Practice Tips

Patient Hand-off

There are many terms used for the patient hand-off process, e.g., handover, sign-out, shift report, etc. According to The Joint Commission Sentinel Event Alert Issue 58, a patient hand-off is “a transfer of and acceptance of patient care and 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 to ensure the continuity and safety of the patient’s care.”

Importance of Patient Hand-offs

Patient hand-offs provide safe transitions and continuity of care as the patient moves through various healthcare settings and eventually is discharged from care. Hand-off communication is used to review the most crucial information related to the patient’s transfer.

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. When hand-off communication fails the potential for patient harm can range from minor to severe. Inadequate patient hand-offs increase patient safety risk and have been directly identified with delays in patient care, inappropriate treatment, medication errors, wrong-site surgery, errors of omission, avoidable readmissions, increased length of hospital stay, and other avoidable patient harm.

Current State of Risk

Communication failures are consistently identified as one of the leading causes of significant patient events (including Sentinel Events). A 2019 Annual Sentinel Event Summary Report notes communication/documentation as one of the three top contributing factor area groups for significant patient events.

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 increase the risk of patient and family dissatisfaction which is a leading contributor to professional licensure complaints and 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 an 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 caregiver (shift change, call coverage)

Discharge:

• From inpatient to long-term care, skilled care, or 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 the process
• Sender does not have adequate information about the 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

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
• Develop/update hand-off policies and procedures
• Standardize critical content to be communicated
• Prepare report ahead of time, gather pertinent information from available resources
• Tailor the process to the users, the environment where the hand-off is occurring, and the type of patient, i.e., ED
• Consider using a standardized tool

Communication Skills

High quality patient hand-offs require 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, keep remarks objective)
• 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. Speak using a moderate pace

Educate the key players:

• Provide training to new staff and refreshers for existing staff. Find role models to demonstrate effective hand-offs
• Emphasize the importance of quality patient hand-off information
• Discuss when a patient hand-off is required
• Teach effective hand-off skills, including assertiveness when there are questions and listening skills
• Discuss how stress, fatigue, and information overload can affect understanding.
• Address cultural variations in communication
• Provide consistent expectations for compliance with hand-offs
• Document hand-off. Receiver- Whom the receiver received the hand-off from and Sender- whom they communicated the hand-off to

Plan the hand-off:

• Coordinate resources such as patient information, transport equipment, and personnel
• Allow adequate time for hand-off
• Perform at the bedside allowing for direct patient visualization and communication between caregivers. Minimize distractions and interruptions. If not at the bedside, choose a quiet location and maintain patient privacy
• Encourage the patient and family to participate. Address any family needs or concerns

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 occurs, such as the emergency department, and the type of patient.

Examples include:

• Checklists such as a pre-operative, pre-MRI, “ticket to ride” and discharge 

Tools:

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)

ISHAPED

• Introduce- allergies, code status, contact information, advance directives, provider teams, ancillary consults.
• Story-hospital problem, treatment plan, admission screening information, learning assessment
• History-pertinent emergency department summary, history and physical, medical and surgical history, and any blood administration history for the past 72 hours (links in EHR if electronic tool)
• Assessment-vital signs, activities of daily living, diet orders, pain management, assessments, current medications, intake and output summary, lab results, radiology results from the past 24 hours
• Plan-care plan goals, orders to be acknowledged and completed, current infusions, as-needed medications, nursing orders, patient-initiated and patient-advocate goal documentation
• Error Prevention-high-alert warnings, patient-specific medication information
• Dialogue-shift report given, how patient and family were involved

Monitor of the Hand-off Process

• Monitor the success of hand-off process and use data to identify opportunities for improvement
• Evaluate and measure hand-off adverse events and use data to identify opportunities for improvement

References

ACOG. Committee on Patient Safety and Quality Improvement. Committee Opinion Number 517. Communication Strategies for Patient Hand-offs. 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.

Freel, Jo and Fleharty, Brandon. “Standardizing Hand-off Communication” American Nurse Journal Volume 16, Number 3.

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

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

The Joint Commission “8 Tips for High-quality Hand-offs” 2017

Wellman, Jesse, DHHS Office of Analytics, for the Division of Public and Behavioral Health (DPBH) – Office of Public Health Investigation and Epidemiology (OPHIE). 2019 Annual Sentinel Event Summary Report

Perfecting the Patient Hand-off: 3 Ways to Improve Your Hand-off Process October 9, 2015 Categories: blog

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

Toolkits

AHRQ TeamSTEPPS: National Implementation 

AORN Perioperative Patient ‘Hand-Off’ Tool Kit 

The Joint Commission, Targeted Solutions Tool for Handoff Communications, 2017