When attendings at Denver Health Medical Center (DHMC) were asked to be available to help supervise the teams of residents and interns with the hand-off process, Eugene Chu, MD, director of the hospital medicine program, quickly knew there was a problem.
“They didn’t really know what they were teaching,” says Dr. Chu. “They had an idea of how to do a hand-off, but they had never explicitly learned what a good hand-off was because it had never been described before. Some of our attendings fell back on what they did best—teach medicine. But that was not necessarily what the house staff wanted at that time of day.”
The house staff did want to learn to give safe, effective, and efficient hand-offs. “Giving a lecture on renal failure was not really the point of the hand-off,” says Dr. Chu.
Time for Training
“Sign outs serve a lot of purposes, not just information [transfer],” says Leora Horwitz, MD, an assistant professor in the division of general internal medicine at Yale School of Medicine, New Haven, Conn. “Signout is also a time for training. It is a time for socialization in terms of how we talk about patients and what is expected. And it is a time for catching errors and for rethinking plans and diagnoses because as you are describing something to someone, they might pick up on gaps or inconsistencies or things that should be done differently.”
Dr. Horwitz, who is also associate medical director of the Center for Outcomes Research and Evaluation at Yale-New Haven Hospital, has researched training for transfer of care over the past three years.1
“The most important thing is that hospitalists should not assume that residents have any skills [pertaining to transfer of care],” says Dr. Horwitz. “In medical schools, students are taught over and over how to present a patient for the first time. There’s a rigid order in which the information is supposed to flow, and there is a rigid list of categories of information that should be conveyed. People are taught that same order and that same flow and that same list of categories at all med schools. Consequently, as residents, everybody has the same sense of how to represent an initial history and physical. There is no such thing for hand-offs.”
Resident duty-hour limitations have increased the number of hand-offs, which creates greater risks for discontinuity of care and patient safety.2, 3 “Hand-offs occur two or three times a day and a patient presentation only occurs once—when the patient shows up,” says Dr. Horwitz. On top of that, when residents appear in their clinical duties, the attendings tend to forget residents don’t have the skills to execute a comprehensive and well-communicated hand-off. “The first thing to remember is that people need to be trained,” she says.
In a study in the Archives of Internal Medicine in 2006 (for which Dr. Horwitz is first author), the investigators asked internal medicine chief residents whether their program provides direct training in how to perform sign outs. Sign-out training varied considerably, and fewer than half the 202 programs that responded (62% of all U.S. residency programs) provided formal sign-out skill training: 40% of the programs taught sign-out skills through a lecture or workshop, 45% supervised oral sign outs, and 38% reviewed written sign outs.4 Residents in 27% of the programs received no training or supervision. Further, in more than one-third of training programs they found hand-offs were left to interns. “Residency programs need to recognize the problem and address it in some way,” Dr. Horwitz says.