Handoff Quality Research Articles

A pilot study to standardize and peer-review shift handoffs in an academic internal medicine residency program: The DOCFISH method.

With increased oversight of residency work hours, there has been an increase in shift handoffs, which are prone to medical errors. To date, there are no evidence-based recommendations on essential elements of shift handoffs. We implemented a standardized shift-handoff rubric at an academic medicine residency program. Compliance, resident/faculty perceptions, and surrogate markers of patient safety were measured.Shift-handoff documents were collected January-February 2016 (control) April-June 2016 (intervention). Signouts were scored based on inclusion of seven elements: Daily events, Overnight events, Code status, Follow up tasks, If/then statements, ‘sick or stable’ and History present illness. The mnemonic ‘DOCFISH’ was taught in a grand-rounds forum then embedded into a shift-handoff tool within our electronic health record (EHR). Senior residents were assigned to supervise/provide feedback on shift handoffs from April-June 2016. Faculty and resident perceptions regarding quality of shift handoffs was measured by the annual ACGME (Accreditation Council Graduate Medical Education) program survey.Patient safety was measured by number of rapid-response teams (RRT) initiated for unstable vital signs. Handoffs were 74% complete in intervention group and 60% in control group (p < .0001). Median DOCFISH features present in patients that required RRT was 3 of 7 whereas, total post-intervention group had 5 of 7 (p < .001). ‘Daily events’ and ‘follow -up tasks’ were less frequent in patients that required RRT (20%, 67% respectively, p < .001).Academic medical centers can implement standardized shift handoffs by embedding high-yield information in an EHR with peer-review. Information during shift changes that may have significant improvement on patient safety includes: ‘daily events’ and ‘follow -up tasks.’

Waterfalls and Handoffs: A Novel Physician Staffing Model to Decrease Handoffs in a Pediatric Emergency Department

Patient handoffs at shift change in the emergency department (ED) are a well-known risk point for patient safety. Numerous methods have been implemented and studied to improve the quality of handoffs to mitigate this risk. However, few have investigated processes designed to decrease the number of handoffs. Our objective is to evaluate a novel attending physician staffing model in an academic pediatric ED that was designed to decrease patient handoffs. A multidisciplinary team met in August 2012 to redesign the attending physician staffing model. The team sought to decrease patient handoffs, optimize provider efficiency, and balance workload without increasing total attending physician hours. The original model required multiple handoffs at shift change. This was replaced with overlapping "waterfall" shifts. This was a retrospective quality improvement study of a process change that evaluated the percentage of intradepartmental handoffs before and after implementation of a new novel attending physician staffing model. In addition, surveys were conducted among attending physicians and charge nurses to inquire about perceived impacts of the change. A total of 43,835 patient encounters were analyzed. Immediately after implementation of the new model, there was a 25% reduction in the proportion of encounters with patient handoffs, from 7.9% to 5.9%. A survey of physicians and charge nurses demonstrated improved perceptions of patient safety, ED flow, and job satisfaction. This new emergency physician staffing model with overlapping shifts decreased the proportion of patient handoffs. This innovative system can be implemented and scaled to suit EDs that have more than single-physician coverage.

Investigating Intraoperative and Intraprofessional Handoffs in Anesthesia

Handoffs occur frequently in healthcare systems, and miscommunications and critical omissions within handoffs have been linked to serious medical errors. Handoff quality is a priority of patient safety initiatives across several international organizations. The majority of previous research in handoffs have focused on postoperative handoffs; yet, there is a need to specifically investigate intraoperative handoffs, especially within individual professions or subspecialties. Each subspecialty within a surgical team may approach handoffs differently. The anesthesia team is especially unique as they take a team-based approach to patient care where multiple anesthesia providers may be involved in one surgical case. We describe an observational study of intraoperative and intraprofessional handoffs in anesthesia. Temporary and permanent handoffs were investigated as well as the contextual elements that influenced handoff procedures. In a sample of 35 video recorded surgeries, a total of 16 handoffs were identified for the maintenance phase of surgery. These handoffs ranged between 33 seconds and 7.42 minutes in duration. Our study revealed variability in intraoperative handoffs during the maintenance phase of anesthesia and emphasizes that intraoperative and intraprofessional handoffs warrant more in-depth examination in order to develop effective strategies or tools for high quality handoffs in anesthesia.

Videographic Assessment of the Quality of EMS to ED Handoff Communication During Pediatric Resuscitations

Background: The National Association of Emergency Medical Services (EMS) Physicians emphasizes the importance of high quality communication between EMS providers and emergency department (ED) staff for providing safe, effective care. The Joint Commission has identified ineffective handoff communication as a contributing factor in 80% of serious medical errors. The quality of handoff communication from EMS to ED teams for critically ill pediatric patients needs further exploration.Objective: This study assessed the quality of handoff communication between EMS and ED staff during pediatric medical resuscitations.Methods/Design: We conducted a retrospective review of video recordings of pediatric patients who required critical care (“resuscitation”) in the ED between January 2014 and February 2016 at a Level 1 pediatric trauma center. Handoff quality between EMS and emergency department teams was assessed for completeness, timeliness, and efficiency. Institutional review board approval was obtained.Results: Sixty-eight resuscitations were reviewed; 28% presented in cardiac arrest, requiring cardiopulmonary resuscitation (CPR). Completeness of information communicated was variable and included chief complaint (88%), prehospital interventions (81%), physical exam findings (63%), medical history (59%), age (56%), and weight (20%). Completeness of specific vital sign reporting included: respiratory rate (53%), heart rate (43%), oxygen saturation (39%), and blood pressure (31%). Timeliness of communication included median patient handoff and report times of 50 seconds [IQR 30,74] and 108 seconds [IQR 62,252], respectively. Inefficient communication occurred in 87% of handoffs, including interruptions by ED staff (51%), questions from the ED physician team leader asking for information already communicated (40%), and questions by ED physician team leader requesting information not yet communicated (65%). When comparing non-CPR to CPR cases, only timeliness of patient handoff was significantly different for those patients receiving prehospital CPR.Conclusion: Handoff communication between EMS and ED teams during pediatric resuscitation was frequently incomplete and inefficient. Future educational and quality improvement interventions could aim to improve the quality of handoff communication for this patient population.

Developing Standardized “Receiver-Driven” Handoffs Between Referring Providers and the Emergency Department: Results of a Multidisciplinary Needs Assessment

Miscommunication during patient transfers is a leading cause of medical errors. Inpatient standardization of handoff communication has been associated with reduced medical errors, but less is known about best practices for handoffs from referring providers to the emergency department (ED). The study aims were to identify (1) stakeholder perceptions of current handoff processes and (2) key handoff elements and strategies to optimize patient care on transfer. A mixed-methods needs assessment study was conducted at a tertiary care children's hospital with a communication center that receives verbal handoff via telephone from referring providers and provides written summary to the ED. ED, primary care providers, and communication center staff were surveyed to understand perceptions of handoff processes and ideal handoff elements. Focus groups were conducted to refine concepts. Descriptive statistics, chi-square analysis, and qualitative content analysis were used to analyze responses. The survey response rate was 129/152 providers (85%). Forty-two percent of respondents described the quality of the handoff process as "very good" or "excellent"; 43% reported miscommunication occurring "sometimes" or "frequently." Within the I-PASS framework-Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver-respondents identified 10 key elements to obtain through a receiver-driven process to optimize care on transfer. Free-text responses revealed a perceived need to standardize communication. A minority of providers perceived handoff quality between outpatient practices and the ED as "very good" or "excellent"; almost half perceived regular miscommunication. A receiver-driven process is a novel approach that may help ensure standardized communication of key handoff elements in this context.

Real-Time Surveys Reveal Important Safety Risks During Interhospital Care Transitions for Neurologic Emergencies.

Critically ill patients may be exposed to unique safety threats as a result of the complexity of interhospital and intrahospital transitions involving the emergency department (ED). Real-time surveys were administered to clinicians in the ED and neuroscience intensive care unit of a tertiary health care system to assess perceptions of handoff safety and quality in transitions involving critically ill neurologic patients. In all, 115 clinical surveys were conducted among 26 patient transfers. Among all clinician types, 1 in 5 respondents felt the handoff process was inadequate. Risks to patient safety during the transfer process were reported by 1 in 3 of respondents. Perceived risks were reported more frequently by nurses (44%) than physicians/advanced practice providers (28%). Real-time survey methodology appears to be a feasible and valuable, albeit resource intensive, tool to identify safety risks, expose barriers to communication, and reveal challenges not captured by traditional approaches to inform multidisciplinary quality improvement efforts.

Inter-department patient handoff quality and its contributing factors in Chinese hospitals

The aims of the current study were to obtain factors contributing to inter-department patient handoff quality and to uncover characteristics of the current handoffs from the point of view of Chinese healthcare staff. A questionnaire was developed to obtain the staff’s views on inter-department handoffs. An online questionnaire survey was conducted between December 2016 and March 2017. A total of 490 valid responses were collected from physicians, nurses, and assistant nurses. Five handoff factors were derived by applying principal component analysis with 44% of cumulative variance accounted for. Significant differences were observed across three professional groups and assistant nurses had the most negative evaluations. However, a similar trend of views was shared, i.e., they showed a good understanding of their own roles and adequate communication during handoffs. In contrast, it was observed that patient care responsibility and information were sometimes discontinued. From the point of view of staff, the overall handoff quality was mainly affected by mutual communication, the handoff system and environment. The inadequacy of information transfer frequency was reported to be higher when receiving patients than when sending patients, particularly when receiving patients from the emergency or outpatient departments. Generally, healthcare staff in China had a high estimation of the overall quality and safety of inter-department patient handoffs. However, it was observed that information and responsibility were sometimes transferred inadequately. To resolve this discontinuity, we suggest a standardized handoff process, effective use of unlicensed staff and fostering a culture of error reporting and learning.

“Workin' on Our Night Moves”: How Residents Prepare for Shift Handoffs

Poor-quality handoffs have been associated with serious patient consequences. Researchers and educators have answered the call with efforts to increase system safety and resilience by supporting handoffs using increased communication standardization. The focus on strategies for formalizing the content and delivery of patient handoffs has considerable intuitive appeal; however, broader conceptual framing is required to both improve the process and develop and implement effective measures of handoff quality. Cognitive task interviews were conducted with internal medicine and surgery residents at three geographically diverse US Department of Veterans Affairs medical centers. Thirty-five residents participated in semistructured interviews using a recent handoff as a prompt for in-depth discussion of goals, strategies, and information needs. Transcribed interview data were analyzed using thematic analysis. Six cognitive tasks emerged during handoff preparation: (1) communicating status and care plan for each patient; (2) specifying tasks for the incoming night shift; (3) anticipating questions and problems likely to arise during the night shift; (4) streamlining patient care task load for the incoming resident; (5) prioritizing problems by acuity across the patient census, and (6) ensuring accurate and current documentation. Our study advances the understanding of the influence of the cognitive tasks residents engage in as they prepare to hand off patients from day shift to night shift. Cognitive preparation for the handoff includes activities critical to effective coordination yet easily overlooked because they are not readily observable. The cognitive activities identified point to strategies for cognitive support via improved technology, organizational interventions, and enhanced training.

SUDDEN DEATH Triathlons more risky for men than marathons

SUDDEN DEATH Triathlons more risky for men than marathons

Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow

Background and objectiveHandoff communication errors are a leading source of sentinel events. We sought to determine the impact of a handoff improvement programme for nurses.MethodsWe conducted a prospective pre-post intervention...

Quality of Handoffs in Community Pharmacies.

The aims of the study were to characterize handoffs in community pharmacies and to examine factors that contribute to perceived handoff quality. A cross-sectional study of community pharmacists in a Midwest State of the United States. Self-administered questionnaires were used to collect information on participant and practice setting characteristics. Data were analyzed using descriptive statistics and multivariate logistic regression. A total of 445 completed surveys were returned (response rate, 82%). In almost half of the time, handoffs that occur in a community pharmacy setting were inaccurate or incomplete. Nearly half of the time handoffs occur in environments full of interruptions and distractions. More than 90% of the respondents indicated that they have undergone no formal training on proper ways of handing off information. Nearly 40% of respondents reported that their pharmacy dispensing technology does not have adequate functionality to support handing off information and that at least 50% of the time, poor handoffs result in additional work to the pharmacist because of the need for complete information before providing patient care. Multivariate analysis showed that being very familiar with patients, lower daily prescription volume, not having a 24-hour operation, and larger percentage of handoffs occurring in a synchronous fashion are all associated with better handoff quality. Handoffs occur frequently and are problematic in community pharmacies. Current pharmacy environments offer limited support to conduct good handoffs, and as a result, pharmacists report loss of information. This could present as a significant patient safety hazard. Future interventions should target facilitating better communication during shift changes.

A Handoffs Software Led to Fewer Errors of Omission and Better Provider Satisfaction: A Randomized Control Trial.

Computer-assisted communication is shown to prevent critical omissions ("errors") in the handoff process. The aim of the study was to study this effect and related provider satisfaction, using a standardized software. Fourteen internal medicine house officers staffed 6 days and 1 cross-covering teams were randomized to either the intervention group or control, employing usual handoff, so that handoff information was exchanged only between same-group subjects (daily, for 28 days). In the intervention group, fewer omissions (among those studied) occurred intravenous access (17 versus 422, P < 0.001), code status (1 versus 158, P < 0.001), diet/nothing per mouth (28 versus 477, P < 0.001), and deep venous thrombosis prophylaxis (17 versus 284, P < 0.001); duration to compose handoff was similar; and physicians perceived less workload adjusted for patient census and provider characteristics (P = 0.004) as well as better handoff quality (P < 0.001) and clarity (P < 0.001). The intervention was associated with fewer errors and superior provider satisfaction.

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.

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings

Handoffs represent a critical transition point in patient care that play a key role in patient safety. Our quality improvement project was a descriptive observational study aimed at standardizing pediatric...

A Vertical Handoff Method via Self-Selection Decision Tree for Internet of Vehicles

Vehicles often communicate among different networks in Internet of Vehicles (IoVs). However, existing unstable network statuses and different user preferences result in vehicle frequent vertical handoffs (VHOs). In this paper, we propose a novel VHO method based on a self-selection decision tree for IoVs. We first establish the respective handoff probability distribution of vehicles according to network attributes and movement trend. Then, based on handoff probability distributions and defined user preferences, we propose a novel handoff method by the self-selection decision tree for IoVs. Finally, we also present a feedback decision method according to the feedback of vehicle handoff, to improve next handoff quality when vehicle movement trend and vehicle service status change. Simulation results show that the proposed method not only supports the VHO among Wireless Access in Vehicular Environments, Worldwide Interoperability for Microwave Access, and third-generation cellular but also reduces switching times and ensures the network update rate and the vehicles’ service quality.

Hand overs in Emergency Medicine a point of ambiguity

Handovers in emergency department is a transfer of care of patients from one shift to another. Communication failure during this process is one the leading cause of providing a low quality handoff, which in turn result into a suboptimal care and jeopardize patient safety. In this paper we are trying to highlight this process and review some literature can aid emergency physicians to come up with a safe and effective sign out. Introduction Emergency department is a unique environment to practice medicine. Its uniqueness comes from the dynamic nature and the crucial of actions and decisions taken in an area where there is no place for error. Routinely the emergency physicians start their day by signing in at the beginning of their shift and end it by signing out. The ED`s hectic nature and the high frequency of interruptions make this communication process very difficult which in turn may result in medical errors. [1] Medical error is defined as: “a commission or omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences.” [2] Lately, medical errors and its effects on patient safety have been brought to the attention of the people and the health care providers. [3] In 1999 Kohn and Colleagues made an estimate about the number of medical errors in the United States. They found that medical errors were responsible for 44.000 to 98.000 deaths each year. [4] Most of the medical errors were found to be as a result of poor communication. [5] Deficiency in communication between physicians was noted to be as results of interruptions and the frantic atmosphere in ED. A review of literature was done to focus on the sign in-sign out process, and found that this vital step was not formal and not following any standards. In this review we will try to bring the attention and shed some light on this of crucial part emergency physicians daily routine, which in turn will result in a better safety outcome to our patients and our colleagues. Discussion The sign out or handoff process is a vital step at the beginning and ending of shifts for all emergency physicians (EPs). The importance of this process came from its ability to reduce medical error. www.jmscr.igmpublication.org Impact Factor 5.244 Index Copernicus Value: 83.27 ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: http://dx.doi.org/10.18535/jmscr/v4i8.36

Quantitative Analysis of the Content of EMS Handoff of Critically Ill and Injured Patients to the Emergency Department

Objectives: Patient handoff occurs when responsibility for patient diagnosis, treatment, or ongoing care is transferred from one healthcare professional to another. Patient handoff is an integral component of quality patient care and is increasingly identified as a potential source of medical error. However, evaluation of handoff from field providers to ED personnel is limited. We here present a quantitative analysis of the information transferred from EMS providers to ED physicians during handoff of critically ill and injured patients. Methods: This study was conducted at an urban academic medical center with an emergency department census of greater than 100,000 visits annually. All patients arriving to our institution by EMS and meeting predefined triage criteria are brought immediately to the ED resuscitation area upon EMS arrival. Handoff from EMS to ED providers occurring in the resuscitation area was observed and audio recorded by trained research assistants and subsequently coded for content. The emergency department team as well as EMS were blinded to study design. Results: Ninety patient handoffs were evaluated. In 78% (95%CI = 70.0–86.7) of all handoffs, EMS provided a chief concern. In 58% (95%CI = 47.7–67.7) of handoffs EMS provided a description of the scene and in 57% (95%CI = 46.7–66.7) they provided a complete set of vital signs. In 47% (95%CI = 31.3–57.5) of handoffs pertinent physical exam findings were described. The EMS provider gave an overall assessment of the patient's clinical status in 31% (95%CI = 21.6–40.3) of cases. Significantly more paramedic handoffs included vital signs (70% vs. 37%, χ2 = 9.69, p = 0.002) and physical exam findings (63% vs. 23%, χ2 = 14.11, p < 0.001). Paramedics were more likely to provide an overall assessment (39% vs. 17%, χ2 = 4.71, p < 0.05). Conclusions: While patient handoff is a critical component of safe and effective patient care, our study confirms previous literature demonstrating poor quality handoff from EMS to ED providers in critically ill and injured patients. Our analysis demonstrates the need for further training in the provision of patient handoff.

Handoffs in the Intensive Care Unit.

Operating room (OR) to intensive care unit (ICU) handoffs are complex and known to be associated with adverse events and patient harm. The authors hypothesized that handoff quality diminishes during nights/weekends and that bedside handoff practices are similar between ICUs of the same health system. Bedside OR-to-ICU handoffs were directly observed in 2 surgical ICUs with different patient volumes. Handoff quality measures were compared within the ICUs on weekdays versus nights/weekends as well as between the high- and moderate-volume ICUs. In the high-volume ICU, transmitter delivery scores were significantly better during off hours, while other measures were not different. High-volume ICU scores were consistently better than those in the moderate-volume ICU. Bedside handoff practices are not worse during off hours and may be better in ICUs used to a higher patient volume. Specific handoff protocols merit evaluation and training to ensure consistent practices in different ICU models and at different times.

Improving the Quality of Handoffs in Patient Care Between Critical Care Providers in the Intensive Care Unit

With the ever-increasing adoption of shift models for intensive care unit (ICU) staffing, improving shift-to-shift handoffs represents an important step in reducing medical errors. The authors developed an electronic handoff tool integrated within the existing electronic medical record to improve handoffs in an adult ICU. First, stakeholder (staff intensivists, fellows, and nurse practitioners/physician assistants) input was sought to define what elements they perceived as being essential to a quality handoff. The principal outcome measure of handoff accuracy was the concordance between data transmitted by the outgoing team and data received by the incoming team (termed as agreement). Based on stakeholder input, the authors developed the handoff tool and provided regular education on its use. Handoffs were observed before and after implementation of the tool. There was an increase in the level of agreement for tasks and other important data points handed off without an increase in the time required to complete the handoff.

P065: Surveying ED transition of care: satisfaction, awareness of risks and barriers to the implementation of a standardized protocol

Introduction: Patient handoffs have been identified as the primary cause of error affecting patient safety. The lack of standardization - and the often-avoidable errors that occur as a result - profoundly affect patient care and emergency department (ED) administration. Our study set out to evaluate emergency doctors’ awareness of these safety concerns, as well as their satisfaction with handoff practices currently used in their respective EDs. We also aimed to identify the potential barriers to the use of a standardized approach to patient transition of care. Methods: Guided by a modified Delphi method, a 29-question survey was developed by a panel of experts on patient transition of care. A printed version of the survey was distributed to ED doctors attending a local emergency medicine conference. An electronic version was subsequently distributed to all ED doctors registered as members of our provincial professional organizations. Results: We achieved a 68% response rate. Amongst the 309 participants, 51% (95%CI 44-56%) acknowledged that handoffs between emergency doctors are a frequent cause of error related to patient care. Frequent interruptions (77% (95%CI 72-82%)) and heavy workloads (73% (95%CI 68-79%)) were identified as the main factors negatively influencing the quality of handoffs. Despite 61% (95%CI 56-68%) satisfaction with the currently employed methods, 74% (95%CI 68-79%) of the respondents believe that handoffs would benefit from standardization and 83% (95%CI 79-88%) are open to changing their current practices. In addition, 53% (95%CI 48-60%) believe that the tools used for transition of care can be improved. Apprehension regarding the increase of handoff burden (86% (95%CI 81-90%)) was identified as the primary barrier to the implementation of a standardized handoff protocol. Conclusion: Doctors are generally satisfied with current handoff practices used in the ED. Nevertheless, their awareness of the possible risks associated with transition of care may be driving their openness to adapting their practice, potentially towards a more standardized approach given the conceivable benefits to patient safety. In light of these results, we aim to develop a comprehensive, standardized handoff protocol, and to evaluate its applicability in the ED with a prospective study.