A Call for Formalized Training in Hand-Off Procedures

7 pm arrives. Your stomach is growling. You realize you haven't taken a bathroom break in the past twelve hours, and it's already time to sign out. Your co-resident arrives, freshly showered, with a large, steaming hot latte in hand. “You ready to talk?” he asks in a chipper manner that makes you shudder inside, knowing that you have at least ten more things to do, several patients to sign out, a lumbar puncture to perform, and a laceration to repair. The bustling from the ED makes you even more anxious as you hand off your patients and run for the door.

Three hours later, your co-resident is approached by one of the nurses. “Did you order a CT scan on Mrs. Pope? She finished her contrast over an hour ago!” she pleads. He quickly runs through his patient list. Mrs. Pope”¦which one was she? Oh, right, follow up on her CT scan – but there is no CT scan ordered. He quickly enters it into the computer. Another two hours pass and he gets a call from radiology. “Well, the patient doesn't have appendicitis”¦ but she is pregnant.” Frantically scaning through the lab results your colleague looks for a urine bHCG. There is none. He runs over to the patient room, apologizing along the way. He has an unfortunate conversation with the patient about the implications of the CT scan and effects of radiation on her unborn fetus. It is not a discussion he ever wanted to have, and he hopes to never have it again.

This type of scenario is all too common in our field. Could this situation have been prevented? As physicians, we all desire to provide safe care. After all, we know the ethic of nil nocere, or do no harm. It has been ingrained in our brains since medical school, yet there are often other factors that come into play during the perilous time we call signing out. Acuity of sick patients, department volume, teaching obligations, and background noise are all part of a much longer list of variables we all know well.¹ In spite of these confounders, important information must be passed quickly between providers, which leaves plenty of opportunity for error. As ED crowding worsens and more detailed evaluations become the standard, the number of patient hand-offs is only likely to increase in the future.²

The need for a standardized hand-off process has been well established in the literature by both policymakers^2,3 and residency training programs,^4,5 yet less than half of emergency physicians reported a formalized hand-off procedure.⁵ Seventy percent of residency program directors felt that a standardized sign-out system would improve communication and reduce medical error.⁴ There remains, however, no standardized method of giving sign-out.

Not only is there a lack of standardization, but also of a formal training program.⁵ In a recent survey of program directors in Academic Emergency Medicine, only 25% of the training programs reported a formal didactic session, and only 10% had a written hand-off policy.⁴ This data is surprising, given that the Accreditation Council for Graduate Medical Education (ACGME) requires that training programs “must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety.”⁶

In my training program, I learned by the trial-by-fire method. My intern year, I distinctly remember receiving hand-off from a second year resident. Six patients. I was overwhelmed. I did not know what was important. I had no idea what to write down. I will admit that I made mistakes that day, but none of them were too serious — as far as I know. But I honestly believe that learning how to hand off patients — or even having a dedicated system to do so — would have decreased the number of errors I made.

Some say that no one can teach you how to sign out, that there are too many variables at play. When something goes wrong they contribute it to the lack of knowledge of the prior physician, or even the system itself. As outlined by Dr. Donald Berwick, administrator for the Centers for Medicare and Medicaid Services (CMS), “blame and accusations are not the answers. Teamwork and improvement are the answers. Commercial air travel didn't get safer by exhorting pilots to please not crash. It got safer by designing planes and air travel systems that support pilots and others to succeed in a very, very complex environment. We can do that in healthcare, too.”⁷

The truth of the matter is that we desperately need a better system for signing out. The Joint Commission reported that the majority of all sentinel medical error events arise from communication breakdowns, and half of these errors occur during the hand-off of care.³ Our current hand-off process is highly variable in both content and effectiveness secondary to each person's unique practice styles and individual preferences.⁸

Other specialties have had success with improving the process. The Pediatric I-PASS program has been shown in a large, multicenter study to reduce the number of adverse events with an improvement in communication and overall workflow.⁹ An electronic hand-off tool for patients admitted from the emergency department to the medicine ward was found to improve the efficiency of sign-out; it failed, however, to show a decline in the rates of reported adverse events.¹⁰

Perhaps a form is not the answer, but rather a systematic approach. In 2013 the Council of Emergency Medicine Residency Directors (CORD) transitions of care task force developed an algorithm based on five steps:¹¹

1. setting the stage
2. assembling the team
3. identification of high-risk patients
4. shift sign-out
5. closing the loop

Focusing on these key transitions streamlines the hand-off process. Furthermore it can be used in conjunction with any tool or written template that already exists. The algorithm serves as a solid foundation to improve our ability to sign out safely and effectively.

As residents we play a key role in producing behavioral and cultural changes within our specialty. Until we all accept the fact that hand-off can be improved, we will continue to make errors. We should advocate for both a consistent hand-off system, as well as a formal training course to be adopted by all residency programs. Standardization would not only allow residents to focus on the development of best practices, it would also reduce the variability of the hand-off process, ultimately leading to safer and more efficient patient care.

References

1. Gibson, Scott C., Jason J. Ham, Julie Apker, Larry A. Mallak, and Neil A. Johnson. “Communication, Communication, Communication: The Art of the Handoff.” Annals of Emergency Medicine 55, no. 2 (February 2010): 181–83. doi:10.1016/j.annemergmed.2009.10.009.
2. Cheung, Dickson S., John J. Kelly, Christopher Beach, Ross P. Berkeley, Robert A. Bitterman, Robert I. Broida, William C. Dalsey, et al. “Improving Handoffs in the Emergency Department.” Annals of Emergency Medicine 55, no. 2 (February 2010): 171–80. doi:10.1016/j.annemergmed.2009.07.016.
3. Joint Commission Resources. Hand-off Communication. National Patient Safety Goal. http://www.jointcommission.org/AccreditationPrograms/HomeCare/Standards/09_FAQs/NPSG/ Communication/NPSG.02.05.01/hand_off_communications.htm. Accessed February 1, 2015.
4. Sinha, Madhumita, Jesse Shriki, Rebecca Salness, and Paul A. Blackburn. “Need for Standardized Sign-out in the Emergency Department: a Survey of Emergency Medicine Residency and Pediatric Emergency Medicine Fellowship Program Directors.” Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine 14, no. 2 (February 2007): 192–96. doi:10.1197/j.aem.2006.09.048.
5. Kessler, Chad, Faizan Shakeel, H. Gene Hern, Jonathan S. Jones, Jim Comes, Christine Kulstad, Fiona A. Gallahue, et al. “A Survey of Handoff Practices in Emergency Medicine.” American Journal of Medical Quality: The Official Journal of the American College of Medical Quality 29, no. 5 (October 2014): 408–14. doi:10.1177/1062860613503364.
6. ACGME Common Program Requirements. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. ACGME approved focused revision: June 9, 2013; effective: July 1, 2013. Accessed Feb 1 2015.
7. New Patient Safety Initiative Stresses Teamwork, Not Blame. Medscape. Apr 12, 2011.
8. Dhingra, Kapil R., Andrew Elms, and Cherri Hobgood. “Reducing Error in the Emergency Department: a Call for Standardization of the Sign-out Process.” Annals of Emergency Medicine 56, no. 6 (December 2010): 637–42. doi:10.1016/j.annemergmed.2010.02.004.
9. Starmer AJ, Spector ND, Srivastiva R, et al. Changes in Medical Erros After Implementation of a Handoff Program. NEJM. 2014:371(19);1803-1812.
10. Gonzalo, Jed D., Julius J. Yang, Heather L. Stuckey, Christopher M. Fischer, Leon D. Sanchez, and Shoshana J. Herzig. “Patient Care Transitions from the Emergency Department to the Medicine Ward: Evaluation of a Standardized Electronic Signout Tool.” International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care/ISQua 26, no. 4 (August 2014): 337–47. doi:10.1093/intqhc/mzu040.
11. Kessler, Chad, Faizan Shakeel, H. Gene Hern, Jonathan S. Jones, Jim Comes, Christine Kulstad, Fiona A. Gallahue, et al. “An Algorithm for Transition of Care in the Emergency Department.” Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine 20, no. 6 (June 2013): 605–10. doi:10.1111/acem.12153.