In Part I of this feature, we highlighted the importance of provider communication and crucial information exchanges in order to promote patient safety. Continuing this important theme, we present the second part of this article on the primacy of the provider-to-provider handoff to safe care for our patients. To read Part I, click here.
Part II
Background The clear, accurate and effective exchange of clinical information has always played a central role in the delivery of health care. Patients and health-care providers, including physicians, have long depended on the exchange of clinical information to deliver quality care. Whether between primary providers and consultants, or transitioning on-call physicians, the handoff communication is an exchange that includes not just information, but a transfer of responsibility for care of the patient. The handoff is defined as “the exchange between health professionals of information about a patient accompanying either a transfer of control over, or of responsibility for, the patient” (1). We will review the background and current literature regarding the importance and method of handoffs and highlight areas for improvement in this vital activity. We hope to encourage further research into the development of data-driven guidelines that would be appropriate for the neurosurgical setting and would include the flexibility to be applicable in multiple environments, ultimately enhancing patient safety.
Provider Handoffs — The Current Evidence
With the growing interest in the handoff process, there have been a number of articles published on the topic in recent years. Robertson et al. (3) reviewed 631 publications on patient handoff and looked for those that consisted of any “intervention developed with the intent of improving handover quality and/or safety,” which also included a hospital setting, with pre- and post-assessments and with assessments of beneficial effect on staff knowledge, time taken, behavioral changes or patient outcomes. Only 29 studies met the criteria. The majority of these were small studies, uncontrolled and unblinded, with a tendency toward rather short follow-up periods. They also tended to focus primarily on the handoff process. Only 10 studies (37-46), included clinical outcomes, and only two of those were able to demonstrate a benefit. One study found a decrease in observed adverse events (42), and the other demonstrated a decrease in length of stay (44).
Riesenberg et al. (7) reviewed 2,590 articles on handoffs and identified 18 that involved research on handoffs and six that included some measure of the effectiveness of the handoff process. They identified as many as 91 common barriers to effective handoffs. They report on 140 different strategies for delivering handoff information. They note that there is a surprisingly consistent anecdotal set of strategies deemed appropriate for proper handoffs across the literature, but very little data to support the effectiveness of any (7).
DeRienzo et al. (30) reviewed 919 articles. They identified three categories of reports: those on handoff structure, including verbal and written components, those on education in delivering handoffs and those on evaluation of the handoff process. Regarding structure, they identified at least 24 different verbal pneumonics published in the literature, SBAR (Situation, Background, Assessment, Recommendation) being the most common. They suggest that some flexibility be built in to any system to allow for local clinical needs. The addition of electronic medical records (EMRs) has allowed for improvement in data recording accuracy, a decrease in the time for data collection and increased efficiency of the handoff process. Education protocols report the positive effects of an education intervention on the handoff process. The formats which the authors found most beneficial tended to include some component of interactive training or simulation. As to evaluation, the literature used the safety measures, quality measures of the data itself or the perception of confidence in the process by the participants. They conclude that there is a “lack of congruence on the ‘best’ structure for standardizing patient handoffs (30).”
Barriers to Effective Handoff Performance
Several authors report on barriers to effective handoff performance. The reliance on shift models for delivery of physician-based care, particularly in the era of the resident duty-hour limitations, has increased the number of handoffs, reduced the quality of the verbal handoff, decreased the number of direct physician communication in the process and limited the capacity for read-back and questions (11), (15), (28), (48), (49), (50). Interruptions affect the quality of handoffs (24), and written handoffs alone are likely to be quite variable in their quality and have a higher likelihood of omissions (49). The lack of standardization of the information being reported can be a barrier to consistent communication (24). Computer generated data has many beneficial features, but can lead to a lack of attention to the detail and can omit important patient issues (24). The experience level of participants in the handoff process can affect quality, with participation of senior level providers affording better handoffs (24).
There is literature to support the association of poor handoffs and patient outcome. Adverse events (27), (51), increased surgical intensive care unit (SICU) admissions (27), (52), longer lengths-of-stay and higher costs (27), (53) have all been associated with improper handoffs. There is also literature on the beneficial effect of education interventions on the quality of the handoff process. However, there is a paucity of literature on the effects of education interventions regarding the handoff process on actual patient safety or patient outcomes.
In 2012, Mueller et al. (27) attempted to determine on a national scale whether training in patient-information transfer would be of benefit in patient outcomes. They reviewed the data from nationally representative internal medicine residency programs and their primary affiliated hospitals in 2008 and found that 70 percent reported resident training in handoffs and 53 percent reported evaluation of their residents’ handoffs. The quality outcome measures used were 30-day risk-adjusted re-admission rates and mortality for their index diagnoses of acute myocardial infarction, congestive heart failure and pneumonia. The only significant difference between the programs that trained their residents in handoffs and those that did not was a significant decrease in mortality from pneumonia (11.0% vs. 11.8%, P=.01); (27).
System-Wide Education Intervention
Graham et al. (11) introduced a system-wide education intervention for their internal medicine resident night float exchange across their institution (Beth Israel Deaconess Medical Center, Boston). They noted ideal handoff content included a summary assessment, the past medical history, an active problem list, current clinical status and anticipatory guidance. They intervened with improved face-to- face exchange and an electronic template. There was overall improved participant satisfaction, improved quality-of-handoff content and significantly fewer data omissions, but no effect on adverse events (11).
Starmer et al. (54) reported on a multi-hospital intervention in nine pediatric residency programs throughout North America to improve resident handoffs. The intervention for each center included the following:
- A six-month measure of pre-intervention data
- A six-month measure of post-intervention data
- A six-month intervention with the institution of a standardized checklist (I-PASS Handoff Bundle)
- A two-hour workshop on communication skills and techniques
- A one-hour role playing and simulation session
- A computer module for independent learning
- A faculty development program, direct observation tools for assessment, feedback and a promotional campaign to encourage participation
They were able to show an overall significant 23-percent reduction in medical error rates from 24.5 to 18.8 per 100 admissions (p<0.001) and a 30-percent reduction in preventable adverse events from 4.7 to 3.3 per 100 admissions (p<0.001) across the entire study group. The authors, however, noted individual institution variability, as three of the nine centers showed no beneficial effect with the intervention. It is also not clear if any one component of their bundled interventional approach was more essential or if it was the total bundle that was required for the observation of benefit (54).
Despite the significance of these findings, there remain important questions regarding effective handoffs. What criteria should be used to measure a quality handoff? What characteristics are key to the performance of the proper handoff, both in terms of content and in terms of the process?
An Area of Growth for Neurosurgery
While these and other studies suggest a beneficial effect to an improved handoff structure across multiple medical and surgical disciplines, there is a distinct lack of literature in neurosurgery that could address the unique characteristics germane to the field. There are particular qualities in the neurosurgical setting that have an impact on the effectiveness of a proper handoff of the neurosurgical patient. Existing literature contains only one survey and one study proposal involving handoffs specifically addressing neurosurgery.
Babu et al. (55) surveyed the 98 accredited neurosurgery residency programs in the U.S. in 2011 and determined several characteristics of the sign-out processes in residency that could indicate areas for focused improvement; noting that 54 percent responded that they did not use a standard protocol, although the majority used both a written and a verbal sign-out. The survey found that 55 percent of respondents indicated that their handovers were always monitored by a chief resident, 72 percent were interrupted one to four times and 37 percent of residents have received formal instruction on proper handoffs (55).
Fallah et al. (56) identified several issues that a neurosurgery service must consider in performing an optimal handoff. The service tends to often have a high patient volume, there is a rapid patient turnover, patients’ clinical statuses can change quickly, the incoming neurosurgeons may be unfamiliar with a large portion of the service, neurosurgical patients are among the sickest in the hospital and families often require frequent updates. To these we would add, based on the aforementioned survey data, the likelihood of an interruption during the handover is increased, the potential for a handoff occurring not in the presence of a chief or advanced resident is relatively high and the ability to exchange the nuances of the neurologic examination must be emphasized for optimal patient care and decision making. The authors propose a specific safety checklist, “the SAAFE sign-out” (Sick Patients, After Surgery Patients, Admissions, Follow Closely, Essential Run-Through) and encourage the adoption of a handoff format that can be properly evaluated in an effort to encourage the development of a useful standardized sign-out tool for neurosurgery (56).
Closing Thoughts
It should be clear that the handoff communication cannot be simplified to an acronym or rigid rubric. There is more to the sign-out process than just the uni-directional conveyance of information, and there are limits to what a checklist alone, even in its most accurate form, can accomplish.
Cohen et al. (57) argue that the actual handoff may be a much more rich and complex interaction in which two providers attempt to co-construct for each patient a mutual image of a complex patient system; including all the subtleties of physiology, laboratory trends, neurologic function, history, social context, etc., in anticipation of likely care needs as the patient undergoes a transition of care from one provider to the next. The handoff is a process that helps to create a mutual mental model of the patient and their health-care needs. It helps to shape the perception of the patient in the minds of the caregivers, gives priority for patients’ medical issues, lets providers come to agreement on the likely upcoming medical needs, reinforces the warning signs to anticipate and also anticipates the potential interventions required.
Hilligoss et al. (58) discuss the two parts of the handoff — the paradigmatic mode of thought, essentially the checklist portion — and the narrative mode of thought. The checklist provides only the outline of the discussion, but the narrative component allows for the introduction of the clinical nuances, the singular nature of the individual patient, and helps “to make sense of the situation.” The narrative aspect of handoffs has had limited study. Hilligoss and Cohen (2) have attempted to apply concepts derived from organizational theory to help identify the key structural components to the handoff.
They identify two key characteristics of the handoff that warrants further investigation if improvements are to be realized — multifunctionality and situatedness. They argue for the multifunctional nature of the handover, indicating it is responsible for information transfer, transfer of responsibility and control, resilience in the system (anticipation of potential errors, flexibility to change), co-construction of shared mental models and overall learning.
Situatedness refers to the environment where the exchange may take place and the factors that influence a proper handoff. These include the participants themselves, their level of training, status and authority, the physical environment (including location and potential for interruptions), the tools available including computer technologies and electronic means of communication and the division of labor, indicating how many care givers and their locations are required for a patient during a hospital stay.
All of these are factors that can be identified, analyzed, individualized and studied to further promote effective communication at all levels. The process of transition-of-care among care providers needs to be studied at the level of the individual service (such as neurosurgery) with its own peculiarities, the individual hospital (with its potential for unique culture), as well as at the more global level — including the needs of a health-care system (2).
Within the field of patient safety, proper and effective communication remains a vital component in the safe navigation of our patients through the inpatient hospital setting. The need to address what constitutes good handoff communication in a scientific, data-driven manner is large and the data to draw on is sparse. Neurosurgery has a need to address for itself just what constitutes an ideal handoff, what aspects are critical to patient-care transitions in our specialty and what training and interventions are the most effective. There are many opportunities ahead to develop improvements in our handover procedures. Beginning with our experiences as residents in training, and evolving into the care we provide our patients in practice, the development of tools and skills that help us communicate effectively with our neurosurgical and health-care colleagues will allow for improved patient care, safety and outcomes. [aans_authors] References
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