handoff time of 12 ± 9 min. There were 1.5 ± 1.8 interruptions per handoff. The majority of handoffs were unstructured. Based on information they were given in the handoff, junior residents had a 58% rate of incompletion of the assigned tasks and 54% incidence of being unable to answer a key patient status question. ConclusionsCurrent handoffs are primarily unstructured, with significant deficits. Determination of key elements of an effective handoff coupled with evaluation of existing deficiencies in our program is essential in developing an institution-specific method for effective handoffs. We propose utilization of the mnemonic PACT (Priority, Admissions, Changes, Task) to standardize handoff communication.

Flow Disruptions in Trauma Care Handoffs

Effective handoffs of care are frequently cited as critical for maintaining safety and avoiding communication problems. Using the flow disruption observation technique, we sought to examine transitions of care along the trauma pathway. Our hypothesis was that an increase in hand-offs in trauma care is associated with an increase in flow disruptions and a decrease in efficiency.

Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist

BackgroundThe increasing fragmentation of healthcare has resulted in more patient handoffs. Many professional groups, including the Accreditation Council on Graduate Medical Education and the Society of Hospital Medicine, have made...

Investigating the scope of resident patient care handoffs within neurosurgery.

IntroductionHandoffs are defined as verbal and written communications during patient care transitions. With the passage of recent ACMGE work hour rules further limiting the hours interns can spend in the hospital, many fear that more handoffs will occur, putting patient safety at risk. The issue of handoffs has not been studied in the neurosurgical literature.MethodsA validated, 20-question online-survey was sent to neurosurgical residents in all 98 accredited U.S. neurosurgery programs. Survey results were analyzed using tabulations.Results449 surveys were completed yielding a 56% response rate. 63% of neurosurgical residents surveyed had not received formal instruction in what constitutes an effective handoff; 24% believe there is high to moderate variability among their co-residents in terms of the quality of the handoff provided; 55% experience three or more interruptions during handoffs on average. 90% of neurosurgical residents surveyed say that handoff most often occurs in a quiet, private area and 56% report a high level of comfort for knowing the potential acute, critical issues affecting a patient when receiving a handoff.ConclusionsThere needs to be more focused education devoted to learning effective patient-care handoffs in neurosurgical training programs. Increasingly, handing off a patient adequately and safely is becoming a required skill of residency.

Three steps forward two steps back: implementing advance care planning across a health care system

Creating a system wide change in Advance Care Planning (ACP) has proven to be challenging. Sentara Healthcare is piloting multiple ACP projects across their health system; Home Care, Skilled Nursing...

The Patient Handoff

In 2010, the Accreditation Council for Graduate Medical Education released its resident duty hours restrictions, requiring that faculty monitor their residents' patient handoffs to ensure that residents are competent in handoff communications. Although studies have reported the need to improve the effectiveness of the handoff and a variety of curricula have been suggested and implemented, a common method for teaching and evaluating handoff skills has not been developed. Also in 2010, engineers, informaticians, and physicians interested in patient handoffs attended a symposium in Savannah, Georgia, hosted by the Association for Computing Machinery, entitled Handovers and Handoffs: Collaborating in Turns. As a result of this symposium, a workgroup formed to develop practical and readily implementable educational materials for medical educators involved in teaching patient handoffs to residents. In this article, the result of that yearlong collaboration, the authors aim to provide clarity on the definition of the patient handoff, to review the barriers to performing effective handoffs in academic health centers, to identify available solutions to improve handoffs, and to provide a structured approach to educating residents on handoffs via a curricular blueprint. The authors' blueprint was developed to guide educators in customizing handoff education programs to fit their specific, local needs. Hopefully, it also will provide a starting point for future research into improving the patient handoff. Increasingly complex patient care environments require both innovations in handoff education and improvements in patient care systems to improve continuity of care.

The Art of Effective Handoffs

The Art of Effective Handoffs

Nursing Handoffs: A Systematic Review of the Literature

Handoffs of patient care from one nurse to another are an integral part of nursing practice; but there is abundant evidence that poor communication and variable procedures result in inadequate handoffs. We sought to conduct a systematic review of articles that focused on nursing handoffs, conduct a qualitative review of barriers to and strategies for effective handoffs, and identify features of structured handoffs that have been effective. We conducted a systematic review of English-language articles, published between January 1, 1987, and August 4, 2008, that focused on nursing handoffs in the United States. The search strategy yielded 2,649 articles. After title review, 460 of these were obtained for further review by trained abstractors. Ninety-five articles met the inclusion criteria; of these, 55 (58%) were published between January 1, 2006 and August 4, 2008. Content analysis yielded identification of barriers to effective handoffs in eight major categories and strategies for effective handoffs in seven major categories. Twenty articles involved research on nursing handoffs. Quality assessment scores for the research studies ranged from 2 to 12 (possible range, 1 to 16). The majority of the research studies on nursing handoffs (17 studies; 85%) received quality scores at or below 8 and only three achieved scores above 10. Ten (50%) of the studies included measures of handoff effectiveness. Despite the well-known negative consequences of inadequate nursing handoffs, very little research has been done to identify best practices. There is remarkable consistency in the anecdotally suggested strategies; but there is a paucity of evidence to support them. We call for high-quality studies of handoff outcomes that focus on systems factors, human performance, and the effectiveness of structured protocols and interventions.

Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications

Background:Limits on resident hours increase the frequency of patient hand-offs and may contribute to information transfer problems that contribute to adverse outcomes. This study analysed attributes that affect hand-off accuracy,...

Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs

Handoffs involve the transfer of rights, duties, and obligations from one person or team to another. In many high-precision, high-risk contexts such as a relay race or handling air traffic, handoff skills are practiced repetitively to optimize precision and anticipate errors. In medicine, wide variation exists in handoffs of hospitalized patients from one physician or team to another. Effective information transfer requires a solid foundation in communication skills. While these skills have received much attention in the medical literature, scholarship has focused on physician-to-patient, not physician-to-physician, communication. Little formal attention or education is available to reinforce this vital link in the continuity of patient care. The authors reviewed the literature on patient handoffs and evaluated the patient handoff process at Indiana University School of Medicine's internal medicine residency. House officers there rotate through four hospitals with three different computer systems. Two of the hospitals employ a computer-assisted patient handoff system; the other two utilize the standard pen-to-paper method. Considerable variation was observed in the quality and content of handoffs across these settings. Four major barriers to effective handoffs were identified: (1) the physical setting, (2) the social setting, (3) language barriers, and 4) communication barriers. The authors conclude that irrespective of local context, precise, unambiguous, face-to-face communication is the best way to ensure effective handoffs of hospitalized patients. They also maintain that the handoff process must be standardized and that students and residents must be taught the most effective, safe, satisfying, and efficient ways to perform handoffs.