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A Hands-on Approach to Hand-offs

From: The Hospitalist, August 2007

by Jane Jerrard

Sunil Kripalani, MD, MSc

In “Developing Hand-off Standards for Hospitalists,” members of an SHM task force on hand-offs presented their findings from an extensive literature review and went on to propose basic standards for hospitalist hand-offs. The speakers included task force members Vineet Arora, MD, MA, assistant professor of medicine, University of Chicago; Lakshmi Halasyamani, MD, associate chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich.; Sunil Kripalani, MD, MSc, an instructor at Emory University, Atlanta, Ga.; and Efren Manjarrez, MD, assistant clinical professor of medicine at the Miller School of Medicine, University of Miami.

Vineet Arora, MD, MA

Literature Review: Slim Pickings

Although the group hoped to determine best practices based on a literature review of hand-offs, shift changes and handovers (excluding transitions in and out of hospitals) they couldn’t find enough appropriate research to support this goal.

After a PubMed search, and a review of the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Net—which is a categorized, reviewed collection of articles and references—the task force reported the following: Of the 334 promising articles they initially identified, only 107 were deemed relevant after a title review. And of those, a significant article review found only 10 met the criteria for inclusion. Three studies of hand-offs appeared in nursing publications and were the only provider-specific studies. The remaining seven were studies of technology solutions for hand-offs—although all articles revealed that any technology fixes were “homegrown,” as nothing specific to hand-offs is widely available commercially.

Efren Manjarrez, MD

Those 10 studies included few interventions, with no studies of hospitalist-specific hand-offs. Studies of shift changes predominated, and there were few studies that included patient outcomes.

“A summary of the literature supports the use of supplementing verbal hand-offs with written documentation in some structured format,” said Dr. Manjarrez. “It also showed a technology solution provided added benefits such as reduced rounding time and prep time and increased time with patients.”

The literature summary also suggests involving the patient in the hand-off conversation. “Signing out in front of the patient does wonders for your patient satisfaction rate,” remarked Dr. Manjarrez.

Lakshmi Halasyamani, MD

As part of the literature review, the task force found and examined five major expert consensus and policy white papers deemed relevant to hand-offs. Dr. Arora cited these papers from the Australian Council for Safety and Quality in Healthcare, the British Medical Association Junior Doctors Committee, the University Health Consortium, the Department of Defense Patient Safety Program, and the Joint Commission’s (formerly JCAHO’s) National Patient Safety Goal 2006.

Dr. Arora reminded attendees that the Joint Commission’s National Patient Safety Goal states that, “hospitals should implement a standardized approach to hand-off communications. This applies to all staff, not just physicians.”

Common themes found in the five white papers include:

• Frontline providers must be educated about acceptable hand-off practices;
• Adequate time must be made by all parties for hand-offs, and interruptions should be reduced during hand-off communications;
• Information must be up to date;
• Interactive questioning should be facilitated;
• Ill patients must be made a priority; and
• Actions to be undertaken should be clearly delineated.

Recommended Standards for Hand-offs

Based on their literature review, the SHM task force has created basic standards for hospitalists to use for hand-offs.

“Our standards needed to be broad enough to work at all hospital medicine programs, so they’re pretty basic,” said Dr. Arora. “They’re actually minimal standards to be met—they’re fairly simplistic, and we do not consider them to be best practices by any means.”

The standards begin with what seems like an obvious statement, but a necessary one for some hospital medicine groups: “A formally recognized hand-off plan should be instituted at the end of a shift or a change in service.” The standards also state that, “Effective hand-offs will require not only a program policy, but standards for verbal exchange and content exchange,” said Dr. Arora.

To guide hospital medicine groups through this exchange, the speakers offered three mnemonic devices: The 3 T’s, the 4 I’s and the 3 A’s.

The 3 T’s: Your program should have a policy in place that stipulates:

• Time set aside for hand-offs. Ensure that busy hospitalists have adequate time blocked out.
• Template or technology solution. “You need a structured template to help people do their work,” said Dr. Arora. “The program needs to decide what kind of template to adopt—and a move to standardization meets that Joint Commission goal.”
• Train new staff on hand-off expectations. Keep everyone in your practice, including appropriate hospital staff, in the loop.

The 4 I’s of verbal, or face-to-face, exchange include:

• Interruptions are limited. There will always be interruptions, but you can take steps to limit them during hand-offs by designating a time and/or place as “interruption free,” or having someone cover the pagers of the involved hospitalists during hand-offs.
• Interactive process is used. “There should be some interactive dialogue” between the physicians, insisted Dr. Arora.
• Ill patients are given priority. Make sure that you give your sickest patients top priority during hand-offs.
• Insight given to receiver on what to expect or do. What would you do if you were staying on for the next shift? Give the receiver a list of “to-do” items.

The 3 A’s of content exchange standards are:

• All data are up to date. This can be a real problem in healthcare. Make sure all information you turn over, both written and oral, reflects your latest knowledge.
• Anticipated events are emphasized. “What do you anticipate will be a problem?” asked Dr. Arora. Think this through and let the receiver know.
• Action items are highlighted. Again, include a to-do list with the information.

What’s Next?

The task force didn’t stop with these new basic standards. They put together a research agenda, a “wish list” of what’s needed in hospital medicine research to improve hand-offs.

“We need to use research to evaluate these standards rigorously,” said Dr. Arora. “And we must emphasize controlled interventions because only 10 of the articles we found were controlled interventions. We have to urge the research community to do more in this area.”

The group would also like to encourage the development of patient-based outcomes that are sensitive to hand-off quality. “This is talked about a lot, but few people are doing anything about it,” Dr. Arora pointed out.

And finally, they’d like to enable additional funding for further research on hand-offs.

Attendees at the session were polled on their hand-off practices. By a show of hands, approximately 40% indicated they had a standardized hand-off procedure. However, virtually no one thought their procedure was ideal.

The task force encouraged attendees and other hospitalists to share their thoughts and input on hand-off standards. If you have ideas for the task force, you can e-mail them at handoffs@hospitalmedicine.org.

The task force plans to revise their recommendations, with attention to SHM member input. They’d also like to engage an expert panel for an external review of their work before they disseminate it. TH