Not surprisingly, regulatory and accrediting organizations, such as The Joint Commission (TJC), are raising awareness about the hazards of handoffs and have mandated that all hospitals develop a standardized approach to handoff communications.
TJC reports that ineffective communication during patient handoffs is a major contributing factor to various adverse events, such as wrong-site surgery, falls, medication errors, and delays in treatment. Their 2016 study indicated that these communication errors resulted in over 1,700 deaths and $1.7B in additional costs to the healthcare system.
For example, a patient might receive care from a primary care physician or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she may receive care from a visiting nurse.
What Is a handoff?
There are a number of terms used to describe the handoff process, such as handover, sign-out, signover, cross-coverage, and shift report. The term handoff can be defined as, “the transfer of information (along with authority and responsibility) during transitions in care across the continuum to include an opportunity to ask questions, clarify and confirm.”
The concept of a handoff includes communication between care providers about patient care, records, and information tools to assist in communication between care providers about patient care. Handoffs are also a mechanism for transferring information, primary responsibility, and authority from one or a set of caregivers, to oncoming staff.
Different types of handoffs include:
- shift-to-shift handoff
- nursing unit-to-nursing unit
- nursing unit to diagnostic area
- handoff between special settings (operating room, emergency department)
- discharge and interfacility transfer handoff
In addition to safe handoffs within the organization, safety is also a concern in the broader area of improving transitions of care, particularly those tasked with reducing 30-day readmissions after hospital discharge.
The scope of the Joint Commission initiative encompasses transitions of patients between health care settings: for example, from a nursing home to a home care agency. Unfortunately, these transitions don't always go smoothly. Ineffective care transitions can lead to adverse events, higher hospital readmission rates, and costs. One study estimated that 80 percent of serious medical errors involve miscommunication during the handoff between medical providers.
Over the past few years, policies by Medicare and other payers have created strong financial incentives to reduce readmissions. Designing the right transition interventions remains a work in progress.
- The SBAR (Situation-Background-Assessment-Recommendation) and ANTICipate (Administrative data, New clinical information, Tasks, Illness severity, Contingency plans) tools offer steps for clinicians to follow as part of a standardized handoff protocol. Other structured tools use computerized and Web-based platforms.
- Another tool is known as I-PASS (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis or read-back). The implementation process for these discharge tools was carefully developed and applied. It included formal training, faculty development, and an effort to engage the primary users in revising their process and workflows.
Researchers studied more than 10,000 patient admissions, using active surveillance strategies to measure rates of medical errors and preventable adverse events. They discovered a 23% reduction in medical errors from the pre-intervention to post-intervention period, accompanied by a 30% reduction in preventable adverse events, according to an article from the Agency for Healthcare Research and Quality (AHRQ).
The area of care transitions, particularly those associated with hospital discharge, have received considerable attention. Unfortunately, the results of several studies served mostly to reinforce the idea that there is no magic bullet for preventing hospital readmissions. One positive is that light has been shed on how to best identify patients at highest risk for readmission, a significant advance.
As with most things in health care and in life, communication is key to success. Basic to the delivery of quality health care is the ability to communicate with one another and safely transition patients in a seamless manner so every patient can have the best outcome from each phase of care.