Handoff Practices Research Articles

Interprofessional Training and Communication Practices Among Clinicians in the Postoperative ICU Handoff

Operating room (OR)-to-ICU handoffs require coordinated communication between clinicians with different professional backgrounds. However, individual studies have not simultaneously evaluated handoff training and OR-to-ICU handoff practices among interprofessional clinicians that participate in these team-based handoffs. The objective of this study was to characterize communication training, practices, and preferences of interprofessional clinicians who engage in OR-to-ICU handoffs. The researchers conducted a mixed methods cohort study using surveys (quantitative) and semistructured interviews (qualitative). Surveys aimed to quantitatively assess the quality of prior handoff training, preferences for clinical information in handoffs, and participation in various handoff activities. Interviews aimed to elicit more in-depth clinician perspectives on these topics through open-ended discussion. The frontline clinicians who were surveyed and interviewed included surgery and anesthesia residents, registered nurses, and advanced practice providers who worked in two ICUs at an urban academic medical center in the United States. In a survey with a 71.8% response rate (130/181), 45.7% (32/70) of residents, 17.4% (4/23) of certified registered nurse anesthetists (CRNAs), 83.3% (10/12) of ICU nurse practitioners (NPs), and 81.0% (17/21) of ICU RNs indicated that their clinical degree-granting education had not provided adequate preparation for OR-to-ICU handoffs. On-the-job training was deemed not adequate preparation by 35.7% (25/70) of residents, 21.7% (5/23) of CRNAs, 58.3% (7/12) of ICU NPs, and 23.8% (5/21) of ICU RNs. Through 30 semistructured interviews, clinicians from all professions expressed interest in interprofessional communication education and in understanding the perspectives and priorities of care team members in OR-to-ICU handoffs. Clinicians also highlighted the potential value of interprofessional communication training taking place early in a clinical career, during degree-granting education. Clinicians exhibit profession-based differences in OR-to-ICU handoff training, practices, and information needs. Education focused on interprofessional communication is a potential approach to facilitate improved OR-to-ICU handoff communication.

Inter-shift handoff: Changes over a 6-year interval.

To capture inter-shift handoff changes over a 6-year interval and to verify whether the handoff supporting system and aids (e.g., guidelines, training, and protocols) and environment really affect handoff performance. A non-experimental cross-sectional research design. Data from the 2017 and 2011 surveys were used for comparisons. A questionnaire survey was conducted among nursing staff in 31 general hospitals in 2017 and 4,282 staff responses were collected from inpatient wards such as internal medicine and surgery, the intensive care unit, emergency department and operating room. These were compared with the 1,182 responses collected in the previous 2011 survey. Changes in the 6-year interval included the introduction of handoff guidelines and increased provision of training. The handoff approach changed significantly and relied more on electronic systems, especially in inpatient wards. However, there was no significant improvement in interruptions. Information transfer improvement was limited and only observed in the surgery wards. Significant correlations verified that in hospitals where nursing staff more positively evaluated the effectiveness of the guidelines, faced fewer interruptions and had more time, handoff performance was better overall, and a higher frequency of sufficient information transfer was evident. Although the inter-shift handoff supporting system had great changes, improvement of information transfer occurred only in the surgery wards and was limited. It was verified that more effective handoff guidelines and a better handoff environment contributed significantly to improving inter-shift handoff performance. This study addressed the question as to whether inter-shift handoffs have really improved. The answer is yes, but in a limited way. Based on the survey results and handoff practices in Japanese hospitals, a mixed approach (verbal, written, technological) is suggested for inter-shift handoffs. In addition, it is important to improve the current handoff procedures, guidelines and training.

Handover Practices in Trauma and Acute Care Surgery: A Multicenter Survey Study

BackgroundThe handover period has been identified as a particularly vulnerable period for communication breakdown leading to patient safety events. Clear and concise handover is especially critical in high-acuity care settings such as trauma, emergency general surgery, and surgical critical care. There is no consensus for the most effective and efficient means of evaluating or performing handover in this population. We aimed to characterize the current handover practices and perceptions in trauma and acute care surgery. MethodsA survey was sent to 2265 members of the Eastern Association for the Surgery of Trauma via email regarding handoff practices at their institution. Respondents were queried regarding their practice setting, average census, level of trauma center, and patients (trauma, emergency general surgery, and/or intensive care). Data regarding handover practices were gathered including frequency of handover, attendees, duration, timing, and formality. Finally, perceptions of handover including provider satisfaction, desire for improvement, and effectiveness were collected. ResultsThree hundred eighty surveys (17.1%) were completed. The majority (73.4%) of respondents practiced at level 1 trauma centers (58.9%) and were trauma/emergency general surgeons (86.5%). Thirty-five percent of respondents reported a formalized handover and 52% used a standardized tool for handover. Only 18% of respondents had ever received formal training, but most (51.6%) thought this training would be helpful. Eighty-one percent of all providers felt handover was essential for patient care, and 77% felt it prevented harm. Seventy-two percent thought their handover practice needed improvement, and this was more common as the average patient census increased. The most common suggestions for improvement were shorter and more concise handover (41.6%), different handover medium (24.5%), and adding verbal communication (13.9%). ConclusionTrauma and emergency general surgeons perceive handover as essential for patient care and the majority desire improvement of their current handover practices. Methods identified to improve the handover process include standardization, simplification, and verbal interaction, which allows for shared understanding. Formal education and best practice guidelines should be developed.

Factors associated with discharge opioid prescription after hip fracture fixation.

Opioid prescribing after hip fracture fixation is variable, but the factors that drive this prescribing variation are not well-described. The purpose of this study was to determine independent factors associated with increased opioid prescription upon discharge after hip fracture fixation. A retrospective cohort study of 296 adult patients who underwent hip fracture fixation between January 2016 and December 2017 at two Level I trauma centers were included in our study. The primary outcome measurement was opioid prescription at discharge in morphine milligram equivalents (MME). Bivariate analysis was used to screen for factors, and multivariable regression analysis was used to identify independent factors associated with opioid prescription upon discharge from the hospital. Discharge opioid prescription amounts were available for 280 out of 296 patients (95%). The mean (±standard deviation) discharge opioid prescription was 212 (±319) MME. Multivariable regression analysis showed that younger age (p = 0.004), diabetes mellitus (p = 0.02), smoking (p < 0.001), treatment at hospital #2 (p < 0.001), and weekend discharge (p = 0.03) were associated with increased opioid prescription at discharge. Increased opioid prescribing after hip fracture fixation is associated with patient- and system-related factors. Prescriber education programs, prescription guidelines, and safe handoff practices that focus on these factors may help to decrease prescription variability and opioid overprescription across institutions.

Developing an emergency medicine handoff tool: an electronic Delphi approach

BackgroundHandoffs at the end of clinical shifts occur with high frequencies in the emergency department setting and they pose an increased risk to patients. There is a need to standardize handoff practices. This study aimed to use an electronic Delphi method to identify the core elements essential for an emergency department physician to physician handoff and propose a framework for implementation.MethodsAn electronic Delphi-style study with a national panel of board-certified emergency physicians in Saudi Arabia. The panel was conducted over four rounds. The first to identify elements relevant to the end of shift handoff and categorize them into domains, while the remaining three to score and debate individual elements.ResultsTwenty-five board-certified emergency physicians from various cities and practice settings were enrolled. All panelists completed the entire Delphi process. Thirty-two elements were identified and classified into 4 domains. The top five rated handoff elements were patient identification, chief complaint history, clinical stability, working diagnosis, and consulting services involved. Panel scores showed convergence as rounds progressed and the final list of elements had a high-reliability score (Cronbach’s alpha 0.93).ConclusionsThis study yielded an itemized and ranked list of elements that are easy to implement and could be used to standardize patient handoffs by emergency physicians. While this study was conducted on an emergency medicine panel, the methods used may be adapted to develop standardized handoff frameworks that serve different disciplines or practice settings.

An Implementation Science Approach to Handoff Redesign in a Cardiac Surgery Intensive Care Unit

The ability of handoff redesign to improve short-term outcomes is well established, yet an effective approach for achieving widespread adoption is unknown. An implementation science-based approach capable of influencing the leading indicators of widespread adoption was used to redesign handoffs from the cardiac operating room to the intensive care unit. A transdisciplinary, unit-based team used a 12-step implementation process. The steps were divided into 4 phases: planning, engaging, executing, and evaluating. Based on unit-determined best practices, a "handoff bundle" was designed. This included team training, structured education with video illustration, and cognitive aids. Fidelity and acceptability were measured before, during, and after the handoff bundle was deployed. Redesign and implementation of the handoff process occurred over 12 months. Multiple rapid-cycle process improvements led to reductions in the handoff duration from 12.6 minutes to 10.7 minutes (P < .014). Fidelity to unit-determined handoff best practices was assessed based on a sample of the cardiac surgery population preimplantation and postimplementation. Twenty-three handoff best practices (information and tasks) demonstrated improvements compared with the preimplementation period. Provider satisfaction scores 2.5 years after implementation remained high compared with the redesign phase (87 vs. 84; P= .133). The use of an implementation-based approach for handoff redesign can be effective for improving the leading indicators of successful adoption of a structured handoff process. Future quality improvement studies addressing sustainability and widespread adoption of this approach appear to be warranted, and should include the relationships to improved care coordination and reduced preventable medical errors.

Improving end-of-rotation transitions of care among ICU patients

BackgroundHospitalised patients whose inpatient teams rotate off service experience increased mortality related to end-of-rotation care transitions, yet standardised handoff practices are lacking.ObjectiveDevelop and implement a multidisciplinary patient-centred handoff intervention to...

Consensus Recommendations for the Conduct, Training, Implementation, and Research of Perioperative Handoffs.

Consensus Recommendations for the Conduct, Training, Implementation, and Research of Perioperative Handoffs.

Strengthening district healthcare in rural Africa: a cross-sectional survey assessing difficulties in pulse oximetry use and handoff practices

Background: Rural hospitals in sub-Saharan Africa suffer from numerous disparities in resources and practices, and subsequently patient care is affected.Methods: In order to assess current practices and opportunities for improvement in pulse oximetry use and patient-care handoffs, a cross-sectional survey was administered to clinicians at a referral level hospital serving a large rural area in Shinyanga, Tanzania.Results: Respondents (n=46) included nurses (50%), medical doctors (48%), and clinical officers (2%). A response rate of 92% was achieved, and 81% of clinicians acknowledged routine difficulties in the use of current devices when obtaining pulse oximetry. Although 83% of respondents reported using a written handoff at shift change, information reporting was inconsistent and rarely included specific management guidance.Conclusions: Further research is needed to elucidate handoff practices in developing settings, but there is a large opportunity for novel point-of-care devices and tools to improve both pulse oximetry use and patient care handoffs in rural Africa.

I-PASS Mentored Implementation Handoff Curriculum: Implementation Guide and Resources.

Communication failures during shift-to-shift handoffs of patient care have been identified as a leading cause of adverse events in health care institutions. The I-PASS Handoff Program is a comprehensive handoff program that has been shown to decrease rates of medical errors and adverse events. As part of the spread and adaptation of this program, a comprehensive implementation guide was created to assist individuals in the implementation process. The I-PASS Mentored Implementation Guide grew out of materials created for the original I-PASS Study, Society of Hospital Medicine (SHM) mentored implementation programs, and the experience of members of the I-PASS Study Group. The guide provides a comprehensive framework of all elements required to implement the large-scale I-PASS Handoff Program and contains detailed information on generating institutional support, training activities, a campaign, measuring impact, and sustaining the program. Thirty-two sites across North America utilized the guide as part of the SHM program. The guide served as a main reference for 477 hours of mentoring phone calls between site leads and their mentors. Postprogram surveys from wave 2 sites revealed that 85% (N = 34) of respondents felt the quality of the guide was very good/excellent. Site leads noted that they referenced the guide most often during the early part of the program and that they referenced the sections on the curriculum and handoff observations most often. The I-PASS Mentored Implementation Guide is an essential resource for those looking to implement the large-scale I-PASS Handoff Program at their institution.

Nurses' handoff and patient safety culture in perinatal care units

To examine nursing handoff, identify causes of handoff errors, evaluate current methods of handoff and determine the factors associated with handoff evaluation in delivery rooms and neonatal units of hospitals in South Korea. Handoff is a critical communication process in clinical settings. Less attention has been paid to the handoff practice to assure safe perinatal care in hospitals. This is a cross-sectional descriptive study. A total of 291 nurses participated in the study. They completed a set of self-reporting questionnaires containing five instruments that evaluated demographic data and current handoff strategies, experience of handoff error, causes of handoff error, perception of patient safety culture and handoff evaluation. The responses were analysed using descriptive statistics and stepwise regression modelling. Perception of patient safety culture was positively related to handoff evaluation, while experience and causes of handoff error were negatively related to handoff evaluation. A regression analysis showed that degree of cooperation among departments and units, reasonable communication and processes, and frequency of reported medical errors were positively related to handoff evaluation and the lack of documented guidelines or checklists was negatively associated with handoff evaluation. This study suggests that hospitals should develop a standardised handoff checklist according to documented guidelines, promote cooperation among hospital units and departments, enhance communication and clarify work processes to achieve safer care to create an affirmative culture that encourages reporting of errors to keep patients safe. This study highlights the importance of standardising handoff process and systems, promoting communication and cooperating with each other to foster patient safety culture in perinatal care units.

A Survey of Patient Care Handoff and Sign-Out Practices Among Podiatric Surgical Residency Programs.

A patient "handoff," or the "sign-out" process, is an episode during which the responsibility of a patient transitions from one health-care provider to another. These are important events that affect patient safety, particularly because a significant proportion of adverse events have been associated with a relative lack of physician communication. The objective of this investigation was to survey podiatric surgical residency programs with respect to patient care handoff and sign-out practices. A survey was initially developed and subsequently administered to the chief residents of 40 Council on Podiatric Medical Education-approved podiatric surgical residency programs attempting to elucidate patient care handoff protocols and procedures and on-call practices. Although it was most common for patient care handoffs to occur in person (60.0%), programs also reported that handoffs regularly occurred by telephone (52.5%) and with no direct personal communication whatsoever other than the electronic passing of information (50.0%). In fact, 27.5% of programs reported that their most common means of patient care handoff was without direct resident communication and was instead purely electronic. We observed that few residents reported receiving formal education or assessment/feedback (17.5%) regarding their handoff proficiency, and only 5.0% of programs reported that attending physicians regularly took part in the handoff/sign-out process. Although most programs felt that their sign-out practices were safe and effective, 67.5% also believed that their process could be improved. These results provide unique information on a potentially underappreciated aspect of podiatric medical education and might point to some common deficiencies regarding the development of interprofessional communication within our profession during residency training.

Mindful EM

patient sign-out: patient sign-outFigureFigureOne of the most dangerous procedures we perform is the patient handoff. Every sign-out from emergency physician to emergency physician carries a risk to the patient and liability to the outgoing and incoming care teams. Patient handoff in the emergency department is analogous to passing the baton in a relay race. Transitioning care is passing the baton of responsibility from one physician or team to the next while minimizing distractions and impediments to ED flow. The emergency physician is prone to cognitive errors because of numerous environmental factors, including frequent distractions, interruptions, loud noises, and phone calls, as well as the complexity and diversity of diseases and conditions in our patients. Physician attributes are also associated with errors during sign-out. Physician decision fatigue is more likely to occur at the end of shift, while an incoming physician is more likely to fall into cognitive error traps such as diagnosis momentum. Recent literature highlights the great variability in handoff practices and our assessment of implementing these procedures. It is surprising that not all ED groups and emergency medicine training programs have systems to avoid errors during sign-out given the dangers and risks of sign-out. Most concerning is that a large group of residents is learning this skill informally and with great variability among programs. Would we accept similar training and outcomes for educating our trainees in airway management? A cross-sectional study investigating handoff practices from emergency physician to emergency physician in academic programs found that more than half of the respondents had a standardized system in place for sign-out, which was an improvement from a comparison study in 2011 when only 43 percent did. The authors still concluded that communication still has room for improvement in education and practice. (Acad Emerg Med 2016;23[2]:197.) Most research on handoffs is centered around emergency to inpatient communication. (West J Emerg Med 2017;18[1]:86.) The most common algorithms used are SBAR and IPASS. ACEP has made available a Safer Sign-Out form, which is to be used for EP-to-EP handoffs and provides recommendations for sign-out procedures. (http://bit.ly/2BcKs2r.) These are made up of the five Rs: record, review, round, relay to the nurse/team, and receive feedback. Using the sign-out form, the incoming EPs have the oportunity to record information about results and outcomes that can be followed up by the outgoing team. Less discussed in the literature is physician resistance to implenting effective handoff procedures and the frequent malignant narratives around the sign-out process. Despite the availability of sign-out forms and algorithms, each ED has its own sign-out culture, and each practioner has his own approach. We came up with several recommendations to troubleshoot dangerous transitions that we think can augment the utility and success of an already established handoff process. DO: Recognize the vulnerability to error that occurs during sign-out. Ensure the outgoing doctor introduces the incoming team to the patient and reviews the current workup and plan together, involving the patient. Make sure the incoming and outgoing teams are on the same page. Involve nursing in rounds and the sign-out process. Ensure the incoming doctor arrives early for shifts and becomes familiar with the board prior to receiving sign-out. Be kind to the outgoing doctor; she has worked a long shift and needs to know she is leaving the ED in good hands. DON'T: Don't rush the person giving sign-out. Expect that sign-out will take time. Don't demand the outgoing doctor stay past his shift for trivialities. Don't delay seeing a patient who was endorsed to you. Don't fall into common diagnostic error traps, such as diagnostic momentum that can occur during the sign-out process. In an ideal sign-out, there would be a checklist and overlapping shifts, allowing enough time for the outgoing and incoming physicians to go to the bedside and make sure they are on the same page. During a sign-out, the incoming team should be introduced to the patient and the patient updated on her care plan. This is a good time to involve the patient in his care. Preferably, the entire team would be involved in the sign-out process: physicians, nurses, technicians, residents, pharmacy, and respiratory therapy. Unfortunately, this may not be feasible given the constant influx of new patients and high turnaround. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

Handoff communication in intensive care: links with patient safety

Abstract Objective: To gather scientific evidence about ICU handoff practices and their implications on the safety of communication among team members about hospitalized patients. Method: This was an integrative review conducted in the Medline, PubMed, Cinahl and Scopus databases with the descriptors patient handoff, communication, patient safety, critical care, health communication and intensive care unit. The adopted criteria were: full text, in Portuguese or English, in the last 10 years, with level of evidence over IV and compliance to the study question. Fifteen articles were submitted to a structured tool and analysis. Results: There is evidence of incompleteness, absence or errors in handoff information, caused by the lack of standardization and preparation for this activity, generating delayed, incorrect or non-performed procedures. The use of tools reduces the amount of omitted information, side talks, and errors, improving team satisfaction. Final considerations: It is necessary to promote safe communication in handoff, implementing practices that ensure care continuity.

Standardization of Post-operative Hand-off Practices in the Pediatric Icu: A Quality Improvement Project

Standardization of Post-operative Hand-off Practices in the Pediatric Icu: A Quality Improvement Project

Formalizing Radiation Oncology Patient Handoff: The GRAY System

Effective transitions of care are vital to patient safety and treatment quality. Inpatient services, which have multiple provider changes daily, have implemented formal patient handoff systems in recent years. However, these systems do not address transition of care issues in Radiation Oncology, where residents typically manage a cohort of patients for several months before handing off to an oncoming resident. Thus, we surveyed and propose a specific method for patient handoff in Radiation Oncology: The GRAY System (General, Review Status, Active Issues, Your Questions?). A survey with questions tailored to understanding current handoff practices in residency programs was distributed to radiation oncology residents and program directors nationwide. Responses were recorded anonymously and used to create a novel handoff system that incorporates the unique demands of the field. 74 surveys were collected from trainees (PGY 2-6) as well as three residency program directors. All respondents answered that a typical rotation at their program was 2-3 months. Use of some form of patient handoff at the end of rotations was reported by 58% (n=42) of respondents. All use an electronic medical record (EMR). When asked how important a formalized process is in Radiation Oncology on a scale of 1-5 (1=least, 5=most), 73% (n=54) answered 3 or higher. Deficient patient handoff was reported to cause issues with patient care according to 42% (n=31), and several (n=16) estimated at least 25% of patients were at risk for care lapses. In a free response question asking what factors were most important for effective handoff, common responses included dedicated sign-out time, concise patient summaries, and a list of pertinent patient issues that may affect treatment. Despite the majority of respondents answering that a formalized transition of care process is important in radiation oncology, only about half of respondents reported utilizing it with an estimated ¼ of patients at risk for care lapses. Because of these deficiencies and the drive towards patient safety and quality, we propose the GRAY System to formalize the patient handoff process in Radiation Oncology. “General” will include a one-sentence summary of patient details (age, sex, stage, histology, location, treatment technique, and prescribed or expected dose/fractionation). “Review status” describes the patient’s status in the treatment process (upcoming CT sim with date, in Physics/Dosimetry for planning, treatment #x/y, and expected end of treatment date). “Active issues” will include a concise list of active patient issues (comorbidities, social issues, labs, treatment breaks, impending boost planning). “Your questions?” will prompt the handoff receiver to ask any questions. We anticipate the GRAY system may streamline patient handoff, reduce the likelihood of care lapses, and provide easily traceable data for future analyses.

Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.

Hospitals have struggled for years regarding the handoff process of communicating patient information from one health care professional to another. Ineffective handoff communication is recognized as a serious patient safety risk within the health care community. It is essential to take communication into consideration when examining the safety of neonates who require immediate medical attention after birth; effective communication is vital for positive patient outcomes, especially with neonates in a delivery room setting. Teamwork and effective communication across the health care continuum are essential for providing efficient, quality care that leads to favorable patient outcomes. Interprofessional simulation and team training can benefit health care professionals by improving interprofessional competence, defined as one’s knowledge of other professionals including an understanding of their training and skillsets, and role clarity. Interprofessional teams that include members with specialization in obstetrics, gynecology, and neonatology have the potential to considerably benefit from training effective handoff and communication practices that would ensure the safety of the neonate upon birth. We must strive to provide the most comprehensive systematic, standardized, interprofessional handoff communication training sessions for such teams, through Graduate Medical Education and Continuing Medical Education that will meet the needs across the educational continuum.

Year-End Clinic Handoffs: A National Survey of Academic Internal Medicine Programs.

While there has been increasing emphasis and innovation nationwide in training residents in inpatient handoffs, very little is known about the practice and preparation for year-end clinic handoffs of residency outpatient continuity practices. Thus, the latter remains an identified, yet nationally unaddressed, patient safety concern. The 2014 annual Association of Program Directors in Internal Medicine (APDIM) survey included seven items for assessing the current year-end clinic handoff practices of internal medicine residency programs throughout the country. Nationwide survey. All internal medicine program directors registered with APDIM. Descriptive statistics of programs and tools used to formulate a year-end handoff in the ambulatory setting, methods for evaluating the process, patient safety and quality measures incorporated within the process, and barriers to conducting year-end handoffs. Of the 361 APDIM member programs, 214 (59%) completed the Transitions of Care Year-End Clinic Handoffs section of the survey. Only 34% of respondent programs reported having a year-end ambulatory handoff system, and 4% reported assessing residents for competency in this area. The top three barriers to developing a year-end handoff system were insufficient overlap between graduating and incoming residents, inability to schedule patients with new residents in advance, and time constraints for residents, attendings, and support staff. Most internal medicine programs do not have a year-end clinic handoff system in place. Greater attention to clinic handoffs and resident assessment of this care transition is needed.

Exploring Physician Perspectives of Residency Holdover Handoffs: A Qualitative Study to Understand an Increasingly Important Type of Handoff.

The term "holdover admissions" refers to patients admitted by an overnight physician and whose care is then transferred to a new primary team the next morning. Descriptions of the holdover process in internal medicine are sparse. To identify important factors affecting the quality of holdover handoffs at an internal medicine (IM) residency program and to compare them to previously identified factors for other handoffs. We undertook a qualitative study using structured focus groups and interviews. We analyzed data using qualitative content analysis. IM residents, IM program directors, and hospitalists at a large academic medical center. A nine-question open-ended interview guide. We identified 13 factors describing holdover handoffs. Five factors-physical space, standardization, task accountability, closed-loop verification, and resilience-were similar to those described in prior handoff literature in other specialties. Eight factors were new concepts that may uniquely affect the quality of the holdover handoff in IM. These included electronic health record access, redundancy, unwritten thoughts, different clinician needs, diagnostic uncertainty, anchoring, teaching, and feedback. These factors were organized into five overarching themes: physical environment, information transfer, responsibility, clinical reasoning, and education. The holdover handoff in IM is complex and has unique considerations for achieving high quality. Further exploration of safe, efficient, and educational holdover handoff practices is necessary.

Implementing standardized, inter-unit communication in an international setting: handoff of patients from emergency medicine to internal medicine.

Standardized handoffs may reduce communication errors, but research on handoff in community and international settings is lacking. Our study at a community hospital in the United Arab Emirates characterizes existing handoff practices for admitted patients from emergency medicine (EM) to internal medicine (IM), develops a standardized handoff tool, and assesses its impact on communication and physician perceptions. EM physicians completed a survey regarding handoff practices and expectations. Trained observers utilized a checklist based on the Systems Engineering Initiative for Patient Safety model to observe 40 handoffs. EM and IM physicians collaboratively developed a written tool encouraging bedside handoff of admitted patients. After the intervention, surveys of EM physicians and 40 observations were subsequently repeated. 77.5% of initial observed handoffs occurred face-to-face, with 42.5% at bedside, and in four different languages. Most survey respondents considered face-to-face handoff ideal. Respondents noted 9-13 patients suffering harm due to handoff in the prior month. After handoff tool implementation, 97.5% of observed handoffs occurred face-to-face (versus 77.5%, p=0.014), with 82.5% at bedside (versus 42.5%, p<0.001), and all in English. Handoff was streamlined from 7 possible pathways to 3. Most post-intervention survey respondents reported improved workflow (77.8%) and safety (83.3%); none reported patient harm. Respondents and observers noted reduced inefficiency (p<0.05). Our standardized tool increased face-to-face and bedside handoff, positively impacted workflow, and increased perceptions of safety by EM physicians in an international, non-academic setting. Our three-step approach can be applied towards developing standardized, context-specific inter-specialty handoff in a variety of settings.