Handoff Plan Should Include Rationale, Precise Language

CHICAGO — Hospitalists looking to improve handoffs during transitions of care and reduce downstream errors may find inspiration at their local Starbucks.

By repeating your order for a triple tall, nonfat, no-whip peppermint mocha, Starbucks is using the simple “read-back” strategy to ensure accuracy.

“In business and restaurants, they have to get the order right or you won't go back,” Dr. Vineet Arora explained during a session on handoff best practices at the annual meeting of the Society of Hospital Medicine (SHM). “And in medicine we have a culture of errors.”

Communication problems have been identified as the primary cause of nearly two-thirds of hospital sentinel events. A study at Chicago's Northwestern Memorial Hospital of telephone read-back of 822 lab results showed that using the strategy took only an additional 12.8 seconds per call and identified 29 errors, including 10 instances in which the patient's name was incorrect, she said (Am. J. Clin. Pathol. 2004;121:790-1).

In recent years, organizations such as the SHM, World Health Organization, Institute of Medicine, and the Joint Commission have focused on the need to improve handoffs of care. Dr. Arora, assistant dean at the University of Chicago Pritzker School of Medicine, and her colleagues advocate a competency-based approach focused on improving communication and professionalism (Qual. Saf. Health Care 2008;17:11-4).

“Handoffs are more than just a transfer of content, but also a transfer of professional responsibility,” she said. “Every patient is your patient.”

Dr. Arora and her colleagues are developing handoff training programs, which are not commonly used.

The SHM recommends that a formal handoff plan be instituted at the end of a shift or change in service, Dr. Arora said, and the plan should include time during shifts dedicated for verbal exchange of information, a template or technology solution to be used for tracking patient information, and training for new users on handoff expectations.

Although information technology can advance communication, it cannot replace it, Dr. Arora cautioned. In one study, replacing a telephone call for critical lab values with a computerized reporting system and no verbal communication resulted in 45% of 3,228 urgent lab results not being read by a clinician (BMJ 2001;322:1101-3).

Precise language is essential, she said, citing a common scenario in which a nurse calls because the patient wants to know if they can eat, but the chart says “patient is NPO for surgery tomorrow.” To avoid confusion, use exact dates instead of terms like today, tomorrow, or yesterday, and state exactly what procedure is planned, she advised.

A verbal handoff also should provide anticipatory guidance and identify tasks that need to be done, she said. Both should be accompanied by a plan and the rationale behind it. For example, a chart that simply says “check BMP at 8 p.m.” doesn't explain what the physician is looking for or what staff should do if that basic metabolic panel reports an abnormality. Before a handoff, hospitalists should also examine the chart for critical omissions, such as “do not resuscitate” status.

Dr. Arora has received consultant or speakers fees related to her work on handoffs from the Illinois Hospital Association, Michigan Health and Hospital Association, Delmarva Foundation/Maryland Patient Safety Learning Center, Clarity Group, MacNeal Hospital, and HCPro.