Published in the October 2005 issue of Today’s Hospitalist
When the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) implements its 2006 national patient safety goals in a few months, it will address an issue that hospitalists have taken a leading interest in: improving hand-offs and sign-outs.
Starting in January, U.S. hospitals that want to maintain their accreditation will have to improve the way their physicians and nurses hand off information about their patients to subsequent caregivers. The new goal stems from a growing body of evidence that one key to a better hand-off is a calmer and more standardized verbal encounter.
The thinking is that it’s no longer good enough just to pass written, electronic or tape-recorded notes to other providers. That’s why beginning next year, the Joint Commission will require hospitals to give providers a quiet location with minimal interruptions for doing hand-offs and sign-outs. Hospitals will also give physicians and nurses on the receiving end of a signout or hand-off an opportunity to ask questions and get more information.
“We know from the communications literature that the most effective way to communicate is verbal,” says Arpana Vidyarthi, MD, a hospitalist at the University of California, San Francisco, and one of the leading researchers on the topic of hand-offs among physicians. “It’s much more effective than written and allows for nuances to be communicated, an area where the written form falls short.”
“I am very pleased with the JCAHO standards coming out that emphasize the verbal aspects of hand-offs,” says Dr. Vidyarthi, who recently received a grant to convene a multidisciplinary group of experts to identify the best way to transfer information. Because verbal communication typically doesn’t receive the same amount of attention as computerized, electronic or even written communications, she adds, the medical community has not focused on that aspect of sharing information as much as it should.
Communication problems
While the new JCAHO rule specifically focuses on the verbal component of handing off information between caregivers, “the ideal is a combination of verbal and some sort of written or electronic documentation,” explains Peter
B. Angood, MD, the Joint Commission’s vice president and chief patient safety officer.
Dr. Angood says that the Joint Commission’s new patient safety goals grew out of an analysis of a decade’s worth of data the organization has collected about sentinel events. That analysis found that more than 60 percent of these sentinel events had their root in a communication problem.
“If there is a problem in health care, it’s communication,” Dr. Angood says. “So the Joint Commission is pushing how institutions can improve aspects of communication in health care. Some of that is patient-related, such as helping patients take a little bit more responsibility for themselves in learning how to do simple things like keeping track of their medications and learning how to speak up to their providers.”
He adds that the Joint Commission will also focus on times when there is a shift in manpower, location of the patient, or a shift in the responsibility of the patient by another area or another individual. In other words, it will focus on when information is transferred.
“If hand-offs are not done effectively,” Dr. Angood explains, “there is a potential for drops of information, and therefore, potential drops in continuity of care and efficiency of care. The end result can be a bad mistake. Poor information plus poor communication equals mistakes.”
Worsening situation
Although hand-offs have been a part of modern medical care for a long time, experts say that several factors are exacerbating the problem of poor hand-offs.
For one, it is not uncommon for hospitalized patients to receive care from four or more units during a single hospital stay. A typical stay might involve a trip from the emergency room to the critical care unit to the step-down unit to the medical service and back again, not to mention rehab units, nursing homes and home care.
At the same time, and perhaps more importantly for hospitalists, more hand-offs are taking place within each service.
In academic hospitals, the two-year-old 80-hour work-week rules for residents have pushed programs into more shift work. Dr. Vidyarthi says that patients on the UCSF inpatient medical service, for example, are experiencing 15 sign-outs during a typical five-day stay, which is about 20 percent more than before the work-hours rules took effect two years ago.
Dr. Vidyarthi also cites another startling statistic her research has uncovered: Interns are handling 300 sign-outs per rotation. While this makes sign-outs the most common task a resident does “more common than admitting patients or even eating, she notes “it is a skill that is rarely taught.
New protocols for attendings
To this end, Dr. Vidyarthi says, UCSF has developed standardized protocols not only for residents, but for medicine ward attendings.
Training in sign-outs is now part of the orientation UCSF’s medicine interns receive. The new policy is based on what little is known about handoffs, which comes primarily from research about hand-offs that occur in other industries like aviation. It is also exactly the kind of policy that JCAHO will be demanding of all accredited health care facilities starting next year.
The UCSF policy for attendings, for example, states that all sign-outs must include both a written and verbal component. The written component follows guidelines based on research of “best practices” by Dr. Vidyarthi and her colleagues, and it will be folded into the hospital’s computerized record in the future.
What is know about effective written hand-offs, Dr. Vidyarthi says, is that written information must be accurate and updated, anticipate problems, and be written in an “if/then” format that is as specific as possible.
The same is true of verbal communication, she explains. “Being specific is key,” Dr. Vidyarthi says. “It leaves little room for guessing what the primary doctor wanted.”
Take the example of a patient with heart failure. A common example, she notes, is to avoid saying something like, “If the patient is total body balance negative, give Lasix.” It is better to say, “If negative 300 cc at midnight, give 40 mg of Lasix.”
The importance of read-backs
Research from other industries has also uncovered another best practice: Verbal communication must include “read-back” and a time for face-to-face questioning.
In the case of a patient with heart failure, Dr. Vidyarthi says, read-backs would give the covering physician a chance to repeat the instructions back to the physician who is handing off the patient. It could go something like this: “So I’m supposed to check their ins and outs tonight and if they are negative 300, then give them a dose of 40 mg of Lasix.”
Research from the aviation industry has also shown that information should always be stated in the same format each time “so that everybody knows what to listen for and when to perk up your ears,” Dr. Vidyarthi says.
In addition, verbal sign-outs need to take place in “quiet, well-lit places where computers are available to look up lab values or other information” and where interruptions won’t occur.
“This is turn-off-the-pager time,” Dr. Vidyarthi explains.” If you train folks to do this well, it should not take more than 10 to 15 seconds a patient.”
While the Joint Commission is giving hospitals some guidelines on how to meet its patient safety goal for handoffs, Dr. Angood says it hasn’t gotten “too prescriptive.” Instead, he notes, it will be up to each health care institution to figure out how best to comply.
“Ideally, the care providers who have been most recently involved in a patient’s care should be doing the hand-offs,” he adds, “and they should still be readily available to answer any questions or concerns after the hand-off has occurred.”
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.
