Of the 374 articles identified by the electronic search of PubMed and the AHRQ Patient Safety Network, 109 were retrieved for detailed review, and 10 of these met criteria for inclusion (). Of these studies, 3 were derived from nursing literature and the remaining were tests of technology solutions or structured templates (). No studies examined hospitalist handoffs. All eligible studies concerned shift change. There were no studies of service change. Only one study was a randomized controlled trial; the rest were pre-post studies with historical controls or a controlled simulation. All reports were single site studies. Most outcomes were staff or system-related, with only two studies using patient outcomes.
Characteristics of Studies Included in Review
Overall, the literature presented supports the use of a verbal handoff supplemented with written documentation in a structured format or technology solution. The two most rigorous studies were led by Van Eaton and Petersen and focused on evaluating technology solutions.17,18
Van Eaton and colleagues performed a randomized controlled trial of a locally created rounding template with 161 surgical residents.19
This template downloads certain information (lab values and recent vital signs) from the hospital system into a sign-out sheet and allows residents to enter notes about diagnoses, allergies, medications and to-do items. When implemented, the investigators found the number of patients missed on rounds decreased by 50%. Residents reported an increase of 40% in the amount of time available to pre-round, due largely to not having to copy data such as vital signs. They reported a decrease in rounding time by 3 hours per week, and this was perceived as helping them meet the ACGME 80 hours work rules. Lastly, the residents reported a higher quality of sign-outs from their peers and perceived an overall improvement in continuity of care. Petersen and colleagues implemented a computerized sign-out (auto-imported medications, name, room number) in an internal medicine residency to improve continuity of care during cross-coverage and decrease adverse events.20
Prior to the intervention, the frequency of preventable adverse events was 1.7% and it was significantly associated with cross-coverage. Preventable adverse events were identified using a confidential self-report system that was also validated by clinician review. After the intervention, the frequency of preventable adverse events dropped to 1.2% (p<0.1), and cross-coverage was no longer associated with preventable adverse events. In other studies, technological solutions also improved provider identification and staff communication.21,22
Together, these technology-based intervention studies suggest that a computerized sign-out with auto-imported fields has the ability to improve physician efficiency and also improve inpatient care (reduction in number of patients missed on rounds, decrease in preventable adverse events).
Studies from nursing demonstrated that supplementing a verbal exchange with written information improved transfer of information, compared to verbal exchange alone.23
One of these studies rated the transfer of information using videotaped simulated handoff cases.24
Lastly, one nursing study that more directly involved patients in the handoff process resulted in improved nursing knowledge and greater patient empowerment.25
White papers or consensus statements originated from international and national consortia in patient safety including the Australian Council for Safety and Quality in Healthcare,26
the Junior Doctors Committee of the British Medical Association,27
University Health Consortium,28
the Department of Defense Patient Safety Program,29
and The Joint Commission.30
Several common themes were prevalent in all white papers. First, there exists a need to train new personnel on how to perform an effective handoff. Second, efforts should be undertaken to ensure adequate time for handoffs and reduce interruptions during handoffs. Third, several of the papers supported verbal exchange that facilitates interactive questioning, focuses on ill patients, and delineates actions to be taken. Lastly, content should be updated to ensure transfer of the latest clinical information.
Peer Review at SHM Meeting of Preliminary Handoff Recommendations
In the presentation of preliminary handoff recommendations to over 300 attendees at the SHM Annual Meeting in 2007, two recommendations were supported unanimously: (1) a formal recognized handoff plan should be instituted at end of shift or change in service; and (2) ill patients should be given priority during verbal exchange.
During the workshop, discussion focused on three recommendations of concern, or those that received greater than 20 ‘negative votes’ by participants. The proposed recommendation that raised the most objections (48 ‘negative votes’) was that interruptions be limited. Audience members expressed that it was hard to expect that interruptions would be limited given the busy workplace in the absence of endorsing a separate room and time. This recommendation was ultimately deleted.
The two other debated recommendations, which were retained after discussion, were ensuring adequate time for handoffs and using an interactive process during verbal communication. Several attendees stated that ensuring adequate time for handoffs may be difficult without setting a specific time. Others questioned the need for interactive verbal communication, and endorsed leaving a handoff by voicemail with a phone number or pager to answer questions. However, this type of asynchronous communication (senders and receivers not present at the same time) was not desirable or consistent with the Joint Commission's National Patient Safety Goal.
Two new recommendations were proposed from anonymous input and incorporated in the final recommendations, including (a) all patients should be on the sign-out, and (b) sign-outs should be accessible from a centralized location. Another recommendation proposed at the Annual Meeting was to institute feedback for poor sign-outs, but this was not added to the final recommendations after discussion at the meeting and with content experts about the difficulty of maintaining anonymity in small hospitalist groups. Nevertheless, this should not preclude informal feedback among practitioners.
Anonymous commentary also yielded several major themes regarding handoff improvements and areas of uncertainty that merit future work. Several hospitalists described the need to delineate specific content domains for handoffs including, for example, code status, allergies, discharge plan, and parental contact information in the case of pediatric care. However, due to the variability in hospitalist programs and health systems and the general lack of evidence in this area, the Task Force opted to avoid recommending specific content domains which may have limited applicability in certain settings and little support from the literature. Several questions were raised regarding the legal status of written sign-outs, and whether sign-outs, especially those that are web-based, are compliant with the Healthcare Information Portability and Accountability Act (HIPAA). Hospitalists also questioned the appropriate number of patients to be handed off safely. Promoting efficient technology solutions that reduce documentation burden, such as linking the most current progress note to the sign-out, was also proposed. Concerns were also raised about promoting safe handoffs when using moonlighting or rotating physicians, who may be less invested in the continuity of the patients’ overall care.
Expert Panel Review
The final version of the Task Force recommendations incorporates feedback provided by the expert panel. In particular, the expert panel favored the use of the term, “recommendations,” rather than “standards,” “minimum acceptable practices,” or “best practices.” While the distinction may appear semantic, the Task Force and expert panel acknowledge that the current state of scientific knowledge regarding hospital handoffs is limited. Although an evidence-based process informed the development of these recommendations, they are not a legal “standard” for practice. Additional research may allow for refinement of recommendations and development of more formal handoff standards.
The expert panel also highlighted the need to provide tools to hospitalist programs to facilitate the adoption of these recommendations. For example, recommendations for content exchange are difficult to adopt if groups do not already use a written template. The panel also commented on the need to consider the possible consequences if efforts are undertaken to include handoff documents (whether paper or electronic) as part of the medical record. While formalizing handoff documents may raise their quality, it is also possible that handoff documents become less helpful by either excluding the most candid impression regarding a patient's status or by encouraging hospitalists to provide too much detail. Privacy and confidentiality of paper-based systems, in particular, were also questioned.
Additional Recommendations for Service Change
Patient handoffs during a change of service are a routine part of hospitalist care. Since service change is a type of shift change, the handoff recommendations for shift change do apply. Unlike shift change, service changes involve a more significant transfer of responsibility. Therefore, the Task Force recommends also that the incoming hospitalist be readily identified in the medical record or chart as the new provider, so that relevant clinical information can be communicated to the correct physician. This program-level recommendation can be met by an electronic or paper-based system that correctly identifies the current primary inpatient physician.
Final Handoff Recommendations
The final handoff recommendations are shown in . The recommendations were designed to be consistent with the overall finding of the literature review, which supports the use of a verbal handoff supplemented with written documentation or a technological solution in a structured format. With the exception of one recommendation that is specific to service changes, all recommendations are designed to refer to shift changes and service changes. One overarching recommendation refers to the need for a formally recognized handoff plan at a shift change or change of service. The remaining 12 recommendations are divided into four that refer to hospitalist groups or programs, three that refer to verbal exchange, and five that refer to content exchange. The distinction is an important one because program-level recommendations require organizational support and buy-in to promote clinician participation and adherence. The 4 program recommendations also form the necessary framework for the remaining recommendations. For example, the 2nd program recommendation describes the need for a standardized template or technology solution for accessing and recording patient information during the handoff. After a program adopts such a mechanism for exchanging patient information, the specific details for use and maintenance are outlined in greater detail in “content exchange recommendations.”
Because of the limited trials of handoff strategies, none of the recommendations are supported with level of evidence “A” (multiple numerous randomized controlled trials). In fact, with the exception of using a template or technology solution which was supported with level of evidence B, all handoff recommendations were supported with C level of evidence. The recommendations, however, were rated as Class I (effective) because there were no conflicting expert opinions or studies ()