Effective and Safe Patient Handoffs

Author: Amy Pound, MD, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine
Editor: Matthew Tews, DO, MS, Medical College of Wisconsin

Objectives

Upon finishing this module, the student will be able to…

  1. Describe when a handoff occurs in patient care
  2. Discuss the potential sources of error for patient handoffs
  3. Identify mechanisms for safe and effective patient handoffs
  4. Utilize SBAR+2 for effective patient handoff

Introduction

Handoffs occur whenever the treatment team for a patient changes, also known as the transition of care. This includes both change of shift, and transfers between units, services or hospitals. The purpose of a handoff is to convey accurate information regarding the patient and their treatment, including the patient’s current condition and any recent or anticipated changes1. In 2006, the Joint Commission added transitions in patient care to its national Patient Safety Goals. There was a recognized need for a standardized approach to handoff communications, including an opportunity to ask and respond to questions2.

Background

Similar to a game of telephone, the handoff process is prone to errors and ambiguity3,4. The Emergency Department (ED) has to function 24 hours a day, relying heavily on shiftwork for nursing, physician and ancillary staff. Discontinuity in patient care is inevitable with frequent shift changes5,6,7. In addition, ED personnel are subject to frequent interruptions due to alarms, phone calls, codes and EMS ambulance arrivals, to name a few. These interruptions contribute to the already high-risk nature of handoffs8,9. Other common sources of errors include the relaying of incomplete or incorrect information, disorganized or confusing discussion, failure to provide a clear clinical impression and plan, inattention or distraction of the recipient of information, meaning they are not effectively listening3. Handoffs between specialist and ED personnel have an additional layer of ambiguity stemming from their different perspectives.4

Up to 80% of serious medical errors involve miscommunication during handoffs10. Furthermore, faulty handoffs are implicated in up to 24% of ED malpractice cases3,11,12.  The use of a patient handoff protocol can decrease medical errors13,14. Structured handoff training is often limited, yet students may be asked to participate.

Characteristics of Good and Poor Handoffs Communication

A good handoff should be clear, concise and complete.  While this can be challenging to do, it should keep the listener’s attention and remain focused through the entirety of the presentation.  It often starts with room number and patient demographics (name, age, & gender) to identify the patient to the listener. This is followed by a brief history of present illness, with any pertinent positives or negatives from the past medical history, review of systems and physical exams. The focus then shifts to any studies resulted, consultant input, working diagnosis and any pending results, such as further labs, imaging or consults. Finally, the known or anticipated disposition should be relayed.  Finally, the presenter should make themselves available to answer questions.

While verbal communication is necessary, using both verbal and written styles of handoffs allowed for higher recall rates15. Using the EMR as a focal point may help insure that accurate labs and imaging results are discussed, as they can be viewed concurrently16. Interruptions or other distractions may lead to incomplete information or omissions of patients being discussed3.

Handoff Protocol

There are several formats available for handoff tools, and although one may be more suited to a particular circumstance or specialty, they share common goals of improving communication between providers17. The purpose of a protocol is to a structured communication process so that it can be repeated in the same manner for all communications.  The sender and receiver of the message both know the process of the communication and can anticipate the delivery of information. It should also provide a two-way exchange of information, providing opportunity to ask questions. The ultimate aim of any patient information handoff would be to provide effective verbal, face-to-face communication, despite distractions or interruptions, although there are limitations to this in most clinical settings18.

One of the more practical and commonly used protocols discussed in the literature and for use in the Emergency Department is Situation-Background-Assessment-Recommendation (SBAR). SBAR was originally developed by the US Navy, as a communication tool on nuclear submarines, when critical information needed to be transmitted quickly and action taken19,20. It has been extensively used by nursing for patient handoffs between shifts and for calling updates to physicians, and several variations have been developed on SBAR7,17. SBAR +2 is a common variation with the +2 providing two additional steps for introduction at the beginning of the presentation and questions and answers (Q&A) at the end.

1 Introduction: Identify yourself and position, role in patient’s care
S Situation: Provide the patient room number, demographics, and chief complaint to provide initial context.
B Background: Give a clear, concise overview of pertinent issues. Does the patient have any complaints, wants or needs.
A Assessment: Offer your conclusion about the present situation. Summarize facts and give your best assessment. What is going on? Use your best judgment. Do you anticipate any changes?
R Recommendation: Are there any tests or lab results pending? What needs to be done in the next few hours? Any recommendations for future care?
2 Q&A: Verify any critical information received, seek clarification, ask questions, and read back critical test results.

SBAR +2 Examples

Good Presentation

I am calling about bed 4, Ms. Jones, who is a 59 year-old female with a history of hypertension and diabetes, who arrived to the ED today complaining of midsternal chest pain. She had associated nausea and neck pain, but otherwise denied other symptoms.  Three hours ago she developed chest pain that radiated to her left neck and was associated with nausea.  She had no other symptoms.  She received aspirin and nitroglycerin by EMS and is currently chest pain-free. She had a blood pressure of 175/85, but her other vitals were in normal range.   Her cardiopulmonary exam is unremarkable. Her ECG showed no ST elevations or T wave inversions, and her CXR was negative. Her first troponin was positive at 0.6; she was given heparin and Plavix.  My diagnosis is a non-STEMI. Cardiology was consulted by phone and recommend we start a beta blocker for improved blood pressure control, only if her urine tox screen is negative for cocaine.  Her urine tox screen is pending. I think she needs admission to the CICU and serial enzymes/ECG’s and likely cardiac catheterization on a non-emergent basis.  Do you have any questions?

The above handoff example can be translated easily into the SBAR+2 format:

1 Introduction: Hello, I’m _______, the ____ year medical student rotating in the ED today.
S Situation: I am calling about bed 4, Ms. Jones, who is a 59 year-old female with a history of hypertension and diabetes, who arrived to the ED today complaining of midsternal chest pain.
B Background: She has a history of diabetes, hypertension. Three hours ago she developed chest pain that radiated to her left neck and was associated with nausea.  She had no other symptoms.  She received aspirin and nitroglycerin by EMS and is currently chest pain-free. She had a blood pressure of 175/85, but her other vitals were in normal range.   Her cardiopulmonary exam is unremarkable.
A Assessment: Her ECG showed no ST elevations or T wave inversions, and her CXR was negative. Her first troponin was positive at 0.6; she was given heparin and Plavix. My diagnosis is a non-STEMI.
R Recommendation: Cardiology was consulted by phone and recommend we start a beta blocker for improved blood pressure control, only if her urine tox screen is negative for cocaine.  Her urine tox screen is pending. I think she needs admission to the CICU and serial enzymes/ECG’s and likely cardiac catheterization on a non-emergent basis.
2 Q&A: Do you have any questions?

Poor Presentation

The SBAR +2 framework can prevent poor handoffs from occurring, by highlighting what is missing, and allowing for further clarifying questions. For example:

Bed 4 is a 59 yo f with hyperglycemia. She’s diabetic, missed her insulin does, but seems ok, a little nauseous. Her Beta hydroxybutyrate is elevated and pH is low. She’s getting insulin. Medicine team already knows about her, that’s about it.

1 Introduction: Missing – are you the nurse, student, resident, attending?
S Situation: Bed 4 is a 59 y/o female with hyperglycemia. How high was the blood glucose? Is this patient stable?
B Background: Diabetic, missed her insulin dose, seems ok, little nauseous.  What kind of insulin does she take, and how often? Did she get anything for n/v?
A Assessment: Beta hydroxybutyrate elevated, pH low. Getting insulin. How low is her pH? What type and route of insulin is she receiving now: Regular insulin, long acting? IV drip, IV push, subcutaneous? Is this patient in DKA? What is the Anion Gap? What is her blood glucose now?
R Recommendation: Medicine knows about her, that’s all you need to know. Who did you speak to? Is she stable enough for the floor, or does she need an ICU bed?
2 Q&A: Missing – Any questions?

Pearls and Pitfalls

  • Use a structured handoff tool like SBAR+2 for efficient handoffs.
  • Use face-to-face handoffs when possible.
  • Ensure two-way communication during the handoff process with Q&A.
  • Use EMR to streamline timely, accurate information.
  • Remember that EMR does not replace verbal communication.
  • Limit interruptions and distractions as much as practically possible.
  • Account for all patients, even if temporarily outside the ED (ex. at dialysis).

Summary

Daily change of shifts and transfer of patients to consultants and admitting teams requires a safe and efficient handoff. Handoffs are a common source for errors through miscommunication due to distractions, unclear plans or differing treatment perspectives. A structured handoff tool allows for improved communication with clear expectations for both parties, providing a two-way exchange of information. Various structured handoffs exist, and SBAR+2 is one example of an efficient structured presentation that can be used by medical students for handoffs from the emergency department.

References

  1. Runy, L. Patient handoff. Hospitals and Healthcare Magazine, 2008. Accessed 6/2016.
  2. The Joint Commission. Comprehensive Accreditation Manual for Hospitals, NPSG 2E rationale statement, 2007. Joint Commission resources, Inc. Oak Park, IL. Joint Commission, transitions of care portal, accessed 6/2016
  3. Cheung DS, Kelly JJ, Beach C, et al. Section of Quality Improvement and Patient Safety, American College of Emergency Physicians. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55(2):171–180. PMID: 19800711
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