CE Article: Five Ways to Perfect the Patient Handoff

Objectives

• Review danger points of poor patient handoffs
• Discuss how the shared mental model improves communications
• Understand how to use the mnemonic EEESS to improve communications during patient handoff

Every healthcare worker will do it at least once for each of their patients. For patients themselves it happens many times during the course of their care. It has been identified as a frequent failure point in medical care by virtually every health agency, yet most providers, including EMS, receive only rudimentary training on how to do it properly.¹ Whether you call it handoff, signout or patient care handover, it is the crucial point at which patient care, information and responsibility is transferred from one provider to another.²

Despite the fact that when a patient handover fails it may cause consequences from minor inconvenience to significant patient harm (including death), mistakes often remain invisible to the providers making them.

The Damage Done

In 2005 the Joint Commission found the root cause of 70% of hospital-related sentinel events involved communications, with 50% of those events occurring during patient care handoffs. “Patient care handoff communications,” the organization asserted, “have been identified as a critical safety and quality problem.”^3,4 Poor handoffs have been shown to cause:

• Treatment delays;
• Treatment errors;
• Increased lengths of hospital stay;
• Avoidable hospital readmissions;
• Increased treatment costs;
• Other minor and major patient harm and inefficiencies. ⁴

In 2014 ACEP claimed that, “The most dangerous point in a patient’s ED journey is the handoff and transition of care.”⁵ Even the Wall Street Journal has referred to patient handoffs as “the Bermuda Triangle of healthcare.”⁶

Consider how many times a patient may experience a handoff during a typical EMS call. Systems vary, but for many it begins with a report given by friends, family or caregivers to first responders. First responders may then give report to the transporting EMTs. Transporting EMTs may next hand off the patient to an arriving paramedic. While the EMTs may stay with the patient for the rest of the call, patient information and responsibility are still transferred. Finally the paramedic will give a report to receiving emergency department staff, but that only begins another series of patient handoffs in the hospital.

Regardless of how many times the patient is handed off, who is doing it or how critical the patient is, both the provider giving the report and the person or team receiving the patient have important responsibilities for ensuring effective transfer of information and care. While most focus tends to be on effective handoffs during life-threatening emergencies, it is when events seem trivial and priorities are low that bad habits are formed and some of the most critical errors occur. Even the transfer of a patient under noncritical circumstances must be a coordinated effort among healthcare professionals.⁷

So how do healthcare providers miss what can seem to be glaring errors? How can a part of the care process that seems so ordinary be so fraught with danger? How can there be so many opportunities to drop the ball? The answers to these questions may lie outside the healthcare industry.

Mission-Critical Communications and the Shared Mental Model

Mission-critical communications are any exchange of information whose disruption will result in the catastrophic failure of the job at hand. While such a definition would certainly apply to patient care handoffs, mission-critical communication concepts have also been used and studied extensively in team sports, commercial aviation, aerospace industries, nuclear facilities, rail transport, and military and fire/rescue organizations.⁸ While the context and content of mission-critical communications will change from industry to industry, many of the recommendations to help avoid errors and improve effectiveness can be employed by EMS and hospital providers.⁸

A concept central to mission-critical communications is the shared mental model. A mental model is the picture an individual has in their head of what’s going on. Individuals on a team may be in different roles and see different things from different perspectives, but for any team to work effectively together, all members must share a mental model.

When a situation is being handed over from one individual (or group) to another—whether it is the changing of watch on a submarine, the transfer of incident command at an emergency scene or the handing off of patient care information and responsibility—the goal of mission-critical communications is an efficient, effective and error-free transfer of the mental model.

For an individual healthcare provider or team to build their mental model, they must address four questions:

1. The focused priority for the patient (i.e., what is the crux of the problem?);
2. The history of prior care (what got us to this point?);
3. The patient’s current state (where are we right now?); and
4. The patient’s immediate needs (what is the very next thing that needs to happen?).

Answering these questions quickly and efficiently will not just help avoid errors and misunderstandings, it will provide a handoff that allows receiving clinicians to “pick up the ball” and continue progress in patient care rather than spending time with unnecessary questions and clarifications—or, even worse, beginning a patient interview and assessment basically from scratch.

When providers have different ideas of what’s going on, situational awareness fails, and problems begin.

Conditions and Cognition

With skilled healthcare practitioners on both sides of most patient transfers, you would be right to wonder how so many problems could occur. A great deal of research on mission-critical communications has been done to answer this question. While reasons vary, they can effectively be grouped into two categories: conditions and cognition.

Conditions that interfere with mission-critical communications include distractions, interruptions, noise, multitasking, high workload, high time pressures, low perceived importance of the communication relative to other tasks, systems with unclear roles of who is reporting or receiving the report, and cultures that lack mutual respect and teamwork.⁹

Problems with cognition that interfere with mission-critical communications include lack of provider competence (actual skill) or confidence (belief in their own ability), using unstructured reports, attempting to give a report entirely from memory, rambling (use of mostly minor and disconnected details), missing major details, not sharing priorities between reporting and receiving parties, and excessive use of technical terminology and jargon (“speaking different languages”).¹⁰

Think of the last few handoff reports you’ve taken from other providers on scene or given to staff in a receiving ED. How many of these issues occurred on one or both sides of the equation?

These problems are so common that one study showed emergency department staff members typically remember less than half the information EMS crews give them during verbal handoffs.¹¹ Three other studies showed EMS providers did not feel ED staff paid attention when patients were being handed off.^12–14 An additional study on information loss in EMS handovers of trauma patients showed an average loss of more than 25% of key information.¹⁵

While responsibility for such failures may rest in part on both the reporting and receiving parties and the systems in which they work, what allows such failures to continue is that those involved do not even realize a failure has occurred. Because the mental model seems clear in their own head, providers often believe they have given a clear, concise and correct report. The receiving ED staff has only the (erroneous) information to go on, so they too may not immediately recognize the problem, and the damage that occurs may not be apparent until the EMS providers are long gone.

In the words of George Bernard Shaw, “The single biggest problem in communication is the illusion that it has taken place.”

Mission-Critical Solutions: Handoff with EEESS

While providers may feel they are particularly careful during high-priority handoffs, it is been shown that bad habits build up during day-to-day handoffs. This is a well-documented occurrence in other industries that rely on mission-critical communications.⁹ Fortunately healthcare providers can turn to these same industries for potential solutions.^16,17 In one example, when London’s Great Ormond Street Hospital turned to Ferrari’s Formula One racing team to teach them how to improve patient care handoffs, technical errors dropped by 42%, and information omissions decreased by nearly 50%.¹⁸

After extensive study I have developed five recommendations included in the “Team Approach to Healthcare” chapter of the 11th edition of the American Academy of Orthopaedic Surgeons’ EMT textbook.¹⁹ The goals of these recommendations are to ensure that responsibility for the patient is clear, critical care is not interrupted, an effective mental model is shared, priority next steps are facilitated, transferred information is complete and errors are minimized.

While the degree of control providers have over the system in which they work will vary, these five recommendations can be used by both reporting and receiving providers in virtually all situations with both critical and noncritical patients. Remember them with the mnemonic EEESS (rhymes with 'ease').

Reporting

1. Eye contact—When handing over patient care, responsibility and information, it is critical, especially during team-to-team transfers and when receiving clinicians are multitasking, to begin by making eye contact with the person to whom the patient is being transferred. This helps identify that the handoff is beginning, which individuals are reporting and receiving, and sends the message that “We are communicating now, you and I.”

2. Environment—Whenever possible try to minimize noise, interruptions and distractions. For example, momentarily turn down a radio, stop nonpriority activities or move to a quieter area to give your report.

3. Ensure the ABCs—If there’s priority critical care that must be initiated or continued, this must be immediately conveyed to and addressed by the receiving clinician or team. These include lifesaving interventions that are needed immediately (for example, placement of a chest tube) or must be continued (for example, CPR) for the patient’s survival. The receiving clinician should either direct the reporting provider’s team to continue care during the handoff report or direct the receiving team to take over the priority task. The receiving clinician must then continue to take the report in order to establish the mental model or “big picture.” If this is not done properly, the receiving team risks starting over from scratch, losing valuable patient care progress made by EMS or, worse, jumping from one critical issue to the next as they are discovered with little coordination and prioritization.

4. Structured report—There are numerous standardized report formats with countless variations, from the widely used SBAR to ATMIST, PACE, the 5 Ps, I-PASS and more. Mission-critical communications research has shown the use of a structured format greatly improves efficiency and reduces errors, but little evidence shows any one system is better than another. The important point is to pick a structured format and use it, preferably one familiar to both reporting and receiving providers.

5. Supply documentation—The verbal report should consist of the patient’s priority issues, prior care, current state and immediate needs. Numerous other details should be transferred on paper or by electronic report. Avoid clouding the handoff with information that’s not immediately critical.

Receiving

1. Eye contact—For the same reasons as above, maintain eye contact.

2. Environment—The recommendation above also applies to this side of the handoff. Many hospitals now establish a “moment of silence” during trauma, cardiac, stroke and sepsis handoffs. When eye contact is established (or another trigger, such as the reporting paramedic standing on a designated spot in the room or the EMS cot being placed next to the hospital cot), the receiving physician announces “moment of silence!” and all team members quiet down and stop noncritical care actions to listen to the handoff report. This is intended to increase the efficiency of the handoff, reduce errors and improve the shared mental model among the receiving team so care can be prioritized and coordinated better.

3. Ensure understanding—Once the handoff report has been given, the receiving clinician should ask questions as necessary to clarify and correct any issues.

4. Summarize—This is not a repeat of the entire handoff report, but a summary of the receiving clinician’s mental model. This summary is verbalized so the reporting provider and members of the receiving team can ask questions or identify any critical errors to ensure the shared mental model is correct.

5. Supplementary documentation—Not only is this a reminder that noncritical details should be transferred via paper or electronic documents, it has been shown that, where possible, patient monitoring (ECG, key vital signs, etc.) should be located so the information is visible to the entire receiving team. This helps keep clinicians aware of the patient’s current state, maintaining that shared mental model.

The great thing about these recommendations is that they can be applied to a whole EMS system or by individual providers. In a recent study in which some of these recommendations were implemented, handovers were shorter, the number of handovers where ED staff asked questions was reduced from 93% to 41%, and requests for paramedics to repeat information were cut by more than half.²⁰

Structure for Your Structured Reports

Because many EMS providers have developed habits of providing handoff reports in a certain way, it can be difficult to change even if they want to. For both individuals and systems looking to adopt a more structured, efficient and safer handoff, it can be helpful to use simple devices to aid in the transition. For example, to adopt the SBAR format, many hospitals have posted the mnemonic (and what it means) on large posters directly in the emergency department and other places where handoff reports are given. Likewise, some hospitals and EMS services distribute notepads using a structured format to help providers organize their thoughts and information even as they acquire it in the field.

Whether you adopt these recommendations as an individual provider or, better yet, encourage their adoption by your EMS system, it is important that you don’t view a good patient handoff as simply avoiding pitfalls. When it’s done properly the patient handoff can provide numerous positive opportunities:

• Receiving clinicians can provide a fresh perspective on the situation;
• Both reporting and receiving groups will re-evaluate and regain focus on the patient’s priority issues;
• Especially for providers preparing to give a report, it encourages critical thinking rather than task-focus tunnel vision;
• Situational awareness is improved by sharing a mental model across care teams;
• A more focused, efficient and professional handoff is a more collegial and pleasant experience for everyone involved;
• Patient satisfaction is greatly improved as their overall care is sped along and they are not forced to answer the same questions repeatedly by different providers.

Example of a Structured Report

An example of a structured report that focuses on priority issues, prior care, current state and immediate needs is:

We have a hypotensive 65-year-old male with an unstable pelvis and left side open radius/ulna fracture.

The patient was struck by a motor vehicle at approximately 35 mph approximately 20 minutes ago. We stabilized his pelvis and left forearm, and both have good distal CMS.

He is conscious and alert but slow to respond. He remains hypotensive despite 1L of fluid. We have administered 1g TXA but withheld analgesia due to the hypotension.

Vital signs are BP 89/50, pulse 122 and irregular, respirations 24. Head-to-toe finds the pelvis and left arm, as well as minor abrasions, but no other significant findings. Nothing on the head, neck, chest, abdomen or other extremities. Patient’s only significant medical history is hypertension and CHF, so we were cautious with administration of fluids. Lungs are clear.

Can we get a few more people to help move him over so we don’t aggravate the arm and pelvis?

Any other questions?

The SBAR Report

Originally developed to standardize reporting in the U.S. Navy’s submarine service, the SBAR format aligns well with (but does not replace) the five recommendations for handoff reports presented here. SBAR includes the following items in order:

• Situation—Identify the general problem and any focused priority.
• Background—Focused history of present issue/injury, prior care and relevant history.
• Assessment—Key findings and vital signs, including the patient’s current state.
• Recommendation—Identify the patient’s immediate needs, if any.

Conclusion

The five EEESS recommendations provide not only specific practices to improve patient handoffs, they help you think differently about the way you interview and assess patients and create an overall patient picture, or mental model, on which to base your treatment.

The medical director of the U.K. National Patient Safety Agency has said, “Handover of care is one of the most perilous procedures in medicine and when carried out improperly can be a major contributory factor to subsequent error and harm to patients.”²¹ However, when that handover is done properly, not only can errors and omissions be avoided, the experience can be a positive one for the reporting and receiving teams while at the same time improving the patient’s care and overall experience.

Additional Reading

Web-Based Tool Helps Slash Hospital’s Patient Handoff Errors

References

1. World Health Organization. Communication During Patient Hand-Overs, www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf.

2. 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): 1,094–9.

3. The Joint Commission. Improving Hand-off Communication, www.jointcommission.org/toc.aspx.

4. The Joint Commission. Hand-off Communications, www.centerfortransforminghealthcare.org/projects/detail.aspx?Project=1.

5. Welch S. 11—The Handoff. American College of Emergency Physicians, www.acep.org/Membership/Sections/Quality-Improvement---Patient-Safety-Section/11---The-Handoff/.

6. Landro L. Hospitals Combat Errors at the ‘Hand-Off.’ Wall Street Journal, www.wsj.com/articles/SB115145533775992541.

7. The Joint Commission. Understanding and Improving Patient Handoffs. J Quality Patient Safety, 2010 Feb; 36(2).

8. Hilligoss B, Cohen MD. “Hospital Handoffs as Multifunctional Situated Routines: Implications for Researchers and Administrators.” In: Blair JD, Fottler MD. Advances in Healthcare Management, Vol. 11: Biennial Review of Health Care Management, p. 91–132. Bingley, U.K.: Emerald Group Publishing, 2011.

9. Coiera EW, Jayasuriya RA, Hardy J, et al. Communication loads on clinical staff in the emergency department. Med J Aust, 2002 May 6; 176(9): 415–8.

10. Dawson S, King L, Grantham H. Review article: Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient. Emerg Med Australas, 2013 Oct; 25(5): 393–405.

11. Talbot R, Bleetman A. Retention of information by emergency department staff at ambulance handover: do standardised approaches work? Emerg Med J, 2007 Aug; 24(8): 539–42.

12. Thakore S, Morrison W. A survey of the perceived quality of patient handover by ambulance staff in the resuscitation room. Emerg Med J, 2001 Jul; 18(4): 293–6.

13. Yong G, Dent AW, Weiland TJ. Handover from paramedics: observations and emergency department clinician perceptions. Emerg Med Australas, 2008 Apr; 20(2): 149–55.

14. Jenkin A, Abelson-Mitchell N, Cooper S. Patient handover: time for a change: Accid Emerg Nurs, 2007 Jul; 15(3): 141–7.

15. Carter AJ, Davis KA, Evans LV, Cone DC. Information loss in emergency medical services handover of trauma patients. Prehosp Emerg Care, 2009 Jul–Sep; 13(3): 280–5.

16. FOJP Service Corp. Handoff Communications: Heeding the Call to Change. in focus, 2007 Nov; https://hicgroup.com/sites/default/files/inFocusNov07.pdf.

17. Weinger MB, Slagle JM, Kuntz A, et al. Improving actual handover behavior with a simulation-based training intervention. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 2010 Sep; 54(12): 957–61.

18. Naik G. A Hospital Races to Learn Lesson of Ferrari Pit Stop. Wall Street Journal, www.wsj.com/articles/SB116346916169622261.

19. American Academy of Orthopaedic Surgeons. Emergency Care and Transportation of the Sick and Injured. Burlington, MA: Jones & Bartlett, 2016.

20. Dean E. Maintaining eye contact: how to communicate at handover. Emerg Nurse, 2012 Mar; 19(10): 6–7.

21. British Medical Association. Safe handover: safe patients, 2006.

Rommie L. Duckworth, LP, is a dedicated emergency responder and award-winning educator with more than 25 years working in career and volunteer fire departments, hospital healthcare systems, and public and private emergency medical services. Currently a career fire captain and paramedic EMS coordinator, Rom is an emergency services advocate, a frequent speaker at conferences around the world, and a contributor to emergency services research, textbooks, and print and online media.