Residents' and Attending Physicians' Handoffs: A Review of the Literature
Purpose: Effective communication is central to patient safety. There is abundant evidence of negative consequences of poor communication and inadequate handoffs. The purpose of the current study was to conduct a systematic review of articles focused on physicians' handoffs, conduct a qualitative review of barriers and strategies, and identify features of structured handoffs that have been effective.
Method: The authors conducted a thorough, systematic review of English-language articles, indexed in PubMed, published between 1987 and June 2008, and focused on physicians' handoffs in the United States. The search strategy yielded 2,590 articles. After title review, 401 were obtained for further review by trained abstractors.
Results: Forty-six articles met inclusion criteria, 33 (71.7%) of which were published between 2005 and 2008. Content analysis yielded 91 handoffs barriers in eight major categories and 140 handoffs strategies in seven major categories. Eighteen articles involved research on handoffs. Quality assessment scores for research studies ranged from 1 to 13 (possible range 1-16). One third of the reviewed research studies obtained quality scores at or below 8, and only one achieved a score of 13. Only six studies included any measure of handoff effectiveness.
Conclusions: Despite the negative consequences of inadequate physicians' handoffs, very little research has been done to identify best practices. Many of the existing peer-reviewed studies had design or reporting flaws. There is remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies. Overall, there is a great need for high-quality handoff outcomes studies focused on systems factors, human performance, and the effectiveness of structured protocols and interventions.
Effective communication is central to patient safety and quality. Inadequate communication consistently appears as a factor contributing to medical errors, across settings and practitioners. These span from an incident with a single patient to broader communication issues between physicians and nurses. In reviews of malpractice claims, communication problems were contributing factors in 26% to 31% of cases. The Joint Commission has reviewed data from 6,244 sentinel events occurring between 1995 and June 30, 2009. Communication problems have long been noted as a major contributing factor to these sentinel events. Sutcliffe et al conducted semistructured interviews with residents, who recalled 70 recent medical mishaps, and indicated that 91% contained communication failures.
Handoffs, the transfer of patient care from one health care provider to another, are known to be vulnerable to communication failures and have been called "remarkably haphazard." As defined by the Joint Commission, handoff communication refers to a standardized process "in which information about patient/client/resident care is communicated in a consistent manner."
Retrospective reviews of malpractice claims in the ambulatory setting and emergency department showed that handoffs were a contributing factor in 20% and 24% of medical errors, respectively. When looking specifically at malpractice cases with communication breakdowns, 43% involved handoffs. A review of 146 surgical errors found that 41 (28%) involved handoffs. Of residents and fellows who reported caring for a patient with an adverse event, 15% indicated the reason for the mistake was a problem with handoffs.
Numerous surveys document health care staff concern. In an Agency for Healthcare Research and Quality 2008 survey, just over half (51%) of the 160,176 hospital staff respondents reported that "important patient care information is often lost during shift changes." When 93 fourth-year medical students and 228 residents responded to a survey about patient safety, (70%) agreed that improved handoffs would reduce medical mishaps.
Reduced resident duty hours were first introduced in New York State in 1989 and were mandated for all U.S. residency programs in 2003. Although reductions in duty hours may lead to less fatigue and improved well-being in residents, many have expressed concern about the resultant need for increased handoffs and reduced continuity of patient care. As a result of reduced hours, patients can be seen by three different physicians in the first 24 hours of their care. Seventy-six percent of 29 surgical residents in a New York study agreed that continuity of care had been negatively affected as a result of duty hours changes.
Discontinuity in patient care, which can occur with cross-coverage and night float systems, has been found to lead to increased in-hospital complications, preventable adverse events, increased cost due to unnecessary tests being ordered by residents not familiar with the patient, and diagnostic test delays. In a study at one teaching hospital during a four-month period, the risk of a preventable adverse event was strongly associated (more than twice as likely) with coverage by a physician from another team.
Night float systems, often implemented to ensure that residents do not exceed duty hours limits, have been noted to result in inadequate information transfer to the covering residents. Nurses have expressed concern over these changes. Fifty-one percent of the 67 nurses who responded to a survey about a new resident night float system agreed that "residents don't know the patients as well as in the old system."
Other issues surrounding attending physicians' and residents' handoffs have been documented. Gandhi notes that inadequate handoffs can lead to diffused responsibility, which can be a major contributor to medical errors. In addition, Coiera found that health care communications are prone to interruptions, with a third of communication events (30.6%) interrupted. Many of these interruptions result in inefficiencies, and interruptions during handoffs are likely to lead to failures of working memory, which result in decreased recall accuracy.
In 2006, the average length of stay for all hospitalized patients was 4.8 days. Assuming that patient care transfers between covering residents and/or attending physicians occur 1 to 2 times per day, the average patient will be handed off 5 to 10 times per admission. Each of these handoffs represents a risk for inadequate communication, which could result in reduced patient safety and increased medical errors.
In response to concerns about inadequate health care handoffs, a number of national patient safety organizations have highlighted the importance of communication, including the Institute for Healthcare Communication and the National Quality Forum. In 2006, the Joint Commission created a new National Patient Safety Goal on handoffs. In 2009, the goal remains virtually unchanged, requiring the organization to implement "a standardized approach to hand-off communications, including an opportunity to ask and respond to questions."
As the preceding paragraphs suggest, there is abundant evidence of the negative consequences of poor communication and inadequate handoffs in health care. The purpose of the current study was to identify all English-language articles on resident and/or attending physicians' handoffs in the United States, conduct a systematic review of research studies, perform a qualitative review of barriers and strategies mentioned across all articles, and identify features of structured handoffs that have been shown to be effective. This review was conducted in conjunction with the Alliance of Independent Academic Medical Centers National Initiative: Improving Patient Care Through GME. The National Initiative was a collaborative formed in 2007 that linked residency programs in 19 teaching hospitals across the United States in efforts to integrate academics and quality through projects coordinated at a national level.
Abstract and Introduction
Abstract
Purpose: Effective communication is central to patient safety. There is abundant evidence of negative consequences of poor communication and inadequate handoffs. The purpose of the current study was to conduct a systematic review of articles focused on physicians' handoffs, conduct a qualitative review of barriers and strategies, and identify features of structured handoffs that have been effective.
Method: The authors conducted a thorough, systematic review of English-language articles, indexed in PubMed, published between 1987 and June 2008, and focused on physicians' handoffs in the United States. The search strategy yielded 2,590 articles. After title review, 401 were obtained for further review by trained abstractors.
Results: Forty-six articles met inclusion criteria, 33 (71.7%) of which were published between 2005 and 2008. Content analysis yielded 91 handoffs barriers in eight major categories and 140 handoffs strategies in seven major categories. Eighteen articles involved research on handoffs. Quality assessment scores for research studies ranged from 1 to 13 (possible range 1-16). One third of the reviewed research studies obtained quality scores at or below 8, and only one achieved a score of 13. Only six studies included any measure of handoff effectiveness.
Conclusions: Despite the negative consequences of inadequate physicians' handoffs, very little research has been done to identify best practices. Many of the existing peer-reviewed studies had design or reporting flaws. There is remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies. Overall, there is a great need for high-quality handoff outcomes studies focused on systems factors, human performance, and the effectiveness of structured protocols and interventions.
Introduction
Effective communication is central to patient safety and quality. Inadequate communication consistently appears as a factor contributing to medical errors, across settings and practitioners. These span from an incident with a single patient to broader communication issues between physicians and nurses. In reviews of malpractice claims, communication problems were contributing factors in 26% to 31% of cases. The Joint Commission has reviewed data from 6,244 sentinel events occurring between 1995 and June 30, 2009. Communication problems have long been noted as a major contributing factor to these sentinel events. Sutcliffe et al conducted semistructured interviews with residents, who recalled 70 recent medical mishaps, and indicated that 91% contained communication failures.
Handoffs, the transfer of patient care from one health care provider to another, are known to be vulnerable to communication failures and have been called "remarkably haphazard." As defined by the Joint Commission, handoff communication refers to a standardized process "in which information about patient/client/resident care is communicated in a consistent manner."
Retrospective reviews of malpractice claims in the ambulatory setting and emergency department showed that handoffs were a contributing factor in 20% and 24% of medical errors, respectively. When looking specifically at malpractice cases with communication breakdowns, 43% involved handoffs. A review of 146 surgical errors found that 41 (28%) involved handoffs. Of residents and fellows who reported caring for a patient with an adverse event, 15% indicated the reason for the mistake was a problem with handoffs.
Numerous surveys document health care staff concern. In an Agency for Healthcare Research and Quality 2008 survey, just over half (51%) of the 160,176 hospital staff respondents reported that "important patient care information is often lost during shift changes." When 93 fourth-year medical students and 228 residents responded to a survey about patient safety, (70%) agreed that improved handoffs would reduce medical mishaps.
Reduced resident duty hours were first introduced in New York State in 1989 and were mandated for all U.S. residency programs in 2003. Although reductions in duty hours may lead to less fatigue and improved well-being in residents, many have expressed concern about the resultant need for increased handoffs and reduced continuity of patient care. As a result of reduced hours, patients can be seen by three different physicians in the first 24 hours of their care. Seventy-six percent of 29 surgical residents in a New York study agreed that continuity of care had been negatively affected as a result of duty hours changes.
Discontinuity in patient care, which can occur with cross-coverage and night float systems, has been found to lead to increased in-hospital complications, preventable adverse events, increased cost due to unnecessary tests being ordered by residents not familiar with the patient, and diagnostic test delays. In a study at one teaching hospital during a four-month period, the risk of a preventable adverse event was strongly associated (more than twice as likely) with coverage by a physician from another team.
Night float systems, often implemented to ensure that residents do not exceed duty hours limits, have been noted to result in inadequate information transfer to the covering residents. Nurses have expressed concern over these changes. Fifty-one percent of the 67 nurses who responded to a survey about a new resident night float system agreed that "residents don't know the patients as well as in the old system."
Other issues surrounding attending physicians' and residents' handoffs have been documented. Gandhi notes that inadequate handoffs can lead to diffused responsibility, which can be a major contributor to medical errors. In addition, Coiera found that health care communications are prone to interruptions, with a third of communication events (30.6%) interrupted. Many of these interruptions result in inefficiencies, and interruptions during handoffs are likely to lead to failures of working memory, which result in decreased recall accuracy.
In 2006, the average length of stay for all hospitalized patients was 4.8 days. Assuming that patient care transfers between covering residents and/or attending physicians occur 1 to 2 times per day, the average patient will be handed off 5 to 10 times per admission. Each of these handoffs represents a risk for inadequate communication, which could result in reduced patient safety and increased medical errors.
In response to concerns about inadequate health care handoffs, a number of national patient safety organizations have highlighted the importance of communication, including the Institute for Healthcare Communication and the National Quality Forum. In 2006, the Joint Commission created a new National Patient Safety Goal on handoffs. In 2009, the goal remains virtually unchanged, requiring the organization to implement "a standardized approach to hand-off communications, including an opportunity to ask and respond to questions."
As the preceding paragraphs suggest, there is abundant evidence of the negative consequences of poor communication and inadequate handoffs in health care. The purpose of the current study was to identify all English-language articles on resident and/or attending physicians' handoffs in the United States, conduct a systematic review of research studies, perform a qualitative review of barriers and strategies mentioned across all articles, and identify features of structured handoffs that have been shown to be effective. This review was conducted in conjunction with the Alliance of Independent Academic Medical Centers National Initiative: Improving Patient Care Through GME. The National Initiative was a collaborative formed in 2007 that linked residency programs in 19 teaching hospitals across the United States in efforts to integrate academics and quality through projects coordinated at a national level.