Perspectives on Safety
What Have We Learned About Safe Inpatient Handovers?
Approach to Improving SafetyResource TypeClinical AreaSafety TargetSetting of Care
The care of hospitalized patients is marked by numerous transitions in care, including handovers of patient care responsibility at changes of shift. A large body of research documents that handovers often lack important elements, and that poor quality handovers can cause adverse consequences.(1) For example, in a study of critical incidents, Arora and colleagues found that face-to-face communication often did not occur between the handover giver and receiver, and handover documents commonly lacked important content, such as a current list of medications, active problems, and pending tests.(2) Horwitz and colleagues determined that omission of key information during handovers resulted in near misses, potentially avoidable escalations in care (e.g., transfer to the intensive care unit), inefficiencies in care, and delays in diagnosis or treatment.(3)
Other research demonstrates that periods of cross-coverage by a physician who is less familiar with the patient represent vulnerable points in hospital care, during which errors and adverse events are common. In a study of hospitalized adults, cross-coverage was a strong independent predictor of preventable adverse events.(4) In another study, 59% of medical and surgical housestaff reported that one or more patients had been harmed in their most recent rotation due to handover-related problems.(5)
In teaching hospitals, the implementation of resident duty hour restrictions in 2003 increased handover frequency by approximately 10%.(6) As the ACGME further reduces the continuous on-duty period for interns beginning in July 2011 (7), it has called upon residency training programs to provide appropriate training and structure to ensure effective handovers.
What is achieved in a high-quality handover? Handovers are critically important for establishing a shared mental model about the patient's condition. Successful handovers avoid unwarranted shifts in goals, decisions, priorities, or plans, including omitting or repeating tasks. The handover provides information about the patients' clinical course and condition, as well as what tasks need to be performed (e.g., following up on a pending laboratory test or re-evaluating a patient's clinical status). Handovers may be divided into four phases: (i) Preparation – when the handover giver updates and organizes information; (ii) Engagement – the giver and receiver stop other tasks to conduct the handover; (iii) Dialogue – giver and receiver exchange information; and (iv) Post-handover – the receiver integrates the new information and assumes care of patient.(8) In addition, handovers often involve three distinct components: (i) verbal exchange, (ii) written communication, and (iii) transfer of professional responsibility.(8)
In 2009, the Society of Hospital Medicine (SHM) Handoffs Task Force published a systematic review of the literature and recommendations to improve inpatient handovers.(9) The review summarized the results of controlled interventions to improve handovers in the inpatient setting among any type of health care provider. The Task Force recommendations were based on this evidence review as well as emerging best practices, and they were vetted among content experts and approximately 300 practicing clinicians before being approved by the SHM Board. The recommendations were designed to be applicable across settings (community and academic), health care providers (hospitalists, internists, subspecialists, residents, nurse practitioners, and physician assistants), and roles (primary inpatient provider, consultant, co-manager). The scope of the report included handovers that occur at change of shift, as well as change of service (i.e., when the outgoing provider is ending a rotation or period of consecutive daily care).
Authors of the report found limited evidence on how to improve handovers, with only 10 controlled studies having been published through January 2007, the cut-off date for the literature review. All of the studies concerned change of shift handovers; none focused on change of service. Three of the investigations specifically concerned nurses; the remainder tested technology solutions or structured documentation templates for medical or surgical residents. The quality of the literature was relatively poor, consisting of nine pre–post studies and only one randomized trial.(10) No studies evaluated the effect of handover interventions on patient outcomes.
In light of limited evidence, what steps should hospital-based clinicians take to improve handover quality? The Task Force report contains many specific recommendations (Table).(9) I will highlight three general practices that appear particularly important and are consistent with the 2010 ACGME Common Program Requirements.(11)
First, physicians should be trained in how to perform safe and effective handovers. Historically, this has not occurred (6), and at the time of the SHM Task Force review, no controlled studies of handover training interventions were found.(9) Recently, Gakhar and colleagues described a curriculum for interns that significantly improved the quality of verbal communication and written handover documentation, compared to pre-training performance.(12) Others have implemented curricula for both medical students (13) and residents (14), which include participation in brief simulated handover exercises. Teaching materials from the University of Chicago are available here. Researchers at Vanderbilt University have developed a higher intensity model of handover training, which includes simulations, standardized patient and clinician exercises, facilitated video debriefing, and interpersonal skills training (e.g., conflict resolution). In Post-Anesthesia Care Units (PACU), this approach proved highly effective in improving handover quality, even among experienced health care providers.(15). As medical centers implement handover education, it remains to be determined what type and intensity of training will prove most valuable across disciplines and levels of provider experience. It also remains to be seen what effect such training will have on patient outcomes. The initial work looks promising, and future studies will address these important questions.
Second, the handover process should be structured. This may include elements such as a dedicated time and place for handover to occur, avoidance of interruptions, and expectations about what should be included in both the verbal and written components of handover.(16) At the end of a busy day, it may be tempting for the departing provider to simply leave information for the next provider with a note declaring there is "nothing to do" or to "call if any questions." This practice, however, fails to provide an adequate opportunity for verbal interaction, conveying goals of care, discussing ongoing active issues, or answering questions, all of which should be included in a formalized handover process. Optimally, handover will be conducted face-to-face, though circumstances may require communication by telephone.
Third, groups should strongly consider use of a structured electronic documentation template. The only randomized trial located in the SHM Task Force review showed that use of an electronic documentation tool reduced the time required to prepare handover documentation and led to higher ratings of handover quality and patient continuity.(10) More recently, others have described handover tools that pre-populate information from the electronic health record (e.g., patient identifiers, age, location, medications), and either pre-populate or provide a space to type in other critical elements such as code status, recent events, and anticipated problems (as well as what to do if they occur).(17-19) As an example, Vanderbilt's current electronic handover tool is shown in the Figure. Administrative information, diagnoses, current medications, and allergies, as well as an editable synopsis from the most recent progress note, import automatically; only the daily to do field must be updated manually. Not only can such tools improve efficiency, but they should also reduce the likelihood of medication discrepancies and other lapses in communication.
Given the current high level of interest in ensuring safe and effective handovers, the next few years are sure to bring additional innovations in curricular development and documentation tools, as well as research to demonstrate which strategies are most effective in different settings. It will also be interesting to see how documentation tools and training programs are adapted for use in other settings, such as ambulatory care or hospital discharge. Until then, the approaches described above provide a good starting point to guide medical centers in their efforts to improve handover quality and patient safety.
Sunil Kripalani, MD, MScChief, Section of Hospital MedicineVanderbilt University
Acknowledgements: Dr. Kripalani wishes to thank Drs. Matthew Weinger (Vanderbilt University) and Vineet Arora (University of Chicago) for their collaboration and for providing the handover training videos.
2. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14:401-407. [go to PubMed]
8. Cheung DS, Kelly JJ, Beach C, et al; American College of Emergency Physicians Section of Quality Improvement and Patient Safety. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55:171-180. [go to PubMed]
10. Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg. 2005;200:538-545.[go to PubMed]
12. Gakhar B, Spencer AL. Using direct observation, formal evaluation, and an interactive curriculum to improve the sign-out practices of internal medicine interns. Acad Med. 2010;85:1182-1188. [go to PubMed]
15. Weinger MB, Slagle J, Kuntz A, France D, Schildcrout J, Speroff T. A handoff training and improvement initiative significantly improved the effectiveness of actual clinical handoffs. Paper presented at: AcademyHealth Annual Research Meeting; June 29, 2009; Chicago, IL. [Available at] [Download Adobe Reader]
18. Bernstein JA, Imler DL, Sharek P, Longhurst CA. Improved physician work flow after integrating sign-out notes into the electronic medical record. Jt Comm J Qual Patient Saf. 2010;36:72-78. [go to PubMed]
Table. Recommendations for Inpatient Handovers.*
1. Have a formal plan for handover at change of shift and change of service
2. Train staff on how to perform a safe and effective handover
3. Document the new responsible physician after a service change
4. The verbal exchange of information during handover should
a. Be structured, occurring at a specified time and place
b. Be interactive
c. Give priority to ill patients
d. Focus on anticipatory guidance (i.e., what to expect and what to do)
5. The written information communicated during handover should
a. Include all patients
b. Be structured according to a paper or electronic template
c. Include the most updated information
d. Be available in a centralized location
e. Clearly label anticipated events
f. Highlight action items ("to do's")
*Adapted from SHM Handoffs Task Force (9)
Electronic Handover Tool.
Click to enlarge.