'Warm' Handoffs Better at End of Rotation, Residents Say

Norra MacReady

August 22, 2017

A "warm handoff" protocol consisting of in-person meetings between incoming and outgoing residents, shared rounds, and use of a bedside rounding checklist improved the incoming clinicians' comfort level with patients and was perceived by the overwhelming majority of participating residents to be safer for patients, researchers report.

The effect on patient outcomes is still uncertain, but "it is clear that residents perceive warm handoffs as a safer way to transition care at the time of service change and rate the exercise as a valuable use of their time," the authors explain.

The residents felt this way even though the new protocol added as much as an hour or more to their working day.

Harry S. Saag, MD, from the Department of General Internal Medicine and Clinical Innovation, New York University Langone Medical Center and New York University School of Medicine, New York City, and colleagues report their findings in an article published online August 14 in the Journal of General Internal Medicine.

A New Approach

Shift-to-shift handoffs are associated with drawbacks such as delayed diagnoses, increased diagnostic testing, and adverse outcomes, the authors explain. End-of-rotation handoffs are associated with even greater dangers, including possibly higher patient mortality, as reported by Medscape Medical News. Yet there is little standardization on how best to handle these care transitions, the authors note. "Strategies that improve end-of-rotation handoffs are urgently needed to address this potentially serious gap in clinical care."

The researchers developed a protocol to test the idea that "unambiguous, face-to-face communication between providers" would improve the handoff process. Starting in July, 2015, postgraduate year (PGY) 2 and PGY 3 residents at three training sites began using a "warm handoff" process in which outgoing and incoming residents met the day before the switch to discuss each patient's medical history, hospital course, and plan, and jointly rounded on the sickest patients. They used a bedside rounding checklist developed by the researchers to help them focus on critical bedside elements such as new symptoms, discharge plans, physical examination, and mental status. All PGY 2 and PGY 3 residents underwent a 1-hour training program before implementation of the new protocol.

Perception of Greater Patient Safety

In April 2016, the authors sent an anonymous eight-question survey to all of the PGY 2 and PGY 3 residents, enquiring about their experiences with the warm handoffs. In addition, they randomly selected six residents to participate in face-to-face interviews.

Of the 99 residents who received a survey, 60 (60.6%) responded. Before the new protocol, only three (5%) said they signed out in person, either at the patient's bedside or in the hospital. The remaining 95% used verbal, written, or a combination of verbal and written signout methods. After the intervention, 55 (92%) reported participation in warm handoffs "half the time" or "almost always."

Fifty-nine of the 60 residents (98%; 95% confidence interval [CI], 95% - 100%) agreed that "end-of-rotation transitions were a vulnerable time for patients." After implementation of the protocol, 51 (85%; 95% CI, 75% - 93%) stated that the warm handoffs were safer for patients than verbal or written handoffs, and 52 (87%; 95% CI, 78% - 95%) said they had a greater knowledge and comfort level caring for patients using warm handoffs (data on one resident were missing).

Although 57 (95%) of the respondents reported that warm handoffs added anywhere from 30 to more than 60 minutes to their workday, 53 (88%; 95% CI, 80%-95%) agreed they were still worthwhile.

Overall, "[p]erception of improved patient safety was associated with residents' improved sense of preparedness (p < .001) as compared to prior handoff techniques and residents' perception of warm handoffs as a worthwhile intervention (p < .001)," the authors write.

Residents participating in the interviews cited the ability to see patients in person and conduct a baseline examination as a particularly helpful feature of the warm handoff. They also liked the in-person communication with the outgoing resident. Disadvantages included time limitations and interruptions during the handoffs, which occurred during their shift.

Study limitations included the inability to survey all of the eligible residents, no monitoring or supervision of the warm handoffs, and the retrospective nature of the study, plus its focus on a single residency program.

Also, the authors warn, the study did not look at patient outcomes. "Further studies will need to assess whether this perceived increase in safety translates to safer outcomes for patients."

The authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online August 14, 2017. Abstract

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