Hands On: A Good Patient Handoff
Dr. Jonathan Phillips
It is a common scene in the hospital at shift change: nurses giving report to the next shift; overnight residents relaying the events of an overnight rapid response to the daytime intern; OR staff calling report about the patient who is leaving surgery and headed to a room on the medical ward. At the end of a long shift it takes determination and a system dedicated to safety to consistently deliver a good patient handoff. But, it is essential to preventing avoidable errors!
In 2006, the Joint Commission made effective handoffs a National Patient Safety Goal–this is a high level of importance that is also given to hand-hygiene and confirming the correct surgical site. (1) This strong emphasis led to additional research which eventually showed that up to thirty percent of serious medical errors may be caused at least in part because of failure of communication. (2) One study showed that in a teaching hospital there are over four thousand handoffs completed each day. Each one of these transitions in care to a different provider leave an opportunity for error or harm. (3)
Healthcare drew upon outside industries to find a solution for this important problem. The Navy had previously developed a mnemonic SBAR that they used to convey important information in an efficient and reproducible way. This mnemonic was later adopted by several major healthcare organizations as well as the Joint Commission as an effective way to improve patient handoffs. (4) Let’s break down the four components into their most basic forms.
Situation: The sender should identify themself, the patient, location, and any immediate concerns that have been identified
Background: It is important to provide a pertinent yet brief summary of the situation surrounding the patients current medical condition.
Assessment: The sender should summarize the patient’s current clinical condition, their baseline clinical condition, as well as any concerns that they feel may need addressed following the handoff.
Recommendation: Ensure there is clarity and a plan to address immediate concerns (5)
Institutions who adopted the SBAR approach to handoffs saw improvements in healthcare outcomes. While it is effective in simple or time sensitive situations, it was also perceived that it lacked the nuance necessary for more critical or complex patients. A new approach called I-PASS was developed to provide a more thorough model for these complex patients. (6)
Illness Severity: Convey whether the patient is stable, unstable, or needs extra attention
Patient Summary: A concise statement that includes reason for admission, hospital course, and brief summary of plan
Action list: Specific actions that the receiving team should complete and own
Situation Awareness: This would include contingency plans relevant to the patient’s clinical condition
Synthesis by receiver: An opportunity to ask clarifying questions and summarize the clinical scenario as necessary (6)
The success of the I-PASS method was demonstrated at the GME level with a large study across different pediatric residency programs. The study included nine programs who did not have a standardized approach to patient handoffs prior to implementing I-PASS. After implementation, the results showed that the medical error rate decreased by 23% and that preventable adverse events decreased by 30%. Furthermore, residents felt more confident in their ability to deliver a quality handoff and the duration of the handoff did not lengthen with this more standardized approach. (7)
These mnemonics provide a framework for an excellent handoff, but it takes an entire system to put it into place. Systems need to provide standardization, leverage their EHRs, allow for face-to-face handoffs, and monitor handoff success within a culture of prioritizing safety. (3)
Jonathan Phillips, D.O.
University of Louisville | Internal Medicine and Pediatrics
Dr. Jonathan Phillips is PGY-4 resident at the University of Louisville for Internal Medicine and Pediatrics. He attended Kentucky Wesleyan College for his undergrad and completed medical school at the Kanas City University of Medicine and Biosciences.
References
Arora VJJ. National patient safety goals - a model for building a standardized hand-off protocol - this model for designing and implementing a standardized hand-off protocol can be applied to a variety of disciplines and health care settings. Joint commission journal on quality and patient safety /. 2006;32(11):646.
Wentworth L, Diggins J, Bartel D, Johnson M, Hale J, Gaines K. SBAR. Journal of Nursing Care Quality. 2012; 27 (2): 125-131. doi: 10.1097/NCQ.0b013e31823cc9a0.
Inadequate hand-off communication. Sentinel Event Alert. 2017 Sep 12;(58):1-6. PMID: 28914519.
Eberhardt S. Improve handoff communication with SBAR. Nursing. 2014; 44 (11): 17-20. doi: 10.1097/01.NURSE.0000454965.49138.79.
Park LJ. Using the sbar handover tool. British journal of nursing (mark allen publishing). 2020;29(14):812-813. doi:10.12968/bjon.2020.29.14.812
Starmer AJ, Keohane C, Spector ND, et al. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics. 2012;129(2):201-204. doi:10.1542/peds.2011-2966
Starmer AJ, Allen AD, Spector ND, et al. Changes in medical errors after implementation of a handoff program. The new england journal of medicine. 2014;371(19):1803-1812. doi:10.1056/NEJMsa1405556
