ED Handoffs – The problem and what we can do to improve

Authors: Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF) and Justin Bright, MD (@JBright2021) // Editor: Alex Koyfman, MD (EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital, @EMHighAK)

What is one quality shared by air traffic controllers, NASA space control, and emergency physicians (EP’s) ? The answer is that these professions depend on great handoffs to excel in their respective fields.

A handoff (or turnover) is a transition between two or more workers with the exchange of information, responsibility, and authority.^1-3 A great deal of research has evaluated shift changes and handoffs in NASA and aviation. Both possess rigid regulations on the conduct of turnovers or handoffs, often with checklists that must be completed. This has resulted in pristine safety and efficiency.³ It has long been recognized that shift change and handoff is one of the most dangerous times for patient care in the emergency department. Research has demonstrated that while the profession strives to be as uniform and pristine as the aviation industry, we still have a long way to go.

The Goal:

Ultimately the goal of a handoff is to develop a shared understanding among providers, providing a clear framework of the patient’s clinical picture, recent course, administered therapies, pending diagnostic tests and their rationale, and likely disposition. A transition is done from one case to another when both providers have adequate understanding of the patient. This creates a seamless transition of care that enables safety and efficiency. Effective communication is at the forefront of the great handoff.^3-6

The Problem:

Where we work is busy, stressful, and chaotic, with little margin for error. The ED is an environment that is constantly changing, with patients who are often unstable and require resuscitation. Furthermore, an emergency physician is repeatedly interrupted throughout a shift. Emergency physicians in this stressful environment must make quick decisions with limited data points while managing multiple patients. Emergency departments provide 24 hours of care every day of the week, and providers work in shifts. Thus, handoffs occur at a minimum of twice per day for providers. Communication is a vital skill in emergency medicine, but providers have different levels of experience, backgrounds, communication skills, and training.^3-6

Close to 100,000 deaths per year are due to medical errors. Communication errors are the root cause of close to 70% of sentinel events, and in 62% of these events, shift change is a major factor.^1,2,4,7 There are multiple parts of a handoff where important information may be dropped or not conveyed. This can affect patient care, length of stay, and department flow.

Breakdown in communication can result in mistakes and lapses, but many of these are preventable.

A survey of ED academic programs has shown concerning results. The majority of programs (73.5%) do not have a uniform written policy regarding patient sign-out in the ED, and half are verbal only handoffs. Transfer of care was rarely documented per 42.9% of physicians, and in academic programs, only 25.6% had formal didactic handoff training. However, 72.3% of those surveyed thought a standardized sign-out system would be beneficial in improving communication and reducing error.⁵

A common finding in the literature is error of omission, whether vital signs, laboratory/imaging data, or synthesis of clinical course including expected disposition.^8,9

A recent paper from Annals of Emergency Medicine found that 14% of handoffs included an error of omission for vital signs. Laboratory handoff errors and omissions have been observed in 29.2% of handoffs.⁶

The Barriers in Handoffs:

EPs thrive in the chaos of the emergency department, handling trauma, resuscitations, and often a waiting room full of patients. However, this environment produces barriers to effective communication, making handoffs difficult. To improve our handoffs and create an environment of safety and efficiency, first we need to better understand where barriers to handoffs exist.^3,4,7-11

1. The Patient: The patient’s level of education, understanding of his/her medical condition, language, and an unclear history or diagnosis contribute to communicating the clinical picture.   A poor relationship formed between the patient and the first provider may affect the handoff and the relationship with the provider who has received the handoff. A second patient barrier can be due to the need to sign out multiple patients, and ED patients are often complex, complicating handoffs.

2. The Provider(s): We have all had those shifts where we are more tired or stressed than our norm. This can affect the handoff, as we may not pay full attention. Poor memory, cognitive biases, inexperience, knowledge deficits, and personal agenda (such as I must get out of the ED to pick up children or attend a social function) all play a role.

3. The Location: The ED is busy, chaotic, and loud. EM is full of competing demands (EKG’s, a patient requiring more medications, the EMS crew rolling in with another patient, labs/studies requiring review, etc.). Thus, we may not receive a full handoff if a crashing patient or trauma suddenly rolls in. Providers must also handle ED boarders versus new patients. These attributes do not lead to clear communication and can cause items to be missed or not communicated.

4. Time: Our currency in EM is time. Handoffs take time: time from seeing new patients, time from resuscitation, time from making the disposition, time from a procedure. Whether an 8 or 12 hour shift, the handoff can be painful when there is a waiting room full of patients.

5. The Team: Even though in EM we pride ourselves on communication and teamwork, the team itself is often a barrier to successful, safe handoffs. The relationship between the two providers can have significant impact. One provider not taking the handoff time seriously can lead to poor understanding of clinical course and missed data points. One common element is the lack of a proper point defining the transition of care, in which one provider takes over completely. This is exemplified when a provider who has signed a patient over to the other provider is still in the ED and the nurse approaches the provider who has signed out with either updates or need for orders. The provider who officially has taken over may not be cognizant of the new orders or updates. Turnovers/handoffs between providers of different training levels can play a large role in missed items. Finally, compensation factors can affect handoffs. Some facilities or pay structures advocate for a physician to quickly turn over patients, resulting in handover of a large number of patients.

6. The Handoff: There are several aspects of the handoff itself that can be a barrier.^3-5,7-11

• Lack of Standard Approach – There is often no standardized approach to handoffs. Physician colleagues may have trained at different institutions that had different sign out cultures. Experiences and expectations often vary. Thus, providers may rely on what they know best causing inconsistent, unpredictable handoffs, especially if there is no standardized handoff procedure. Content, location, style, and length all can vary. This can cause trouble with proper communication.

• Lack of High-Risk Triggers for Dangerous Handoffs – EM providers are hard wired to identify potential high risk patients and are known to focus on red flags in a patient’s story. Yet little research or emphasis exists on the handoff of patients a provider recognizes as high risk. Patients with uncertain diagnosis in the midst of workup or resuscitation, instability, unknown disposition, deviation from the usual workup or management, psychiatric complaints, consultant involvement, and ED boarding should be considered high risk. Any patient with these attributes should increase a physician’s awareness and concern during a handoff situation.

• Type of Handoff – EM providers know that time is one of the most important resources in the ED. Thus, a handoff needs to be balanced between completeness and conciseness. Some handoffs are simple and require one sentence, but some may need five minutes based on complexity. A patient with ankle pain just waiting on final Xray read is much different than the patient with DKA and sepsis with elevated lactate. Knowing what kind of patient requires a more thorough handoff often requires experience and training.

• Signal to Noise ratio – The ED is loud and chaotic. A prior disorganized handoff can also affect subsequent handoffs, as the receiving provider may have unanswered questions that they are focusing on rather than paying attention to the current handoff. Data that may not be important can drown out the important information. In addition, the general environment in the ED can hamper adequate communication. The constant disruptions including radio calls, loud noise, chaos, staff interruptions, patient questions/concerns all affect communication.

• Bias – This is a complex topic. All providers have bias; it’s an aspect of medicine and being human that we can limit, but we can never truly remove. The receiving provider often relies on the clinical picture painted by the departing provider. This can lead to adverse outcomes through a faulty clinical impression of the departing physician. Diagnostic momentum is present in almost every handoff. The receiving physician also suffers from bias with misinterpretation of the clinical picture. Anchoring can also occur, where a provider relies on a single piece of information or diagnosis.

How to Improve Handoffs:

Even though standardized handoffs have been proposed, little agreement exists concerning essential information and what should be included. Based on the literature, several themes to improve handoffs arise that are discussed below.^4,5,7-9

1. Attitude/Mindset: Both providers need to be mentally prepared before and during the handoff. We know that handoffs are a particularly dangerous time, and we should treat them like an acute resuscitation. Missed information can be deadly. Both providers must take it seriously and give full attention to communicating the necessary information. One key aspect in improving handoffs is rounding on patients shortly before the next provider shows up for his/her shift. The provider preparing for turn over can evaluate the patient, discuss the changing care, and discuss the plan with the patient and family. The provider who receives the hand off should also round on all patients he/she received to evaluate and form a clinical picture. Whenever possible, the first provider should introduce the new provider to the patient, so both providers can clearly see how the patient looks and understand what the end goals of the ED visit are.

2. Limit interruptions/Location: EM Providers love the chaos of the ED, but this chaos and unpredictability can harm patients. A quiet, dedicated place for a handoff is best, but it may not be available. If at all possible, a location that fulfills these attributes will allow better attention and communication. All providers should know when and where handoffs take place in order to minimize disruption during the handoff process. The location and handoff itself should be face-to-face with direct interaction between providers. Whenever possible, the outgoing provider should bring the new provider to the bedside of each patient so they can both understand the current clinical appearance, vital signs, and include the patient in the remainder of the clinical course.

3. Standardized Aid: Many institutions use an aid in some manner. For example, one template includes the following: chief complaint, a sentence detailing the history and exam, pertinent study results, diagnosis, pending consults/labs/treatments, and disposition. The form requires a signature from the provider handing off, and below this, space is provided for the receiving provider assessment and signature. This form encourages providers to thoughtfully examine the clinical course and the receiving provider to evaluate the patient. Having a written or computer form can assist providers in minimizing omissions.

4. Concise Overview: One of the biggest goals of the handoff is providing a clear summary of the chief complaint, vital signs, important studies and results, treatments, and expected disposition. The pertinent positives and negatives of the patient’s clinical course and visit are important. A clear presentation of the clinical course, pending studies/consults, and expected disposition ensure a concise handoff. Labs and imaging tests should be ready for discussion before handoff. Again, this is where a standardized aid can benefit.

5. What are the outstanding tasks, consults, labs, and imaging? The provider handing off the patient must discuss all pending studies, consults, and treatments. A discussion should also occur concerning anticipated results and contingency plans, in case the expected result does not occur. Unclear dispositions increase the risk of adverse event during a handoff. A specific plan should be created to provide as much clarity as possible.

6. Discuss Assessment and Questions: The provider receiving the handoff should feel like they can ask questions to clarify the clinical course, especially if there is an area that he/she does not understand. Questioning the clinical course and assessment will catch errors, as a new, fresh mind is looking objectively at all of the data and may catch something the first provider missed. The provider handing off the patient should also ask the other provider if there is anything they have questions on.

7. Clear Transition in Care: A visible transition should occur. If a handoff has been completed and someone approaches the prior provider concerning the patient, the provider (who handed off the patient) should direct the questions to the other provider who received the handoff. If an electronic ED tracking board and/or EMR are used, officially assigning the patient to the provider can be useful, which increases visibility.

Department Handoff: Some programs or departments utilize this method. One particular study sought to create a standardized form and tool based on survey in order to most efficiently turn over an entire department.¹² The investigators surveyed providers on what they felt was important for a good department handover. The following items were vital to adequate handoff per their survey: written record of handoff, discussion of patients, equipment problems, four hour standard performance, bed issues, current waiting times, death occurring in the department, violence/aggression issues, staff illness, and agency staff presence. The group conducting the study then sought to create a tool, the ABC of handover:

Researchers created a standardized form from this tool and then took steps to implement the handover tool and standardized form, which they list in their manuscript. If your ED turns over in this manner, this paper is well worth the read and provides numerous tips and tools.

Summary:

Handoffs are high risk and can result in adverse events. A successful handoff requires clear communication and full attention of the providers. The ED is a chaotic environment with multiple barriers including the patient, providers, location, the team, and the handoff itself. Several strategies to reduce errors in handoffs, improve communication, and improve patient care include: treating the handoff seriously, limiting interruptions as much as possible, using a standardized aid (whether written or computerized), providing a concise overview, discussing pending studies/consultations/treatments, encouraging a discussion of the assessment, encouraging questions on clinical course, and demonstrating a clear transition of care to other team members.

References / Further Reading:

1. Committee on the Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2004:45.
2. Committee on the Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000:36.
3. Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004 Apr;16(2):125-32.
4. Cheung DS, Kelly JJ, Beach C, Berkeley RP, et al.; Section of Quality Improvement and Patient Safety, American College of Emergency Physicians. Improving handoffs in the emergency department. Ann Emerg Med. 2010 Feb;55(2):171-80.
5. Sinha M, Shriki J, Salness R, Blackburn PA. Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors. Acad Emerg Med. 2007 Feb;14(2):192-6. Epub 2006 Dec 27.
6. Venkatesh AK, Curley D, Chang Y, Liu SW. Communication of Vital Signs at Emergency Department Handoff: Opportunities for Improvement. Ann Emerg Med. 2015 Aug;66(2):125-30.
7. WHO Collaborating Centre for Patient Safety Solutions. Communication during patient hand-overs. Patient Safety Solutions. 2007; 1:solution 3.
8. Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008 Sep 8;168(16):1755-60.
9. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12):1094-9.
10. Maughan BC, Lei L, Cydulka RK. ED handoffs: observed practices and communication errors. Am J Emerg Med. 2011 Jun;29(5):502-11.
11. Riesenberg LA, Leitzsch J, et al. Residents’ and attending physicians’ handoffs: a systematic review of the literature. Acad Med. 2009 Dec;84(12):1775-87.
12. Farhan M, Brown R, Woloshynowych M, Vincent C. The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department. Emerg Med J. 2012 Dec;29(12):941-6.
13. http://www.ncbi.nlm.nih.gov/pubmed/25109535
14. http://www.ncbi.nlm.nih.gov/pubmed/25216535