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Hand–off Communication

What is a patient hand-off?

According to The Joint Commission (2010), a patient hand-off 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."

Why are patient hand-offs important?

Patient hand-offs provide for safe transitions and continuity of care as the patient moves through various healthcare settings and eventually is discharged from care. The potential for patient harm from a medical error increases when patient hand-off communication fails to provide the patient-specific information necessary to ensure the patient continues to receive appropriate care. Inadequate patient hand-offs increase patient safety risk and have been directly identified with delays in patient care and inappropriate treatment, medication errors, wrong-site surgery, errors of omission, avoidable readmissions, increased length of hospital stay and other avoidable patient harm.

What is the current state of risk?

Eighty percent of medical errors involve miscommunication between providers during patient hand-offs at transitions of care. Patient hand-offs are complex and require excellent communication between the sender and the receiver of the patient information. Communication failures are consistently identified as one of the leading causes of significant patient events (including Sentinel Events). A 2016 study indicates communication failures in U.S. hospitals and medical practices contributed to 1,744 deaths over a five-year period. Communication failures increase the risk of patient and family dissatisfaction which is a leading contributor to professional licensure complaints and 30% of all malpractice claims.  

Typical patient hand-offs that occur in the healthcare continuum where risk can occur.

Change in level of care:

  • Long-term care, skilled care, home health, physician practice to the ED
  • Outpatient area (ED, clinic, ambulatory unit) to inpatient setting
  • Acute care to ICU or surgical services and vice versa

Short-term transfer of care:

  • Movement from primary care location (inpatient, ED, community-based organization) to diagnostic service and back
  • Change in provider (shift change, call coverage)

Discharge:

  • From inpatient to long-term care, skilled care, home health
  • Inpatient to home with PCP and/or referral follow-up

Challenges in patient hand-offs.

Patient hand-offs are a significant challenge in health care due to high frequency, lack of a required structure to the patient hand-off, ineffective communication skills, distractions, interruptions, timing, lack of time or staff.

Common reasons identified for hand-off communication failures include:

  • Hand-off not appropriately timed between sender and receiver (room is not ready, or change of shift)
  • Insufficient resources allotted for hand-off (inadequate time/staffing/equipment)
  • Location is noisy, prone to interruption
  • Patient and/or family not included in process
  • Sender does not have adequate information about patient; therefore, provides inadequate hand-off
  • Sender unable to contact receiver in a timely manner
  • Sender has to repeat information that has already been shared
  • Receiver is unaware of the transfer or has competing priorities (TJC 2010)

How patient hand-off communication can be improved.

Make high-quality patient hand-offs a priority for helping to sustain a culture of patient safety.

High quality patient hand-offs require the use of excellent communication skills by the person/team sending the patient (sender) and the person or team receiving the patient (receiver), to ensure the receiver understands the patient care information provided by the sender. 

Excellent communication skills require both the sender and receiver to:

  • Seek information (ask pertinent questions: "is there anything else I should know")
  • Give information (clear, concise and complete)
  • Verify information (clarify, repeat back, double-check calculations/equipment settings)
  • Validate each other (communicate with warmth and respect, thank the other)
  • Use clear language. Avoid unclear or potentially confusing terms ("she's a little unstable," "he's doing fine," or "she's lethargic"). Avoid abbreviations or jargon that could be misinterpreted
  • Review these Practice Tip on communication:

Define success:

  • What does a successful inter-facility hand-off look like for the sender, receiver and patient
  • What does a successful shift change hand-off look like 
  • What is the right amount of information to share for a short-term hand-off to diagnostic imaging
  • Monitor success and use this data to identify opportunities for process improvements

Educate the key players:

  • Importance of quality patient hand-off information
  • When a patient hand-off is required
  • What is the most effective and efficient method to provide essential patient hand-off information

Plan the hand-off:

  • Coordinate resources such as patient information, transport equipment and personnel
  • Allow for adequate time
  • Choose a quiet location and minimize interruptions

Use a standardized form or tool:

Standardize critical content to be communicated. Tailor the hand-off protocol to its users, the environment in which the hand-off is occurring, such as the emergency department, and to the type of patient.

Examples include:

  • Checklists such as a pre-operative, pre-MRI, "ticket to ride" and discharge 
  • Mnemonics:

ISBARR

    • Introduction - introduce yourself including your department and role
    • Situation - specify the situation. What has triggered this conversation and what is the patient's current condition
    • Background diagnosis, pertinent medical history, care to date
    • Assessment - assess current needs, any outstanding studies or information
    • Recommendation - explain what is being requested ("I would like you to see the patient now," or "I would like to schedule the ambulance, when will you be ready to receive the patient") 
    • Repeat - ask the receiver to summarize the important details and ask if there are any questions

I-PASS

    • Illness Severity
    • Patient Summary
    • Action List
    • Situation Awareness and Contingency Planning
    • Synthesis by Receiver (Pediatrics 2012)

I PASS the BATON

    • Introduction 
    • Patient - name, age 
    • Assessment - diagnosis, symptoms, chief complaint, vital signs 
    • Situation - current status of each patient
    • Safety concerns - allergies, outstanding tests 
    • the
    • Background - family history, comorbidities, previous episodes and current medications 
    • Actions - what actions were taken or are required 
    • Timing - level of urgency and explicit timing 
    • Ownership - who is responsible for the patient now and specify when transfer of ownership occurs 
    • Next (AHRQ 2008 and ACOG 2012)

References:

ACOG. Committee on Patient Safety and Quality Improvement. Committee Opinion Number 517. Communication Strategies for Patient Handoffs. February 2012

Agency for Healthcare Research and Quality. (2008). Pocket Guide: TeamSTEPPS. Strategies & Tools to Enhance Performance and Patient Safety. AHRQ Publication No. 06-0020-2, Rockville, MD.

Ong, M. and Coiera, E. (2011). A systematic review of failures in hand-off communication during intra-hospital transfers. The Joint Commission Journal of Quality and Patient Safety, 37(6): 274-283.

Starmer AJ, Spector ND, Srivastava R, et al. and the I-PASS Study Group. (2012). I-PASS, a mnemonic to standardize verbal handoffs. Pediatrics. 129(2): 201 -204.

The Joint Commission, Sentinel Event Alert “Inadequate hand-off communication”, Issue 58, September 12, 2017.

The Joint Commission Center for Transforming Healthcare, “Improving transitions of care: Handoff communications”, 2014.

Toolkits:

AHRQ TeamSTEPPS: National Implementation 
AORN Perioperative Patient 'Hand-Off' Tool Kit 
The Joint Commission, Targeted Solutions Tool for Handoff Communications, 2017