How Hospitalists Can Improve Shift-to-Shift Patient Handoffs

Jennifer L.W. Fink, BSN

Disclosures

January 18, 2019

Approximately 80% of serious medical errors involve miscommunication during the transfer of care from one healthcare provider to another, according to the Joint Commission.[1] At times, important information is inadvertently omitted; a 2011 study published in Minnesota Medicine[2] found that 69% of patient handoffs between internal medicine residents were missing medication information and 22% lacked complete patient problem lists. The transfer of inaccurate information during handoffs is also problematic; the Minnesota study revealed that almost 6% of handoffs included code status errors and nearly 3% involved medication allergy errors.[2]

Miscommunication can occur on the receiving end as well. Humans, after all, are fallible. A physician who is interrupted during handoff may not remember what he is told. An overwhelmed physician may not retain information as well as an individual with a calm, uncluttered mind.

Strategies for Improving Patient Handoffs

Hospitalist physicians can improve patient care and increase efficiency by working to improve handoff communication. Here are five strategies you can use to build better handoffs.

1. Standardize

Institutions that have standardized handoff procedures have seen dramatic decreases in medical errors.[3,4] After adopting the I-PASS Handoff Bundle, an evidence-based and standardized approach to patient handoffs,12 hospitals, including 20 academic and 12 community hospitals, achieved a 47.1% reduction in major harm events and a 46.9% reduction in minor harm events.[5,6]

A cornerstone of the I-PASS Handoff Bundle is the mnemonic I-PASS, which helps clinicians remember the essential parts of an effective handoff:

  • Illness severity: a description of how sick the patient is, especially in relationship to the other patients.

  • Patient summary: a brief summary of what brought the patient to the hospital, and what's happened so far.

  • Action list: a review of next-steps in care. What should the on-coming provider do for the patient?

  • Situation awareness and contingency plans: a look ahead at what might need to be done if the patient's condition changes.

  • Synthesis by receiver: time for the oncoming provider to verbally review the information shared during handoff.

Using a standardized format for handoff communications ensures the inclusion of essential information and establishes mutual expectations. But the quality of the handoff may fluctuate according to the communication skills of the participants.

"Standardization and templates help, but many physicians still struggle with how to do a really effective verbal handoff," says Vineet Arora, MD, a hospital medicine physician and professor of medicine at University of Chicago. "More is not always better; a long handoff is not necessarily what's needed." Veteran hospitalists can role-model precise, succinct communication, and help newer hospital medicine physicians refine their communication skills.

2. Chunk Information

"A lot of handoff education in recent years has focused on 'here's how you hand off one patient,'" Arora says. "That's fine if you're a resident who only has a few patients, but when you're caring for 30, 50, or 100 patients, you don't have time to verbally review everybody." Handing off care for a cohort of patients requires a different approach, she says.

Arora recommends "chunking" patients into related groups, rather than simply going down a list alphabetically or by room number. Group one may include the sickest patients, the ones who are likely to experience a change in condition during the subsequent shift. Group two might be patients who are doing well but require some simple follow-up. Group three could be stable patients with no foreseeable needs.

"What you really need to do is provide a framework of the situation," Arora says. Sorting patients into groups can help the oncoming physician remember important information and prioritize her actions before stepping out onto the floor.

Oncoming physicians can "chunk" patients even if the off-going physician reports on each patient by room. After the off-going physician has finished report, the oncoming physician can summarize the information received: "Mr X, Ms Y, and Mrs Z are probably going home tomorrow. Mr A and Mr B aren't doing so well; I'll check in on them first."

3. Carve Out a Dedicated Time and Space

It's extremely difficult—if not impossible—to perform a high-quality patient handoff in a high-traffic clinical area, while pressed for time. Interruptions are practically unavoidable in that environment and take a toll on both clinicians and patient care. Adjusting your scheduling and workflow to allow dedicated time and space for handoff can create immediate dividends, because interruptions create delays and contribute to failures of working memory and decreased recall accuracy.[7]

The aviation industry follows what's called the "sterile cockpit rule," a Federal Aviation Administration regulation requiring aircraft pilots to refrain from nonessential activities in the cockpit during critical phases of flight. Hospital physicians would be wise to adopt a similar policy during patient handoffs. "It's important to have a rigid structure with a defined beginning and end, so people don't arrive late and take the transfer of responsibility seriously," Arora says.

At Brigham and Women's Hospital, there is a 1-hour overlap between scheduled physician shifts. "That hour is really intended to be dedicated to the handoff of the patient," says Stephanie Mueller, MD, MPH, a hospitalist and instructor of medicine at Harvard Medical School in Boston. "During that time, we pull up the handoff portal built into our electronic medical record; it's in a template format, so it guides us through a standardized handoff."

4. Use Closed-Loop Communication

When you order coffee at your local coffee shop, your barista typically repeats your order back to you before ringing up or starting to prepare your order. "That's a business model they've developed to decrease their error rate, so you don't have someone making the wrong coffee," Mueller says.

Closed-loop communication—which requires the receiver to repeat back the information conveyed by the sender, to check for understanding—can improve handoff communication as well.

"Traditionally, we don't do a whole lot of closed-loop communication in medicine," Mueller adds. "It's recently been introduced into some high-risk areas—you may need to do a mandatory read back when you are notified of a positive blood culture, for instance. We need to remember that handoffs are a high-risk area. Patients are at risk during that time."

Repeating back the information received doesn't need to be time-consuming; in fact, a concise summation of the patient report is more likely to reveal gaps in understanding than a word-for-word read back.

5. Schedule for Continuity

The fewer times a patient's care transitions from one care provider to another, the better. "Handoffs can be less risky if team members have some repeated interaction with each other and with the patient," Arora says. Longer stretches of on-duty days (7 vs 5, for instance) increase the likelihood that the same two physicians (one day, one night) might manage a patient's entire hospitalization.

"Ideally, you want to hand off to a person who is going to have repeated interaction with that patient."

The emergency department at Seattle Children's Hospital has reduced patient handoffs by 25% by adopting a "waterfall" shift model, which staggers and overlaps physician shifts.[8] The first physician on duty begins attending to patients; when another physician arrives a few (usually 3-5) hours later, the first physician transfers care of the more complex patients to the second physician, who also takes on new admissions. Meanwhile, the first physician wraps up care of the less complex patients on his list, ideally discharging them before his shift is over.

Of course, hospital medicine is different from emergency medicine; a hospitalist typically cares for patients for a period of days, not hours. But an adapted version of the "waterfall" model—one that staggers physicians' on/off days rather than having Group A come on when Group B goes off—may be able to reduce hospitalists' handoffs and improve patient care.

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