Communication and Handoffs

Division of General Internal Medicine and Geriatrics
Hospital Medicine
Rev. 2015
Goals and Objectives

 Define clinical handoffs
 Recognize the importance of effective handoffs
 Understand key components of an effective standardized
handoff
Clinical handoff

 A clinical handoff is the temporary transfer of care and
responsibility from the primary physician to the covering
physician
 Verbal
 Written
 IOM report 2000 To Err is Human Preventable adverse events are a major cause of death
 Medical errors are really expensive
 Patient safety should be a priority
 Improving handoffs is a national patient safety goal
Handoffs and Patient Safety

 Sentinel events commonly results from communication
breakdown – 65 % of the time
 92% of communication errors occur during verbal
communication between 1 transmitter and 1 receiver
 Errors commonly result from omission of content or lack
of direct discussion
Ideal handoff components

 Face to face interaction for verbal communication
 Considered gold standard although studies on benefit are
conflicting
 Updated written or computerized information (use actual
dates)
 Clarity about the patient’s current condition, including severity
of illness
 Anticipating changes in patient condition with specific
interventions
 Minimal interruptions
 Structured format (time, place)
Summary of Themes from
“White Papers”

 Need for training
 Ensure adequate time for handoff
 Reduce interruptions
 Keep information updated in template or technology
solution
 Facilitate interactive questioning
 Focus on ill patients
 Delineate actions to be taken
2011 ACGME Duty Hour
Restrictions

 Interns no longer allowed to do 24 hour call
 Intern shifts limited to 16 hours
 Unintended consequences
 Increase in self-reported medical errors
 130-200% increase in number of handoffs
Sen et al. Effects of the 2011 Duty Hour Reforms on Interns and Their Patients. JAMA Intern Med 2013.
Current Status of Handoffs in
Residency Programs

 ACGME requires residency programs to be competent in
handoffs
 Transitions of care is one component assessed in CLER
(Clinical Learning Environment Report) visit with goal of
increasing emphasis on patient safety
 Most programs have dedicated handoff curriculum
 Written templates
 Face-face discussion
 Opportunities to ask questions
Home Institution

• AHRQ housestaff patient safety survey found
handoffs and communications the lowest
ranking area of safety
Disagree / Neutral/ Agree
Things “fall between the crack” when transferring
patients from one unit to another
Important patient care information is often
lost during shift changes
Problems often occur in the exchange of
information across hospital units
Shift changes are problematic for patients in
this hospital
MUSC Handoffs

iCATCH

GME-wide intern orientation
Focus on quality and safety
Observed verbal handoffs (OSHE)
Orientation survey data
Only 23 % of incoming interns had formal
training on handoffs
Improvements:
 Extract key points from a large medical record
 Convey pertinent info effectively
Allen et al, Acad Med Oct 14
Proposed Medical Student EPA

Give or receive a patient handover to transition
care responsibility
Functions for transmitter of information
• Conduct handover communication that minimizes known threats to
transitions of care (e.g., by ensuring you engage the listener, avoiding
distractions).
• Document—and update—an electronic handover tool.
• Follow a structured handover template for verbal communication.
• Provide succinct verbal communication that conveys, at a minimum, illness
severity, situation awareness, action planning, and contingency planning.
• Elicit feedback about the most recent handover communication when
assuming primary responsibility of the patients.
• Demonstrate respect for patient privacy and confidentiality.
AAMC 2014
Proposed Medical Student EPA

Functions for receiver of information
• Provide feedback to transmitter to ensure informational needs are
met.
• Ask clarifying questions.
• Repeat back to ensure closed-loop communication.
• Ensure that the health care team (including patient/family) knows
that the transition of responsibility has occurred.
• Assume full responsibility for required care during one’s entire care
encounter.
• Demonstrate respect for patient privacy and confidentiality.
AAMC 2014
I-Pass Handoff Bundle

 Prospective study 2014; >10,000 patients
 I-PASS





I- Illness Severity
P-Patient Summary
A-Action Items
S- Situation Awareness and Contingency Planning
S- Synthesis by Receiver
 Bundle





Standard format for written and oral handoffs
Resident physician training and practice
Faculty development and direct observation with feedback
Active surveillance for medical errors – collaborative cross-checking
Sustainability campaign for culture change
 Decreased medical errors and preventable errors without increased time
Starmer et al; NEJM 2014
Key Messages

 Good handoffs





Use standardized formats
Interactive
Focus on ill patients
Provide anticipatory guidance
May reduce sentinel events / improve patient safety
References

 Allen S, Caton C, Cluver J, Mainous A, Clyburn B. Targeting improvements
in patient safety at a large academic center: an institutional handoff
curriculum for graduate medical education. Acad Med 2014; 89(10):1366.
 Arora V, Johnson J, et al. Communication failures in patient sign-out and
suggestions for improvement: A critical incident analysis. Qual Saf Health
Care 2005; 14 (6):401
 Arora VM, Manjarrex E, et al. Hospitalist handoffs: A systematic review
and task force recommendations. J Hosp Med 2009; 4(7):433
 Greenberg CC, Regenbogen SE, et al. Patterns of communication
breakdowns resulting in injury to surgical patients. J Am Coll Surg 2007;
204(4):533
 Joint Commission Sentinel Event Database
 Starmer A, Spector N, Srivastava D, et al. Changes in medical errors after
implementation of a handoff program. N Eng J Med 2014; 371(19): 1803.
Revision History

 Original Version: Cathryn Caton, MD 2013
 Revised 4/9/2015: Ashley Duckett, MD