What Should Health Professionals Know About Handoffs?
Michael D. Cohen, PhD, is the recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research, and the William D. Hamilton Professor of Complex Systems, Information and Public Policy at the University of Michigan School of Information.
Handoffs are a critical link in maintaining continuity of care during a hospital stay. Whenever there is a shift change, or when a patient moves between departments (such as from an Emergency Room to an inpatient unit), there should be communication between the personnel who have been caring for the patient, and those who are to assume responsibility. These handoffs have to be done effectively. Root cause analyses of sentinel events find communication breakdowns to be major contributing factors nearly two-thirds of the time, and a large fraction of those problems occur during handoffs.
It seems logical that nurses and doctors should receive some training in how to conduct these vital conversations, but in interviews during my research on handoffs, it has been rare to find a practitioner who learned anything in nursing or medical school about how to hand off effectively.
The Joint Commission has recognized the importance of handoffs, and since 2006 has pushed hospitals to institute standard methods for handing off. While the Joint Commission did not mandate handoff procedures based on the SBAR mnemonic (Situation Background, Assessment, Recommendation), it has strongly suggested SBAR as a solution in many of its advisory publications. To the extent that some teaching about handoffs is now getting off the ground in schools or hospitals, much of it is based on mnemonics, such as SBAR, that prescribe discussion topics and their order.
There is debate about this approach to improving handoffs. Our own research indicates that expert physicians (very experienced ICU attendings) don’t follow a rigid sequence of topics when handing off – and perhaps for good reasons. But even if one believes that training doctors and nurses to follow a set mnemonic can improve handoff communication, there are still a number of important points about handing off effectively that should also be a part of training, but so far are not getting much attention. I hope readers will add to my list in the comments, but for starters, here are four:
1. To be effective, a handoff has to happen.
It may seem incredibly commonplace, but all too often preventable injuries or even deaths trace back to handoffs that were abbreviated, conducted in awkward conditions, or downright skipped. The easy cases to identify are things like leaving before handoff is done, or rushing the handoff in order to get out the door.
Unfortunately, many other causes are also in play. Some major examples derive from schedule or workload incompatibilities. If patients are sent from the PACU (post-anesthesia care unit) to a floor unit during its nursing report, the nurses accepting the patients will necessarily miss out on the handoff of existing patients. If a patient is moved from the Emergency Department (ED) before her doctor or nurse has time to complete phone calls to the destination unit, the patient endures some period of having been transferred without benefit of handoff. If there is a shift change in the ED just before a patient moves, the handoff is conducted by a doctor or nurse who has only second-hand familiarity with the events. To improve handoffs, we may need to teach participants to think about the organizational structures that make it hard to do them well.
2. An effective handoff is not a telegram.
Even if a mnemonic, checklist or computer report is used in an effort to assure transmission of key data, that is far from fulfilling one of the central functions of a handoff. As colleagues and I have argued recently, a handoff is not a telegram. The correct transmission of routine data about patients can be useful, but handoffs also function to establish for the receiving party a working mental model of the trajectory of the patient’s illness and treatment. They highlight what is unusual about the patient (co-morbidities, family decision making, personality or cultural traits that may affect treatment options). Good handoffs answer the question “what does the next caregiver need to know about this patient to do a good job?” Often the data transmitted are of secondary importance, or have value mainly as they support the development of the next caregiver’s “big picture” of the patient. To improve handoffs, we may need to provide training in taking the other party’s perspective in order to discern what they really need to understand.
3. Handoffs come in many flavors, and it’s vital to recognize the differences.
Although the research on handoff is overwhelmingly focused on shift change settings, there are in fact many varieties of handoff. For example, one of the most important distinctions is between those occurring within a unit, such as at a shift change, and those occurring between units, as when a patient is admitted through the ED. (Around half of all admissions occur this way.) To improve handoffs, we may need to teach participants how to adjust their discussions to the distinctive type of handoff they are conducting.
4. Handoffs often occur in batches, creating a “portfolio effect” that also must be managed.
Although the research has focused on how to hand off a single patient, in reality the vast majority of handoffs are in shift changes where several patients are normally handed off in a single session. Our research has shown that the discussion order is often set by an arbitrary list not related to case complexity or severity. We’ve also studied a group of experienced participants and found they spend about 50 percent more time on a case at the front of their list than on a case at that back. So even though they are experts, they are misallocating some of their scarce discussion time. If we want to improve handoffs, we may have to teach methods of assessing which patients need the most discussion, and managing the conversation to achieve that.
By conservative estimate, there are more than half a billion handoff discussions in U.S. hospitals annually. We don’t have to raise our “batting average” very much to save quite few lives. An important first step is defining what good handoff training should include.
Read about Cohen’s new study on handoffs.
Learn more about the RWJF Investigator Awards in Health Policy Research.