A care transition poses a danger point for patients—failing to “hand off” needed information from one clinician to another can lead to significant morbidity and mortality. The Joint Commission was so concerned about handoffs that in 2017 it issued a sentinel event alert on the topic.
“Handoffs are a safety opportunity because they promote a fresh look, which can help catch safety hazards,” says Meghan Lane-Fall, MD, MSHP, FCCM, assistant director, Penn Center for Healthcare Improvement and Patient Safety; codirector, Penn Center for Perioperative Outcomes Research and Transformation at the University of Pennsylvania in Philadelphia; and assistant professor of anesthesiology and critical care at the Perelman School of Medicine, University of Pennsylvania.
Tools such as checklists can provide a framework for the handoff, but the key component is communication. “Handoffs are about communication, not about checking a box on a checklist,” says Amanda Lorinc, MD, assistant professor in the division of pediatric anesthesiology at Monroe Carell Jr Children’s Hospital at Vanderbilt University Medical Center in Nashville, Tennessee. “You need to tailor the process to your hospital and to the various locations within the hospital so that it’s most effective.”
In this two-part series, we first explore the nature of handoffs and how they benefit patients and OR leaders (Part 1). We then outline best practices for ensuring handoffs are both efficient and effective (Part 2).
Research related to handoffs has focused on how to improve the process, and many studies have taken place in a single facility. Despite study limitations, good handoffs have been shown to reduce technical errors and omission of critical information, Dr Lane-Fall says. She and Dr Lorinc both emphasize, however, that more outcomes-based research is needed.
But in terms of outcomes, it’s difficult to study handoffs the same way as other clinical interventions. “There isn’t a one-to-one relationship between handoffs and patient outcomes,” Dr Lane-Fall says. “You can have a perfect handoff in a really sick patient who still dies, and you can have a terrible handoff with a patient who is healthy, and he doesn’t die.”
The number of factors affecting communication, such as level of staffing, patient volume, and competing priorities, that aren’t related to the handoff are too numerous to be able to draw conclusions about how handoffs are linked to mortality and morbidity outcomes. Dr Lane-Fall says that doesn’t mean handoffs aren’t important, but it does mean outcomes metrics have to be carefully chosen.
Metrics such as time saved might be better and have the added advantage of making the business case for handoffs. “There are efficiencies to be gained from doing handoffs well,” she says. For example, a good handoff avoids multiple calls from the clinician receiving the patient to the previous caregiver to obtain missing information. The minutes saved add up and are particularly important for busy ORs seeking to minimize turnover time and maximize other production metrics such as first case on-time starts. (See related story, p 24.) A good handoff also avoids redundancies in test ordering, thus reducing costs.
Dr Lorinc says handoffs don’t have to add time to the workday and can even save time in relaying critical information. She was the lead investigator for a study that found implementing a clinician-centered preoperative handover process and checklist for patients being transferred from the neonatal ICU to the OR reduced information transfer time from an average of 11.7 minutes to 10.1 minutes, with the time needed to complete the handover checklist averaging 4.7 minutes. In addition, the effectiveness of the handoff increased from 2.9 to 3.85 (with 5 being extremely effective).
In addition to saving time, handoffs can protect the organization from liability. Hospitals that do not follow standards from the Joint Commission or professional associations like AORN are vulnerable to potential lawsuits stemming from an error caused by poor communication during a care transition.
The Joint Commission Provision of Care standard PC.02.02.01, element of performance (EP) 2, requires that “The organization’s process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information.” And the AORN Guideline for Team Communication recommends healthcare organizations establish and implement a standardized hand-over process for the transfer of patient information between individuals and teams.
Good handoffs also have the potential to address burnout and turnover. “If people feel like they are spinning their wheels because communication isn’t effective, that’s going to contribute to dissatisfaction,” Dr Lane-Fall says. Although no one is likely to quit over problematic handoffs, effective ones can reduce frustration and make clinicians feel valued as part of a team, which can boost job satisfaction.
Handoffs have seven basic functions (sidebar above). Dr Lane-Fall categorizes handoffs into three types of transfers:
• Shift change: The same type of clinicians exchange places, for example, a circulator relieves a circulator. Research shows that standardization can improve these handoffs.
• Duty relief: One clinician is relieved for a short amount of time, as in a meal break. This can be an opportunity to discover problems. For example, a 2016 study by Terekhov and colleagues found that anesthesia breaks were associated with a 6.7% decrease in adverse outcomes.
• Transitions in care: Care is transferred from one team to another or from one site of care to another, for example, from the OR to the postanesthesia care unit (PACU) or from the OR to the ICU.
Handoffs can also be classified by geographic location (sidebar below).
Good handoffs can have a positive impact on patient care, particularly when it comes to cross-disciplinary handoffs, such as surgeon to PACU nurse.
“We think we know what our colleagues do in clinical practice and what they need to know, but we often don’t,” Dr Lane-Fall says. A simple example is ICU nurses mistakenly believing surgeons and anesthesiologists weren’t interested in conducting a handoff, and not understanding that they were under pressure to return to surgery to start the next case.
“If we don’t understand what our colleagues do and what information they need, we may negatively affect patient care,” Dr Lane-Fall says. Handoffs can bridge the gap and help ensure patients receive the care they need. But to serve as that bridge, handoffs must follow best practices, which are outlined in Part 2 of this series.
Note: The goal of the Multicenter Handoff Collaborative is to develop a network that can address handoffs from clinical, education, and research perspectives. The relatively new group continues to expand. For more information, go to https://www.handoffs.org/. ✥
A 2010 article by Patterson and Wears outlines seven functions of handoffs.
Information processing: What most people think about when they consider handoffs—the transfer of data. Standardization and tools such as checklists can help ensure accuracy.
Stereotypical narratives: Shorthand stories that allow clinicians to give information quickly. For example, “a typical lap chole.” These can result in errors, particularly when the receiver lacks the same experience as the sender. Using care pathways can help reduce these errors.
Resilience: Refers to checking for assumptions. Encouraging active participation will, in turn, promote resilience and avoid erroneous assumptions.
Accountability: Responsibility for the patient is transferred. It’s important that the transfer be explicit: “Mr. Jones is now in your care.”
Social interaction: Considers the perspective of the participants in the exchange; it’s important to avoid distractions during the handoff.
Distributed cognition: Acknowledges that valuable insights can occur when multiple providers consider the patient.
Cultural norms: relates to how group values in an organization or suborganization are negotiated and maintained over time. Handoff training, along with audits and feedback, reinforce how handoffs should be conducted.
Sources: Patterson E S, Roth EM, Woods D D, et al. Handoff strategies in settings with high consequences for failure: Lessons for health care operations. Int J Qual Health Care. 2004;16:125-132; Meghan Lane-Fall, MD, MSHP, FCCM.
Agarwala A, Lane-Fall M. The evidence base for optimal conduct of handoffs. Anesthesia Patient Safety Foundation Newsletter. 2017;32(2):36-39.
Greilich P E, Keebler J R. Multicenter handoff collaborative. Anesthesia Patient Safety Foundation Newsletter. 2017;32(2):47-48.
Joint Commission. Sentinel Event Alert: Inadequate hand-off communication. 2017. https://www.jointcommission.org/assets/1/18/SEA_58_Hand_off_Comms_9_6_17_FINAL_(1).pdf.
Lorinc A, France D, Roberts D, et al. Perioperative neonatal intensive care unit handovers: Effectiveness & non-routine events before & after implementation of a handover tool & process change. 2019. AUA Poster Session. www.aievolution.com/ars1901/index.cfm?do=abs.viewAbs&abs=2720.
Lorinc A, Henson C. All handoffs are not the same: What perioperative handoffs do we participate in and how are they different? Anesthesia Patient Safety Foundation Newsletter. 2017;32(2):29-33.
Patterson E S, Roth E M, Woods D D, et al. Handoff strategies in settings with high consequences for failure: Lessons for health care operations. Int J Qual Health Care. 2004;16:125-132.
Patterson E S, Wears R L. Patient handoffs: Standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf. 2010;36(2):52-61.
Terekhov M A, Ehrenfeld J M, Dutton R P, et al. Intraoperative care transitions are not associated with postoperative adverse outcomes. Anesthesiology. 2016;125(4):690-699.