High-quality patient handoffs can reduce medical errors and prevent adverse events in patient care, but learning how to effectively manage handoffs requires a special skill of its own. Follow these expert tips to improve handoffs and enhance team-based care in training.
Vineet Arora, MD, an academic hospitalist and associate professor at the University of Chicago Medicine, specializes in improving the learning environment for medical trainees and the quality, safety and experience of care delivered to hospitalized adults. She also is an internationally recognized expert on patient handoffs.
While there is no magic “cure all” for bad handoffs in complex health systems, Dr. Arora said there are certain guidelines and best practices physicians in training can implement to improve communication in clinical settings and improve patient safety. She discusses some of these in a video that is part of the AMA’s Succeeding from Medical School to Practice resource:
Avoiding “back channeling”
This often occurs in “data dump” situations when one physician quickly runs through his or her notes about a patient while the person receiving the handoff nods or utters filler phrases like “uh-huh” during the conversation to passively express that they understand the information that’s being communicated, Dr. Arora said. “[T]hat is not an active display of understanding,” she said. “Handoffs are meant to be a conversation, so the next time you are in a handoff [ask yourself], ‘How can I, as the receiver, take a more active role and assure the sender that I really understand everything?’”
2. Conducting intern interviews. “Understanding what went wrong and why things fail is the first step to improving patient safety,” Dr. Arora said, which is why she conducted “critical incident interviews” with interns at the University of Chicago. These interviews were designed to ask honest questions about communication errors that could lead to patient harm and solicit suggestions for improvement. In these interviews, she learned that “the worse event interns reported from a bad handoff was resuscitating somebody who is a DNR … and the most minor or annoying distraction people reported was their printer being out of paper.” Residency programs seeking to improve handoffs can pilot a similar feedback process to determine the key barriers to effective patient communication among trainees, she said.
Ensuring that all written sign-outs are clear
While sign-out processes vary by specialty and program, “the overall features of an effective written sign-out [are] that they should be …accurate and update to date,” Dr. Arora said. She noted that keeping the patients’ information updated is an intrinsic but pertinent challenge for trainees who often act as the “masters of information” for patients.
Offering face-to-face interaction
A study of handoff processes among internal medicine residents confirmed that “[physicians in training] desired a verbal sign-out that was face to face [and] only reviewed the anticipated issues [about a patient].” While physicians have multiple channels for communication, “the highest level of communication still occurs when we are face to face with someone,” she said. “That is the highest, most effective level of communication.”
Providing the most pertinent patient information
When conducting or receiving a handoff, ask yourself, “What information do I really need to effectively care for this patient right now?” Instead of offering unnecessary biographic details about your patient or running through every review system in their physical exam, Dr. Arora urges physicians in training to focus on the major “if-then” and “to-do” items about the patient. “Don’t worry about [explaining] that Mrs. Smith is from Michigan, and this is what her CT showed,” she said. “If it doesn’t relate to the anticipatory guidance, it’s probably okay to leave it on the written information and move on.”
Knowing which clinical tasks are susceptible to fatigue
“There are familiar tasks that are more susceptible to handoffs,” she said. “A lot of them deal with complex decision making.” For instance, “studies show that when you’re tired, it takes you four times longer to put in an arterial line.” Shortness of breath, patient discharge and end-of-life care also have been linked to studies on fatigue.
Paying special attention to high-risk handoffs
“You have to think about the type of handoffs you’re working with,” Dr. Arora said. “There are many different types of handoffs, and some of the highest-risk handoffs are when the patient’s physically moving, they’re critical or unstable.” High-risk handoffs also increase in situations where the handoff may be permanent or it marks the first time the physician is hearing about a patient, Dr. Arora said.
Physicians in training can access a variety of resources to help hone their handoff skills, including model procedures, educational videos and specialty-specific recommendations. Learn more about these resources for safer, more streamlined handoffs.