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Problems with handoffs?
Experts say doctors need to unlearn bad communication behaviors

Keywords: Handoffs: Big Information Gap in Hospital Medicine


by Marcia Frellick



Published in the August 2011 issue of Today's Hospitalist

How well do you think you communicate information during handoffs?
If you're like other physicians, you're probably not nearly as effective as you think.

Study after study has shown that human beings don't communicate very well, not just during handoffs but in everyday life. And given the number of times that hospitalists must do just that in the form of handoffs, the problem is daunting. Hospitalist Arpana Vidyarthi, MD, an associate professor of medicine at the University of California, San Francisco, estimates that at her 550-bed medical center, 4,000 handoffs take place every day.
"All information is not created equal."

–Vineet Arora, MD
University of Chicago

That adds up to a whopping 1.5 million handoffs in one hospital per year.

In a session exploring the dos and don'ts of handoffs at this year's Society of Hospital Medicine annual meeting, Dr. Vidyarthi worked with hospitalist Vineet Arora, MD—who have both done extensive research on handoffs—to diagnose the problems that can sabotage handoffs. One recurring theme was that most people underestimate just how challenging communication can be.

The psychology of miscommunication
"There are great data showing that speakers systematically overestimate how well their messages are understood by listeners," said Dr. Arora, associate professor of medicine at the University of Chicago. "We use vague language and assume people know what we're talking about."

To test that concept in the hospital setting, Dr. Arora and her colleagues observed pediatric interns handing off at the end of an overnight shift. Researchers then asked the physicians presenting the handoff to guess what information recipients would say was most important.

"Unfortunately, the most important piece of information was not communicated 60% of the time," Dr. Arora said. But despite that rampant miscommunication, both the presenters and receivers of the information consistently reported the quality of their communication as very high. (Results of the study were published in the Feb. 8, 2010, Pediatrics.)

Why the disconnect between what's said and what's heard? According to Dr. Arora, that has to do with the psychology of miscommunication: Receivers desperately want to make sense of what they hear, so they convince themselves that they know the answer.

"We really are not good with uncertainty," said Dr. Arora. "We will rewrite the story in our mind and pretend like we knew what the answer was. This actually goes on a lot in handoffs. We need to break through these time-worn biases to make sure the person is on the same page with us."

Passive behaviors
Another problem with handoffs is that they often are not a two-way street. While the onus is generally placed on the person delivering the handoff, Dr. Arora has come to realize that it's very easy for recipients to look like they are listening when in fact a dialogue may not be taking place at all.

Nodding, eye contact and body language are all passive listening behaviors that don't signify that someone is actually listening or comprehending. To fully participate, receivers need to use active listening behaviors, which include note-taking, asking questions and using read-back.

"I guarantee that if you go through a drive-through or a Chinese takeout, you participate in read-back," Dr. Arora said. "That is because the restaurant has an incentive to get it right."

Interruptions are another big obstacle to effective handoffs. While most physicians assume that nursing pages constitute their biggest source of interruptions, research shows that physicians most frequently interrupt themselves to engage colleagues in side conversations.

Physicians who arrive late for handoffs—and then have to rush through them—are another problem. That's an even bigger issue when schedules don't allow sufficient time for doctors to ask and answer questions.

"If your sender's shift ends at 7 p.m. and your shift starts at the same time, your sender is out the door," Dr. Arora pointed out. "You need 15 minutes of overlap built into the schedule so people know that handoffs are still part of their job."

Focus on action items
But the big key to successful handoffs is remembering that "all information is not created equal," said Dr. Arora. "You really need to focus on what receivers can remember. How can I not overwhelm them with information and just get to the heart of the matter?"

Other findings from her study of pediatric interns provide clues: 69% of the interns on the receiving end of those handoffs remembered if-then items, while 65% recalled to-do items.

Dr. Arora said those data show that handoffs should focus on action items that receivers have a better chance of remembering. While sign-out templates may start by listing patients who have been in the hospital the longest or may organize patients according to units, that's probably not the most efficient way to order handoffs.

"Focus on your sickest patients first with their daily progress, with today's baseline and updated events," Dr. Arora said. "Then present your to-do and if-then items."

And when giving to-do and if-then directions, Dr. Arora pointed out, give the receiving physician a rationale for them. "You need to avoid ambiguity, so don't just say 'check CBC,' " she said. "Is that person supposed to follow the white count or the platelets? Give the reason for doing something and explain what should be done with those results."

Senders also need to make sure receivers understand their message by encouraging them to ask questions. And receivers need to engage in active listening and feedback, Dr. Arora said, and "use a system to keep track of to-do items."

"CoPaGA"
Written handoffs can also go awry, either because doctors include too little or too much information.

Many written handoffs now suffer from what Dr. Arora called "CoPaGA": copy paste gone amok. It's become too easy to just copy and paste the entire past medical history with all the radiology findings thrown in, particularly since the advent of electronic health records.

"Signouts have become a shadow chart, so receivers can't remember what was most important on your list," she said. "Handoffs lose their primary function for the receiver."

Copying and pasting for the written portion of your handoff is OK, Dr. Arora said, as long as physicians appropriately whittle down and update the information. Doctors may change high-risk medications, including antibiotics and pain drugs, on a daily basis, so old information can quickly become out of date.

The risk of out-of-date information is even greater the longer your patient stays in the hospital. For that reason, Dr. Arora said she gives herself a timeout before handing off any patient who's been in the hospital three days or longer. She makes sure she updates the record in terms of drugs, diagnoses, and to-do and if-then items.

Dr. Vidyarthi pointed out that like verbal handoffs, written signouts should focus on new or recent information and give physicians an idea of what to anticipate—and do if that eventuality comes to pass.

"It's important to be able to get a quick gestalt of what's likely over the course of the day if the patient is sick enough," she said. "You don't necessarily get that out of the chart."

Marcia Frellick is a freelance health care writer based in Chicago.


Saved by a checklist? Maybe not

BECAUSE SO MANY THINGS can potentially fall through the cracks during handoffs, many people are looking for a silver bullet that will ensure that the right information is handed off all the time. One popular solution is checklists, which have (rightfully) been credited with saving lives in hospital settings.

But according to hospitalist Arpana Vidyarthi, MD, an associate professor of medicine at the University of California, San Francisco, checklists aren't necessarily the answer. Dr. Vidyarthi was a co-presenter of a session on handoff techniques and behaviors at this spring's Society of Hospital Medicine meeting.

"The checklist itself doesn't do anything," she noted, particularly if doctors simply develop a check-the-box mentality and don't really pay attention to how actively they're interacting with one another.

Checklists also may not allow for the kind of nuanced information—like "stay away from that patient's aunt!"—that doctors need to pass along.

The same is true for SBAR (situation/background/assessment/recommendation), a communication technique that Dr. Vidyarthi said is fast becoming a popular template for handoffs. "If SBAR isn't tailored to what you need it for, it can—like checklists—actually cause harm," she said. "There are many misuses of SBAR, and one is the assumption that just using it will produce all the information that you need."

And given how effectively doctors can apparently ignore electronic information like lab values, physicians can't count on technology to get themselves off the hook for learning the right ways to communicate.

"IT solutions alone cannot substitute for successful communication," said Vineet Arora, MD, a hospitalist and associate professor of medicine at the University of Chicago who also presented the session. "You can't just rely on the fact that the computer is going to do it for you, at least not yet."

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