Published in the August 2012 issue of Today’s Hospitalist
LONG CONSIDERED the Achilles’ heel of hospital medicine, the handoff is certainly not going away. If anything, the number of handoffs that hospitalists perform is proliferating, not going down in number.
Many day teams, for instance, now sign out patients to someone on a swing shift, who in turn hands those patients off to a nocturnist. More groups also have dedicated admitters signing out to rounders, and new work-hour restrictions mean more handoffs among housestaff.
While there’s been a lot of talk about best handoff practices, rising volumes and time constraints have many hospitalists looking for ways to pare back the time spent on handoffs.
“It’s easier to speak free-flowing thoughts than type something out formally. It’s just easier to talk.”
That’s particularly true for morning signout, where many groups still meet face-to-face. The good news is that hospitalists are finding a host of technological tools to shave minutes off handoffs without dropping key information.
Overlapping shifts, multiple handoffs
When it comes to handoffs, face-to-face communication is increasingly reserved only for patients who are unstable or have urgent pending tests. Evening signout is particularly casual, with many programs having no formal procedure to hand off stable patients.
At St. Joseph’s Hospital in Syracuse, N.Y., overlapping shifts mean multiple layers of handoffs. Day physicians typically turn patients over in the evening to a midlevel working a 2 p.m.-2 a.m. swing shift, but give a verbal signout to that shift’s physician only if a patient is unstable or problems are anticipated. The nocturnists don’t arrive until 10 p.m.
Given how many handoffs take place, the hospitalists needed a place to store patient information that physicians could access around the clock. The hospital’s IT programmers designed a custom “handoff” tab that is now part of the McKesson EMR system.
James Leyhane, MD, the director of the hospitalist group, says the tool has helped streamline the hospitalists’ internal communication. The physicians update that information at least once a day, although “we sign out specific to-do items verbally.”
The group has also changed how it does its 7 a.m. handoff. While morning handoff used to be face-to-face, that changed several months ago when the hospital opened a new ED “where the night hospitalist is usually encamped “much farther away from the hospitalist office where the day physicians gather.
Now, instead of meeting in person, the nocturnist phones in, and the day doctors pass a cellphone among themselves as each finishes taking his or her allotment of night patients. Because some day physicians arrive earlier than others, most don’t spend too much time waiting for their turn on the phone.
As far as Dr. Leyhane is concerned, moving away from face-to-face meetings may have improved signout quality. “There’s less pressure than if the nocturnist walks in and he’s got eight docs staring at him,” Dr. Leyhane explains. “He might feel more pressure to get through each signout and get on to the next person.”
For most groups, morning handoff is still done in-person. But groups are trying to reduce the amount of time that these day physicians spend receiving new assignments.
At Saint Francis Memorial Hospital in San Francisco, says hospitalist Kamal Ghei, MD, all three daytime doctors used to sit and listen to all the handoffs from the night physician. But “it wasn’t that useful waiting for your turn,” he says, “and it took up valuable time that could be used seeing patients early in the morning.”
Now, the day physicians rotate being what Dr. Ghei calls the early doctor, coming in at 7 a.m. and taking signout for new admissions from the nocturnist. The night physician completes a signout sheet for those admissions, listing key information like the names of primary care physicians or consultants.
It’s the early physician who divides the new patients among the day teams and passes any additional information not described on the signout sheet to the day physicians “if it’s urgent,” Dr. Ghei explains. “Many times, the info on the signout sheet is sufficient.”
In a decidedly low-tech approach, the day physicians prepare an Excel spreadsheet with all pertinent patient information to give to the night doctor in the evening. “If a patient at night needs a more serious intervention,” says Dr. Ghei, “we also place a note in the patient chart.”
The group has asked the hospital IT department to incorporate signout tabs into the EMR. But hospitalists want to preserve their ability to pass along information that won’t be part of the medical record.
“I may want to tell a colleague, ‘Ortho is dragging their feet, push them to see the patient early tomorrow’ or ‘I think this patient is rude and drug-seeking,'” says Dr. Ghei. “But I don’t want that opinion to be discoverable. We want a signout where we can freely discuss patient concerns.”
At Methodist Hospital in Omaha, Neb., hospitalist Nicole Paulman, MD, says her group has also moved to designate only one doctor “the day call physician “to take the handoff from the night shift. That doctor meets with the nocturnist at 8 a.m., while the other day physicians arrive between 8 a.m. and 9 a.m.
The day call doctor divides patients among the day teams and may pass along any urgent information about individual patients. But most of the handoff information that the day doctors need has been recorded by the nocturnist over the phone.
Phoning in works fine
Since 2006, Dr. Paulman explains, the hospitalist group has relied on a modified version of the VoiceCare telephone system. Nurses use this system to either phone in and dictate handoff information at the end of a shift or to listen to patient reports when their shift begins. The hospitalists use the system to record handoffs at the end of their service block and for all new admissions (or cross coverage issues) at night.
As far as Dr. Paulman is concerned, phoning in handoffs beats typing. “It’s like dictation,” she notes. “It’s easier to speak free-flowing thoughts than type something out formally.” Typing handoff information or using a handoff template, she says, just ensures that “things get abbreviated or left out.”
She points out that the hospital’s Cerner EMR is being upgraded and, for the first time, the hospitalists can use the EMR to send each other electronic notes. At some point, she and her colleagues may migrate more internal communications to the Cerner system.
In the meantime, they’re used to recording most of their handoffs and don’t believe they’re missing key information. “It’s just easier,” Dr. Paulman says, “to talk.”
Then again, some physicians find that it’s easier to type. In Canton, Ohio, the 20 hospitalists with Aultman Inpatient Medicine used to listen to all cross-coverage issues and new admissions at morning handoff.
But two new developments in the last 18 months have improved that process. For one, the group hired a nurse practitioner who now handles all night-time cross coverage, leaving the night physician to do admissions and codes. And the group started using Ingenious Med billing software, which is now integral to the handoff process.
The night-time NP uses the software to note any night issues that crop up, writing in two or three lines. That gives the doctors more insight into night-time problems than they used to receive, says Muhannad Samaan, MD, the group’s associate medical director.
“The night doctor used to forget to sign out those patients because it was a busy night,” says Dr. Samaan. With the NP’s notes, the information no longer falls through the cracks.
As for new admissions, those are being handled differently as well: They’re being divided up by the night physician among the day teams after looking at each team’s census and illness severity. The night physician then signs out individually to the day physicians.
“By dividing the list earlier, we allow the physician picking up the patient to ask more specific questions,” says Dr. Samaan. “That’s made the whole process more efficient.”
For the nocturnist, total morning-signout time has dropped from 45 minutes to 30, while each day physician now spends between five and 10 minutes receiving new patients, instead of 45 minutes hearing about them all.
Another innovation is overlapping shifts. Instead of the night physicians working 7 p.m. to 7 a.m., that shift now goes from 8 p.m. to 8 a.m.
“They used to have to stay 45 minutes late,” Dr. Samaan points out. “Now, they usually finish at 7:30 or 7:40 and they can leave, which is more satisfying.”
Preserving face time
In Raleigh, N.C., Charles Hodges, MD, the medical director of the hospitalist group at Duke Raleigh Hospital, says his group relies on technology for some handoffs.
When handing off patients to day rounders, the two dedicated day admitters (from the day before) type a blurb about the patient and update the patient’s problem list in the computer.
But “we also ask them to speak about the patient as a kind of verbal handoff” into a digital recorder, Dr. Hodges says. That recorder stays in the hospitalists’ office on top of the admitters’ handwritten signoff.
“They usually record between three and five minutes on each patient,” he notes. “We just pick up the recorder and listen.”
But for morning signout, Dr. Hodges’ group is strictly old school. Each morning, the night person first tells all five day rounders what Dr. Hodges refers to as “FYIs” ” anything that came up during the night for previously admitted patients. The night physician then goes through all new admissions.
“I like the verbal, despite some pressure to get rid of it,” Dr. Hodges says. By having all the physicians in the room, he adds, “we end up having a conversation, bouncing things off each other for those patients who might be more interesting” or whose care is confusing. Usually, Dr. Hodges notes, the group has between four and six night admissions, although “a horrible night” might bring as many as nine.
The process definitely eats up time, he admits. But “nobody has been able to convince me that this isn’t important or that there is a better way to do it.” Most of his colleagues agree. “They understand the value of it so they are willing to live with that loss of time,” Dr. Hodges notes. “I still think that the key to medicine is listening.”
Turning to the Web
Other groups, however, have too much volume “and variability “to absorb that time loss. A case in point is the Sound Physicians group that serves a 276-bed regional medical center in Ohio.
Doctors coming off shift give each other a heads-up on any unstable patients or urgent labs or issues. But for handoffs, they rely on SoundConnect, proprietary Web-based software used exclusively by Sound Physicians practices.
The tool, which is for hospitalists’ eyes only, contains all patients’ diagnoses, clinical summaries, medications and follow-up notes. Physicians use the software for billing and coding, and to fax reports to primary care physicians on admission and discharge.
The internal communication tool is also critical for handoff information, in part because Sound Physicians took over the hospitalist program in April. As in many startup programs, coverage is provided by both permanent, employed doctors and locum physicians. Given how many new physicians are providing care, chief hospitalist Joe Joseph, MD, notes that “having standard processes in handoff communications reduces variation and error” that could easily crop up among doctors not familiar with one another.
The tool also standardizes different physicians’ communication styles. “The advantage is that it’s uniform, and you can put only so much information into the tool,” Dr. Joseph explains. “It’s a guideline that prevents you from typing a 10-page summary.”
With some physicians spending only a short time in the practice, do they sometimes forget to update the Web tool altogether?
“We make sure doctors are trained during their orientation on how to use it,” Dr. Joseph says. “That’s something that we mandate.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Handoffs’ bad rap
The fact that hospital medicine features so many handoffs is considered the specialty’s big vulnerability. Physicians, the conventional thinking goes, risk dropping vital information as they hand patients off after every shift and service block.
But according to Kamal Ghei, MD, a hospitalist at Saint Francis Memorial Hospital in San Francisco, signouts are being singled out unfairly. He argues that because his workday features so many interruptions, handoffs represent only one of many potential voltage drops.
His group doesn’t yet have the volume, for instance, to justify a dedicated admitter. So he and his colleagues have to put rounding and discharges on hold to do daytime admissions.
They also have an open ICU, where one patient can keep him busy for hours. “There are so many breaks in the day that I think you start to miss things,” Dr. Ghei says. “The day gets very choppy.” His personal preference would be to have an admitter and a closed ICU with an intensivist, at least during the day. “Then,” he says, “we could concentrate on rounding.”
In Raleigh, N.C., Charles Hodges MD, the medical director of the hospitalist program at Duke Raleigh Hospital, has dedicated admitters. In fact, 80% of the hospital’s patients are admitted by physicians who don’t end up treating them.
In an ideal world, Dr. Hodges points out, patients would be followed throughout their hospital stay by one physician. But he also finds a creative side to the handoffs that take place. That’s particularly true, he says, when he picks up patients from another rounder going off service.
“It’s not uncommon to find things that are mildly or even significantly incorrect, so there can be a benefit” to having a new set of eyes, he notes. As an example, he mentions a recent patient whose physician didn’t realize that she was suffering from a complicated UTI, although her original diagnosis was pneumonia; Dr. Hodges was able to get her on the right antibiotics. “Handoffs aren’t all negative.”
GIVEN THIS SUMMER’S NEWLY ARRIVED INTERNS, many academic centers are trying to figure out how to train residents to do better handoffs.
The need for that training is greater than ever, says Robert Chang, MD, an assistant professor of internal medicine at the University of Michigan at Ann Arbor, because of the latest work-hour restrictions. This last academic year was the first time that residents routinely started taking admission handoffs “handing off a newly admitted patient to another doctor for subsequent care “from other residents.
Physicians find admission handoffs particularly discomforting, Dr. Chang says, referring to a study that he and his group presented at this year’s Society of Hospital Medicine meeting in San Diego.
While attendings in the study were more comfortable with admission handoffs than residents, physicians across the board had a much higher comfort level with patients they had themselves admitted. At least two-thirds of all physicians surveyed had run into incomplete or inaccurate information during an admission handoff “and were either sometimes or often uncertain on how to proceed with patient management.
“It is possible that no amount of experience or training may overcome this discomfort,” says Dr. Chang. “You may never be as comfortable unless you admit the patient.” In his experience, physicians taking admission handoffs compensate by “making that patient their own by taking another history. If I’m uncertain, then I need to fill the blanks in my head about the story, and we may need to accept that as part of the cost of doing business.”
Another study presented at the SHM meeting looked at a different type of handoff: from day teams to a nocturnist who typically was a resident or an internal medicine fellow. The study, conducted at the University of New Mexico in Albuquerque, applied the triage techniques honed in the ED to the medical and hem/onc patients being signed out by seven ward teams to the night covering physician.
Nightly signouts have the potential to be “all over the place,” says study author and hospitalist Percy Pentecost, MD. He found variation both in terms of the details offered by the handoff “senders” and what different “receivers” wanted.
In a pilot that lasted 14 nights, ward physicians divided patients being handed off into one of four groups: A patients were unstable or acutely ill, B patients were becoming stable, C patients were consistently stable, while D patients had a pending discharge.
Only patients in the A and B groups were verbally handed off (typically, over the phone) while physicians for the C and D groups relied only on notes written in the medical center’s Cerner EMR. The triage system, Dr. Pentecost notes, shaved 20% off the time it took to do night signout.
“We encourage this, but we haven’t universally adopted it,” Dr. Pentecost admits. “The fellows and residents who cross-cover patients at night are actually moonlighting, so are not part of the formal team structure.” And with new interns this summer, “the onus will be on us and on me to continue to encourage this approach and resell it.”