Patient handoffs

INTRODUCTION — The increasing fragmentation of health care has the unintended consequence of more care transitions. Transitions of patient care between providers occur frequently and require providers to transmit critical clinical information. If information is omitted or misunderstood, there may be serious clinical consequences [1,2]. Several studies have shown that handoffs are often variable and represent a major gap in safe patient care [3-5].

In addition to care transitions into and out of the hospital (extra-hospital handoffs), hospital care itself has become increasingly fragmented due to the increase in number of resident handoffs secondary to duty-hour regulations [6] and the adoption of the shift-work type systems utilized by hospitalists. In-hospital handoffs are common in hospitals and represent a vulnerable time during patient care. For example, hospitalized patients are often passed between doctors an average of 15 times during a single five-day hospitalization [7]. Poor handoffs lead to uncertainty during clinical decision-making, which then leads to potential harm (near misses) and inefficient work in both resident and hospitalist service changes [8]. Handoffs between levels of care, such as critical care to floor, or operating room to post-anesthesia care unit (PACU), also represent potential for information loss and communication failure.

This topic will discuss patient handoffs that occur in the hospital. Transitions of care focused on hospital discharge are discussed elsewhere. (See "Hospital discharge and readmission".)

TYPES OF HANDOFFS AND TERMINOLOGY — Terminology used to describe patient handoffs includes:

●Sender – Provides the information about the patient for the handoff.

●Receiver – Receives the information and then assumes care of the patient.

●Shift change – The transfer of responsibility that occurs when one clinician finishes and another one begins their shift.

●Sign out – The action of transferring responsibility when the primary team caring for the patient transfers care either temporarily to another clinician for cross-coverage or permanently during a service change or transfer. This term can also refer to the written document used to transfer information ("written signout").

●Cross-coverage – The care that a clinician provides when assuming temporary coverage (generally at night) for emergencies until the primary team returns.

●Service change – The transfer of responsibility that occurs when transferring the care of a patient from one group of clinicians to an entirely new set of providers, usually at the chronologic completion of a rotation or specified block of time [8]. In this case, the outgoing clinicians will not be returning to the care of the patient. Typically, the patient is not moving to a different location or service; they are cared for before and after the service change by clinicians who have the same expertise or specialty background (eg, hospital medicine or surgery).

In a study at 10 Veterans Administration hospitals, representing nearly 240,000 discharges, end-of-rotation handoffs were associated with increased in-hospital mortality for those patients undergoing a transition from one team to another [9]. Poor information exchange and a lack of ownership of these patients have been posited as reasons for these findings [10].

●Holdover – A specific type of service change handoff where the patient’s admission is done by a provider, usually during an overnight shift, and the patient is then transferred to a different provider who assumes the care. The nighttime admitting and holdover process has increased since the implementation of the duty hour regulations.

While few studies have examined holdovers, qualitative work has shown similar challenges to those in traditional service change handoffs (eg, information accuracy, task accountability, and closed-loop communication) [11]. The holdover process warrants further study to elucidate ideal handoff processes.

●Service transfers – The transfer of responsibility from one group of clinicians to an entirely new set of providers, usually because a patient's specific care needs require a different expertise or specialty background. In a service transfer, the outgoing clinicians will not be returning to the care of the patient. This could involve change in level of care (eg, to or from an intensive care unit [ICU]) or transfer between clinical services (eg, medicine to surgery).

Patients are at risk for adverse events during service transfers [12]. A systematic review found a lack of well-conducted studies about improving safety for the ICU to floor service transfer [13]. A few interventions have been examined using descriptive outcomes [14]. Potential novel strategies have been suggested, including involving the patient and family during the transfer and designating an inter-professional team member to provide continuity in the critical care to general floor transition [13].

●Clinical panel handoffs – A type of service transfer that occurs when a panel of ambulatory patients, or clinic panel, is transferred to a new provider. This often happens when graduating residents complete a training program and hand off their clinic to a new, incoming provider, usually an intern. Despite being identified as a common practice, a national sample of Internal Medicine residency training programs found that only one-third have an end-of-year ambulatory handoff program [15].

●Intraoperative handoffs – A type of transfer in which one provider (eg, anesthesia provider, assisting surgical nurses) hands off the patient to a different provider at different points during a surgical procedure [16]. Work in orthopedic surgery has demonstrated that intraoperative handoffs between assisting surgical nurses did not have an impact on patient outcomes but did result in increased operative times for various procedures [17]. Additionally, a large cohort study in cardiac surgery demonstrated intraoperative anesthesia handoffs were associated with a higher risk of 30-day mortality and increased health care resource utilization [18].

THE HANDOFF PROCESS — The handoff process is described as "a fluid, dynamic exchange that is subject to distraction, interruptions, fluctuates on aptitude of and confidence in off-going and on-coming clinician and is contingent on the on-coming clinician's confidence in the quality, completeness of the information" [19].

Steps — As with any other process, in order to improve upon its performance, one must consider the steps in the handoff [20]. Handoffs are comprised of four phases [21]:

●Pre-handoff – Sender organizes and updates information in preparation for the handoff.

●Arrival – Work stopped in order to conduct the handoff. Ideally, time is protected for the handoff to occur.

●Dialogue – An exchange takes place between the sender and the receiver. Ideally, this is verbal but it may be written/electronic as well.

●Post-handoff – The receiver of patient information integrates the new information and assumes care of the patient(s).

Components to an effective handoff — The overall goal of the handoff is to create a shared understanding of the patient. Handoff failures arise due to failures in any of these processes. Elements of an effective handoff include the following:

Transfer of professional responsibility — A handoff is more than just the transfer of patient care information; it is also the transfer of professional responsibility [22]. As such, some acknowledgment of the accountability for a patient's care is an important feature for successful handoffs (eg, assuming pager responsibility or assigning themselves onto the treatment team in an electronic medical record).

Verbal communication — Ideally, a handoff should have some element of verbal communication, either face-to-face dialogue or via the phone. Verbal communication allows for the handoff to include active questioning and the creation of a "shared mental model" by focusing the exchange on anticipatory guidance and tasks to be done. A shared mental model is the concept that teams function more effectively when they have a shared understanding of the task that is to be performed [23]. Verbal communication allows the sender to assess the level of knowledge (or lack thereof) the receiver has about the patient (what “common ground” they share) [24].

Written communication — These documents, whether paper-based or electronic, serve as a "transition record" for both critical and supplemental information to complement the verbal handoff.

STRATEGIES FOR EFFECTIVE HANDOFFS — While strategies to improve in-hospital handoffs have been evaluated, fewer have been rigorously studied. Systematic reviews have found that many studies evaluating interventions (including electronic interventions) find improvement in self-reported or process measures, but most studies did not measure patient outcomes [25-27].

System-based strategies — Strategies to employ on systems level include:

Standardization — Standardization defines and structures the content of the verbal and written handoff. When used by pediatrics residents, standardization of both the verbal and written handoff using the IPASS (illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis by receiver) mnemonic/structure was associated with a 30 percent decrease in preventable adverse events [28,29]. While residents using IPASS agreed it improved patient safety, only 12 percent endorsed using the IPASS framework at the midpoint of the study [30]. The most commonly cited reasons for nonadherence was time, prior knowledge of patients, and limited patient complexity.

A systematic review including 19 studies of interventions to improve patient handoff in surgery (eg, checklists or standardized protocols) found that all interventions were associated with an improvement in handoffs [31]. Additionally, one study found that, compared with verbal handoff alone, the use of both a verbal and written handoff resulted in more information retention [32].

Technological advances have often been used to close the communication gap [33,34]. Many of these systems streamline electronic information and centralize it for sharing in either the written or verbal phase of the handoff. Using a combination of resident-entered patient data and auto-filled information from an electronic health record was widely used and popular at a large academic medical center [33]. Follow-up evaluation revealed that the utilization of such a system improved both patient care and safety [34]. In a study of internal medicine residents, standardization through a structured web-based application improved the consistency of information during handoffs [35]. Residents were also more confident in their patient handoffs and were less likely to perceive near-miss events.

Face-to-face verbal communication and interactive questioning — Studies (both within medicine and other industries) have concluded that face-to-face communication with the ability to perform interactive questioning is critical to the adequate transfer of information [20,36-38]. Although this is not always possible, verbal communication between the sender and receiver is strongly encouraged. This is also a practice recommended by both the Joint Commission and the Society of Hospital Medicine [36].

The use of standardized language during the verbal portion of the handoff helps to ensure transmission of consistent information and allows for questioning. The SBAR (situation, background, assessment, recommendation) model has been used successfully by allied health professionals, such as those in nursing [39]. While the IPASS and SBAR structure has been associated with improvements in patient care outcomes, other handoff mnemonics have not been well evaluated or validated in research settings [29,40].

Written templates for handoffs — The use of standardized or structured templates, whether paper-based or electronic, ensures consistency in the information relayed between the sender and the receiver. Identifying critical content, some of which is dependent on the type of transition occurring, ensures continuity in medication administration, test or procedure follow-up, and resumption of care [41].

The essential elements for a written handoff include: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, patient and hospital service identifiers, and code status.

Substantial variation in handoff documents exists. A study including structured review of handoff documents from nine sites found substantial variation in both structure and content of the printed handoff documents, with only 17 percent of the possible data elements uniformly present [42]. Additionally, the accuracy of this type of documentation degenerates quickly during the course of a shift, and the “half-life” of information in the physical written handoff document can be as little as six hours [43].

Optimizing the setting — Ensuring an optimal setting for the handoff can improve the quality of exchange that occurs between the sender and the receiver of the handoff. Having a specific location and time for the handoff to take place, in addition to minimizing interruptions, allows for the sender and receiver to focus on the exchange of information. Avoiding interruptions is crucial to conducting an effective handoff. Systems-level strategies can be utilized such as shift structure, which includes overlapping to allow for adequate time for the handoff to take place.

Optimizing the schedule and team structure — Different call schedules and structure can promote more ideal handoff conditions by having handoffs occur among providers who have some prior knowledge of the patient. One way to do this is through the use of team-based care, where a team of clinicians are responsible for patient care, rather than an individual clinician [44]. Maximizing team continuity, rather than individual provider continuity, may decrease potentially harmful clinical uncertainty during handoffs since team members are all familiar with the patient's care. This could be done by having providers from the same team work serial shifts instead of in tandem shifts, for example. However, simply being on the same team does not mean that all team members know the patients. In one study, only one-quarter of interns on the same team had seen the other interns’ patients [45].

Also, schedules should be arranged so that "double handoffs" are avoided. "Double handoffs" occur when a provider covers the patient temporarily for a short time and then transfers care to another provider [44]. In this scenario, neither the sender nor the receiver in the second handoff have primary knowledge of the patient. A study from emergency medicine demonstrated that while a “waterfall” attending physician schedule (overlapping attending shifts) did improve door-to-doctor and door-to-disposition time, it did result in an increase in patient handoffs between providers [46].

Scheduling factors should be considered in service transfers as well as shift transfers. For example, a major barrier in the development of an end-of-year ambulatory panel handoff process is lack of overlap between the graduating and incoming resident, as well as lack of dedicated time to perform this information transfer [15]. Several strategies have been identified to improve the safety of this unique type of handoff, including focusing on the most at-risk ambulatory patients, enhancing attending supervision during the process, and establishing care with the new provider as soon as possible to solidify the new therapeutic relationship [47].

Customize handoffs for highest-risk patients — It is important to signal during the handoffs those patients who may be sickest. This is especially useful when there is a physical exam finding, such as mental status, that is fluctuating, and it may be critical to impart to the oncoming clinician a sense of the baseline mental status.

When considering the risks associated with in-hospital handoffs, the following three questions may be utilized to assess patient risk level for any patient handoff:

●Is the patient physically moving locations?

●Is the patient clinically unstable?

●Is the handoff permanent (eg, service change, transfer of care, at-risk ambulatory patient)?

If the answer to any of these questions is "yes," then experts agree that the risk of a failed handoff is inherently higher [48]. For example, in a systematic review and meta-analysis, intraoperative anesthesia handoffs were associated with worse patient outcomes [49].

There is also a specific risk of handoffs in the critical care setting [50]. A mixed-methods study demonstrated that 87 percent of residents identified at least one adverse event in the care of their critically ill patients in a medical intensive care unit (ICU) secondary to a handoff error. Residents indicated that more than 60 percent of ICU-ward handoffs included an omission or miscommunication. Additional work done in a multisite trial involved 985 patients transferred from an ICU to non-ICU location [51]. Of the patients studied at the 58 ICUs, 450 (45.7 percent) of patients had at least one medication error in their transfer from the ICU to the ward, while 75 percent of those errors reached the patient but did not result in patient harm. A study standardizing the transfer process from a neuro-critical care environment to a lower level of care noted that, while bounce-backs to the neuro ICU were not decreased, a standardized approach to ICU floor handoffs did improve provider-rated safety outcomes and identification of high-risk patients [52].

Bedside handoffs and knowledge of the patient's acuity score may facilitate handoffs for the sickest patients. In one study of hypothetical signouts, interns were more likely to share the primary team's concern for the patients when given access to a patient acuity score [53]. Anecdotal studies from the nursing literature highlight that bedside handovers for the sickest patients can be very helpful [54]. A warm handoff strategy for more critically ill or at-risk patients involving a bedside handoff between the incoming and outgoing resident increased resident perception of the safety of the handoff for the patient and improved the incoming resident’s knowledge of and comfort with the patient, despite the additional time taken [55,56]. A standardized handoff from the operating room to the surgical ICU setting conducted at the bedside resulted in reduced information omission but no change in outcomes [57]. A similar intervention was also performed among hospitalist clinicians [58]. Warm handoffs have also been shown to improve patient outcomes for at-risk patients, specifically those with limited access to care or those who suffer health care disparities related to social determinants of health [59,60].

Sender-based strategies — In addition to the systems-based strategies, there are specific strategies that senders can employ to improve the communication of information during the verbal handoff.

Focus the verbal handoff on the most important items — Senders of the handoff can focus on the more important information to relay to the receivers. In one study, even in optimal handoff conditions (dedicated room, time, etc), the number-one item that senders thought they had effectively communicated to receivers was not actually reported by the receiver 60 percent of the time [37]. This highlights the need for senders to understand the burden of the receiver and communicate in a structured manner. Specifically, senders can prioritize and focus on the sickest patients before others. In addition, senders are encouraged to provide a snapshot of the patient's daily progress and their baseline clinical status for these patients.

Emphasize tasks to be done and give specific anticipatory guidance — It is critical to relay the clinical tasks that require completion by the covering clinician (the "to-do" items). In addition, the sender should make explicit suggestions or recommendations for anticipated events that may occur (eg, if a patient has congestive heart failure, the sender should specify the dose of furosemide that should be given if the patient has shortness of breath) [36]. There are data that suggest if/then items and to-do items are much more likely to be remembered by receivers than general knowledge items [37].

Check for receiver understanding — Utilizing read-back and interactive questioning to ensure that the information has been relayed adequately and effectively.

Receiver-based strategies — The receiver has an equally important role in the handoff. The receiver must confirm successful comprehension of information and ensure transfer of professional responsibility [61].

Use of read-back — "Read-back" allows the sender to check the information received by the recipient. While it is not possible to perform a read-back of the entire handoff exchange, the use of focused read-back on the high-priority items of the handoff (eg, to-do items) is encouraged. A study found that the use of read-back for the telephone delivery of over 800 abnormal critical laboratory tests resulted in the discovery of 29 errors in communication, all of which were corrected [62]. Improving communication by asking the recipient to read back the critical portions of the message relayed (eg, to-do items) can serve as a simple strategy for preventing patient harm. Studies show read-back is rarely employed during handoffs, highlighting an opportunity for improvement [38].

Actively listen — Encouraging active listening behaviors amongst receivers can improve receipt of the handoff. Although passive listening behavior, such as head-nodding or neutral utterances, may cue to potential listening during receipt of a handoff, they do not confirm comprehension. Active listening behavior, such as notetaking and questioning, signals comprehension and processing of information. Passive listening behaviors are much more common during handoffs than active listening behaviors [63].

Writing or typing notes during the handoff process has been described as a demonstration of an active listening behavior and also has been shown in prior work to reduce data loss that may impact the delivery of care by the cross-covering clinician [64]. Notetaking has also been shown to substantially improve the retention of information when compared with only verbally handing over patients without the use of notetaking [32]. Encouraging notetaking during the handoff may serve to accomplish these two critical functions.

EXISTING POLICY — Numerous studies suggest that handoffs are plagued by communication failures that ultimately lead to patient harm [41]. Given this, efforts to prevent handoff errors have been the subject of numerous policy and patient safety initiatives. The Joint Commission made implementing a "standardized approach to handoffs" a National Patient Safety Goal for acute care hospitals in 2006 [20]. Additionally, the World Health Organization labeled prevention of "handover errors" as one of the top five patient safety solutions, giving it equal footing with such high-priority areas such as hand hygiene. In 2006, the Society of Hospital Medicine generated its recommendations for handoffs for hospitalists [7]. The Accreditation Council of Graduate Medical Education has made handoffs a focus of their 2011 standards, stating that all residents must be "competent in handoff communications" and that programs must monitor handoffs for safety [6].

EDUCATION AND EVALUATION FOR HANDOFFS — While handoff education and evaluation is now required by numerous educational or accrediting organizations in the United States, the best methods and tools to measure handoff performance are unclear. At the medical school level, the Association of American Medical Colleges (AAMC) has included handoffs on the list of competencies needed for residency. For graduate medical education, the Accreditation Council for Graduate Medical Education Clinical Learning Environment Review (CLER) program has made care transitions and handoffs one of the six focus areas for which teaching institutions must assure education and clinical alignment. The Society of Hospital Medicine has also made handoffs one of the core competencies for hospitalists [65-67].

Education about handoffs, however, may be useful for others besides graduate medical education or hospital medicine clinicians. Increasingly, the benefit of inter-professional involvement in patient care handoffs is being recognized [68], as is the need for handoff training to begin as early as undergraduate medical education to prepare students to effectively handoff patients during their internship training [69].

Despite the calls to improve handoffs from an educational level, a common method for teaching and evaluating handoff skills has not been developed. An effort to create an educational blueprint for teaching and assessing handoffs included numerous modalities, including techniques such as simulation, video, didactic teaching, case conference, supervision during the time of the handoff, and faculty feedback [70]. A systematic review of educational interventions to improve handoffs yielded 18 studies that were mostly single-patient exercises based on simulation and roleplay with outcomes that focus on learner satisfaction or knowledge/skill improvement [71].

While numerous interventions have aimed to improve patient handoffs, standardized, reliable measurement tools are not widely used [72]. Work in this area includes the creation of the handoff clinical evaluation exercise (Handoff CEX), which is a direct observation instrument that has been validated for use in both nurses and clinicians [73,74]. In addition, the Patient Knowledge Assessment Tool (PKAT) is an instrument that was validated to specifically measure shared clinical understanding for pediatric cardiac intensive care unit (ICU) patients [75]. In the surgical field, a Postoperative Handover Assessment Tool (PoHAT) was evaluated at two large European hospitals and found to be feasible to use and highly reliable [76]. The Verbal Handoff Assessment Tool (VHAT) demonstrated an increase in scores after the implementation of standardized handoffs with the IPASS (illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis by receiver) structure. This study found that the resident VHAT score should be based on observation of verbal handoff of ≥21 patients [77]. In addition to evaluating verbal handoffs, rubrics and checklists to evaluate the quality of the written signout document have also been developed and tested in several residency programs across settings including critical care [78-81].

SUMMARY AND RECOMMENDATIONS

●In-hospital handoffs are common in hospitals and represent a vulnerable time during patient care. (See 'Introduction' above.)

●The overall goal of the handoff is to create a shared understanding of the patient. Handoff failures arise due to failures in any of these processes. The handoff process includes verbal communication, written communication, and a transfer of professional responsibility. (See 'Components to an effective handoff' above.)

●Strategies for improving handoffs include employing strategies at the system level such as standardization; face-to-face verbal update with interactive questioning; use of a written template; optimizing the setting, schedule, and team structure; and customizing handoffs for the sickest patients. The use of the IPASS (illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis by receiver) structure to standardize verbal and written handoffs has been associated with a reduction in preventable medical errors. (See 'System-based strategies' above.)

●Strategies for verbal handoff can also be targeted at the individual (ie, “sender” and “receiver”) level. Sender strategies include focusing the verbal handoff on the most important items and emphasizing tasks to be done and specific anticipatory guidance. Receiver strategies include actively listening as well as use of read-back or notetaking. (See 'Sender-based strategies' above and 'Receiver-based strategies' above.)

●While handoff education and evaluation is now required by numerous accrediting agencies and bodies in the United States, it is unclear what the best methods and tools to measure handoff performance are. (See 'Education and evaluation for handoffs' above.)