Which Patient Should The Nurse Assess First After Receiving Change-of-shift Report?

Background

The transfer of essential information and the responsibility for intendance of the patient from one health care provider to another is an integral component of communication in health care. This disquisitional transfer signal is known as a handoff.^i–3 An effective handoff supports the transition of critical information and continuity of care and treatment. However, the literature continues to highlight the furnishings of ineffective handoffs: agin events and patient condom risks.^4–11 The Establish of Medicine (IOM) reported that "it is in inadequate handoffs that safety often fails get-go"¹² (p. 45). This chapter presents an overview of handoffs, a summary of selected literature, gaps in the knowledge, and suggestions for quality improvement initiatives and recommendations for future research.

What Is a Handoff?

Showtime i needs to recognize the term "handoff" and synonymous terms that are used in a wide variety of contexts and clinical settings. In that location are a number of terms used to depict the handoff process, such as handover,¹ ^, ¹³ ^, ^fourteen sign-out,¹⁵ ^, ^sixteen signover,¹⁷ cross-coverage,¹⁸ ^, ¹⁹ and shift study.^20–22 For the purpose of this discussion, the term "handoff" will be used and defined as, "The transfer of data (forth with authority and responsibility) during transitions in intendance across the continuum; to include an opportunity to ask questions, clarify and confirm"²³ (p. 31). The concept of a handoff is complex and "includes communication between the change of shift, advice between intendance providers about patient care, handoff, records, and information tools to help in communication between care providers nearly patient intendance"¹ (p. 1). The handoff is also "a mechanism for transferring information, primary responsibility, and dominance from 1 or a ready of caregivers, to oncoming staff"¹⁷ (p. ane). So, conceptually, the handoff must provide disquisitional information about the patient, include communication methods between sender and receiver, transfer responsibility for intendance, and be performed inside complex organizational systems and cultures that impact patient safety. The complexity and dash of the type of information, communication methods, and various caregivers for each of these factors impact the effectiveness and efficiency of the handoff every bit well as patient rubber.

Why Is In that location a Problem With Handoffs Today?

As health care has evolved and become more than specialized, with greater numbers of clinicians involved in patient care, patients are likely to encounter more handoffs than in the simpler and less complex wellness care delivery system of a few generations ago.^eleven Ineffective handoffs tin can contribute to gaps in patient intendance and breaches (i.e., failures) in patient condom, including medication errors,¹⁹ ^, ²⁴ wrong-site surgery,⁹ and patient deaths.⁴ ^, ^seven Clinical environments are dynamic and complex, presenting many challenges for effective communication among wellness care providers, patients, and families.^25–27 Some nursing units may "transfer or discharge 40 percent to 70 percent of their patients every day"²⁸ (p. 36), thereby illustrating the frequency of handoffs encountered daily and the number of possible breaches at each transition point.

Our expanding cognition base and technological advances in health care spawn additional categories of wellness care providers and specialized units designed for specific diseases, procedures, and phases of illness and/or rehabilitation. This dynamic, ever-increasing specialization, while undertaken to improve patient outcomes and heighten health intendance commitment, tin can contribute to serious risks in wellness care delivery and promote fragmentation of care and problems with handoffs.ⁱⁱⁱ ^, ¹⁰ ^, ²⁹ It is ironic that as health care has become more sophisticated due to advances in medical technology focused on saving lives and enhancing the quality of life, the risks associated with the handoffs have garnered attending in the pop press^xxx and reports from wellness intendance organizations and providers.³ ^, ⁴ ^, ⁶ ^, ^x ^, ^31–35 The hazard that "fumbled handoffs"⁷ ^, ¹⁰ pose to patient safety and the commitment of quality health care cannot be ignored. Ineffective handoffs can pb to a host of patient safe problems; research¹ and evolution of strategies to reduce these issues are required.³³ ^, ³⁴

What contributes to fumbled handoffs? An examination of how communication breakup occurs amid other disciplines may have implications for nurses. A study of incidents reported past surgeons plant communication breakdowns were a contributing cistron in 43 percent of incidents, and 2-thirds of these communication bug were related to handoff issues.³⁶ The use of sign-out sheets for advice between physicians is a common do, yet one written report found errors in 67 percent of the sheets.¹⁵ The errors included missing allergy and weight, and wrong medication information.¹⁵ In another study, focused on near misses and agin events involving novice nurses, the nurses identified handoffs every bit a concern, particularly related to incomplete or missing information.³⁷

Astute intendance hospitals accept go organizationally complex; this contributes to difficulty communicating with the advisable wellness care provider. Due to the proliferation of specialties and clinicians providing care to a single patient, nurses and doctors have reported difficulty in even contacting the correct health care provider.³⁸ 1 report constitute that simply 23 percent of physicians could correctly identify the primary nurse responsible for their patient, and only 42 percent of nurses could place the physician responsible for the patient in their care.³⁹ This study highlights the potential gaps in communication amidst health care providers transferring data about care and treatment.

A handoff is largely dependent on the interpersonal advice skills of the caregiver³³ as well as the knowledge and experience level of the caregiver. There is reported variability in quality,⁴⁰ lack of construction in how handoffs usually occur,³³ and variances in shift handoffs.²² ^, ^41–43 Concern has been raised that the transition of care betwixt providers during handoffs will continue to be problematic as research indicates that "merely viii percent of medical schools teach how to hand off patients in formal didactic session"³ (p. 1097), creating a large educational gap in new professionals and persistence of traditional models. Physicians and nurses communicate differently. Nurses are focused on the "big moving-picture show" with "broad and narrative"⁴⁴ (p. i86) descriptions of the situation, whereas physicians are focused on bullets of critical information.⁴⁴ A technique that seeks to bridge the gap between the dissimilar advice styles of nurses and physician is the situation, background, assessment, recommendation (SBAR) conference model⁴⁴ that is being used successfully to raise handoff communication.⁴⁵

The issue of handoffs has become so prominent that the Joint Committee (formerly the Joint Committee on Accreditation of Healthcare Organizations, JCAHO) introduced a national patient safety goal on handoffs that became effective in January 2006.⁴⁵ The national safety goals, developed by the Joint Commission with input from the Sentinel Event Informational Group, place new actions with the potential to protect patient safety.⁴⁶ The patient prophylactic goal requires health care organizations to "implement a standardized approach to "handoff" communications, including an opportunity to inquire and respond to questions."⁴⁷ While the goal is simply stated, it is challenging to develop and implement constructive strategies for handoffs across various health care settings, given the complexity of health care delivery. The Articulation Commission'southward guidelines for implementation of the safe goal are presented in Table 1,⁴⁸ and suggested strategies for effective handoffs are listed in Table 2.

Table 1

Articulation Committee 2008 Hospital Patient Prophylactic Goals Implementation Expectations for Handoffs

Table 2

Strategies to Ameliorate Handoff Advice

Following are examples of each of these handoff expectations:

Nurse Brown on unit A is receiving report from Nurse Dark-green who is transferring the patient from unit B to unit A. The patient medication administration record (MAR) does not indicate the patient has received any hurting medication in the by shift. When Nurse Brown asks well-nigh this, Nurse Dark-green realizes she gave morphine sulfate but did not certificate it on the MAR. Due to Nurse Chocolate-brown's question, Nurse Greenish realizes the omission and communicates the data and documents it in the medical record, preventing an accidental overdose of a medication.
A patient who had undergone a surgical procedure has non been out of bed since beingness transferred to the nursing unit. The offgoing nurse alerts the oncoming nurses that the patient will need assistance getting out of bed, possibly preventing a patient fall.
Handoffs require a process for verification of the received information, including read back, every bit advisable. For instance, the receiver of the telephone message regarding a laboratory value is asked to write information technology downwardly and read the message back, including the name of the patient, the test, and the test result/interpretation.⁴⁹ ^, ⁵⁰ Data to exist recorded should also include the name and credentials of sender and receiver and the date and time.⁵⁰

Laboratory Technician: I am calling with the lab results on Mr. Green.

Nurse: Let me get a notepad. You are calling the lab results for Mrs. Marie White?

Laboratory Technician: No, I am calling results for Mr. Tom Green ID #12345678. Mr. Green'south potassium level is 5.i, which was fatigued at 0700 today.

Nurse: You reported that Mr. Tom Dark-green's potassium level is v.ane. This is Nancy Jones, RN.

Laboratory Technician: Thank you, Nancy. That is right; Mr. Tom Green'south potassium level is 5.ane This is Nib Smith, lab tech.
The receiver of the handoff information has an opportunity to review relevant patient/client/resident historical data, which may include previous care, treatment, and services. A patient has been transferred, and the nurse notes several omissions from previous medication orders, including insulin. The nurse notifies the physician and obtains correct and complete medication orders, thereby avoiding a potentially serious medication error.
A nursing unit schedules staffing coverage to adjust the shift modify and minimize the occurrence of interruptions during change-of-shift written report. Ancillary staff does not leave the nursing unit until report is completed to clinch phones are answered and timely responses to telephone call lights are made so nurses tin provide written report effectively and efficiently.

It is of import to understand the context in which care is provided and be cognizant of the impact of the environmental processes on health care providers. The physical piece of work surroundings may not be conducive to effective handoffs equally it may be noisy⁵⁸ ^, ⁵⁹ and prone to interruptions, (i.e., pagers, telephone calls),^60–63 and the handoff may be conducted under physical and emotional pressures.¹¹ A study examining communication patterns among physicians and nurses found xxx one percent of communication exchanges involved intermission, translating into roughly 11 interruptions an hour for physicians and nurses.^lx Spencer and colleagues⁶² institute 15 interruptions per hour. Barriers to manual of accurate information in a patient transfer include incomplete medical record, lack of complete information provided by nurses, and the omission of essential information.⁶⁴ Handoffs are compromised if disquisitional pieces of information are omitted because of difficulties with information access⁴ ^, ²⁹ or if documentation is illegible³¹ ^, ³³ or non transferred.⁵⁵ Despite efforts to promote the apply of electronic patient records, according to a 2002 survey, less than 10 percentage of hospitals have complete access to electronic systems such equally computerized md order entry (CPOE).⁶⁵

The always-increasing abundance of data requires that health care providers synthesize and make decisions using big amounts of complex data. Unfortunately, data quickly degrades; for example, critically ill patients have many clinical parameters that are beingness monitored oftentimes.⁶⁶ Decisions demand to exist based on trends in the data and electric current information, which is essential to making informed decisions.⁶⁶ Tremendous amounts of data are constantly existence generated, such equally monitored clinical parameters, diagnostic tests, and multidisciplinary assessments. When this big amount of data is combined with the numerous individuals—clinical and nonclinical—who come in contact with a patient during a treatment episode and data transmission, not all members of the health intendance team may be aware of all the information pertinent to each patient.⁶⁶

In an effort to compress information and make it manageable among wellness care providers, handoffs may result in a "progressive loss of information known as funneling, equally certain information is missed, forgotten or otherwise not conveyed" ⁶⁶ (p. 211). The omission of data or lack of easy accessibility to vital information by wellness intendance providers tin can have devastating consequences.⁴ ^, ¹¹ Such gaps in wellness care advice tin cause aperture in the provision of safe intendance⁶⁷ and impede the therapeutic trajectory for a patient. These gaps present major patient condom threats and tin can touch on the quality of care delivered.

Where Do Handoffs Occur?

Handoffs occur across the entire wellness intendance continuum in all types of settings. At that place are different types of handoffs from one wellness care provider to another, such equally in the transfer of a patient from i location to another inside the hospital⁶⁴ or the transition of data and responsibleness during the handoff between shifts on the same unit.^ane ^, ⁴¹ ^, ⁴³ Interdisciplinary handoffs occur between nurses and physicians, and nurses and diagnostic personnel, while intradisciplinary handoffs occur betwixt physicians³ ^, ^xv ^, ³¹ or between nurses.^xiii ^, ¹⁴ ^, ⁴¹ ^, ⁴² ^, ⁴³ Interfacility handoffs occur between hospitals and amidst multiple organizations,⁶⁸ including home health agencies,⁶⁹ ^, ⁷⁰ hospices,⁷¹ and extended-care facilities.⁷² ^, ⁷³

Handoffs may involve use of specialized technology (due east.k., audio recorders, pagers, mitt-held devices, and computerized records),² fax,⁷³ ^, ⁷⁴ written documents,⁵⁴ and oral communication.⁴¹ ^, ⁷⁵ ^, ⁷⁷ Each type and location of handoff presents similar as well as unique challenges. Given the variety of handoffs, the following discussion volition focus on:

Shift-to-shift handoff
Nursing unit of measurement-to-nursing unit handoff
Nursing unit to diagnostic area.
Special settings (operating room, emergency department).
Belch and interfacility transfer handoff
Handoffs and medications
Dr.-to-physician handoffs

Shift-to-Shift Handoff

There are paradoxes in communication and handoffs, especially at shift changes.^twenty Many human factors play a part. Human being factors (ergonomics) focus on behavior and interaction betwixt human beings and their surroundings. Human factors engineering focuses on "how humans interact with the world around them and the awarding of that noesis to the design of systems that are safe, efficient, and comfortable"⁷⁶ (p. 3). The handoff poses numerous human factors engineering implications. From the perspective of patient condom, the primary purpose of the shift study or shift handoff is to convey essential patient care information,^fourteen ^, ⁴³ ^, ⁵⁵ ^, ⁷⁸ ^, ⁷⁹ promote continuity of care¹³ ^, ⁴¹ ^, ⁷⁷ ^, ⁷⁸ ^, ^lxxx to meet therapeutic goals, and assure the safe transfer of care of the patient to a qualified and competent nurse. Even so, other reported purposes of shift report include educational activity,⁴¹ ^, ⁷⁸ ^, ⁸¹ debriefing,^fourteen ^, ⁴¹ socialization,⁷⁸ ^, ⁸² planning and organisation,⁷⁸ enhancement of teamwork,⁸¹ and supportive functions.⁸³

The intershift handoff is influenced by various factors, including the organizational civilization. An arrangement that promotes open communication and allows all levels of personnel to ask questions and express concerns in a nonhierarchical fashion is congruent with an environment that promotes a culture of safe.⁵⁸ Interestingly, i report reported novice nurses seeking information approached those seen equally "less authoritarian."⁸⁴ The importance of facilitating communication is critical in promoting patient condom. The shift-to-shift handoff is a multifaceted activity.⁷⁸ ^, ⁸⁵ ^, ⁸⁶ A poor shift study may contribute to an agin result for a patient.⁵⁵

Handoff intricacies

A phenomenon well known to nurses is the use of nurse-adult notations, "cheat sheets" or "scraps" of information, while receiving or giving intershift reports. A study of such annotation taking found scraps are used for a diverseness of purposes, including creating to-do lists and recording specific information and perceptions about the patient and family.⁸⁷ This approach presents some challenges, as no 1 else has easy access to the information; therefore, continuity of care may be compromised during a meal break, for example, or if the scrap or crook sheet is misplaced.

Method of shift-to-shift handoff

Handoffs are given using various methods:¹³ ^, ⁴¹ ^, ⁸⁸ ^, ⁸⁹ verbally,⁷⁵ ^, ⁷⁷ with handwritten notes,⁸⁰ ^, ⁸⁷ at the bedside,⁴¹ ^, ⁵² ^, ⁵⁶ ^, ⁵⁷ ^, ⁹⁰ ^, ⁹² by telephone,⁹¹ by audiotape,⁴¹ ^, ⁵³ nonverbally,⁵⁴ using electronic reports,⁹² computers printouts,¹⁴ and retention.¹⁴ The force of the bedside report method is its effort to focus on and include the patient in the report. There accept been concerns regarding patient confidentiality,⁴¹ ^, ⁵² ^, ⁵⁶ ^, ^ninety which could exist compromised if non carefully addressed. A qualitative report focused on describing the perceptions of patients who were present during a bedside written report found some patients are in favor of bedside handoff, while others are not.⁵² Patients besides expressed concern regarding the jargon used by nurses.⁵² One patient noted that including the patient in the handoff added another level of safety equally erroneous information could be addressed and corrected.⁵² Case studies indicate the bedside handoff may be implemented for a number of reasons, including addressing specific issues and improving intendance commitment.⁵⁷ ^, ⁹² A summary of the strengths and weaknesses of verbal, bedside, written, and taped shift-to-shift reports is included in Tabular array three.

Table 3

Nurse-to-Nurse Change-of-Shift Handoff Report

The challenge during handoffs across settings and times is to identify methods and implement strategies that protect against data decay and funneling,⁶⁶ contributing to the loss of important clinical data. Information technology is a challenge to develop a handoff process that is efficient and comprehensive, as example studies illustrate.⁵⁷ ^, ⁸⁸ ^, ⁹² ^, ⁹³ Observation of shift handoffs reveals that 84.half dozen per centum of data presented in handoffs could exist documented in the medical tape.⁴² A concern that emerged in this report was some handoff reports actually "promote confusion," and therefore the authors advocated improving the handoff procedure.⁴²

Another business with handoffs is the degree to which the report is really congruent with the patient'south condition. I study found 70 per centum congruence between the shift report and the patient's actual condition, with an omission rate of 12 percent.²² A synthesized case example of a psychiatric patient presents the agin consequences for the patient if essential information is not communicated.⁹⁴ The importance of communicating objective descriptions of the patient condition is highlighted.

A study focusing on assessing the furnishings of manipulating information in a shift handoff on the receiving nurse's care planning found in the different types of taped reports that the data recalled ranged from 20 percent to 34 percent.⁹⁵ Another study, by Pothier and colleagues,⁵⁵ examined different methods for transferring information during five sequent simulated handoffs of 12 fictional patients. Three methods of handoffs were analyzed; the method demonstrating the greatest amount of information retentiveness involved utilization of a preprinted sheet containing patient information with verbal report, followed by note taking and verbal report method, and lastly, merely verbal report. The retained total data points for each fashion of handoff varied considerably during the 5 handoffs. Over 96 percent to 100 percent of data was retained using the preprinted sail containing patient data and verbal report. Only 31 percent to 58 percent of the data were retained using the note taking style and verbal report.⁵⁵ The verbal-simply way demonstrated the greatest amount of information loss, with retention ranging from 0 percent to 26 per centum.⁵⁵ None of the data was retained using the verbal-only method for ii handoff cycles. The insertion of incorrect information was observed in the verbal-only method. The generation of incorrect data did not occur at all during the handoff with the written or preprinted grade style of report. This study⁵⁵ supports the utilise of a consequent preprinted form with relevant patient information during shift report, with less reliance on verbal-merely reports, in order to optimize communication.

Nursing Unit-to-Nursing Unit of measurement Handoff

Patients may be transferred frequently during their hospital stays.²⁸ Yet, the patient transfer is fraught with potential issues and can have an adverse impact on patients.⁹⁶ ^, ⁹⁷ Problems have been identified in the transfer handoff procedure, including incomplete medical records and omission of essential information during the handoff report.⁶⁴ A number of factors that contribute to inefficiency during patient transfers from i nursing unit to another take been identified,⁹⁷ including delay or wasted time caused by communication breakdowns, waiting for responses from other nurses or physicians or a response from patient placement management or bed control.⁹⁷ Bed control involves personnel who manage the bed assignments of new and transferring patients. Decreasing the number of transfers is a possible strategy to decrease risks associated with handoffs.⁵⁸

Nursing Unit to Diagnostic Area

Patients are oftentimes sent from a nursing unit to diagnostic areas during the normal course of a hospitalization. Transfers take been cited equally a contributor to medication errors between nursing units and diagnostic areas (east.g., radiology, cardiac catheterization, nuclear medicine).¹⁹ It is important when patients modify nursing units, particularly to a different level of intendance, or go to a procedure in another department that there is clear, consistent communication and that the receiving surface area staff take the information they demand to safely care for the patient.³⁴ Complication of the patient'due south condition may require that the nurse caring for the patient actually accompanies the patient to the new setting.

Special Settings

Operating room and postanesthesia

Several special handoff situations occur in certain hospital settings. The operating room (OR) is considered "i of the near complex work environments in health care"⁹⁸ (p. 159), with a reported mean of 4.8 handoffs per example. Nursing staff average 2.8 handoffs per example, with a range of i to 7 handoffs.⁹⁸

There have been at to the lowest degree 615 wrong-site surgeries reported to the Joint Committee between 1995 and 2007.⁹⁹ To help prevent wrong-site surgery, the Joint Committee developed the Universal Protocol for Preventing Incorrect Site Surgery, Incorrect Procedure, Wrong Person Surgery^{TM.100, 101} Information technology is based on the consensus of experts and endorsed by more than than 50 professional organizations.¹⁰⁰ Constructive interdisciplinary communication is critical. For instance, a health care system using a perioperative briefing process reported that no wrong-site surgeries take occurred since the adoption of the interdisciplinary briefings.⁴⁴

Dierks suggests five categories for handoffs in the OR: (1) baseline metrics/benchmarks, (2) most recent phase of care, (three) current status, (iv) expectations for the side by side stage of care, and (v) other bug such as "who is to be contacted for specific bug"¹⁰² (p. 10). The use of a squad checklist in the OR was pilot tested in another report and found to bear witness "promise as a method for improving the quality and safety of patient intendance in the OR"¹⁰³ (p. 345).

A study focused on OR communication processes identified a number of patterns and institute the about common reason for communication in 2,074 episodes was coordination of equipment, followed by "preparedness" for surgery.¹⁰⁴ The authors recommend increasing the use of automatic processes to enhance process flow, especially related to "equipment management," thereby helping with manual of information in a more efficient manner.¹⁰⁴

Advice in handoffs is critical in all phases of care. However, a survey of 276 handoffs conducted in a postanesthesia care unit of measurement (PACU) revealed 20 percent of postoperative instructions were either non documented or written illegibly.¹⁰⁵ The nurses rated the handoffs from anesthesia staff as "skillful" in 48 percentage of cases, "satisfactory" in 28 per centum, and "bad" in 24 pct.¹⁰⁵ A number of suggestions for improving the quality of the postanesthesia care unit handoff protocol were presented including the demand to communicate data verbally to the nurse.¹⁰⁵

Emergency department

A study of five emergency departments (EDs) revealed that in that location were differences in the characteristics of handoffs among the EDs studied, simply "nearly universal" attributes of handoffs were besides noted.¹⁰⁶ The researchers adult a conceptual framework for addressing handoffs in the emergency setting. The handoffs were not one style advice processes as both the offgoing and oncoming providers were engaged in interactive handoffs. ¹⁰⁶ Co-ordinate to Behara and colleagues,¹⁰⁶ eight of 21 handoff strategies used in other industries² were observed "consistently" in the ED setting, while iv were used less frequently and nine were not or rarely used. The handoff in the ED setting is viewed as a "rich source for adverse events"¹⁷ (p. 1). At that place are inherent risks in handoffs, but information technology was likewise noted that the handoff tin can provide the opportunity for ii health intendance providers to assess the same situation and identify a "previously unrecognized problem"¹⁷ (p. 2).

Studies focused on emergency nursing handoffs highlight unique aspects of this procedure.¹⁰⁷ ^, ¹⁰⁸ Currie reported in a survey of 28 ED nurses that the pinnacle three concerns nurses had with handoffs were missing information, distractions, and lack of confidentiality.¹⁰⁸ Recommendations included the evolution of guidelines to improve the handoff process in the ED.

Belch and Interfacility Transfer Handoff

Handoffs from one facility to some other occur frequently between many different settings.^68–lxx ^, ⁷¹ ^, ⁷² ^, ⁷³ ^, ^109–111 Handoffs take identify betwixt hospitals when patients require a dissimilar level of care. The usual interfacility handoffs are between hospitals and long-term care facilities, rehabilitation centers, home health agencies, and hospice organizations. The factor that tends to brand these handoffs challenging is gaps and barriers to communication among these agencies.⁶⁸ ^, ¹¹¹ ^, ¹¹² Handoffs between facilities are also impacted by the cultural differences between the types of facility.⁷³ Agencies are frequently geographically carve up, requiring physical relocation of the patient, property, and paper records. Once the transfer has taken place, seeking boosted data becomes a challenge.⁷³

The continuity of patient intendance requires communication among various wellness care organizations.⁶⁸ ^, ⁷¹ ^, ⁷³ ^, ¹¹⁰ ^, ^113–115 One trouble noted is nurses in different settings have different perceptions about what is of import to be conveyed, such as unlike perceptions between the infirmary and home wellness care.⁷⁰ ^, ¹¹⁶ Another area of business concern noted in transfers from hospitals to other health care organizations is incomplete documentation. More information was transmitted when a standard form to communicate information was utilized betwixt a hospital and home health agency (HHA).⁶⁹ The usage of referral forms varies among health care institutions.¹⁰⁹ Rates of manual of data differ from hospitals to HHAs⁶⁹ ^, ¹⁰⁹ ^, ¹¹³ and to extended-care facilities.⁷² Information technology was found that HHAs affiliated with hospitals received more referral data than free-standing HHAs.¹¹³

Discharge planning forms accost "the anticipation of a certain type of gap and as well of an endeavour to create a bridge to permit care to flow smoothly over the gap"⁶⁷ (p. 793). 1 example of the development of such a grade using "a consensus process" resulted in the implementation of a Patient Transition Information Checklist to assistance better communication betwixt hospitals and nursing homes.¹¹⁴ Another type of class for communication of patient information amid health care organizations was developed in Germany; however, followup revealed apply of the form was not as widespread as anticipated because procedure barriers emerged, precluding users from hands completing and transmitting the forms.¹¹¹ Development of any type of "patient accompanying form"¹¹¹ requires numerous considerations and a residuum betwixt being comprehensive and not existence cumbersome to use.¹¹¹ There besides needs to be adequate resource to let health care providers to retrieve necessary data and transmit patient information between agencies.¹¹¹

Inadequate discharge planning has been implicated in adverse outcomes of patients.¹¹⁷ ^, ¹¹⁸ ^, ¹¹⁹ A study of 400 patients found 76 patients incurred an agin issue after discharge from the infirmary. The researchers reported "ineffective communication contributed to many of the preventable and ameliorable adverse events"¹¹⁹ (p. 166). The most frequent type of adverse upshot was related to medications. The implications of this written report point the demand to heighten communication in the handoff between the hospital and posthospital care. Suggested potential strategies to meliorate the handoff include discharge planning and education of patients related to medications prior to belch.¹¹⁹

A number of contributors to a failed handoff in the discharge planning process have been identified, including, lack of noesis almost the discharge process,¹¹⁷ lack of fourth dimension,¹¹⁷ lack of effective communication,¹¹⁹ ^, ¹²⁰ patient and family unit problems,¹¹⁷ ^, ¹²⁰ system bug,¹²⁰ and staffing problems.¹¹⁷ ^, ¹²⁰ Communication issues have emerged as a potential contributor to readmissions.¹²¹ An ineffective nursing handoff has been identified as a contributor to miscommunication within the discharge process.¹²² The improvement of discharge planning requires that emphasis be placed on collaboration and interdisciplinary advice.¹¹² Well-orchestrated belch planning is recommended to help improve patient safety¹²³ by controlling the risk of gaps occurring in the discharge process and its inherent handoffs.

Handoffs and Medications

Medication errors are considered preventable events.¹²⁴ Handoff issues (e.g., transfer, shift change, cross-coverage) have been identified by the United States Pharmacopeia (USP) through its MEDMARX® reporting program as a contributing factor to medication errors within health care organizations.¹⁹ ^, ²⁴

Incomplete transfer of medication information is recognized equally a possible contributor to patient safety problems equally patients are discharged from the hospital.¹¹⁹ ^, ¹²⁵ Reasons for medication handoff failures include incomplete patient pedagogy and the "inability of ambulatory care providers (including nursing homes) to receive discharge medication information"¹²⁶ (p. 93). Medication changes during the transition (handoff) from infirmary to skilled nursing facilities were identified as a cause of adverse drug events in a New York study.¹²⁷ One report reported patients who received medication information and counseling demonstrated more compliance with their medication regimen than patients who did not receive such information.¹²⁸

At that place are multiple case examples of medication errors related to handoffs across the continuum of care.¹²⁹ ^, ¹³⁰ In fact, USP has reported that 66 percent of medication reconciliation errors occur during the transfer or transition of a patient to another care level.¹³⁰ A number of recommendations accept been developed to improve the medication reconciliation process and reduce risks for patients.¹³⁰ ^, ¹³¹ In improver, medication reconciliation is a Joint Commission patient safety goal,⁴⁷ with specific requirements for the process.⁴⁷ ^, ¹³²

Physician-to-Physician Handoffs

Studies conducted to better understand physician-to-physician handoffs³¹ ^, ³³ may accept implications for nurses. Poor handoffs included omissions of essential information such equally medications, code condition, and anticipated problems.³¹ Other issues contributing to failed communication processes included lack of face-to-face interaction and illegible documentation.³¹ The weaknesses identified in some other handoff study included incomplete and or illegible information, difficulty accessing clinical information speedily, communication failures, and difficulty contacting other doctors.³³ Strategies to address handoff problems include providing legible, accurate, relevant, comprehensive information and the apply of a face-to-face written report.³¹ Suggestions for improvement include development of a procedure to enhance transmission of information, for case, the adoption of templates; use of technology; use of advice processes such as SBAR, education, and evaluation of handoffs;³¹ and a standardized handoff process.³³

Evidence-Based Practice Implications—Handoffs for Today'due south Health Care Surroundings

The Australian Council for Safe and Quality in Health Care evaluated 777 papers for possible inclusion in a literature review on handoffs.ⁱ A full of 27 papers met the inclusion criteria, just information technology was reported that "no best practice" (p. 2) existed related to systems emerged in the search—although a number of recommendations were provided for systems, organizational, and individual factors.^ane Handoffs are an extremely complex phenomenon to study as they occur in a diverseness of settings; stages along the continuum of care; and among various personnel with different skill sets, priorities, and educational levels.

Contributors to handoff problems included failed communication,⁴ ^, ^five ^, ⁶ ^, ^seven ^, ¹⁰ ^, ³¹ omissions,³¹ ^, ⁶⁴ ^, ¹⁰⁸ distractions,¹⁰⁸ lack of or illegible documentation,³¹ ^, ³³ ^, ⁷³ lack of utilization of transfer forms,⁶⁹ incomplete medical records,⁶⁴ lack of medication reconciliation,¹²⁹ ^, ¹³⁰ and lack of like shooting fish in a barrel accessibility to information.^vi ^, ³³ ^, ⁷³ A variety of environmental issues emerged—including designs²⁸ ^, ⁵⁸—that served to increase, rather than decrease, the number of handoffs. Interfacility handoffs posed a number of challenges, including cultural differences⁷³ and lack of integrated systems, thereby increasing the likelihood of transmission difficulties between organizations. Organizational and system failures or lack of systems to back up the handoff process emerged every bit contributors to agin events.⁴ ^, ⁶ ^, ^seven ^, ^x A lack of noesis was found regarding effective handoff processes,¹¹⁷ and education on effective handoff strategies was also lacking.ⁱⁱⁱ ^, ¹¹⁷ Handoff processes need to include consideration of the person involved in the handoff and their level of pedagogy, expertise, and comprehension (e.g., the novice nurse'southward informational needs may exist dissimilar from the adept nurse).⁴¹ Novices as well differ from expert nurses in their use of data.⁸⁴

There must be an organizational commitment to the development and implementation of systems that support constructive handoffs as well as a just civilisation.¹³³ ^, ¹³⁴ This includes cultures of safety and learning.¹³⁴ A safety civilization supports identifications of issues and errors to be addressed to prevent the recurrence.^134–136 A civilization of learning promotes learning from the experiences of the by to foreclose a recurrence of tragic fumbled handoffs. Environments and processes demand to exist designed to promote desired outcomes⁷⁶ and enhance patient condom.¹³⁷

Electronic Back up of Handoffs

A number of reports and studies have called for systems that allow ease of admission to authentic information to improve handoffs.⁶ ^, ¹⁰ ^, ¹⁵ ^, ²⁹ ^, ⁸⁹ ^, ¹³⁸ Electronic technology requires that blueprint issues be considered and acceptable resources be allocated for successful implementation and acceptance.¹³⁹ Research of computerized support for physician handoffs suggests this is a strategy that claim further consideration and evaluation.¹⁶ A study at two hospitals reported the implementation of a computerized system for resident handoff enhanced delivery of intendance and decreased the number of patients missed on rounds.¹³⁸ At that place have been express studies on computerized clinical documentation systems (CDS) in the nursing shift handoff. 1 study reported nurses perceived shift-to-shift handoffs more positively afterward the implementation of the CDS.¹⁴⁰ Access to a physician computerized sign-out was rated positively by nurses and was reported to improve advice.¹⁴¹

Decrease Transfers of Patients

Decreasing the number of patient transfers may reduce the risks that occur during handoffs.⁵⁸ It has been suggested that "many patient transfers could be prevented by altering facility designs and nursing care models found in acute care hospitals"⁹⁷ (p. 163), thereby decreasing the need for handoffs. The implementation of "vigil-adaptable rooms" demonstrated a 90-percent subtract in patient transports; the same study too reported a decrease in medication errors of seventy percent.²⁸ More enquiry of this strategy is recommended.⁵⁸

Constructive Handoff Procedure

A recurrent theme observed in the handoff literature is the need to convey essential data to the oncoming shift or provider. A standardized process to guide the transfer of critical information has been recommended.³³ ^, ³⁴ ^, ⁴⁵ ^, ⁴⁸ ^, ¹⁰⁸ The utilise of protocols that include the use of phonetic and numeric clarifications are important in helping convey information accurately.¹¹ ^, ¹³⁶ The Sentara health intendance organization adopted behavior-based expectations to meliorate the handoff process and used tools including the five Ps (patient/project, plan, purpose, problems, and precautions).¹³⁶ Information technology reported a 21-per centum increase in effective handoffs.¹⁴² A medical middle using SBAR in the handoff process reported less missing information in handoffs after implementation of SBAR.⁴⁵ The apply of protocols such equally safe practice recommendations related to reconciling medications¹³¹ ^, ¹³² and communicating disquisitional test results⁴⁹ ^, ⁵⁰ should be used in designing strategies for more than effective handoffs. Some hospitals have reported developing strategies to improve the advice between the infirmary and other providers.⁴⁴ ^, ⁷¹ ^, ⁷³ ^, ⁷⁴ ^, ¹¹⁴ A summary of problems and barriers with handoffs observed in this review of literature are presented in Tables 4, 5, and 6. Strategies that have been reported in the literature are also included in the tables; however, more than research is needed to identify bear witness-based guidelines. The Show Table at the end of this chapter presents a summary of selected sources addressing handoffs.

Table iv

Factors, Problems, and Strategies Cited in the Literature

Table 5

Problems, Bug, and Strategies Cited in the Literature

Table six

Issues, Problems, and Strategies Cited in the Literature

Evidence Table

Selected Sources on Handoffs—Nursing Handoffs, Quality Improvement Activities, Interdisciplinary Handoffs

Homo Factors

The written report of homo factors engineering is currently beingness used to ameliorate patient safety,⁷⁶ and at that place are an increasing number of strategies and tools that tin be used to design systems in a manner to decrease adverse outcomes. Designs to promote patient prophylactic should include integration with "forcing" functions to prevent errors. However, there needs to be testing of proposed solutions to assure validity of these tools in the wellness care surroundings.⁷⁶ Lessons learned from other industries are fostering the adoption of human factors principles and increasingly being used in wellness care.⁴⁴ ^, ¹³⁷ ^, ^143–146

Studies of handoffs in other industries have been analyzed for possible implications for health care. Patterson and colleagues² analyzed information from four studies^147–150 and described 21 handoff strategies. According to their findings, strategies that could be applied to shift handoff included interactive questioning, contiguous handoff, forcing functions such equally passing a pager to initiate handoff to the oncoming nurse to betoken an unambiguous transfer of responsibleness, flagging critical information, and reduction of interruptions.² The researchers note a question remains "if the strategies tin be generalized to wellness care"² (p. 132), and phone call for additional research in this area.

Enquiry Implications

Following are suggested questions for hereafter research:

What are the best systems designs to reduce unnecessary handoffs? How tin they best be implemented?
What are all-time strategies for handoffs in various settings (i.east., nurse to nurse, unit of measurement to unit of measurement, bureau to agency, physician to nurse)?
What are the nigh effective strategies, instruments, and tools to utilize to assure maximum transfer of and receipt of authentic, relevant, up-to-date information?
How tin electronic applied science best exist deployed to support and heighten effective handoffs, decrease errors, and meliorate patient safe and patient outcomes?
What are the all-time techniques for assuring critical data is forwarded and non omitted or overlooked when received?
How can handoff contributors to medication errors be addressed and decreased?
What are the disquisitional data elements that should be transferred by type of service, specialty, profession, and setting?

Basic to the provision of quality health care is the ability to communicate with 1 another and safely handoff patient intendance in a seamless way so every patient can do good from each phase of care through a well-executed handoff. This is a procedure that is ubiquitous but also a high-gamble endeavor in many settings. More enquiry is needed in this disquisitional patient safety loonshit to promote interdisciplinary approaches to patient safety throughout the continuum of care.

Search Strategy

To recollect pertinent literature on the topic of handoffs, the following databases were reviewed: Academic Search Premier, CINAHL, Pre-CINAHL, EMBASE, Ovid'south Medline, PubMed, and PsychInfo. The databases were searched for variants of the words "handover" and "handoff," "shift written report," and "changeover." Additionally, the databases were searched for groups of subject terms representing the concepts of patient transfer, communication, and continuity of intendance. The employ and combination of subject headings varied depending on the characteristics of each database. Searches for the concept of patient transfer used the following subject headings: transfer, discharge; transfer, intrahospital; patient discharge; transportation of patients; and patient transfer. The concept of communication was represented by terms such as "advice barriers," "advice," "communication skills," "communication theory," and "interpersonal communication." Field of study headings focusing on the concept of overall wellness care commitment or quality included quality of intendance, health care delivery, continuity of patient care, patient safe, and medical care.

Acknowledgments

Acknowledgment

The authors wish to acknowledge Stephanie Narva Dennis, Thousand.50.S., for support and assistance in conducting the literature search.

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Source: https://www.ncbi.nlm.nih.gov/books/NBK2649/

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