Resources for Improving Patient Handoffs
In 2006, the Joint Commission added transitions in patient care to its national Patient Safety Goals, referencing the need for "a standardized approach to hand-off communications, including an opportunity to ask and respond to questions." This goal is even more essential since limits on duty hours have also increased the use of "cross coverage," defined as residents outside of the primary care team providing care in the absence of the primary team. Despite the ACGME's requirement that programs ensure that residents are competent in the hand-over process, resident physicians believe transitions are not adequately addressed in education and practice. Many note that processes are haphazard, with no system of organized interaction.
Handoffs in the News:
- May 17, 2013: "Emergency physicians develop protocol for safer handoffs." ACEP News.
- May 14, 2013: "Mobile Apps: Taking the Edge Off Patient Handoffs." Health Biz Decoded.
- April 17, 2013: "Emergency Doctors Promote Patient Handoff Checklist." American Medical News.
- April 15, 2013: "Taking the Guesswork out of Patient Handoffs." Hospitalist News.
- March 30, 2013: "Reducing risk: Structure may lead to safer handoffs." ModernHealthcare.com
Handoffs should provide timely, accurate information about a patient's care plan, treatment, current condition and any recent or anticipated changes. Handoffs should: 1) be standardized and clearly defined; and 2) involve face-to-face exchange between the caregivers involved. Below are some of the model procedures used by institutions to standardize effective handoffs. Being aware of them can help you remember the most important information to communicate during a handoff.
From Sentara Health Care, 2008
- Patient: Communicate the patient's name, identifies, age, sex, and location
- Plan: Communicate the patient diagnosis, treatment plan and next steps
- Purpose: Provide a rationale for the care plan
- Problems: What's different or unusual about this specific patient?
- Precautions: What's expected to be different or unusual about the patient?
From the Department of Defense Patient Safety Program, 2008
- I: Introduction - Individuals involved in the handoff identify themselves, their roles and jobs
- P: Patient - Communicate the patient name, identifies, age, sex, and location
- A: Assessment - Present the patient's chief complaint, vital signs, symptoms and diagnosis
- S: Situation - Communicate the current status and circumstances, including code status, level of certainty or uncertainty, recent changes and response to treatment
- S: Safety Concerns - What are the critical lab values and reports? Any socioeconomic factors to be aware of? Any allergies or alerts (ex: risk for falls)?
- B: Background - Identify comorbidities, previous episodes, current medications and family history. Verify the patient's insurance. Is the family available for support? Are there any advance directives?
- A: Actions - Detail what actions were taken or are required and provide a brief rationale for those actions
- T: Timing - What is the level of urgency? Include explicit timing and prioritization of actions.
- O: Ownership - Who is responsible (nurse/doctor/team), including patient and family responsibilities?
- N: Next - What is the plan of action? Are there any time critical actions needed? Any anticipated changes? Are there any contingency plans?
- A: Administrative data. Communicate the patient's name, medical record number, and location) must be accurate.
- N: New clinical information must be updated.
- T: Tasks to be performed by the covering provider must be clearly explained.
- I: Illness severity must be communicated.
- C: Contingency plans for changes in clinical status must be outlined, to assist cross-coverage in managing the patient overnight.
From Hospitals and Health Networks Mag, 2008
- I: Introduction - Who are the individuals involved in the handoff? What are their roles in the patient's care?
- S: Situation - What is the patient's diagnosis and treatment plan? Do they have any complaints, wants, or needs?
- B: Background - Communicate vital signs, mental and code status, list of medications, and lab results
- A: Assessment - What is the current provider's assessment of the situation? Does the current provider anticipate any changes?
- R: Recommendation - Are there any tests or lab results pending? What needs to be done of the next few hours? What is the current provider's recommendation for future care?
- Q: Make time for Q&A - Handoffs should be an interactive affair between all parties involved in the handoff.
From the Emergency Medicine Patient Safety Foundation (EMPSF). The Safer Sign Out site contains the forms referenced below and more in-depth information on the key components of good sign outs:
- Record - Patient, critical details, follow-up items
- Review - Safer Sign Out's form and Computer/Chart Data
- Round Together - Meet the patient and assure a plan
- Relay to the Team - Confirm the plan with the nurse/team
- Receive Feedback - Use Safer Sign Out's form for clinical follow-up and process QA
From Matthew P. Connor, MD, Anneke C. Bush, ScD, MHS, and Joseph Brennan, MD. Originally featured in Laryngoscope in April, 2013.
I: Identify data
M: Medical course
OU: Outcomes possible tonight
T: Responsibilities to do tonight, and
A: Opportunity to ask questions and give morning feedback in the AM
From Allison S. DeKosky, MD, Ananya Gangopadhyaya, MD, Bobby Chan, MD, and Vineet M. Arora, MD, MAPP. Originally published in the Journal of Graduate Medical Education, June 2013. This "Rip Out" article includes a method for scoring handoffs.
Updated administrative data?
- Is all administrative data present, including patient name, room number, code status, allergies, PCP, family contact information, and treatment team?
Problem list prioritized and accurate?
- Should be prioritized and updated.
Diagnosis listed in one-line summary?
- Includes detailed if/then statement.
Too much information?
- Includes no superfluous data categories, easy to identify problems, and if/then and to-do statements
Error-prone medications clear and correct?
- All medications should be listed clearly and all antibiotics with start dates
Directions clear and concise?
- The Do's & Don'ts of Patient Handoffs - Hospitalists may be tempted to rely on their electronic health record systems to do all the work on patient handoffs, but that probably won't turn out very well. Instead, Dr. Vineet Arora offers three strategies to improve patient handoffs.
- The Art and Science of Handoffs - From the AMA's Succeeding from Medical School to Practice Video Library
- Hospital Handoffs for Intern Orientation - A teaching video from Dr. Vineet Arora for new resident physicians to avoid the pitfalls of the handoffs process.
- Attending Supervision: First Day on the Wards - Demonstrates common pitfalls of new attending physicians supervising residents and walks through the SUPERB supervision model.
- Handoffs Workshop: Two Hour Training
- Integrating Quality and Patient Safety Education Across the Continuum
- The Care Transitions Program
- "There and Home Again, Safely: 5 Responsibilitites of Ambulatory Practices in High Quality Care Transitions.". Part of the AMA’s Making Strides in Safety Program
- Malpractice Threats in Well-Intentioned Patient Handoffs. Medscape Today (October 2012)
- HHS Patient Handoff Case Studies with Commentary
- Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research (November 2012)
- Improving Physician Hand-offs (November 2011)
- Communication Key to Reducing Liability Claims in Patient Handoffs (June 2011)
- Lost in Translation: Challenges and Opportunities in physician-to-physician communication during patient handoffs (December 2005)
- A Longitudinal Approach to Handoff Training PDF (May 2012)
- Improving Patient Safety by Taking Systems Seriously PDF (January 2008)
- Examining links between sign-out reporting during shift changeovers and patient management risks. (August 2008)
- Reducing error in the emergency department: A call for standardization of the sign-out process (December 2010)
- Chart biopsy: an emerging medical practice enabled by electronic health records and its impacts on emergency department – inpatient admission handoffs (September 2012)
- The Hospitalist (July 2010): Audio interviews with transition of care experts: Hospitalists Arpana Vidyarthi, MD, Anuj Dalal, MD, and Sunil Kripalani, MD, MSc, discuss care transitions
- Managing discontinuity in academic medical centers: Strategies for a safe and effective resident sign-out. (July 2006)
- Change You Should Believe In: Care transitions challenge hospitalists to improve systems, communication. The Hospitalist (July 2010)
- Hospitalist handoffs: A systematic review and task force recommendations. (September 2009)
- Consequences of Inadequate Sign-out for Patient Care (September 2008)
- Residents Report on Adverse Events and Their Causes (December 2005)
- Obstetrics–gynecology Committee on Patient Safety and Quality Improvement. ACOG committee opinion. Number 517. February 2012. Communication strategies for patient handoffs.
- Optimizing physician handover through the creation of a comprehensive minimum data set. (September 2010)
- Making good better: implementing a standardized handoff in pediatric transport. (January 2013)
Pediatric Emergency Medicine
- Perioperative Patient Handoff Toolkit from AORN and the U.S. Department of Defense Patient Safety Program
- The Top 10 List for a Safe and Effective Sign-Out (2008)
- Royal College of Surgeons of England. Safe Handover: Guidance from the Working Time Directive Working Party (2007)
- Integration of a Formalized Handoff System Into the Surgical Curriculum (January 2011)
- Six Things Every Plastic Surgeon Needs to Know About Teamwork Training and Checklists (February 2013)