The trusted source for
healthcare information and
Hospitals are paying more attention to patient handoffs as a crucial element in quality and patient safety, with an evolution toward seeing them as not just a distinct task, but more as a comprehensive strategy.
The importance of good patient handoffs has been recognized for years, but healthcare professionals now are looking beyond the primary handoff scenarios such as shift changes and moving a patient from one hospital department to another, says Faye Sullivan, RN, healthcare coach for the Studer Group, a consulting group based in Pensacola, FL.
Good handoffs still are vitally important in those situations, of course, but quality leaders also are looking to improve handoffs in other ways.
“The idea of a handoff and what that means has grown recently so that people are now looking at the 30 days after the acute care event in the hospital,” Sullivan says. “They are looking at some of the strategies they may have employed in the past, like the post-visit phone call or interdisciplinary rounds, through a new lens and retool those to drive different outcomes from the same strategies.”
Hospitals are including the discharge and aftercare process as a patient handoff, Sullivan says, with many using data analytics to determine which patients are most likely to return to the hospital and why, and then formulating a series of post-visit phone calls to address those risks.
“If you go home from the hospital after an appendectomy, we’ll call you at day two or three to make sure you’re progressing as expected, but if you go home with congestive heart failure we’ll call you at day twoor three, but we’ll also call you at day seven,” Sullivan says. “That’s because we know that around day nine or 10 we often see congestive heart failure patients back the hospital because they’ve not followed through on home care instructions. If we call you back at day seven to find out if you’ve filled your prescriptions and whether you’re gaining weight, we’re much more likely to avert readmissions.”
Those patients also receive a call after three weeks because data indicate that they often return to the hospital at about four weeks. Patients leave the hospital “scared straight” about their condition and determined to do what is necessary to maintain their health, but that conviction wanes over time and their health begins to fail, Sullivan says.
“If we call them at day 21 and ask them to compare the first week after discharge to how they are managing their healthcare now, we can look for slippage and get people back on the right track so they avoid that day 21 to day 30 readmission,” Sullivan says. “The concept is not new, but it’s been retooled in light of the data showing what we need to pay attention to.”
That approach also plays into another facet of patient handoffs getting more attention: the patient’s engagement in his or her own healthcare. Hospitals are working to meet patients where they are in terms of understanding, motivation, and ability to care for themselves.
“If I’m a patient who is highly engaged in managing my own health, I may not need that 21-day phone call because I’m less likely to fall off a cliff,” Sullivan says. “But if I am a newly diagnosed patient or a patient who has been admitted many times in the past and you know I’m not engaged in managing my care, that will drive not only the frequency of contact but the style of contact you have with them.”
For instance, with patients who are less engaged in their own care, Sullivan encourages healthcare professionals to provide little bits of information more often. Giving them too much information at once overwhelms them and can further disengage them, she says.
Sullivan and her colleagues also urge healthcare providers to change the terminology from patient handoffs to patient handovers. They think the word “handoff” sounds like clinicians are offloading patients and the clinician stops caring, whereas the word “handovers” conveys that one caregiver is transitioning care to another caregiver in a meaningful and thoughtful way.
“‘Handoff’ implies that I’m handing you to someone else and I’m washing my hands of you, I’m done,” she says. “A ‘handover’ implies more of a continuum of care. I’m still invested in you and I’m still a member of your care team. Just because you’re not in the bed in front of me doesn’t mean I no longer care for you or have any responsibility for you.”
That distinction is more than just symbolic, Sullivan says. Healthcare professionals must be encouraged to think of themselves as still involved in a patient’s continuum of care even if the patient is not physically under their care now, she says. The patient may have been transferred to another department or another professional’s care, but the professional making the handoff must still be ready to participate by providing needed information or other support, she says. (See the story in this issue for one hospital’s take on patient handoffs.)
“The days of looking at the doors to your unit and thinking you’re off the hook once they pass through those doors are over,” Sullivan says. “It’s not about who has custody of the patient now. It’s about the organization and everyone involved taking responsibility for the whole continuum of care.”
The best strategies for improving patient handoffs take a more comprehensive approach instead of focusing exclusively on that moment when a patient’s care is transferred from one caregiver to another, says Christopher Landrigan, MD, MPH, pediatric hospitalist at Boston Children’s Hospital and associate professor of pediatrics and medicine at Harvard Medical School. Landrigan also is founder and a board member of the I-PASS Patient Safety Institute, which promotes safe patient handoffs, and principal investigator with the I-PASS Study Group.
I-PASS is a mnemonic used to ensure caregivers address the key elements of a good handoff: Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver. (See the story on in this issue for other tips on what to cover in a patient handoff.)
He notes that the I-PASS program originated with efforts to reduce resident work hours, which resulted in more patient handoffs. As Landrigan and colleagues looked at how to make those handoffs safer, they realized that other successful quality improvement efforts took a broad approach.
“When you look at reducing hospital-acquired infections, the most successful interventions were not just focusing on handwashing as the sole thing you should do, but rather a whole series of complementary interventions that resulted in reducing infections,” Landrigan says. “They optimized handwashing efforts with improved use of sterile precautions, prepping the site well, avoiding the femoral site — a whole series of little steps that, in the aggregate, drove hospital-acquired infections down by about 80%.”
Landrigan and his colleagues took the same approach with patient handoffs, not focusing on just a computerized handoff tool or teamwork training, but bundling those strategies with others for a comprehensive way to improve handoffs. They developed a training program, an improved verbal process with the I-PASS mnemonic, and a handoff tool that reinforces best practices.
A hospital quality professional seeking to improve patient handoffs must first determine whether it is a priority for the organization. Though good handoffs should be the goal of all healthcare professionals, an organization may not be able to prioritize it now, and that will stymie any improvement effort, Landrigan says.
“This requires a substantial amount of support and input from the highest levels. This is a culture change,” Landrigan says. “You’re asking people to speak differently, and that requires a lot of time and effort to make it happen day in and day out for every patient every time. It’s one thing to train people, but it’s another thing entirely to get people to actually change what they do daily.”
A common occurrence is to provide training, maybe even change the electronic medical record to encourage proper handoffs, but two months later no one is doing what you taught them, he says.
Integration of services also is a key component of good patient handoffs, says Rohit Uppal, MD, SFHM, president of Acute Hospital Medicine, TeamHealth, a company in Knoxville, TN, that provides physician staffing and support services.
“We spend a lot of time talking about patient handoffs within a service line, how to hand off a patient from one doctor to the next. Less attention has been paid to how all the departments and service lines are coordinating their efforts for the good of the patient,” he says. “As patients come through the emergency room and need to be admitted to the hospital, we work to ensure good communication through that continuum as soon as possible. That means good communication around clinical issues and coordination of care.”
For instance, the company encourages parallel processes rather than waiting for one physician to complete care before the next begins. One challenge is that in many hospitals, communication lines between services is asynchronous, Uppal says.
“People are depending a lot on documentation and reading each other’s notes. If you can design workflow so that you have more verbal interactions, you can have people asking questions more freely and cut through a lot of the inefficiencies in the EMR, with information not being transmitted effectively,” he says. “As you have people from different service lines interacting more, they start to understand each other’s challenges and they find ways to make the transitions smoother and better for the patient.”
Workflows tend to be well ingrained in service lines, so expect some resistance, Uppal says. Technology also can pose roadblocks, as well as the lack of resources needed to make any change.
“You have to spend a lot of time building the ‘why’ behind it, because it won’t be hard for people to come up with reasons to stick with the way it’s always been done,” he says. “It’s easy for providers to be blind to the negative impact of that lack of coordination and communication. Having leaders who can shine light on the errors, inefficiencies, and quality problems that are occurring can drive clinicians to be more open to change in their workflow.”
A football analogy can help explain handoffs with some clinicians, says Dennis Deruelle, MD, FHM, national medical director for acute services with IPC Healthcare/TeamHealth, a company providing healthcare professional staff and integrated care providers in Tampa, FL. Think of the patient as the football.
“In a football game, the football is all important and you never want to fumble it, drop it. People are very careful to take care of it, and in healthcare you have one person handing it another, with one person as the giver and another at the receiver,” Deruelle says. “If either one of them isn’t paying attention or doesn’t do everything necessary to take care of that football, you have a fumble. When that happens, it’s bad and that’s where errors happen.”
It also is important to get patients involved in good handoffs, Deruelle says. They often have no idea how many times they are handed off from one caregiver to another.
“Patients need to be aware of when they are being handed off, such as with shift changes, and they need to understand the importance of a good handoff. If they think the handoff hasn’t gone well, they need to pick up that fumble and protect themselves,” Deruelle says. “This requires education and encouraging patients to speak up when they hear the doctor tell someone he’s going home that day, when the patient knows he’s not. The patient has to know when a handoff has occurred, and when it doesn’t occur in the right way they have to fill in the gap.”
A California hospital is using a walk-around, patient education, and a “ticket to ride” to ensure safe patient handoffs.
The effort is aimed at ensuring good communication among all participants, including the patient and family members, says Gemma Seidl, RN, MSN, MPH, PHN, executive director of critical care, telemetry, and renal services at St. Joseph Hospital of Orange.
During shift change, registered nurses and nursing assistants perform a walk-around in which the outgoing staff introduces the incoming staff to the patient and family. They also inform the patient that they are handing off the care, and use a template to review key items such as medication.
When transporting patients to procedural areas, for both monitored and non-monitored patients, the RN in charge of the patient completes a “ticket to ride” documentation in the electronic medical record, prints the form, and hands it to the receiving procedural RN or transporter.
Upon the patient’s return to the unit, the transport RN or transporter will hand the ticket to ride back to the nurse with a handoff signature. The receiving RN signs the form to acknowledge arrival and acceptance of the patient.
Lack of communication is the single most common root cause factor that leads to liability claims, and those claims often involve patient handoffs, according to The Doctors Company, a medical liability insurer in Napa, CA.
Appropriate communication among physicians, nurses, and all other members of the healthcare team is essential in preserving continuity of care for the patient, so The Doctors Company offers the following tips for improving communication during handoffs:
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Dana Spector, Nurse Planner Fameka Leonard, AHC Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.