A hospitalist is working one night when a nurse calls and asks if a certain patient can eat. The doctor checks the signout, which says “Patient is NPO for surgery tomorrow.” What should the hospitalist do?
The answer isn't clear cut, said Vineet Arora, FACP, at a talk on handoffs during the 2009 Society of Hospital Medicine meeting. Since the signout doesn't specify a date—instead using the nebulous “tomorrow”—or the surgical procedure, it's unclear whether it's safe for the patient to eat in this situation.
The real-life case example is just one of many that illustrates the bind a hospitalist can be put in when a handoff is incomplete—which in turn can affect patient safety and care. Concerned about such situations, several agencies, from The Joint Commission to the Institute of Medicine to the World Health Organization (WHO), have focused on improving handoffs in recent years, Dr. Arora noted.
“The WHO in 2006 came out with five patient safety solutions they want to promote, and improving handover errors was one,” said Dr. Arora, associate program director of internal medicine residency at the University of Chicago. “This is a worldwide issue.”
Handoffs as communication
To improve handoffs, it's important to understand them as a form of communication—and to grasp the pitfalls that often hamper good communication, Dr. Arora said.
“We are hardwired to miscommunicate, and that's something we must accept,” Dr. Arora said. “I go to lots of talks where people talk about communicating better, but no one really talks about how it is that we miscommunicate. And we can learn from this.”
Research has shown that speakers systematically overestimate how well their messages are understood by listeners, and assume a listener has all the same knowledge they do—an assumption that gets worse the better the speaker knows someone, Dr. Arora said. A study of pediatric handoffs, for example, found that the most important piece of information in the handoff wasn't communicated a whopping 40% of the time, despite the fact that the sender believed it was, she said.
“Even if we accept that there is some voltage drop when we communicate, we don't realize how bad it is,” Dr. Arora said.
Some may feel that the issue of handoffs will become moot once hospitals have converted to electronic health records. But research hasn't borne this out: A 2001 study in the British Medical Journal found that replacing phone calls for critical lab values with an electronic results-reporting system resulted in 45% of urgent lab results going unchecked, Dr. Arora noted.
“(Information technology) solutions alone can't substitute for a successful communication act,” Dr. Arora said. “Human vigilance is still required.”
The communication strategies of other high-risk industries, such as the aerospace and nuclear power industries, can be instructive in trying to improve handoffs at the hospital, Dr. Arora said. Research done at NASA and nuclear power plants, for example, reveals that communication improves when interruptions are limited, and when information is updated regularly and standardized (i.e., the same order or template is used).
Face-to-face verbal updates with interactive questioning also help communication, because the questioning offers insight into how well the information is understood, Dr. Arora said. “Read-backs” work especially well at improving accuracy, she added.
“What do I mean by a read-back? Well, if I go to Starbucks and order my chai latte skim at the drive-through window, the employee reads the order back to me. Sometimes they get it wrong, and I correct them. That's a read-back,” Dr. Arora said.
In a 2004 study in the American Journal of Clinical Pathology, read-backs were shown to reduce errors in lab reporting. During the study, 29 errors were reported during requested read-backs of 822 lab results at Northwestern Memorial Hospital and were subsequently corrected.
“This study also showed that read-back was cost-effective, because the time it took to do the read-back and correct the error was pretty minimal,” Dr. Arora said.
Improving verbal, written handoffs
When speaking to a colleague during a shift or service change, it's important to include “anticipatory guidance”—what may happen overnight, and what the incoming provider can do about it. Always use precise language, and give priority to ill patients first, Dr. Arora said.
An especially helpful tool for remembering what's important to include in verbal signouts was developed by Leora Horwitz, ACP Member, at Yale University. It uses the mnemonic “SIGNOUT?”
- S: Sick or DNR? For example, the outgoing provider may say, “This is our sickest patient, and he's in full code.”
- I: Identifying data. For example: “Mr. Jones is a 77-year-old man with a right middle lobe pneumonia.”
- G: General hospital course. For example: “He came in a week ago hypoxic and hypotensive, but improved rapidly with IV levofloxacin.”
- N: News events of the day. For example: “Today he spiked to 39.5°C and his white count bumped from 8 to 14. Portable chest X-ray was improved from admission; we sent blood and urine cultures. U/A was negative but his IV site looked red so we started vanco.”
- O: Overall health status. For example: “Right now he is satting 98% on 2 L NC and is afebrile.”
- U: Upcoming possibilities with plan and rationale. For example: “If he becomes persistently febrile or starts to drop his pressures, start normal saline at 125 cc/h and have a low threshold for calling the ICU to take a look at him, because of possible sepsis.”
- T: Task to complete overnight with plan and rationale. For example: “I'd like you to look in on him around midnight and make sure his vitals and exam are unchanged. I don't expect any blood culture results back tonight, so there is no need to follow those up.”
- ?: “Any questions?”
Written signouts should also be used, and should be more detailed than the verbal signout, Dr. Arora added.
“You simply can't store everything in your head; there is going to be information you need to refer to,” Dr. Arora said. “We advocate for including all patients in written sign-outs, even those who are discharged that day. As we all know, discharge may not occur even though you want it to.”
Some of this information may become useful in a critical situation, she added.
“So, in a verbal signout of a stable patient, you don't need to go through the PCP's name or contact information, or their IV access or code status,” Dr. Arora said. “But you need to have this in a written signout, because you never know when someone may actually turn a corner and your colleague may need that information available.”
The key information to include in a written handoff includes: administrative data (for example, name, gender, room number, admission date); new information (for example, chief complaint, updated medication list, current baseline status, recent procedures and events); what needs to be done, including the use of if-then statements and warnings about incoming information like lab results; and contingency planning (for example, what may go wrong and how to handle it, what has or hasn't worked before, and code status.)
Hospitalists need to be sure to set time aside in their daily shifts to update written signouts, with a special focus on medication changes and to-do lists, Dr. Arora added.
“A frightening statistic from our (research) is that 80% of daily signouts from patients contain at least one medication omission—and more than 50% of those are potentially harmful. Nearly 40% of signouts contain a commission—i.e., a medication is left on that shouldn't be,” Dr. Arora said. “This can easily be avoided.”