Taking the guesswork out of patient handoffs

Dr. Jennifer O’Toole is a pediatric and adult hospitalist who splits her time between two different Cincinnati hospitals where she teaches residents, conducts educational research, and sees patients. She understands that hospitalists and residents are facing work-hour compression while caring for more complicated patients. But no matter how busy they are, physicians need to take the time to perform a concise, standardized handoff of their patients, she said.

Dr. O’Toole is the site principal investigator for Cincinnati Children’s Hospital in the I-PASS Study Group. I-PASS is an acronym of acronyms: the IIPE (Initiative for Innovation in Pediatric Education) and PRIS (Pediatric Research in Inpatient Settings) Network Accelerating Safe Sign-outs Study. The project, which is currently underway at 10 sites across North America, tests the use of a standardized, evidence-based handoff bundle among residents. The bundle includes team training, a verbal mnemonic, and a structured printed tool. Each of the sites is implementing the bundle and measuring how it impacts medical errors, verbal and written miscommunications, and satisfaction and work flow among residents.

Dr. O’Toole is also the lead investigator for an I-PASS ancillary study, which is developing and evaluating a handoff bundle for medical students. In an interview with Hospitalist News, she shared her thoughts on how hospitalists can improve their handoff techniques.

Question: The data collection for the I-PASS study ends in May. What have you learned so far at your site?

Dr. O’Toole: We have learned that handoffs need to be a standardized process that is practiced consistently. Practicing a standardized handoff is not something that you can turn on or off. One must use the same consistent structure for every patient handoff.

We have also learned that effective handoff education requires more than just a one-time workshop training session. In order to develop and refine one’s skill in handoffs, there need to be intermittent refreshers and reinforcement via observation and feedback from peers and faculty. This feedback needs to be targeted at the various components of an effective handoff. For instance, did they speak too quickly, did they include superfluous information, or did they include an assessment of a patient’s illness severity?

Last, we learned that robust faculty development is critical to successfully implementing a handoff training program during medical school or residency. Many of our faculty were never formally trained in handoff communication and therefore were not well equipped to teach and evaluate these skills. We had to implement an intensive faculty development program for the I-PASS study, and in response, we noticed a change in how our faculty executed their own handoff communication.

Question: Can you have successful handoffs without a standardized process?

Dr. O’Toole: No. I believe that standardization during handoffs is critical.

We developed a standardized mnemonic for the I-PASS study and tailored our handoff documents to reflect the structure of the mnemonic. There are a lot of handoff mnemonics out there, and I don’t think we have the evidence to say one is better than another. Regardless of what handoff process or mnemonic one uses, I think it all comes down to being very structured and methodical about how you perform a handoff. For example, one needs to consistently provide a patient summary in a familiar format and consistently articulate contingency planning for every patient. Reliable use of a standardized structure is imperative to ensure that critical elements are not omitted during handoff communication.

When residents or hospitalists are tired, stressed, or busy, they run the risk of leaving out important elements during a handoff. A structured mnemonic and printed handoff document provide a stable framework to prevent lapses in effective handoff communication.

Question: Does the handoff protocol need to be site specific?

Dr. O’Toole: While we implemented a consistent handoff bundle during the I-PASS project at all of our sites, we found that there were minor ways each site tweaked the elements of the handoff bundle to fit the needs of its program and its individual institutional culture. These site-specific adaptations were critical for the successful implementation of the program at each site. For example, at our site we were able to easily incorporate our I-PASS printed handoff document into our electronic health record. However, this wasn’t the case for all of the study sites. Each site had to develop a printed handoff document according to the resources available at its institution. I have encountered similar experiences during the dissemination of the I-PASS handoff bundle to my internal medicine residency program at the University of Cincinnati Medical Center.