Pass the baton or NUTS for safer handoff

Pass the baton or pass the NUTS, but either way you're passing on vital patient information that can improve patient safety and reduce the risk of adverse events, say the risk managers who use these innovative patient handoff strategies.

Patient handoff is widely recognized as a point at which errors in communication are likely to jeopardize patient safety. In January 2007, The Joint Commission began requiring a standardized protocol for handoff communication (Patient Safety Goal 2E). (Editor's note: For more on The Joint Commission's goal and its advice on how to improve handoffs, go to The Joint Commission site at Select the "Patient Safety" tab and then "National Patient Safety Goals.")

Some hospitals are coming up with creative ways to make sure critical information gets from one caregiver to another, whether the patient handoff happens at a shift change, when the patient is moving from one unit to another, or any other time important information might be lost along the way. One example is Trinity Medical Center in Rock Island, IL, where nurses and doctors actually "pass the baton." Jennifer Dehlman, RN, BSN, OCN, interim director of nursing, says the method grew out of a brainstorming session in which staff members were visualizing a relay race in which the runners must successfully pass a baton before the next runner can take over.

"We decided we could actually use a baton to accomplish the physical handoff. If the information were placed inside the baton and we handed that to the next person, that would be a way of getting the information across and a very visual, tactile way to make sure it happened," she says. "The batons are actually created for track teams to use in practice. They're bright yellow."

Baton used with SBAR

The baton is part of a larger patient handoff program that uses the popular "SBAR" format for recording and passing on patient information. SBAR stands for Situation, Background, Assessment, and Recommendation. (See article below for background on the SBAR system.) Trinity began using SBAR about four years ago but added the baton about a year and half ago.

SBAR offers way to better handoffs

SBAR stands for the key elements to be communicated in the patient handoff process: Situation, Background, Assessment, and Recommendation. The system was developed by Kaiser Permanente in Oakland, CA, and provides clinicians a framework for communicating effectively about a patient's condition and needs.

The checklist helps overcome a key cause of errors at patient handoff: the difference in how doctors and nurses communicate. Nurses tend to frame their comments in relation to a nursing plan, and physicians are more interested in whatever might be a problem at the moment and what they need to do to fix it, according to the SBAR developers.

The SBAR checklist is used throughout the Kaiser Permanente system and is spreading quickly to other providers.

The batons at Trinity are plastic, easily cleaned, and Trinity purchased hundreds of them from an athletic supply company for less than a dollar each. They are hollow and open on both ends. The batons are cleaned frequently with disinfectant wipes.

Staff and physicians roll up the SBAR form and place it in the baton, handing it to the next caregiver. The baton stays with the patient during any transit, Dehlman says. (The system is modified for the emergency department. See article below.)

Baton method can be altered for ED

Staff at Trinity Medical Center in Rock Island, IL, quickly realized that their system of passing the baton must be tweaked somewhat for transferring patients from the emergency department to the inpatient unit, because that transfer often involves numerous pages of information on a chart that cannot be distilled down to an SBAR form.

For those patients, the ED uses canary yellow folders that are the same color as the baton and they place a large sticker on the folder that "I am a yellow baton." It was a tongue-in-cheek solution that still strives for consistency, says Jennifer Dehlman, RN, BSN, OCN, interim director of nursing, at Trinity.

"The yellow baton is part of our culture now," she says. "That alone is an important part of the improvement, getting everyone on board to try to do the same thing in the same way."

"People are used to others walking by and asking, 'Do you have the SBAR?' or 'Can I see the baton?'" Dehlman says. "It's hard to miss that yellow baton, and we always have that SBAR information handy if something happens to the patient, like a code during transit."

Dehlman notes that the staff did not immediately embrace the baton concept once it was introduced, because it involved changing some of their reports to an SBAR-consistent report that could be used in the baton. But after using the system for months, staff members are enthusiastic about how much it streamlines communication while also improving patient safety, she says. "They don't circumvent the baton because they understand how important it is, and they appreciate having that information when a new patient is delivered to them," she says. "It's reciprocal."

Hospital uses NUTS

Another innovative strategy is used at Blount Memorial Hospital in Maryville, TN, where staff are encouraged to "Pass the NUTS." In this case, NUTS stands for some of the most vital information to be exchanged in the handoff: Name, Unusual factors, Tubes, and Safety concerns. [The NUTS poster is available here.]

Simple and easy to remember

The program began in March 2006 when the hospital did a mock survey and found inconsistencies in patient handoff, says Susan L. Wood, RN, the patient safety officer. To standardize the system, staff came up with an idea that is simple and easy to remember.

"We adopted the 'Pass the NUTS' idea and took it to our nursing division, where we came up with ways to educate the staff on how to do this," Wood says. "However, it's not just for nurses to use. This applied whenever a patient is handed off from one person to another, such as when a transporter arrives to take the patient for testing. The transporter needs to know, for instance, if that patient is at risk for falling."

NUTS passed verbally

The NUTS information is passed verbally. NUTS doesn't negate the need for any written communication, and in fact Blount uses SBAR for some nurse/physician communication. However, the verbal exchange allows the caregivers to ask questions of each other and to clarify any information that may not be clear in written communications, Woods says.

"When nurses are passing on information, such as at a shift change, they go to a quiet area and use the NUTS to discuss each patient so they are using the same format each time," she says. "They discuss more with some patients than with others, but the NUTS framework gives them a consistent format to start and makes sure they exchange the most vital information on each patient."

Blount was surveyed by The Joint Commission in October 2006, after the NUTS program was implemented, and Wood says the hospital received high marks for communication during patient handoffs. "They said it was consistent," she says. "Whenever they asked about a patient, the nurse used NUTS and the surveyor said the information flowed smoothly. They gave us very high marks for that."


For more information on the handoff strategies, contact:

  • Jennifer Dehlman, RN, BSN, OCN, Interim Director of Nursing, Trinity Medical Center, 2701 17th St., Rock Island, IL 61201. Telephone: (309) 779-2255. E-mail:
  • Susan L. Wood, RN, Patient Safety Officer, Quality Management, Blount Memorial Hospital, 907 E. Lamar Alexander Parkway, Maryville, TN 37804. Telephone: (865) 980-4903. E-mail: