Transitions in Care: Improving the Handoff

Transitions in Care: Improving the Hand-offPenni Foster, PhDHand-offA hand-off is the transmission of essential patient care information that occurs during a transition in responsibility from one provider to another.

Inadequate hand-offs and negative outcomesInadequate hand-offs, including the omission of key information about a patients clinical condition and plan, have been associated with delays in diagnosis and treatment, inefficient and redundant work, and adverse patient outcomes.

Horwitz et al. Consequences of inadequate sign-out for patient care.Archives of Internal Medicine. 2008. 168 (16): 1755-1760.

Who performs a hand-off?Hand-offs occur when responsibility in care is transferred one professional provider to another, such as physician attendings, residents, and nurses.

When should hand-offs occur?A hand-off occurs each time in any of the following situations:

Move to a new unitTransport to or from a different area of the hospital for care Temporary assignment to a different physician or other provider (e.g., overnight/weekend coverage, rest breaks, meal breaks, changes in call) Fixed changes in physician assignment (e.g., rotation change)Discharge to another institution or facility

Hand-offs must occur for every patient, including inpatients, emergency room patients, clinic patients, and observation patients.What information is included in the hand-off?Hand-offs should include specific and essential information:

Patient name/DOB/ locationDiagnoses/problems/impressionMedical history and advanced directivesMedications/fluids/dietAllergiesCurrent labs and vitalsPending tests requiring follow upSpecific treatments/protocols in placePast and planned proceduresPlan for the next 24+ hours

Threats to a quality hand-offResidents surveyed reported being ill-prepared by the hand-off for events that occurred during call.

Research shows that hand-offs are often unstructured, incomplete, error-prone, and adversely effected by noise, crowding, and interruptions.

Manser T. Effective handover communication: An overview of research and improvement efforts. Best Practice & Research Clinical Anaesthesiology. 2011. 25 (2): 181191.

What can I do?To improve patient safety, hand-offs (whether verbal or written) MUST include the following:

Interactive communication allowing for questions between giver and receiverLimited interruptions Up-to-date informationVerification process of repeat-back or read-back