Care Handoffs Research Articles

A quality improvement study to improve patient and family satisfaction through handoff of patient care between emergency department and inpatient nurses

Lack of handoff between the emergency department and inpatient units may result in increased errors and decreased patient/family satisfaction due to a lack of nursing knowledge of the patient upon admission. To address this concern, a quality improvement study was implemented by utilizing the organization’s established text messaging system to promote communication between these two units regarding pertinent patient information and expected time of arrival to the inpatient unit. Despite efforts, nursing engagement was minimal due to the ongoing COVID-19 pandemic. Future successful implementation of this handoff process requires continued administrative support and nursing engagement.

Evaluating the Safety and Quality of Intraoperative Anesthesia Handoffs from the Perspective of Anesthesia Providers

Handoffs, that is, care transitions, convey information, responsibility, and authority between care providers. Intraoperative handoffs, which occur during surgery either due to shift changes or breaks, are high-risk, error-prone and linked with inadequate verbal communication and documentation. We explored perspectives about safety and quality of intraoperative handoffs between anesthesia providers at an academic medical center. Through an anonymous online survey, we asked participants to share their opinions on current handoff practices including teamwork, staffing and work pace, and handoffs and information exchange. The results showed positive perceptions about teamwork, while only half of the participants were positive about staffing and work pace. We also found that opinions of participants about staffing and work pace vary based on their role. Our study emphasizes the importance of considering diverse perspectives and employing a systems-based approach to address challenges and implement effective interventions for safe, high-quality handoffs in intraoperative care.

Peer review for handoff education in a transition to residency course: A prospective cohort study.

Association of American Medical Colleges (AAMC) and Accreditation Council for Graduate Medical Education (ACGME) mandate training in handoff delivery for students and residents. Communication errors, including errors during handoffs of patient care, account for over 2/3 of sentinel events. This study aims to assess the effectiveness of peer-assisted learning (PAL) in handoff education within a longitudinal framework. This study involved the analysis of fourth-year medical students (n = 67) enrolled in a transition to residency program designed to reinforce skills essential for success in internal medicine residencies. We modified the I-PASS handoff rubric for a single-encounter evaluation. Before attending the transitions of care workshop, students submitted one written handoff report. During high-fidelity simulation sessions, peers evaluated the written document as well as verbal handoffs, while faculty evaluated a recorded verbal version. The primary outcome measured was improvement in handoff quality and accuracy over time and secondary outcomes compared peer- and self-evaluations to faculty assessments. Overall, students demonstrated a statistically significant improvement in handoff quality and accuracy across all scoring criteria after completing the peer evaluation process. Peer evaluations did not demonstrate statistically significant differences in scores for quality or accuracy questions as compared to faculty. Peer evaluators effectively assessed handoff reports using the modified I-PASS checklist yielding outcomes similar to faculty while providing feedback. These findings provide exciting evidence that should prompt training programs to consider incorporating standardized peer review into handoff education for medical students and, potentially, residents. The detailed evaluation of individual handoff events fosters feedback skills essential for ongoing professional growth and clinical excellence.

Using mobile health to expedite access to specialty care for youth presenting to the emergency department with concussion at highest risk of developing persisting symptoms: a protocol paper for a non-randomised hybrid implementation-effectiveness trial

IntroductionPaediatric concussion is a common injury. Approximately 30% of youth with concussion will experience persisting postconcussion symptoms (PPCS) extending at least 1 month following injury. Recently, studies have shown the...

Effects of an Electronic Checklist on the Quality of Patient Care Handoff Process from the Operating Room to Intensive Care Unit

Effects of an Electronic Checklist on the Quality of Patient Care Handoff Process from the Operating Room to Intensive Care Unit

The Warmest of Handoffs: A Neighborhood Physician's Transfer of Care.

Transitioning care of a patient from an outgoing to an incoming physician provides a precious opportunity to transfer knowledge and trust. We explore this process from the perspectives of 2 practitioners, an incoming physician who recently completed training and a retiring physician leaving a practice of 40 years. The method we arrived at for this transfer provided the space for collaboration on what the essence of caring for a unique individual will entail. We discovered that a handoff of care is the intergenerational transfer of culture. It involves worrying and watching and relaxing into hopefulness. It is both witnessing and launching a life's work. It is reliving and inheriting and reinventing relationship.

Focused Wound Care Handoff Improves Burn Center Physician-Nursing Communication and Wound Care Education.

Burn patients require changing wound care routines dependent on wound characteristics and operative interventions. Order discrepancies on electronic medical systems and poor communication between providers leads to incorrect wound care treatment which can be harmful to the complex burn patient. By dedicating a daily wound care discussion for each patient involving integral components of the team: physician, charge nurse, and wound care technicians, enhanced communication amongst team members and improved patient care was noted. A single-center burn unit conducted pre- and postintervention survey of nursing staff measuring various components of wound care. The time spent on the wound care discussions were measured daily. Additional time required to conduct the rounds were minimal with nurse reported increased clarification in patient care without additional work burden. Thus, focused wound care meetings assist with communication between providers, clarification of wound care needs, and avoidance of errors without increasing strain on the team.

Chronic care handoffs in otolaryngology: Pediatric to Adult Care Providers

ObjectiveThe transfer of care from pediatric to adult otolaryngology remains unexplored. Our study investigated practice patterns among pediatric otolaryngologists. MethodsTwenty-question survey administered to otolaryngologists at the Society for Ear Nose and Throat Advancement in Children (SENTAC) and American Society of Pediatric Otolaryngology (ASPO) in December 2020 and July 2021 respectively. Data analyzed in RedCap including demographics, frequencies, means, and standard deviations. ResultsThe survey was completed by 48 participants. The majority of respondents practiced for at least 16 years (n = 28) at a University-based practices (n = 38), serving an entirely pediatric population (n = 44). Providers’ expertise included chronic ear disease, voice disorders, and laryngeal stenosis. Few respondents (n = 12) had a transfer of care policy formalized at their practice. However, 38.8% of respondents were interested in developing one. Respondents rarely discussed topics such as drugs, tobacco, or alcohol use (mean 30.1%, SD 30.18%) with patients; and only 55.5% (SD 32.98) of providers asked patients 14 years and older to describe their condition, medications, or treatment plans. None of the providers were familiar with standardized transition of care tools. The majority of providers transferred patients between 18 and 25 years old to adult care. ConclusionThere is significant variation between otolaryngology providers’ awareness and clinical practice patterns surrounding pediatric to adult transfer of care. Further studies are needed to evaluate the implications of these biases for patient outcomes and the opportunities for a standardized approach.

A pediatric hospital-wide asthma severity score: Reliability and effectiveness.

Asthma is a leading cause of pediatric hospitalization in the United States. Children hospitalized with asthma are often managed in different care settings during hospitalization, posing challenges to accurate communication among care providers about illness severity. Our objective was to study the feasibility, reliability, and safety of a new pediatric hospital-wide asthma severity score (HASS) across different care units within a single tertiary-care pediatric center. 150 patients between the ages of 2 and 18 years hospitalized with a principal diagnosis of status asthmaticus were included in this study. Study patients were followed from the time of initial triage in the emergency department until the time of medical readiness for discharge. Rates of medical errors, early transfers to a higher level of care and medically indicated hospital length of stay (LOS) were compared between 75 patients before and 75 patients after widespread implementation of the HASS using retrospective chart review and anonymous staff reporting. Interrater reliability was determined by collecting independent HASS scores from blinded staff members after tandem or simultaneous patient assessment. Interrater reliability among untrained staff members using the HASS was high. Hospital LOS, rates of adverse events, medical errors, and early transfer to a higher level of care were not significantly different before and after widespread HASS implementation. The HASS is a reliable asthma severity tool that can be used throughout hospitalization and among multiple clinical providers to trend clinical progress and optimize communication, particularly during times of care handoffs.

585 Focused Wound Care Handoff Improves Burn Center Physician-Nursing Communication and Wound Care Education

IntroductionBurn patients often require changing wound care routines dependent on wound characteristic and operative interventions. Unfortunately, order discrepancies on electronic medical systems, poor communication between providers, nursing, and wound care technicians leads to incorrect wound care treatment. By creating a daily dedicated wound care discussion involving integral components of the wound care team (provider, charge nurse, and wound care technicians), we hope to improve communication amongst team members and provide wound care education at all levels.MethodsThe study was carried out at a single-center burn unit. A pre-intervention, de-identified survey was distributed to the nursing staff to determine familiarity with wound care as well as assessment of communication regarding wound care in the burn unit. A planned intervention was then initiated for a period of four weeks. Daily, timed dedicated wound care rounds were carried out. The wound plan was then reflected on a personalized diagram for each patient, on electronic medical records and updated on resident/fellow notes. Nursing staff satisfaction and assessment of communication was completed again using a post-intervention, de-identified survey.ResultsInitial data from our planned four-week intervention showed that on average, we round on 7.9 patients on burn wound unit, 4 patients on intermediate care unit (IMC), and 2.9 patients on intensive care unit daily. During wound care handoff, we discussed 12.5 patients daily with an average time of 51 seconds per patient. When wound care routines are added to morning rounds, we spend 50 seconds per each burn wound unit patient, 120.5 seconds per each IMC patient and 735 seconds per each ICU patient. There was a total of 19 surveys collected prior to intervention. Four of the 19 surveys were filled by burn wound floor nurses and 15 were filled by ICU nurses. On average, nursing reported their wound care proficiency to be 4 out of 5 (5 being the highest score). Majority reported spending about 1-3 hours per shift on wound care (58%). Most nurses review wound care routine on nursing handoff (66%), resident/fellow notes (22%) and electronic medical record orders (11%). Mid-intervention satisfaction survey showed that most nurses felt that communication was improved, discrepancies between staff members were minimized, and that 100% of nurses wanted this intervention to be continued.ConclusionsAdverse wound care events can happen despite nursing self-reported high level of wound care proficiency. To ensure accurate plan of care, wound care routine needs to be communicated at multiple levels: during rounds, in daily progress notes, and on electronic medical record orders.

Information handoffs in critical care and their implications for information quality: A socio-technical network approach

ObjectiveThe design of health ICTs, as well as human factors, have been shown to influence patient information quality. The aim of this study was to understand how patterns of interaction between these factors influence information quality aspects in a critical care environment. MethodWe conducted an ethnographic study of socio-technical information handoffs in a critical care unit. Data collection methods included non-participant observations and semi-structured interviews. Methodological principles from network analysis (SNA, VNA) were used to develop visual network diagrams, as well as to analyze the composition of the information network and its influence on patient information quality. ResultsThe network patterns that emerged uncover that human actors have many information processing and dissemination roles at the critical care unit. However, ICTs play key network roles, acting as information intermediaries and gatekeepers. We further identify three types of information handoffs in the critical care environment – human–human, human-ICT and ICT-human. On the one hand, we find that human–human and ICT-human handoffs influence contextual and intrinsic aspects of patient information, such as information completeness and accuracy. On the other hand, human-ICT handoffs influence information accessibility and representational quality, such as consistency and interpretability. DiscussionThe results suggest that standardizing change of shift handoff communication may not be sufficient to prevent information decay in complex care trajectories. In particular, we argue that ensuring information consistency and interpretability across disciplines and professions is as important as ensuring information completeness and accuracy during change of shift handoffs. ICT and workflow design opportunities are discussed as means to address overlapping or conflicting information needs across disciplines and professions, increase information consistency, and reduce information redundancy across the network.

Safe transitions from the hospital to home: A review of the pediatric hospitalist's discharge workflow

For children to have safe transitions from the hospital to home, inpatient physicians, nurse practitioners, and physician assistants, should use a standardized discharge process that focuses on thorough discharge planning, multidisciplinary teamwork, communication, and effective hand-offs of care. Using quality improvement science will help physicians analyze and improve their discharge process and ensure safe discharges.

Improving Safety and Quality During Interhospital Transfer of Patients With Nontraumatic Intracranial Hemorrhage: A Simulation-Based Pilot Program.

The presentation of critically ill patients to emergency departments often necessitates interhospital transfer (IHT) to a tertiary care center for specialized neurocritical care. Patients with nontraumatic intracranial hemorrhage represent a critically ill population subject to high rates of IHT and who is thus an important target for research and quality improvement of IHT. We describe the use of an innovative simulation methodology engaging transfer staff, clinicians, and stakeholders to refine and facilitate the adoption of a standardized IHT protocol for transferring patients with neurovascular emergencies. This was a qualitative study using a phenomenological approach. Participants consisted of IHT call center staff members, neurointensivists, neurosurgeons, and emergency physicians. We conducted a standardized telephone-based simulation case to prime participants for feedback on their experiences with IHT for intracranial hemorrhage patients. Facilitators conducted focus groups immediately after the simulation to identify process improvement opportunities. A structured thematic analysis identified overarching concepts from the data. We achieved data saturation with 7 simulations and a total of 24 participants. Thematic analysis identified 3 IHT-specific themes: (1) challenges unique to multispecialty critical illness, (2) interdisciplinary relationships and dynamics, and (3) communication and information processing for IHT. Three quality improvement initiatives emerged from the debriefings: standardized communication checklist, early acceptance protocol, and structure for telephone-based care handoffs. We demonstrate the use of telephone-based simulation technology to identify potential pitfalls and accelerate the adoption of a new IHT protocol for patients with nontraumatic intracranial hemorrhage. New quality improvement strategies can organically result through interprofessional debriefings for patients with potentially complex handoffs between hospitals.

Barriers to physical distancing among healthcare workers on an academic hospital unit during the coronavirus disease 2019 (COVID-19) pandemic.

Physical distancing among healthcare workers (HCWs) is an essential strategy in preventing HCW-to-HCWs transmission of severe acute respiratory coronavirus virus 2 (SARS-CoV-2). To understand barriers to physical distancing among HCWs on an inpatient unit and identify strategies for improvement. Qualitative study including observations and semistructured interviews conducted over 3 months. A non-COVID-19 adult general medical unit in an academic tertiary-care hospital. HCWs based on the unit. We performed a qualitative study in which we (1) observed HCW activities and proximity to each other on the unit during weekday shifts July-October 2020 and (2) conducted semi-structured interviews of HCWs to understand their experiences with and perspectives of physical distancing in the hospital. Qualitative data were coded based on a human-factors engineering model. We completed 25 hours of observations and 20 HCW interviews. High-risk interactions often occurred during handoffs of care at shift changes and patient rounds, when HCWs gathered regularly in close proximity for at least 15 minutes. Identified barriers included spacing and availability of computers, the need to communicate confidential patient information, and the desire to maintain relationships at work. Physical distancing can be improved in hospitals by restructuring computer workstations, work rooms, and break rooms; applying visible cognitive aids; adapting shift times; and supporting rounds and meetings with virtual conferencing. Additional strategies to promote staff adherence to physical distancing include rewarding positive behaviors, having peer leaders model physical distancing, and encouraging additional safe avenues for social connection at a safe distance.

Assessment of Care Handoffs Among Hospitalist Physicians and 30-Day Mortality in Hospitalized Medicare Beneficiaries

Inpatients treated by hospitalist physicians, who often work contiguous days, experience handoffs at the end of a scheduled shift block. Evidence suggests that transitions of patient care, or handoffs, among physician trainees are associated with adverse patient outcomes. However, little is known about the association between handoffs and patient outcomes among attending physicians, even though similar concerns apply. To examine the association between inpatient handoffs of hospitalist physicians and patient mortality among hospitalized Medicare beneficiaries. This cross-sectional study analyzed a random sample of Medicare beneficiaries who were hospitalized with a general medical condition between January 1, 2011, and December 31, 2016, and treated by a hospitalist. The study compared outcomes of patients with low vs high probability of physician handoff based on date of patient admission relative to the admitting hospitalist's last working day in a scheduled block, hypothesizing that otherwise similar patients admitted toward the end of a physician's shift block would be more likely to be handed off to another physician compared with patients admitted earlier in the shift block. Data analysis was performed from July 1, 2018, to January 12, 2021. High vs low probability of physician handoff. The main outcome was patient 30-day mortality rate. A total of 1 074 000 patients (mean [SD] age, 75.9 [13.7] years; 57.4% female; 82.1% White) were studied. Multivariable regression models adjusted for beneficiary clinical and demographic characteristics and hospital fixed effects (a within-hospital analysis, effectively comparing patients treated at the same hospital). Among 597 288 hospitalizations, no overall difference in 30-day mortality was observed between patients admitted in the 2 days prior (days -1 and -2) to the treating hospitalist's last working day (a high handoff probability) compared with days -6 and -7 (a low handoff probability) (adjusted rate, 10.6%; 95% CI, 10.5%-10.7% vs 10.6%; 95% CI, 10.5%-10.7%; adjusted difference, 0.0%; 95% CI, -0.2% to 0.1%). However, in an exploratory analysis, among patients with high illness severity, defined as those in the top quartile of estimated mortality, 30-day mortality was higher for those with high vs low likelihood of physician handoff (adjusted mortality, 27.8%; 95% CI, 27.6%-27.9% vs 26.8%; 95% CI, 26.6%-27.1%; absolute adjusted difference, 1.0%; 95% CI, 0.5%-1.4%). In this national analysis of Medicare beneficiaries hospitalized with a general medical condition and treated by a hospitalist physician, physician handoff was not associated with increased mortality overall.

Healthcare handoffs among lay caregivers.

Much of home healthcare is also performed by informal caregivers. This paper seeks to add understanding to the home healthcare field, specifically studying care handoffs between informal caregivers. This study included 16 trained and 20 lay participants to determine differences due to expertise. This comparison is useful because there is a lot of published research on healthcare handoff happenings involving healthcare professionals, and the results indicate how much of the published research can be applied to care handoffs between informal caregivers. The primary objective of this study is to identify differences between lay and professional caregivers when there is uncertainty in a caregiving handoff from their fellow caregiver. The study design included between-group analysis of Expertise (layman and expert) and within-group analysis of Task Difficulty and Communication Modality. Dependent variables included willingness to ask for help, confidence in handoff instructions, confidence in the ability to complete tasks and task accuracy. Both Expertise groups were given the same four scenarios in a repeated measures study design. The findings suggest statistically significant differences in how informal caregivers respond to unclear handoff instructions, where lay participants were more confident in understanding instructions, more confident in executing the tasks, less willing to ask for help and also less able to spot and resolve conflicting information compared to trained participants. Lower performance in resolving conflicting information was exhibited by the lay participants. However, when comparing with the syringes that were prepared correctly, it was observed that the accuracy of those prepared syringes was higher for lay participants than for trained participants. It was anticipated that lay participants would be more willing to ask for help due to lack of subject matter expertise and trained participants would be more confident in completing tasks due to their superior subject matter expertise, but the opposite was true in both cases. It was also anticipated that lay and trained participants would be equally confident of the instructions given by their fellow caregiver, yet trained participants were less confident. The results from this study have impacts on the design of instructions (often by formal caregivers) for informal caregivers.

Using a Direct Observation Tool (TOC-CEX) to Standardize Transitions of Care by Residents at a Community Hospital.

Background: High-quality transitions of care are crucial for patient safety in hospitals, yet few undergraduate curricula include transition-of-care training. In 2012, the Wayne State University Office of Graduate Medical Education (WSUGME) required its residency programs to use the SAIF-IR mnemonic (summary, active issues, if-then contingency planning, follow-up activities, interactive questioning, readback) to ensure accurate and uniform handoffs. Subsequent program evaluations indicated that resident awareness and adoption of the mnemonic at our primary clinical site, Ascension Providence Rochester Hospital (APRH), could be improved. According to our institution's 2016 Clinical Learning Environment Review (CLER), 88% of residents reported following a standardized transition of care handoff, and 53% reported that faculty rarely supervised their handoffs. A 2016 WSUGME internal survey also revealed low rates of awareness (7% to 10%) of the mandated mnemonic. WSUGME then created a direct observation tool, the Transitions of Care-Clinical Evaluation Exercise (TOC-CEX), for faculty to monitor resident skill in using the mnemonic and thus standardize transitions of care as a practice habit at APRH.Methods: Since 2014, WSUGME had relied on 2 methods for training residents in the required handoff mnemonic: (1) introduction to the SAIF-IR mnemonic during the WSUGME orientation for all interns and (2) simulations during an objective simulated handoff evaluation activity for all postgraduate year (PGY) 1s and PGY 2s. In 2017, WSUGME innovated a direct observation tool, the TOC-CEX, for adoption by faculty at APRH to assess resident knowledge of and monitor their skill in using the SAIF-IR mnemonic in 3 primary care programs. The total number of possible participants was 138, and the actual number of individuals in the sample was 95. A majority (86%) of the observations during the study period were of PGY 1 residents, and thus the analysis reflects the ratings of 99% of all interns but only 69% of all possible residents.Results: WSUGME found that faculty use of a direct observation instrument in the clinical learning environment during 2017-2019 increased awareness and adoption of the SAIF-IR mnemonic among residents. Using a z-test of equal proportions on resident responses on an internal WSUGME survey, we found a significant rise in the percentage reporting yes to the question “Does your program have a mechanism for monitoring handoffs?” (χ2[3]=23.6, P<0.0001) and in the percentage identifying SAIF-IR in response to the question “Does your program endorse a specific mnemonic for organizing the contents of a verbal handoff?” (χ2[3]=45.0, P<0.0001). The increase from 2016 to 2017 is the result of the implementation of the TOC-CEX in the interim (question 1: χ2[1]=12.4, P<0.0005; question 2: χ2[1]=10.1, P<0.0025).Conclusion: Our research found that use of the TOC-CEX to monitor resident handoffs resulted in improved awareness and adoption of the SAIF-IR mnemonic in the clinical learning environment. Program leadership reported that the practice was both feasible and well accepted by residents, faculty, and the APRH chief medical officer as the TOC-CEX became a customary component of APRH organizational culture and was perceived as central to quality patient care.

AneSBAR Handoff Rubric for Nurse Anesthesia Students

BackgroundPoorly executed handoffs, particularly those omitting important clinical information or conveying ambiguous instructions, increase the risk of adverse events among anesthetized patients. Currently, there are no specific standards for the training and assessment of anesthesia care handoff among student registered nurse anesthetists. The Anesthesia SBAR (AneSBAR) Handoff Rubric was developed to assess nurse anesthesia students on their SBAR (Situation, Background, Assessment, Recommendation) reporting skills. MethodNine anesthesia professionals participated in instrument validation. Thirty-four nurse anesthesia students participated in simulations involving patient handoff. Anesthesia professionals were surveyed on validity of the rubric. Nurse anesthesia students practiced simulated performances of surgical patient handoff and were rated using the rubric. ResultsThe rubric was determined reliable and valid. ConclusionThe AneSBAR Rubric may be useful to teach, assess, and implement in simulation as a cognitive aid to assure complete and accurate transfer of patient information.

Using Peer Feedback to Promote Clinical Excellence in Hospital Medicine.

Hospitalists provide a significant amount of direct clinical care in both academic and community hospitals. Peer feedback is a potentially underutilized and low resource method for improving clinical performance, which lends itself well to the frequent patient care handoffs that occur in the practice of hospital medicine. We review current literature on peer feedback to provide an overview of this performance improvement tool, briefly describe its incorporation into multi-source clinical performance appraisals across disciplines, highlight how peer feedback is currently used in hospital medicine, and present practical steps for hospital medicine programs to implement peer feedback to foster clinical excellence among their clinicians.

I-PASS Mentored Implementation Handoff Curriculum: Frontline Provider Training Materials.

IntroductionThe I-PASS Handoff Program is a comprehensive handoff curriculum that has been shown to decrease rates of medical errors and adverse events during patient handoffs. Frontline providers are the key individuals participating in handoffs of patient care. It is important they receive robust handoff training.MethodsThe I-PASS Mentored Implementation Handoff Curriculum frontline provider training materials were created as part of the original I-PASS Study and adapted for the Society of Hospital Medicine (SHM) I-PASS Mentored Implementation Program. The adapted materials embrace a flipped classroom approach with an emphasis on adult learning theory principles. The training includes an overview of I-PASS handoff techniques, TeamSTEPPS team communication strategies, verbal handoff simulation scenarios, and a printed handoff document exercise.ResultsAs part of the SHM I-PASS Mentored Implementation Program, 2,735 frontline providers were trained at 32 study sites (16 adult and 16 pediatric) across North America. At the end of their training, 1,762 frontline providers completed the workshop evaluation form (64% response rate). After receiving the training, over 90% agreed/strongly agreed that they were able to distinguish a good- from a poor-quality handoff, articulate the elements of the I-PASS mnemonic, construct a high-quality patient summary, advocate for an appropriate environment for handoffs, and participate in handoff simulations. Universally, the training provided them with knowledge and skills relevant to their patient care activities.DiscussionThe I-PASS frontline training materials were rated highly by those trained and are an integral part of a successful I-PASS Handoff Program implementation.