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Researchers provide new template for more effective handoffs
Designed for same-department handoffs, can be used in other settings
Citing the elusiveness of "standardized and reliable measurement tools" for patient handoffs, a group of researchers has come up with a set of seven "framings," or interventions, they say can be used to improve them:
1. information processing the most prevalent intervention in the literature;
2. stereotypical narratives highlighting deviations from typical narratives;
3. resilience transparency of thought processes, through conversation, to identify erroneous assumptions and actions;
4. accountability the transfer of responsibility and authority;
5. social interaction the perspectives of the different participants;
6. distributed cognition how the transfer of care to a new provider can affect the network of specialized practitioners;
7. cultural norms how group values are negotiated and sustained over time.1
"We initially approached this looking for weaknesses [in handoffs], because the conventional wisdom is there are weak points," says Robert L Wears, MD, MS, professor of emergency medicine at the University of Florida and co-author of the article. "We started to do some basic observations on handoffs, with an initial goal of finding out how many minutes they took, how often the providers were interrupted, and so on. However, with the assistance of some social scientists who specialize in communication, we quickly came up with cases where the handoff was a mechanism for recovery where things had not reached a disaster point yet. So, we determined that we had it all wrong and that we needed to start over from a blank slate."
The team ended up reviewing about 400 articles in the literature. "These all involved shift changes in the emergency department," Wears explains. "That's where we work, and we had a limited budget." The reviews involved five hospitals three in the United States and two in Canada.
It was important that the researchers made this distinction, notes Charlotte Huber, RN, MSN, patient safety analyst with the Pennsylvania Patient Safety Authority.
"I believe there is a consensus about the purpose of handoffs, but what they're trying to say is there's not a consensus about how they should be done in different units; there are different types of handoffs in different units, and between health care providers and paraprofessionals it depends on who's doing the handoff," she says. "If you have a handoff from one nurse to another nurse, that a clearer handoff; where if a nurse is handing off to a physician assistant, that's a different type of handoff.
"If I work in the ICU and transfer a patient to a regular floor, I would probably have clean communication," she continues, "but if the nurse handing off works in the ED and I'm in a different area, the areas are different and the technology is different."
Are framings transferrable?
Despite these challenges, Wears believes the framings could be applied in different settings. "It depends on the setting," he says. "Some of the framings may be more dominant in some transfers than in others." Actually, he adds, that is one of the reasons the researchers came up with multiple framings so the providers would not have to choose just one. "Several may be operative at one time; some may be more dominant in different times," he notes. "Understand what you are doing, and choose what is most useful for that type of setting."
Huber agrees. "I really like how they describe those seven framings, and they are absolutely applicable outside a given department," she says. "One misnomer is that handoffs only involve information processing; they are so much more complicated than that. Sometimes one framing would be emphasized more, and sometimes less. It depends on who the giver and receiver of information are and where the patient is coming from or going to."
Huber says she found much of value in the article. "One of the things that is really important is to have a coordinated pre-transport communication process; you can't just rely on a piece of paper having every single solitary thing you can think of," she says. "The other thing that was identified in the paper that was essential was a lack of noise trying to do the handoff in a quiet area. I cannot tell you how loud the units can be [for nurses], and it's the same for physicians; when you have several admissions at the same time when you get to the floor, you have to coordinate that in a quiet area. You have monitors and respirators going, a lot of technology that's beeping the IVs, the pumps, all those other competing sounds."
Robust education and competencies also are critical, she says. "Those who are developing the tools have got to get them to the physicians and nurses doing the handoffs, so they're not asking for extraneous information." Huber notes. Simulations, she adds, "are awesome."
Making it work
The handoff processes, says Huber, should be handled by an interdisciplinary team. "One thing that would be really great to do is for departments to keep a log and figure out all of the transports or those kinds of handoffs they do daily," she says. "Administration would see where the predominance of them occur and focus on them that way they'd get the most bang for the buck."
When working within a given unit, says Wears, "We like a co-construction framework, where both parties try to mutually build a shared description of what's happened with the patient so where they've been, where they're headed, what pitfalls exist, and what remains to be done. Typically, you do not need a lot of details about unrelated facts; you need the big picture like 'This is a GI bleeder,' which conjures up a mental picture. You need some idea of what the course of treatment has been; this is important to co-construction, because the oncoming party then starts to probe for clarification. They might ask, 'Why would you do that?' or 'Why did you not think about aortic dissection?' The reply might be, 'We considered X, but we ruled it out,' or, 'Well, we actually did not think about that.' Ultimately, they will have the same picture."
Wears says he just heard of a facility that instituted a policy requiring the "off-going" person to call back in an hour to make sure all the important issues had been covered. "I think this is a nice policy," he says. "Formalizing something like that is probably a good idea."
When crossing organizational boundaries, Wears continues, "People do have different expectations, but I like to think that articulating those expectations and coming up with an approach would be useful." This is more difficult, he concedes, in teaching settings, in that residents turn over often, so "communal wisdom" is more difficult to attain. "But in other settings, it's possible because staff stick around longer," says Wears. What's important, he adds, is "the ability to have some sort of shared information artifact. For example, people have had some success with the ability to look at a face sheet summary of what's going on i.e., 'Things that need to be checked tonight.' This way, both parties can look at the same artifact." It doesn't have to be extremely detailed, he adds. "You can just hit the high spots."
Interns overestimate handoff effectiveness
It seems that effective handoffs plague interns, too. In a recent article in Pediatrics, post-call interns were asked to predict what the on-call interns would report as the important pieces of information communicated during the handoff about each patient.1 They also guessed on-call interns' rating of how well the handoffs went. In addition, on-call interns were asked to list the most important pieces of information for each patient that post-call interns communicated during the handoff, and how well the handoffs went. Interns had access to written handoffs during the interviews.
Out of 52 interviews that were conducted, the most important piece of information about a patient was not successfully communicated 60% of the time despite the fact that the post-call interns believed that it was. The authors say the study demonstrates that "systematic causes of miscommunication may play a role in handoff quality."
One of the things he learned from his co-author, he emphasizes, "is that the purpose of a handoff is not a complete data dump, but [providing enough information to] let the next person act safely and effectively. If you send every possible bit of information, the important stuff will be drowned out by the irrelevant stuff. Focus on what might happen, and what might be useful."
Charlotte Huber, RN, MSN. Patient Safety Analyst, Pennsylvania Patient Safety Authority, P.O. Box 706, 5200 Butler Pike, Plymouth Meeting, PA 19462-0706. Phone: 1-610-825-6000 x5036. Fax: 610-567-1114 Email: email@example.com.
Robert L. Wears, MD, MS, University of Florida. Phone: (904) 244-4405. E-mail: firstname.lastname@example.org.