Industry Focus: Q&A: How to Improve Patient Handoffs
By Brian Ward
Patient handoffs continue to be a major concern for hospitals. In 2017, The Joint Commission published Sentinel Event Alert 58 on inadequate handoff communications and its effect on patient care. Handoffs (also known as transitioning) are the passing of patients between caregivers, plus the information that caregivers exchange during the process. The latter represents a major point of failure for healthcare; each handoff runs the risk of key treatment information being garbled, forgotten, or not passed on.
These transfers can be as dramatic as air-lifting a patient to a remote specialty hospital and telling the EMTs that the patient thinks he can fly and will try to jump out of the helicopter, or as mundane as a nurse ending her shift and telling her replacement the patient has been taken off a certain medicine. In both cases, not passing on this information can potentially harm the patient.
“Potential for patient harm—from the minor to the severe—is introduced when the receiver gets information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed,” The Joint Commission wrote. “When handoff communication fails, many factors are involved, such as healthcare provider training and expectations, language barriers, cultural or ethnic considerations, and inadequate, incomplete, or nonexistent documentation, to name just a few.”
The following is an edited Q&A with Nan Tomsky, MN, RN, CPHRM, a principal consultant at Compass Clinical Consulting, on improving patient handoffs.
Q: How much of an impact do patient handoffs have on care quality? What can happen if they go wrong?
Tomsky: Patient handoffs have a profound effect on the quality of care and patient outcomes. The information provided during a handoff plays a key role in assuring that the care the patient needs is seamlessly provided. Failure to properly transfer knowledge about the patient can result in serious outcomes when the receiving caregiver is ignorant of critical information. Needed medications may be omitted, key symptoms/indications of patient changes can be missed, and patients can fall and suffer serious injuries among other outcomes.
Q: Is there a national, standardized handoff procedure in healthcare? In other words, is there a set of procedures all hospitals are meant to follow, or do they decide individually how their facility will conduct handoffs?
Tomsky: There is not a current standardized handoff procedure that is used in healthcare. Each healthcare organization can establish its own procedures to meet the needs of their patients, providers, and patient care staff. That said, there are models, or formats, that are adapted by many hospitals to develop their procedures. For example, “ISBAR” (Identification, Situation, Background, Assessment, and Recommendation) and “I-PASS” (Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver) are two such tools.
Q: When handing off a patient within a healthcare organization, what information needs to be shared (e.g., transferring care from a surgeon in the hospital ER to a nurse in the inpatient wing upstairs)?
Tomsky: No matter who is handing off or who is receiving the patient, information should be consistently shared. The Joint Commission has identified the following elements that, at a minimum, should be considered for inclusion in handoff communications:
> Sender contact information
> Illness assessment, including severity
> Patient summary, including events leading up to illness or admission, hospital course, ongoing assessment, and plan of care
> To-do action list
> Contingency plans
> Allergy list
> Code status
> Medication list
> Dated laboratory tests
> Dated vital signs
I would want to be sure that IVs, other lines, and drains are included, as well as last medications given and times of administration with particular focus on those that could cause drowsiness or unsteady gait.
I would also include the patient’s preferred language and whether the patient has an advance directive in the list of information to be shared within these categories.
Q: What information needs to be shared when handing off a patient between healthcare organizations (e.g., between a primary care physician and an unaffiliated outpatient surgery center)?
Tomsky: The information provided by a healthcare organization upon the transfer of an inpatient to another inpatient facility should be very similar to the handoff from one unit to another with the notable difference of an additional handoff from the transferring attending physician to the accepting physician at the other facility. A discharge summary is also provided to the accepting organization.
Between a primary care physician and an unaffiliated outpatient surgery center, a complete history and physical should be provided to the surgeon who will perform the procedure, ensuring that recent lab work is included. The outpatient surgery center will receive basic information from the surgeon upon scheduling the procedure, and the surgeon will provide an updated H&P.
Transfer information provided when a patient is transferred from an emergency department to another inpatient facility is driven in part by EMTALA (Emergency Medical Treatment and Active Labor Act) regulation.
The transfer document does acknowledge a handoff from the ED nurse to the nurse who will provide care upon arrival at the other institution as well as acknowledging the physician-to-physician handoff. A discharge summary is provided and the transfer form also specifies the mode of transportation as well as other support needed during transport.
Q: Is using an electronic health record (EHR) the best way to ensure a proper handoff? What about handwritten and verbal information exchanges?
Tomsky: I believe that the best way to ensure a proper handoff is a verbal exchange. This allows the person to whom the patient and his/her care is being handed off to ask clarifying questions and to discuss potential issues and concerns.
That does not mean that the electronic medical record and handwritten handoff documents aren’t part of the process. Developing an electronic or handwritten document that is used during the verbal handoff can help ensure that information isn’t unintentionally missed and gives the receiving area a document to refer to if needed. An electronic or handwritten handoff document is extremely helpful as a resource when a patient is being handed off to a support department such as radiology for a test.
Q: What sorts of things can cause a bad handoff? And what can be done to prevent them?
Tomsky: The two conditions that contribute most significantly to a poor handoff are related to distraction among those giving or receiving the handoff and incomplete information. If either of these occur, it is much more likely that critical information will be missed.
To mitigate these causes, handoffs should occur, if possible, in an environment that allows participants to concentrate on the job at hand. Handing off in the middle of a busy hallway is not conducive to a successful handoff. As for incomplete information, I recommend using a template thoughtfully developed by members of the organization’s healthcare team to prompt documentation and sharing of all the necessary information.
Q: How much of a role does a patient (or family) play a role in their handoff? And what should patients know about the handoff process?
Tomsky: Whenever possible, it is helpful to include the patient and or family to ensure that they understand the plan and goal. This is especially important for shift-to-shift handoff. The patient or family can contribute to goal setting and is more aware of what they may need or want to communicate during the shift.
When handing off to a support department such as radiology, participation by the patient/family may be minimal, but it does offer an opportunity for the patient to ask questions and clarify information when appropriate.
Q: Any other tips or advice on improving patient handoffs?
Tomsky: Organizational leadership’s commitment to establishing a clear and thoughtful process is important. Educating staff and physicians about the process and monitoring compliance will help.
Perhaps one of the most important drivers of handoff improvement is the analysis of adverse events of issues related to handoffs. Involving staff in analyzing what happened, including the barriers to providing the expected handoff, will help to continually improve the process. *
Editor’s note: This article was originally published in the newsletter Briefings on Accreditation & Quality.
Handoff Mnemonics
I-PASS
> Illness severity
> Patient summary
> Action list
> Situation awareness
and contingency plans
> Synthesis by receiver
ISBAR
> Identification
> Situation
> Background
> Assessment
> Recommendation
Tips for high-quality handoffs
In Sentinel Event Alert 58, The Joint Commission gives the following seven recommendations on improving patient transfers:
> Have leadership demonstrate its commitment to successful handoffs and a safety culture.
> Standardize critical content to be communicated (verbally or written) by the sender during a handoff.
> Conduct face-to-face handoff communication and sign-outs between senders and receivers in distraction-free zones. Be sure to include all appropriate team and family members as well.
> Standardize handoff training.
> Use your EHR and other technologies to improve the handoff process.
> Monitor the success of interventions to improve handoff communication and use the lessons to drive improvement.
> Sustain and spread best practices in handoffs and make high-quality handoffs a cultural priority.