In a previous Patient Safety feature, we highlighted the importance of teamwork to promote patient safety. Continuing this important theme, we present the first part of this two-part article on the primacy of the provider-to-provider handoff for the safe care of our patients.
Part I
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 Communication — The Stakes are High
The 21st century has seen ever-more complex and specialized teams of care providers participating in the patient-care experience. As a result of this complexity, transfers of information and of care are more frequent and more sophisticated (2). Patients experience multiple transitions of care during an inpatient stay. Their care is exchanged between types of care providers, shifts of providers, different medical or surgical services, or workday and on-call providers. It has been estimated that the number of physician shift handoffs has increased by 40 percent with the introduction of reduced work hours for in-training physicians (3, 4, 5, 6).
Furthermore, the average inpatient will require 24 physician handovers during the average hospital stay. With over 36-million discharges per year in the country, as calculated by the Department of Health and Human Services, the opportunity to effect quality of health care delivery in the U.S. is tremendous (3, 7, 8, 9).
Regulatory agencies and patient safety advocacy organizations see the handoff as a target of quality improvement in health-care delivery. The Joint Commission has established the Center for Transforming Healthcare to help “solve healthcare’s most critical safety and quality problems.” The Center states that “the consequences of substandard hand-offs may include delay in treatment, inappropriate treatment, adverse events, omission of care, increased hospital length of stay, avoidable readmissions, increased cost, inefficiency from rework, and other minor or major patient harm” (19). The Joint Commission, along with the Department of Health and Human Services, the Institute of Medicine (IOM), the World Health Organization (WHO), and other stakeholders have developed initiatives to help establish guidelines, standards, education and assessment tools to help improve communications in patients’ transitions of care. The National Quality Forum (NQF) and the National Patient Safety Foundation (NPSF) have also identified provider communication as a target for improvement (11, 20, 21, 22, 23).
Crucial Information Exchanges
The physician-to-physician handoff is one of the most crucial information exchanges during a patient’s hospitalization, both from the patient-safety perspective and the resource-utilization standpoint. According to the Joint Commission, up to 60 percent of inpatient medical adverse events may be attributed to improper communication (2, 10, 11, 12). Inadequate handoffs have been associated with an increase in patient-safety events and medical errors as well as increases in health-care utilization (11, 13, 14, 15, 16, 17, 18).
Effecting improvements in physician handoffs becomes complicated because of the various roles the handoff plays in patient-care delivery. A number of environmental factors impact handoff performance, including the expertise of individuals involved, potential for interruption, variability between electronic and face-to-face communications and utilization of the electronic-medical record. For handoffs involving physician trainees, improvements in patient-care quality obtained by the reduction in duty hours may be compromised by more frequent transfers of care.
For physician trainees, the importance of learning proper handoff communications is vital. With the establishment of resident duty-hour restrictions in 2003, and their further revision in 2011, by the Accreditation Council for Graduate Medical Education (ACGME) (24, 25, 26), patient care now requires an increased number of handoffs (4, 11, 27, 28, 29). The ACGME has revised its residency program requirements to include an evaluation of clinical rotation staffing with an eye toward minimizing patient care transitions and handoffs. They now include a requirement that each institution monitor the handoff process of its trainees and ensure trainee competence in communication regarding handovers (30, 31). The American Medical Association includes in its resident resources, material for improving patient handoffs (32). The Agency for Healthcare Research and Quality promotes the development and dissemination of information on improving quality in health care, including that related to transition of care. Finally, third-party computer, tablet and smartphone applications have been developed to help structure the handover process (35, 36).
[aans_authors] References
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