Improving the Patient Handoff Process in the Intensive Care Unit: Keys to Reducing Errors and Improving Outcomes

Mai O. Colvin; Lewis A. Eisen; Michelle Ng Gong

doi:10.1055/s-0035-1570351

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 2016; 37(01): 096-106
DOI: 10.1055/s-0035-1570351

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Improving the Patient Handoff Process in the Intensive Care Unit: Keys to Reducing Errors and Improving Outcomes

Mai O. Colvin

¹Department of Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York

,

Lewis A. Eisen

²Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York

,

Michelle Ng Gong

³Division of Epidemiology and Population Health, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York

› Author Affiliations

Abstract

Patient handoffs are highly variable and error prone. They have been recognized as a major health care challenge. Patients in the intensive care unit are particularly vulnerable due to their complex clinical history and the critical nature of their condition. Given a general movement from traditional long call to shift schedules, the number of patient handoffs will likely continue to increase. Optimization of the handoff process has become even more critical to ensure patient safety. In this review, we reflect on the importance of the handoff process, review common errors, identify barriers and challenges, and propose different methods to improving the handoff process. The purpose of this article is to examine the overall scope of the problem; provide the most up-to-date evidence on the handoff process; and identify ways to perform handoffs in an accurate, safe, and efficient manner to provide high-quality patient care. The direction of future research is also proposed.

Keywords

handoff - handover - critical care - patient safety - communication - continuity of care - medical error - quality improvement

Full Text

References

References
1 Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care 2004; 16 (2) 125-132
2 Abraham J, Nguyen V, Almoosa KF, Patel B, Patel VL. Falling through the cracks: information breakdowns in critical care handoff communication. AMIA Annu Symp Proc 2011; 2011: 28-37
3 Manser T, Foster S, Gisin S, Jaeckel D, Ummenhofer W. Assessing the quality of patient handoffs at care transitions. Qual Saf Health Care 2010; 19 (6) e44
4 Behara R, Wears RL, Perry SJ , et al. A conceptual framework for studying the safety of transitions in emergency care. In: Henriksen K, Battles JB, Marks ES, , et al., eds. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville, MD: Agency for Healthcare Research and Quality (US); 2005. . Available at http://www.ncbi.nlm.nih.gov/books/NBK20522/
5 Raduma-Tomàs MA, Flin R, Yule S, Williams D. Doctors' handovers in hospitals: a literature review. BMJ Qual Saf 2011; 20 (2) 128-133
6 Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff mnemonics literature. Am J Med Qual 2009; 24 (3) 196-204
7 Bomba DT, Prakash R. A description of handover processes in an Australian public hospital. Aust Health Rev 2005; 29 (1) 68-79
8 Roughton VJ, Severs MP. The junior doctor handover: current practices and future expectations. J R Coll Physicians Lond 1996; 30 (3) 213-214
9 Volpp KG, Grande D. Residents' suggestions for reducing errors in teaching hospitals. N Engl J Med 2003; 348 (9) 851-855
10 Horwitz LI, Meredith T, Schuur JD, Shah NR, Kulkarni RG, Jenq GY. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med 2009; 53 (6) 701-10.e4
11 Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician to physician communication during patient hand-offs. Acad Med 2005; 80: 1094-1099
12 Rogers Jr SO, Gawande AA, Kwaan M , et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery 2006; 140 (1) 25-33
13 Joint Commission Sentinel Event Data. Root Causes by Event Type 2004–2014. Available at http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2Q_2014.pdf . Accessed February 2, 2015
14 Philibert I, Leach DC. Re-framing continuity of care for this century. Qual Saf Health Care 2005; 14 (6) 394-396
15 Patterson ES, Woods DD. Shift changes, updates, and the on-call architecture in space shuttle mission control. Comput Support Coop Work 2001; 10 (3–4) 317-346
16 Wears RL, Perry SJ, Shapiro M, Beach C, Croskerry P, Behara R. Shift changes among emergency physicians: best of times, worst of times. Proc Hum Fact Ergon Soc Annu Meet 2003; 47 (12) 1420-1423
17 Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med 2006; 1 (4) 257-266
18 Barden CB, Specht MC, McCarter MD, Daly JM, Fahey III TJ. Effects of limited work hours on surgical training. J Am Coll Surg 2002; 195 (4) 531-538
19 Lockley SW, Cronin JW, Evans EE , et al; Harvard Work Hours, Health and Safety Group. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med 2004; 351 (18) 1829-1837
20 Landrigan CP, Rothschild JM, Cronin JW , et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351 (18) 1838-1848
21 Charap M. Reducing resident work hours: unproven assumptions and unforeseen outcomes. Ann Intern Med 2004; 140 (10) 814-815
22 Tokode M, O'Riordan B, Barthelmes L. “That's all I got handed over”: missed opportunities and opportunity for near misses in Wales. BMJ 2006; 332 (7541) 610
23 Mukherjee S. A precarious exchange. N Engl J Med 2004; 351 (18) 1822-1824
24 Laine C, Goldman L, Soukup JR, Hayes JG. The impact of a regulation restricting medical house staff working hours on the quality of patient care. JAMA 1993; 269 (3) 374-378
25 Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events?. Ann Intern Med 1994; 121 (11) 866-872
26 Joint Commission Annual Report. Improving America's Hospitals The Joint Commission's Annual Reports on Quality and Safety 2007. Available at: http://www.jointcommission.org/assets/1/6/2007_Annual_Report.pdf . Accessed February 2, 2015
27 Van Eaton E. Handoff improvement: we need to understand what we are trying to fix. Jt Comm J Qual Patient Saf 2010; 36 (2) 51
28 Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian health care study. Med J Aust 1995; 163 (9) 458-471
29 Lingard L, Espin S, Whyte S , et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 2004; 13 (5) 330-334
30 Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med 2004; 79 (2) 186-194
31 Shojania KG, Fletcher KE, Saint S. Graduate medical education and patient safety: a busy—and occasionally hazardous—intersection. Ann Intern Med 2006; 145 (8) 592-598
32 Singh H, Thomas EJ, Petersen LA, Studdert DM. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med 2007; 167 (19) 2030-2036
33 Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 2005; 14 (6) 401-407
34 Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med 2008; 168 (16) 1755-1760
35 Borowitz SM, Waggoner-Fountain LA, Bass EJ, Sledd RM. Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey. Qual Saf Health Care 2008; 17 (1) 6-10
36 Kitch BT, Cooper JB, Zapol WM , et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf 2008; 34 (10) 563-570
37 Joint Commission Center for Transforming Healthcare Releases Targeted Solutions Tool for Hand-Off Communications. Jt Comm Perspect 2012; 32 (8); Available at http://www.jointcommission.org/assets/1/6/TST_HOC_Persp_08_12.pdf . Accessed April 10, 2015
38 Collins SA, Mamykina L, Jordan D , et al. In search of common ground in handoff documentation in an Intensive Care Unit. J Biomed Inform 2012; 45 (2) 307-315
39 Streitenberger K, Breen-Reid K, Harris C. Handoffs in care—can we make them safer?. Pediatr Clin North Am 2006; 53 (6) 1185-1195
40 Lofgren RP, Gottlieb D, Williams RA, Rich EC. Post-call transfer of resident responsibility. J Gen Intern Med 1990; 5 (6) 501-505
41 Smith AF, Pope C, Goodwin D, Mort M. Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room. Br J Anaesth 2008; 101 (3) 332-337
42 Anwari JS. Quality of handover to the postanaesthesia care unit nurse. Anaesthesia 2002; 57 (5) 488-493
43 Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg 2010; 252 (2) 402-407
44 Steinberger DM, Douglas SV, Kirschbaum MS. Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation. Prog Transplant 2009; 19 (3) 208-215
45 Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004; 13 (Suppl. 01) i85-i90
46 Meissner A, Hasselhorn HM, Estryn-Behar M, Nézet O, Pokorski J, Gould D. Nurses' perception of shift handovers in Europe: results from the European Nurses' Early Exit Study. J Adv Nurs 2007; 57 (5) 535-542
47 Cheung DS, Kelly JJ, Beach C , et al; Section of Quality Improvement and Patient Safety, American College of Emergency Physicians. Improving handoffs in the emergency department. Ann Emerg Med 2010; 55 (2) 171-180
48 See KC, Phua J, Mukhopadhyay A, Lim TK. Characteristics of distractions in the intensive care unit: how serious are they and who are at risk?. Singapore Med J 2014; 55 (7) 358-362
49 Ballermann MA, Shaw NT, Mayes DC, Gibney RT, Westbrook JI. Validation of the Work Observation Method By Activity Timing (WOMBAT) method of conducting time-motion observations in critical care settings: an observational study. BMC Med Inform Decis Mak 2011; 11 (1) 32
50 Westbrook JI, Ampt A, Kearney L, Rob MI. All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Med J Aust 2008; 188 (9) 506-509
51 Horwitz LI, Moin T, Green ML. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med 2007; 22 (10) 1470-1474
52 Sawatsky AP, Mikhael JR, Punatar AD, Nassar AA, Agrwal N. The effects of deliberate practice and feedback to teach standardized handoff communication on the knowledge, attitudes, and practices of first-year residents. Teach Learn Med 2013; 25 (4) 279-284
53 Cleland JA, Ross S, Miller SC, Patey R. “There is a chain of Chinese whispers”: empirical data support the call to formally teach handover to pre-qualification doctors. Qual Saf Health Care 2009; 18: 267-271
54 Thakore S, Morrison W. A survey of the perceived quality of patient handover by ambulance staff in the resuscitation room. Emerg Med J 2001; 18: 293-296
55 Rivera-Rodriguez AJ, Karsh BT. Interruptions and distractions in healthcare: review and reappraisal. Qual Saf Health Care 2010; 19 (4) 304-312
56 Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf 2010; 36 (2) 52-61
57 Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med 2009; 4 (7) 433-440
58 Starmer AJ, Sectish TC, Simon DW , et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA 2013; 310 (21) 2262-2270
59 Li P, Ali S, Tang C, Ghali WA, Stelfox HT. Review of computerized physician handoff tools for improving the quality of patient care. J Hosp Med 2013; 8 (8) 456-463
60 Brownstein A, Schleyer A. The art of HANDOFFS: a mnemonic for teaching the safe transfer of critical patient information. Resid Staff Physician 2007; 53 (6) 15 ; http://healthcare-professionals.sw.org/resources/docs/authorized/ome/TheArtOfHandoffs.pdf . Accessed December 18, 2015
61 Berkenstadt H, Haviv Y, Tuval A , et al. Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk. Chest 2008; 134 (1) 158-162
62 Anderson J, Shroff D, Curtis A , et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf 2010; 36 (2) 62-71
63 Denham CR. SBAR for patients. J Patient Saf 2008; 4 (1) 38-48
64 Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006; 32 (3) 167-175
65 Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC ; I-PASS Study Group. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics 2012; 129 (2) 201-204
66 Bigham MT, Logsdon TR, Manicone PE , et al. Decreasing handoff-related care failures in children's hospitals. Pediatrics 2014; 134 (2) e572-e579
67 Starmer AJ, Spector ND, Srivastava R , et al; I-PASS Study Group. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014; 371 (19) 1803-1812
68 Healthcare Communication Toolkit to Improve Transitions in Care. Falls Church VA: Department of Defense Healthcare Team Coordination Program, TRICARE Management Activity. Available at: http://www.oumedicine.com/docs/ad-obgyn-workfiles/handofftoolkit.pdf?sfvrsn=2 . Accessed March 3, 2015
69 Nasca TJ, Day SH, Amis Jr ES. ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med 2010; 363 (2) e3
70 Gordon M, Findley R. Educational interventions to improve handover in health care: a systematic review. Med Educ 2011; 45 (11) 1081-1089
71 Chen JG, Mistry KP, Wright MC, Turner DA. Postoperative handoff communication: a simulation-based training method. Simul Healthc 2010; 5 (4) 242-247
72 Chu ES, Reid M, Schulz T , et al. A structured handoff program for interns. Acad Med 2009; 84 (3) 347-352
73 Farnan JM, Paro JA, Rodriguez RM , et al. Hand-off education and evaluation: piloting the observed simulated hand-off experience (OSHE). J Gen Intern Med 2010; 25 (2) 129-134
74 Gakhar B, Spencer AL. Using direct observation, formal evaluation, and an interactive curriculum to improve the sign-out practices of internal medicine interns. Acad Med 2010; 85 (7) 1182-1188
75 Brown JP. Closing the communication loop: using readback/hearback to support patient safety. Jt Comm J Qual Saf 2004; 30 (8) 460-464
76 Miller A, Scheinkestel C, Limpus A, Joseph M, Karnik A, Venkatesh B. Uni-and interdisciplinary effects on round and handover content in intensive care units. Hum Factors 2009; 51 (3) 339-353