Published in the March 2006 issue of Today’s Hospitalist
Patient safety experts have long suspected that handoffs and signouts “and the dropped balls and fumbled catches that can accompany them “represent a weak link in medical care. A recent study of medical interns at the University of Chicago has produced evidence that not only confirms that belief, but sheds light on what makes a “good” handoff.
After interviewing 26 interns caring for 82 patients after two different nights of call, researchers found 25 “incidents,” which they defined as near misses and adverse events. All were the result of what investigators described as “a communication failure in the written or verbal signout from the preceding shifts.”
The study found that the most common problem involved the omission of critical information. Incidents included failing to report an active medical problem or a medication, or failing to mention that a diagnostic test or consult had already been ordered.
While these results may not be particularly surprising to hospitalists, their emphasis on the critical role of communication will likely be an eye-opener for others in U.S. health care .
“We are starting to understand that medical errors are linked to communication and teamwork,” says Vineet Arora, MD, a hospitalist and associate program director of the University of Chicago’s internal medicine residency who served as lead author of the study. “These are complex processes that revolve around how we communicate in health care.”
The trouble with handoffs
Dr. Arora says that the few studies that have looked at handoffs have all found these transactions tend to be “variable, unstructured, and prone to error.” She explains that the variability in the way that physicians and nurses talk to each other during handoffs is the prime culprit in many handoff problems.
Of the sentinel events reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), for example, communication failures account for more than 60 percent of the root causes of all events.
Starting this year, JCAHO is requiring hospitals and other health care organizations “that includes both academic and community hospitals “to demonstrate that they have a standardized handoff process in place. That process must give providers a chance to ask and respond to questions.
While patient safety advocates have applauded JCAHO’s emphasis on streamlining handoff communication, that doesn’t necessarily help physicians and hospitals on the front lines struggling to improve handoffs. The problem is that no one knows exactly what that process should look like.
“This is an example of where the policy has preceded the research,” Dr. Arora says.
Building a better transition
That’s where her study of handoffs among interns, which was published in the December issue of Quality and Safety in Health Care, comes into play. The research provides some clues about how to build a better handoff by pointing to some traits shared by nearly all effective handoffs.
First of all, Dr. Arora says, good handoffs typically include both written and verbal components. In terms of the written component of signouts, the study found problems most commonly with legibility (poor handwriting), relevance (giving too much information, such as including a patient history in a document), accuracy (providing the wrong room number) and out-of-date information (medication lists).
When it came to information that was omitted from the handoff altogether, interns in the study said they were all too often missing information on code status, anticipated problems, active problems, the results of a baseline exam like neurological status, and lists of pending tests and consults.
Interns interviewed for the study said that the most obvious solution to these problems was to increase verbal communication. A number of interns said that face-to-face communication would help eliminate many of the problems they witnessed.
“Face-to-face communication is just a richer way of communicating,” Dr. Arora says. “You can allow for interactive questioning. You can emphasize the priority of things. You can say, ‘This is really important.’ Just the fact that you are having a face-to-face conversation increases the priority of the handoff.”
The value of standardization
Dr. Arora says that her research identified a second element of good handoffs: standardization.
Even a simple written form or computer template, she explains, can go a long way in making sure that critical information is not left out. Requiring that handoffs and signouts include a face-to-face conversation takes the process a step farther, she adds, because physicians and nurses must justify any deviations they make from accepted standards.
And standardization isn’t helpful only for young and relatively inexperienced physicians. “Because of the unpredictable nature of hospital care,” Dr. Arora explains, “even experienced physicians who have done great signouts in the past can have a difficult day. That can lead to failed communication processes or omitted content. A system that standardizes handoffs can help ensure that physicians don’t fall into those traps.”
The third key component of a successful handoff, Dr. Arora says, is teaching physicians why handoffs are so important. She notes that her study has convinced her that physicians, starting with residents and medical students, must be taught how to do an effective handoff.
Young physicians need to learn more than just the nuts and bolts of handoffs, she adds. Teaching about handoffs also drives home the point that covering physicians have just as much responsibility for patients as their primary physicians.
“There is a valid concern out there that professional responsibility is not as high as it should be during these coverage periods,” Dr. Arora explains. The worry is that if physicians don’t view patients as their own “they think they are babysitting until the patient’s primary physician comes back “they won’t go the extra mile. That’s a big problem, she says, because patients sick enough to land in the hospital today demand 24-hour care.
Countering the shift-work mentality
“This is very concerning because you are coupling that mentality with a potentially failed process,” Dr. Arora explains. “We need to think about why these communication failures are occurring, and part of that may be that the signout is not a high priority. Maybe built into the organization’s culture is that you are just getting through the night and not really caring for those patients.”
To address some of those concerns, Dr. Arora, along with her co-author Julie Johnson, PhD, will conduct a workshop this spring on how to do an effective handoff for fourth-year medical students at the University of Chicago.
They are also leading an institutional effort to ensure that in-hospital handoffs in all residency specialties at the University of Chicago (pediatrics, obstetrics, specialty surgery, etc.) are standardized and meet JCAHO’s rules. Their expertise will also benefit other area hospitals through a series of learning sessions for handoffs sponsored by the Illinois Hospital Association.
While Dr. Arora predicts that these types of efforts will improve patient safety, she also thinks they may make physicians’ professional lives better.
“One of the interesting things we found is that there is a great deal of uncertainty in caring for patients in the setting of discontinuity, and that can be pretty anxiety-provoking,” Dr. Arora says. “We can use the handoff process as a way to ameliorate that uncertainty.”
Good news for hospitalists
How will hospitalists be affected by the growing amount of attention being paid to handoffs? As hospital medicine evolves into a shift style of practice, Dr. Arora says, the ability to successfully transfer patient information to the next shift of physicians is becoming ever more important.
She hopes that teaching young physicians how to do handoffs will help counter concerns about a mounting shift-work mentality in hospital medicine. “I think that a good handoff not only communicates the necessary content through a well-defined process,” Dr. Arora explains, “but it also is a transfer of professional responsibility.”
While it’s difficult to say whether hospitalists are doing a better job of handoffs than the physicians in her study, Dr. Arora hopes the specialty will accept responsibility for improving handoff processes.
“Hospitalists are in the perfect position to take the lead on developing these protocols for how best to hand off patients,” she says. “This is what they do every day.”
And while much of the news about handoffs may seem glum, Dr. Arora says her research did produce an encouraging discovery: Simply asking about handoffs led many of the young physicians she studied to start thinking about how they could do better. Improving the handoff and signout process, it turns out, is an area that interns have an interest and incentive to improve.
“One intern called me back and told me a story about how a week before, they were concerned that they had performed a bad handoff,” she says. “I thought this was a nice example of how once you make people aware of the problem, even just by asking the question, they are very ready to commit to change and improvement.”
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.