Better handoffs

Hospitalists explore new tech and face-to-face strategies.

A significant percentage of avoidable adverse events in hospitals can be traced back to poor communication during patient handoffs, according to a number of studies, yet there are no universal standards for how that process should occur.

In fact, the ideal handoff may be different for each institution, experts say. Many hospitals now use computerized tools integrated with their electronic health records (EHRs) that allow clinicians to enter key clinical information and notes to facilitate handoffs. However while such tools offer a potential solution, they appear to work best as a supplement to—not a replacement for—face-to-face communication.

Photo by Thinkstock
Photo by Thinkstock

“Electronic tools and standardized curricula are very helpful, but they don't seem to reduce the number of adverse outcomes,” said Richard Frankel, PhD, professor of medicine at the Indiana University School of Medicine in Indianapolis and a core investigator at the Veterans Administration's (VA) Center for Health Information and Communication. “The quality of the handoff is also affected by different styles and personal preferences of physicians as well as different institutional cultures.”

In a recent study, published in BMJ Quality and Safety in February, Dr. Frankel and colleagues recorded conversations between nurse and resident teams during handoffs and found that informal communication between clinicians was often critical to the course and outcome of a patient's care. The findings corroborated an earlier VA study, based on video recordings, which found that nonverbal cues, such as eye rolling or shoulder shrugging, also provide important context for incoming clinicians.

“Face-to-face interactions convey not only the content of what's being handed off but also the clinician's attitudes or beliefs about what is happening or might happen with the patient,” said Dr. Frankel. “Such contextually sensitive information is crucial to ensuring high-quality care, but it is often not included in electronic or written records.”

At the same time, many physicians are enthusiastic about the potential for newer web-based tools to improve the accuracy and quality of handoffs. For example, a recent study of handoffs at Brigham and Women's Hospital in Boston found that a web-based system, coupled with clinician training, led to a significant reduction in errors due to miscommunication. The findings were published in the September JAMA Internal Medicine.

“Our study suggests that electronic tools can help clinicians avoid errors,” said the study's lead author, ACP Member Stephanie Mueller, MD, MPH, a hospitalist at Brigham and Women's Hospital and instructor of medicine at Harvard Medical School in Boston. “However, it's clear that these tools require training to be effective and that they are complementary to good teamwork and verbal communication.”

New web-based tools

Failures to communicate information during handoffs contribute to almost 80% of serious and preventable adverse events in hospitals, according to research by the VA Center for the Study of Healthcare Innovation in Los Angeles. Awareness of that problem, along with rapid improvements in EHR technology, has fueled efforts to create web-based tools aimed at improving accuracy and efficiency.

A recent review identified 37 studies of various electronic tools that support shift handoffs, mostly among residents. The main advantage of such tools is the ability to standardize information and draw from data in patients' electronic records, the authors noted in the June 2015 Journal of Graduate Medical Education. However, many had flaws, including lack of real-time updating and integration with EHRs and the potential for human errors in data entry.

The success of the web-based handoff tool used at Brigham and Women's was due, in part, to its ability to resolve some of those issues, notes an invited commentary in the same issue of JAMA Internal Medicine.

Specifically, it was tightly integrated with the EHR to allow continuous updating of the most current clinical and demographic information as well as physician progress notes. Those features likely improved efficiency and satisfaction and potentially prevented miscommunications about medications, diagnoses, and resuscitation preferences, the authors added.

However, it is impossible to tease apart the impact of the new tool from the effect of training and other complementary interventions, said Dr. Mueller. Prior to implementation, all clinicians participated in a series of training workshops on how to use the tool as well as in effective communication and teamwork skills.

At the same time, the hospital made complementary system improvements that ultimately supported use of the new tool, she said. For example, it converted to a regionalized team structure that provides a dedicated time for handoffs by allowing a 1-hour overlap between morning and afternoon shifts.

“After implementing the regionalized structure, we saw a stepwise reduction in error rates,” said Dr. Mueller. “It suggests that hospitals may benefit from making changes to their systems or processes to support implementation of these electronic tools.”

Incorporating mobile devices or smartphones also has the potential to improve communication around handoffs, according to a study conducted at McGill University Health Center in Montreal, Canada. Researchers tested a smartphone application called The FLOW that allows users to view patient data on their own devices and enter short notes in free-form text. The study, conducted in 3 pediatric ICUs, was published online Aug. 22 by the Journal of the American Medical Informatics Association.

The app has 2 innovative features: It allows nurses and other clinicians to enter notes in the same string as physicians and allows users to decide whether to incorporate their personal notes into the patient record, said the study's lead author, Aude Motulsky, PhD, a researcher in McGill University School of Medicine's clinical and health informatics research group.

In the study, almost 60% of respondents said that using the app improved patient care and 86% said they wanted to continue using it. The accuracy of information transmitted during handoffs was considered improved by 51%, and 58% believed that handoffs were quicker when using the app.

The main advantage of the app is its flexibility, said Dr. Motulsky.

“The app was designed so clinicians can use their smartphones to communicate in a structured, but still very flexible, way,” she said. “It provides support to the interaction around the patient and allows physicians to log in from home to check on patients' progress or update their notes.”

Filling in the gaps

Despite their benefits, electronic handoff systems typically still lack the nuance and situational context of face-to-face conversations, experts noted. Sensitive issues concerning family dynamics or socioeconomic issues that might be affecting or impeding care tend not to be entered into the official record but might be shared verbally between providers.

“On its own, an electronic signout often has too much information and some of it may be outdated or not that important,” said Adam Schoenfeld, MD, coauthor of the commentary on the Brigham and Women's study. “It doesn't give the outgoing provider's perspective on what should take priority or particular concerns the physician has about the patient.”

A face-to-face handoff may be the only opportunity for the incoming physician to ask questions before taking over the patient's care, he added. That's a key element in the I-PASS mnemonic (I: Illness severity; P: Patient summary; A: Action items; S: Situation awareness and contingency planning; and S: Synthesis by receiver), which is the standard handoff protocol used in resident education and many hospitals.

However, as evidenced by the VA study, the quality of face-to-face interactions varies widely across clinicians and hospitals.

“The all-time shortest handoff we've seen took 2 seconds—long enough for the outgoing clinician to say, ‘The patient is doing fine,’” said Dr. Frankel. “What that leaves out is anticipatory management.”

The most useful verbal interactions, according the study, were those that gave a “heads up” to incoming clinicians about what to expect or possible issues that might arise during their shift. The authors defined “heads up” information as things important to providing optimal care that may not be included in the EHR, such as the patient's current emotional state or physical limitations.

“Even an optimal electronic tool cannot necessarily replace a handover that is conducted verbally,” Dr. Frankel and colleagues wrote. “Using conversational exchange to make information contextually relevant in transferring roles and responsibilities is a key feature of timely and safe patient care.”

With that said, each case is different and patients with lower-acuity illnesses or few complications may not require as much discussion as more complicated cases, noted Dr. Mueller.

“In the real world it may not be feasible to do verbal signouts on every patient,” she said. “It should be a minimum expectation for very sick and unstable patients, but you have to figure out a good balance and adopt best practices that are feasible in your institution.”

Making it work in practice

Like Brigham and Women's, other academic centers have implemented overlapping shifts to facilitate handoffs. Both the University of Chicago and the University of California, San Francisco, medical centers, for example, created mid-day bridge shifts to handle patient admissions in order to free up physicians to participate in face-to-face handoffs.

“A good handoff starts with an investment in making sure it takes place,” said Vineet Arora, MD, FACP, a hospitalist and associate professor of medicine at the University of Chicago Medical Center who has done extensive research on handoffs. “In order to ensure dedicated time for a handoff to occur, there has to be a commitment by both physicians, as well as the program as a whole.”

That might mean extending training beyond residents, she added. All physicians stand to benefit from periodic refresher courses in handoff protocols and best practices.

“Experience isn't necessarily a buffer against bad handoffs,” she said. “It helps with figuring out different clinical scenarios, but if you don't have key information about a specific patient, you can still waste time reordering tests and tracking down information.”

Most studies have focused on handoffs that occur between shifts, but communication is also important during service handoffs—when a physician hands over responsibility for a panel of patients at the end of a weeklong service. According to a recent study published in the October Journal of Hospital Medicine, a poor service handoff can contribute to fragmented care and a negative patient experience.

Of the 40 patients who agreed to participate in the study, 85% said they were unaware that a transition had occurred, according to the findings. However, many said they would like to see a more formal transition and better communication of the care plan.

“It's clear that many patients don't appreciate being ‘dropped’ when a new physician arrives who doesn't seem to know their back story or social context,” said lead author Charlie Wray, DO, assistant clinical professor of medicine at the University of California, San Francisco. “Many said they would like the transition to occur at the bedside and include a formal introduction of the new attending physician.”

However, having physicians overlap shifts and dedicate time to a bedside handover is a resource-intensive strategy that may not be feasible at smaller hospitals, Dr. Wray acknowledged. When researchers tested the idea in a small pilot study, they found that it took about an hour for each physician to complete a bedside service handoff.

“Most physicians we talked to said they enjoyed doing bedside handoffs but one major caveat is time,” he said. “Overall, it may be better for patient care, but there are barriers to implementing it in practice.”

The best solution is probably a hybrid of electronic and in-person approaches, customized to the needs of each institution, said Dr. Mueller.

“The goal of the handoff is to communicate to the next provider essential pieces of information to ensure safe and high-quality care,” she said. “Electronic tools and verbal communication are both essential to creating a shared mental model of what's going on with a patient.”