Elsevier

Journal of Surgical Education

Volume 65, Issue 6, November–December 2008, Pages 476-485
Journal of Surgical Education

2008 APDS spring meeting
Simple Standardized Patient Handoff System that Increases Accuracy and Completeness

https://doi.org/10.1016/j.jsurg.2008.06.011Get rights and content

Purpose

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines a “handoff” as a contemporaneous, interactive process of passing patient-specific information from one caregiver to another for the purpose of ensuring the continuity and safety of patient care. The purpose of this study was to conduct a comprehensive investigation on the determinants of an effective handoff management system. Specifically, we sought to address the following null hypotheses: There is no difference before and after implementation of a new, low-cost, low-tech process for surgery patient handoffs in accuracy of information, completeness, clarity of exact time of patient transfer, and number of tasks appropriately handed off.

Methods

Baseline description of the handoff process was mapped from 3 direct observation sessions by an efficiency operations team. A focus group with residents, nurses, hospital administrators, and surgeons was held to identify concerns with the baseline process and to identify important features of a handoff system. These data were used to create an electronic survey for residents to indicate level of agreement with importance of various features and qualities of a handoff system. Longitudinal telephone surveys were performed with residents throughout and after the development period to determine the residents' perceptions of the completeness, accuracy, clarity of handoff time, and method of information transfer, as well as the frequency with which residents were expected to perform tasks that should have been performed by outgoing residents. An online survey was sent to residents before and after the new handoff system was implemented to study perceptions of information quality, process operations, clarity of responsibility, and satisfaction with the handoff process. Perceptions were rated on operationally defined scales. All instruments underwent expert review for content validity and clarity of instructions and scale definition appropriateness. A standardized, and partially automated, handoff form was then developed. After a 2-week pilot study, telephone surveys were repeated. Data were analyzed using descriptive statistics, the Student t-test, and multivariate analysis.

Results

Compared with baseline, residents reported increased accuracy, as measured by the perceived number of inaccuracies found on sign-out sheets (p = 0.003). Completeness of the information on sign-out sheets also was improved (p = 0.015). Clarity as to the time of transfer of care from outgoing (day team) to incoming (night float) improved (p = 0.0001). The type of rotation (intensive care unit vs non-intensive care unit) did lead to an improvement (confidence interval< 99%). Across both shifts, the perceived number of inappropriate tasks transferred decreased significantly. Experience (months of training) and type of rotation did not affect these measures.

Conclusions

By simplifying and standardizing the handoff instrument, we demonstrated improvements in resident perceptions of accuracy, completeness, and number of tasks transferred. This low-cost, low-tech paradigm may be useful to others.

Introduction

In 2001, the Association of American Medical Colleges (AAMC) established 80 hours as a reasonable upper limit that residents should be scheduled to be on duty per week. As part of this monumental overhaul of graduate medical education, it was noted that the new guidelines must be applied with sufficient flexibility to “ensure that thorough exchange of information and proper transfer of patient care responsibilities whenever residents who are going off duty sign over the care of patients to other residents.1” A national survey recently documented that although transfers of care are increasingly more frequent, few residency programs have care systems in place to accommodate this change.2 Furthermore, little study to date has been executed specifically regarding the handoff of patient care responsibilities between resident physicians or how this process may be optimized in the era of stringent work-hour regulations. The Joint Commission (Joint Commission on Accreditation of Healthcare Organizations, JCAHO) notes that the primary objective of a handoff is to “provide accurate information about a patient's care, treatment, and services, current condition and any recent or anticipated changes.” It is saliently noted that “the information communicated during a handoff must be accurate in order to meet patient safety goals.3

Research that concerns injury to surgical patients has clearly implicated poor communication between physicians as a common factor that results in harm to patients.4, 5 One recent study that attempted to elucidate specifically the types and causes of medical errors involving trainees noted that handoff problems were 1 of the most prevalent types of teamwork problems that led to patient injury.6 Furthermore, it was noted that handoff issues were disproportionately more common among errors that involved trainees, as compared with similar cases in which no resident was involved. Thus, it is of little surprise that a prospective study of the sign-out process among residents at a major academic medical center noted that residents receive little formal instruction on how to sign-out patients, or to assess their ability to properly sign-out patients to an incoming resident physician.7 This lack of regulation is in stark contrast to other high-risk, high-precision fields, such as air traffic control, nuclear submarines, space missions, and nuclear power plants, in which handoff skills are practiced repetitively to optimize precision and anticipate errors.8 Thus, it has been suggested that the patient care handoff system must be standardized, and that residents should be taught the most effective, safe, satisfying, and efficient way to perform handoffs.9

The purpose of this study was to conduct a comprehensive investigation of the determinants of an effective handoff management system among surgical residents at a tertiary-care, urban, academic medical center. More specifically, we studied the impact of a simple, low-tech, low-cost handoff system. Our study sought to address the following research questions:

  • 1

    What were baseline perceptions of residents regarding quality of handoffs before intervention?

  • 2

    To what extent were nurses clear as to the exact time the day team resident transferred call to the night float resident and/or the night float resident transferred call to the day team?

  • 3

    What is the effect of a standardized template on residents' perceptions of patient handoff information completeness, accuracy, and clarity of responsibilities, process efficiency, and appropriateness of task delegation?

  • 4

    What is the effect of resident experience and type of rotation (intensive care unit versus non-intensive care unit) on handoff information completeness, accuracy, clarity of exact time of patient responsibility transfer, process efficiency, and appropriateness of task delegation.

Section snippets

Methods

Baseline description of the traditional handoff process was mapped by direct observation, a focus group session, a written survey completed by nurses, a phone survey, and an electronic survey.

Three direct observation sessions occurred on weekdays and weekends by an efficiency operations team from The Northwestern University Kellogg Graduate School of Management. Three authors (R.T., G.R., and S.C.) were chosen for collaboration in this project because of their expertise in operations

Results

The efficiency operations team observed 12 separate services while communicating patient handoffs. Method of handoff typically employed at baseline included face-to-face encounter (4 services), handoff primarily via telephone (4 services), and handoff without direct interaction (4 services) (Table 1).

Forty nurses who represented the cardiovascular intensive care unit, surgical intensive care unit day, surgical intensive care unit night, and 3 surgical floors completed the 1-item written survey.

Discussion

As of July 1, 2003, all residency programs under the aegis of the ACGME were required to reduce duty hours to no more than 80 per week averaged over a 4-week period.1 In response to this challenge, the Department of Surgery at Northwestern University Feinberg School of Medicine hosted a 2-day think-tank consortium to identify critical educational components of a surgical residency and to identify models that could satisfy not only the educational mission, but also the duty-hour limitations set

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