Handoff Rx: knowing what to say and how to say it
From the October ACP Observer, copyright © 2006 by the American College of Physicians.
By Gina Shaw
When the resident handed off the patient to night coverage, he covered the basics, but not that the patient was scheduled to go home the next day. Overnight, the patient lost IV access and the covering physician scheduled the patient to have a central line inserted. When the resident arrived the next day, he was shocked.
It's a classic example of the problems of not having standardized handoffs, said Lia S. Logio, ACP Member, director of the internal medicine residency program at Indiana University School of Medicine in Indianapolis, where the incident occurred several years ago. "We talked about it, and realized that everyone does handoffs a little differently," she said.
Lia S. Logio, ACP Member: “We realized that everyone does handoffs a little differently.”
Concerned about these types of incidents among residents and buoyed by studies showing communication lapses in general contribute significantly to medial errors, IU and other teaching hospitals have taken steps to revamp their hand-off programs, incorporating such ideas as standardized forms and requiring both a written and oral report for each handoff.
And instead of just identifying residents as a problem link, they're beginning to address the lack of training that has led to the problem. Now residents need to know the new rules of the road.
The weakest link?
There's no question residents have been a weak link. A study in the December 2005 issue of Academic Medicine found significant gaps in communication among residents as they handed off patients to one another in the hospital. Ironically, the study was co-authored by the former IU resident involved in the hand-off confusion, Darrell Solet, MD—now a cardiology fellow in Texas—and Richard Frankel, PhD, professor of medicine and geriatrics at IU School of Medicine.
Part of the problem is that fewer than 10% of residency programs have formal training in how to conduct a handoff, Dr. Frankel explained. "If you think about handoffs in everything from relay races to air traffic control to docking a space station, people practice this element over and over again to develop proficiency," he said. "In medicine, we just assume you'll know how to do it."
Not only is that assumption flawed, it's compounded by the other part of the hand-off problem: Most training programs have not addressed the lack of standardization.
For example, more than half of training programs don't require both a written and an oral signout during transfers, while 34% leave signouts to interns, according to the results of a national survey of internal residency programs, published in the June 12, 2006, Archives of Internal Medicine, that concluded that patient transfers in many internal medicine wards are spotty at best. Moreover, 59% of programs have no way to let nurses know that a transfer has taken place, the study noted.
"In medicine, we have a lot of safety nets built in, but errors continue to remain at the same level or perhaps are even increasing slightly [because of] the human factor," Dr. Frankel said. While other fields have addressed that problem—aviation, for example, has introduced such measures as a worldwide non-punitive reporting system—medicine is not quite there yet. "We're slowly moving in that direction, but we have a long way to go," he said.
Those pushing for change say a relatively new impetus for improving handoffs is the January 2006 implementation of the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) patient safety goal 2E: "Implement a standardized approach to 'hand off' communications."
But finding resources to help develop that approach is another matter. "There have been lots of case reports of problems, but few systematic studies of what people should say in a signoff, how people should say it, and whether or not computerized signoffs are better than scribbled notes on note cards,” said Leora Horwitz, ACP Member, a postdoctoral fellow in internal medicine at Yale University and the author of the Archives study.
As a result, some programs are convening committees or taking other steps to devise their own general guidelines (see sidebar).
Programs take the plunge
At the same time, others are leaping into the fray with what are, at least in part, "homegrown" standardized hand-off systems, Dr. Horwitz said.
Yale, for example, has developed a formal structure for oral signout that it is now being taught to the house staff, and has implemented a new one-hour sign-out curriculum for interns. "Consistently using a standardized structure for verbal communication helps the listener focus and retain information, and helps the sign-out provider to be organized, concise and comprehensive," Dr. Horwitz said.
The State University of New York at Stony Brook started using a new standardized hand-off system in May. The new format, developed with the hospital's director of quality improvement, identified and addressed three problems:
Problem #1: Uncertainty as to who was responsible for patient care between 5 p.m., when the day team leaves, and 8 p.m., when the night float arrives.
Solution: Mandatory sign-out times at 5 p.m. and 8 p.m. for both interns and residents.
Problem #2: Handoffs were written and verbally communicated from the primary care team to the call team, but not necessarily from the call team to the night float team.
Solution: An attending in-house between 4 p.m. and midnight is required to be at the signout. This ensures that important information is transferred and that it makes sense, said William A. Wertheim, FACP, who directs the internal medicine residency program.
Problem #3: The data sheet wasn't standardized, and information was placed haphazardly.
Solution: Dr. Wertheim and his team got hospital approval to acquire new computers and a protected server site, as well as a dedicated hand-off room, so that a new, standard written form—just a Word document with a six-column text box—could be used and updated for signoffs.
The first column includes basic demographics—name, record number, location of patient, code status, allergies—plus a 1-4 acuity scale, with the most urgent patients ranked 1 and those who are unlikely to require much attention ranked 4. This helps the new shift prioritize patients at a glance, Dr. Wertheim explained. Column two is for a brief medical history and reason for admission; column three for current major issues, column four for plans related to each problem, column five for an updated medication list, and column six for issues to watch: What occurred during the last shift and what needs to be done during the next. The idea, he emphasized, it to ensure that handoffs follow a consistent protocol.
The overall goal of Stony Brook's new system is to provide both oral and written electronic communications and face-to-face signoffs, which has been shown to lead to a more complete exchange of information, Dr. Wertheim said.
So does the standardized hand-off system Dr. Solet created that debuted in the spring of 2006 at the Indiana VA hospital. Based on the SOAP note (Subjective, Objective, Assessment and Plan), it's now in a second round of revisions. "He couldn't really change the national VA informatics system," Dr. Logio said. "So what he did was take out the key elements of the last progress note on the patient and then combine with key data like allergies, if they're DNR, and so on, and we created a form that can be printed with those key elements."
Finally, Jeremy Wittenborn, MD, chief resident on the internal medicine service at Wishard, a county hospital in Indiana, has used the existing electronic system to create a customized hand-off form, based in part on Dr. Solet's pilot project.
"The goal is to make the handoff as focused as possible. You don't want everything that you'd present to a staff physician. The changeover should be focused on the central components—what the problem is, what's been done for it, and what things are pending for the day—rather than trying to tell a story," he said. "The full history and physical note are in the chart if you need them."
And like Dr. Wertheim's program in New York, Dr. Wittenborn has found that setting established times for handoffs improves communication. "We do our changeover at 7 p.m. every night, in the same place every time," he said. "Everyone shows up, hands over their code pagers, and discusses the patients they're accepting for the day. There's no trying to track people down or find a time when it's convenient."
Getting it right
One of the biggest challenges in systematizing handoffs is resisting the urge to convey too much information. "It's like Mark Twain said: 'I apologize for the length of this letter, but I didn't have time to make it shorter,'" said Jeffrey L. Schnipper, ACP Member, a hospitalist at Brigham and Women's Hospital in Boston.
He noted that his hospital's handoffs are computer generated, and so contain lab results, medication lists and updated data. However, he noted, there's a downside. "They're long, disorganized, and almost written as if they were the beginning of the discharge summary," he said. "You would have to read paragraphs to find out why the patient came into the hospital, but the fact that they coded yesterday would be missing. It was at once too long, yet missing important information."
So after a series of resident focus groups and workshops at meetings of the Society of General Internal Medicine and Society of Hospital Medicine, Dr. Schnipper and colleagues at the University of San Francisco and the University of Chicago developed a format they dubbed ANTIC-ipate:
A: Administrative information, such as patient name, record number, location.
N: New information. A clinical update, featuring the current physical exam, especially cardiopulmonary status and cognitive status.
T: Tasks, preferably in an if-then format: "If hematocrit=x, then transfuse=y."
I: "Is the patient sick?" An assessment of the severity of illness.
C: Contingency planning and code status. What could go wrong tonight, and what can you do about it?
Now, Dr. Schnipper said, he and his colleagues are trying to develop methods to evaluate the new system, and hope to create workbooks or slide decks to make it available to other institutions. An article about their system, "Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out," appears in the July/August edition of the Journal of Hospital Medicine (Volume 1, #4).
A culture shift
But these and other efforts will be meaningless unless programs send the message that handoffs are important and that they will be monitored, some say.
"Think about it. Attending physicians on service give residents feedback all the time on their admissions, presentation of case histories and physicals. But no one gives anyone feedback on handoffs. That sends the message that it doesn't matter," Dr. Schnipper said.
"We really need a culture shift so that people understand that this is important and has to be done well."
Next month: Discharge Summaries
Creating to-the-point discharge summaries can be challenging for busy residents. Find out what programs are doing to improve your skills.
Given a lack of widely accepted hand-off solutions, some programs are extrapolating from expert opinion to devise—or suggest—their own:
Forming a best practice group: The University Health System Consortium (UHC), an alliance of nearly 100 academic health centers convened a "best practice" group on hand-off communications in the wake of JCAHO's announcement of the new patient safety goal in 2005, after finding that none of its centers had any model guidelines to share. In May 2006, it released UHC Best Practice Recommendation: Patient Hand Off Communication, which recommends that institutions adopt a specific, standardized format for hand-off communications that includes—at minimum—these four basic elements:
- Patient name plus medical record number or date of birth.
- Physician name.
- Pertinent medical history, including:
- diagnosis, current condition,
- anticipated changes in condition or treatment and
- what to watch for in the next interval of care.
- Opportunity to ask and respond to questions.
Trying SBAR: Some institutions are standardizing handoffs using SBAR, (Situation-Background-Assessment-Recommendation), a popular system that has been used to establish consistent professional communications in health systems like Kaiser Permanente to reduce errors. But SBAR may not be as appropriate for the kind of handoffs that happen as residents go off-shift, said Leora Horwitz, ACP member, a postdoctoral fellow in internal medicine at Yale University. "It's really designed for communication of situational events," she said, such as when a nurse calls a doctor about a patient who is short of breath. "I'm not convinced that it's as useful a format for the somewhat more lengthy and detailed handoffs between residents," she said.
Going electronic: As more and more institutions shift to electronic medical records, some say developing PDA-based tools for physicians linked to the patients' medical records is the logical way to standardize hand-off communications. Unfortunately, few vendors have. One scheduled to be released this fall is MercuryMD's PDA-based MData® Handoff program. It features a centralized hand-off list that tracks diagnosis, code status, allergies and to-do tasks, with access to meds, labs and reports. Also included is an integrated problem list with both current and historical diagnosis and a collaborative history of encounters with each care team member. The tool can be customized to meet a hospital's specific needs. More information is online.
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