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Patient Handoffs

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:

Resources from the Joint Commission
Model Handoff Procedures

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.

The Five-Ps

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?

I PASS the BATON

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)?
The
  • 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?

ANTICipate

From the U.S. Department of Health and Human Services

  • 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.

ISBARQ or SBAR + 2

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.

Safer Sign Out

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

IMOUTA

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

The UPDATED Approach

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?

Anticipated problems?

  • 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?

 

Educational Videos

General Resources on Handoffs
Resources on Specialty-Specific Handoff Recommendations

Anesthesia

Critical Care

Emergency Medicine

Hospitalists

Internal Medicine

Obstetrics-Gynecology

Pediatrics

Pediatric Emergency Medicine

Surgery