When we talk about handoffs with physicians, nurses, and technicians and when we watch clinicians at work, we do see that they are concerned to hear about important tests and treatments and to transmit to-do items and the background data that support those plans. But they also display a keen interest in getting what is often called 'the big picture'. Imagine the example of a 63-year-old man with septic shock. Different types of information will be exchanged during the handoff of this patient:
1. Background clinical information ('He is known to have COPD [chronic obstructive pulmonary disease] and hypertension'.)
2. Course of the acute illness ('This is a patient with septic shock from perforated ischemic bowel, who had acute lung injury and acute kidney injury. He has been extubated for the past 24 hours and is starting to diurese spontaneously'.)
3. To-dos (clear tasks that need to be completed in a certain time frame, such as 'He needs to have a new catheter inserted to re-start dialysis tomorrow'.)
4. Uncertainty ('He was slightly hypotensive overnight. I think we might have made him hypovolemic with the ultrafiltration. He was on a low dose of pressors this morning, but he is off pressors now after a fluid challenge. I am not sure whether he is becoming septic again'.)
5. Anticipation of events ('In case his blood pressure drops again, I'd re-start antibiotics and arrange for an abdominal CT [computed tomography] scan'.)
These common features of the handoff conversation show that it orients the oncoming party toward the patient, sensitizes the new caregiver to some events that may be important signals, and implicitly steers other issues toward the background. The crucial feature of this aspect of handoff is that it shapes the viewpoint of the receiving party
, situating the patient within existing health-care practices and knowledge and altering the framework of expectations within which new events will be perceived. This is actually the root meaning of to inform
to give shape to' an actor's subsequent interpretations. It is a far deeper sense of information
than the more common image that we often fall back on, that of transmitted data, as when text characters or other signals are moved along a wire or an optical fiber, as conceived in the engineering approach to communication which stems from the seminal work of Claude Shannon [19
]. What ultimately matters is not just the completeness, or even the detailed accuracy, of what arrives at the other end, instrumental though these data items may be. Indeed, as electronic records of patients make the basic data ever more widely accessible, these data become less crucial in a handoff. Rather, what matters most is the effect of handoff interaction on the mind of the receiver, on the subsequent ability to make sense of the patient's unfolding episode of illness and treatment and to take the appropriate actions. In fact, we have evidence that handoffs are ineffective in having this shaping effect on the receiver's mind: physicians agreed on the main problem of patients admitted from an emergency department to hospital wards in less than 50% of handoffs, doing worse with patients who were more complex [20
]. This has obvious implications for critical care patients, as they are all complex. To see how the same information can influence the receiver's perception of clinical situations in different ways, suppose that the physician in the previous example said simply, 'Oh, and he was just a bit dry overnight'
, which identifies the same issue (hypovolemia) but with a different emphasis on the uncertainty and its diagnostic and treatment implications.
Once we acknowledge this crucial function of handing off, it is clear that we need to focus not only on what is transmitted by the so-called 'sender' in the handoff but just as heavily on actions of the newly responsible party and on the structure of the interaction between them. Many substantial lines of social science research show that the effectiveness of communication in altering subsequent action depends on the knowledge state [21
] and the active engagement of the receiving party and on the unfolding interaction pattern among those taking part in the communication, an interaction that may be affected by differences in the prior experience, social status, motivation, or specialized training of the participants [22