The Physician Handoff and Its Role in Quality and Safety

Introduction

The clear, accurate, and effective exchange of clinical information has always played a central role in the delivery of health care. It remains one of the most critical events that allows for health care providers to be effective at managing patients and their conditions. There are multiple examples of the central aspect of interprovider communication in daily care delivery in the hospital setting. Delivering quality care depends on the accurate, efficient, complete, and appropriate exchange of information; whether between primary providers and consultants, preoperative evaluators and surgeons, among on-call physicians, between nurses at shift changes, or essentially between and among all manners of allied health, nursing, and physician providers. The handoff process for physicians' communication is that exchange that includes not just an information exchange, but also a transfer or a transition of the responsibility for care of the patient. It has been defined as “the exchange between health professionals of information about a patient accompanying either a transfer of control over, or of responsibility for, the patient.”

In this chapter, the scope and background of the importance of the handoff for effective patient care delivery will be reviewed. A background of the current literature will be discussed. Studies demonstrating the importance of handoffs and those describing some of the limitations found in the current literature will be reviewed. The current thinking on the complexities of the handover process and the implications for further study and improvement will be described in an effort to encourage quality projects in this area. The limitations of available research specifically in Neurosurgery will be addressed. Further research into the development of data driven, safety promoting guidelines and best practices are desired that are acceptable for the neurosurgical setting with its particular complexities and its need for flexibilities in multiple environments, that will still provide for quality and safety in patient care. Guidelines shown to have improved clinical outcomes based on study data are needed. With more attention to quality projects that feature the development of the characteristics of the proper handoff in Neurosurgery, the implications are for improved quality and safety in the care and treatment of our neurosurgery patients.

Central Role of the Handoff in Health Care, Focus on Improvement

The evolution of health care delivery has seen the development of increasingly complex delivery systems. Individual providers responsible for complete care have evolved into complex care teams focused on areas of expertise. Care is more and more subdivided, the consultative teams are providing more complex interventions, and the transfers of information that accompany such complexities are themselves more complex and detailed.

The number of handoffs that a patient currently experiences during a typical hospital stay has increased dramatically. Their information is exchanged between different types of professional providers, between shifts of similar providers, between different medical or surgical services, or between workday and on-call providers. With ever increasing ability to provide specialty care in multiple medical fields, multiple nursing specialties, and multiple ancillary fields, there is an overwhelming amount of patient information exchange that occurs during the hospital stay. Constraints of time have increased the number of handovers that occur. It has been estimated that the number of physician shift handoffs has increased by 40% with the introduction of reduced work hours for in-training physicians. It has also been estimated that the average inpatient will require 24 physician handovers during the average hospital stay. There are over 36 million discharges per year in the country, as calculated by the Department of Health and Human Services, so the opportunity to effect quality of health care delivery in the United States with improving the handoff experience is large.

Traditionally, the physician-to-physician handoff remains one of the critical communication exchanges that occurs during a patient's hospitalization. These handovers occur at multiple levels and in varied situations. They include twice daily handoffs between residents on morning and evening rounds, cross-cover handoffs between day physicians and night physicians, handoffs between primary attending physicians and on-call physicians, transfer handoffs between physician specialists as patients transition services, and handoffs between physicians as they provide coverage for holidays or vacations or at the time of a change of primary attending responsible for a service. The physician-to-physician handoff exchange has been identified as a critical handoff in the link to both patient safety and to resource utilization. In their analyses of patient care events and their relationship to communication among all providers in general, the Joint Commission was able to identify that up to 60% of inpatient medical adverse events may be attributed to improper communication. The literature has been able to associate inadequate handoffs with increases in patient safety events and with increases in healthcare utilization. Additional studies have implicated inadequate or poor transitions in medical errors. As the delivery health care attempts to evolve further toward higher quality and fewer adverse events, any focus on improving the handoff process among physicians at all levels of training and interaction is appropriate. Many factors have been identified as influences on the effective handoff. Efforts to educate, implement, and improve the transfer of information are as complex as the very health care system itself. Research into the handover has shown that the efficacy of the handoff is influenced by the environment in which it takes place, the characteristics of the persons involved, interruptions, the availability of electronic versus face-to-face communication, the utilization of the electronic medical record, and the multiple benefits the system of health care delivery hopes to derive from the handover process. It remains an important concern among providers that any perceived or actual benefits in patient care quality obtained by the reduction in duty hours for physicians in training have not been undone by the potential increase in adverse events associated with the addition of more frequent and more complex transfers of care.

Third parties such as governmental agencies and health care advocacy groups have come to recognize the central role of communication in quality health care delivery and have recognized that improvements in handoff exchange are potential means to affect the quality and safety in health care. The Joint Commission has established the Center for Transforming Healthcare to help “solve healthcare's most critical safety and quality problems.” It has also defined the clinical handoff and tried to state its importance as a component of quality health care. It identifies the clinical handoff as “a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient's care.” It goes on to state “the consequences of substandard hand-offs may include delay in treatment, inappropriate treatment, adverse events, omission of care, increased hospital length of stay, avoidable readmissions, increased cost, inefficiency from rework, and other minor or major patient harm.” The Joint Commission along with the Department of Health and Human services, the Institute of Medicine, the World Health Organization, and multiple participating hospital systems all have developed initiatives to help further the creation of guidelines, standards, education, and assessment tools to help improve communications in patients' transitions of care. Multiple working groups such as theNational Quality Forum (NQF) and the National Patient Safety Foundation (NPSF) have evolved to advocate for health care quality improvements and effective communication in particular.

The Accreditation Council for Graduate Medical Education (ACGME) established resident duty hour restrictions in 2003 and revised them further in 2011. Studies have shown that patient care delivery now requires an increased number of patient handovers. In recognition of the central role of handovers in patient care, and the need to train future physicians in proper handoff delivery, the ACGME has revised its program requirements and oversight for residency training. It now includes evaluation of each program with regard to the staffing of clinical rotations to minimize the number of daily patient care transitions. It now requires each institution to not only monitor the handovers performed by their residents in training, but also ensure that training programs provide education in the handoff process to assure trainee competence in handover communication. The American Medical Association (AMA) also recognizes the importance of education in the handover process. It provides web-based access to resources for residents for improving patient handoffs. The Agency for Healthcare Research and Quality is a section within the US Department of Health and Human Services. Its stated mission is “to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the US Department of Health and Human Services and with other partners to make sure that the evidence is understood and used.” Through literature review, resource tools, and grant funding, it promotes the development and dissemination of information on improving quality in health care including that related to transitions of care. The Patient Safety Network (PSNet) is an AHRQ subsite that provides a clearinghouse for distribution of research and resources on patient safety, including handovers. “The site offers weekly updates of patient safety literature, news, tools, and meetings (‘What's New’), and a vast set of carefully annotated links to important research and other information on patient safety (‘The Collection’)”. Finally, third-party vendors are beginning to come to market with computer, tablet, and smartphone applications developed to help give standardized structures to the handover process.