Time Spent in Handoff Discussions was Longer for Patients Discussed First, Regardless of Complexity
Abstract & Commentary
By Leslie A. Hoffman, RN, PhD, Professor Emeritus, Nursing and Clinical & Translational Science, University of Pittsburgh. Leslie A. Hoffman reports no financial relationships relevant to this field of study.
This article originally appeared in the February 2013 issue of Critical Care Alert. It was edited by David J. Pierson, MD, and peer reviewed by William Thompson, MD. Dr. Pierson is Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
Synopsis: Disproportionately longer time was allocated to ICU patients discussed early in attending physician handoff sessions, regardless of complexity or severity of illness.
Source: Cohen MD, et al. The earlier the longer: Disproportionate time allocated to patients discussed early in attending physician handoff sessions. Arch Intern Med 2012;172:1762-1764.
Handoffs have been extensively examined as a potential source of communication failure. Such studies typically focus on how to best share details of care when patient responsibility is transferred from one clinical care team to another. In contrast, this study analyzed the handoff process in regard to the order of discussion and, in particular, time spent discussing individual patients. Video recordings were made of 23 end-of-week handoff sessions in a 21-bed ICU located in a tertiary medical center. The ICU was staffed by two teams, each led by an outgoing attending physician who handed off to an incoming attending. The procedure followed in this unit was to discuss patients in “bed-list” order. With frequent admissions and discharges, the discussion of patients was therefore effectively randomized, making severity of illness or other patient characteristics unrelated to discussion order. For the 262 sessions recorded, mean session duration was 142 ± 98 seconds. The average time allocated to each patient declined steadily from the first to last patient discussed. First-discussed patients received about 50% more time than those discussed last in a handoff session.
This article presents an interesting perspective regarding the content of handoff sessions. Time spent discussing patients “first on the list” was disproportionately longer than that spent discussing those later in the session, regardless of acuity, complexity, time of admission, or other factors. To confirm findings, the authors used three statistical approaches, all of which produced highly similar estimates. Through patient handoffs, responsibility, authority, and information about patients are exchanged between care providers. If incomplete or quickly verbalized, the information shared can impact the quality of patient care, predispose patients to unnecessary procedures/tests, and increase risk of adverse events.
A recent systematic review identified 18 articles analyzing characteristics of handoffs conducted in hospital settings.1 Studies identified in this review analyzed outcomes regarding a wide range of factors believed to influence subsequent care: use or non-use of a handoff sheet/mnemonic to standardize topics discussed, team behavior, clinician characteristics, patient characteristics, etc. None of these articles included consideration of “place in line.” Findings of this study suggest a simple-to-implement, no-cost solution that can improve the transfer of information during handoffs, i.e., discussing the most complex, most unstable, or new admissions first and/or setting blocks of time for return to cases that require further discussion.
1. Foster S, Manser T. The effects of patient handoff characteristics on subsequent care: A systematic review and areas for future research. Acad Med 2012;87:1105-1124.