Handoffs of care — also known as transitions of care — occur when the responsibility for a patient’s care moves from one health care provider to another. Handoff processes in other high-risk industries, such as aerospace, aviation and nuclear power, are noted to be structured and have become fine-tuned.
Health care is realizing that processes used in other industries have a role in ensuring safe and quality care for patients. Consistently structuring two-way communication that is scripted, precise, impersonal and efficient within a framework that allows for reassessment and read-back of information is extremely valuable.
A new AAP policy statement and clinical report highlight best practices and offer evidence and rationale for standardizing handoff processes. The policy Handoffs: Transitions of Care for Children in the Emergency Department is available at http://dx.doi.org/10.1542/peds.2016-2680 and is jointly issued by the AAP Committee on Pediatric Emergency Medicine, the American College of Emergency Physicians and Emergency Nurses Association. The clinical report Standardization of Inpatient Handoff Communication, from the AAP Committee on Hospital Care, is available at http://dx.doi.org/10.1542/peds.2016-2681. Both will be published in the November issue of Pediatrics.
The policy statement offers rationale for structuring transitions of care for children in the emergency setting and includes a description of strategies, with resources for educating health care providers. Recommendations are given for development, education and implementation of transition models.
The clinical report aims to guide shift change communication for inpatient handoffs between providers on the same service. The report also identifies best practices for physicians who provide direct clinical care to pediatric patients in the inpatient or critical care unit.
Transitions a ‘risky juncture’
Communication errors are the root cause of a significant proportion of reported sentinel events, according to The Joint Commission. The period of time when care is transitioned from one provider to another has been implicated as a particularly risky juncture. As regulators, payers, professional organizations and hospitals attempt to curb medical errors, there is an intense focus on handoff communication.
The emergency setting, which involves multiple disciplines, frequent shift changes and varying degrees of patient acuity, is especially vulnerable to communication difficulties. In addition, newer practice strategies that decrease shift length in the inpatient setting, thereby creating a need for more frequent handoffs, also is an area where structured transition of care processes can be beneficial.
Current handoff practices have been criticized as being highly variable and unreliable, as well as unstructured, informal and error prone. Nonstandardized approaches can lead to adverse clinical consequences, near misses and inefficient or duplicative care.
Value of structured processes
The medical literature indicates that structured communication facilitates handoffs and that handoffs can be improved. Although much of the literature focuses on trainees at academic centers, the research has widespread implications on the importance of handoffs for physicians at all levels of training. In one study, implementation of a standard handoff process among trainees decreased preventable medical errors by 30% (Starmer AJ, et al, N Engl J Med. 2014;371:1803-1812).
Structured handoff practice can promote quality of care and protect patient safety by providing the opportunity to detect and mitigate potential errors, e.g., when the receiving health care provider may notice something overlooked by current providers. Handoff procedures offer the opportunity for rescue and recovery when situations are unclear or a practitioner’s thinking is incomplete.
Bedside handoffs allow patients to be a part of the transition of care between providers, promoting positive outcomes for patients and the health care team. A physician exchange of information at bedside has been shown to be a patient-preferred methodology that encourages patients to participate in their care (Lehmann LS, et al. N Engl J Med. 1997;336:1150-1155).
While these two statements take aim at specific practice settings, the principles elucidated have relevance to all who practice pediatric medicine.
Recommendations
- Handoffs improve when communication is standardized. Handoffs are optimized when sign-out is an active process, without interruptions, in a dedicated place and at a dedicated time.
- Handoffs allow a time to review clinical events and studies. They are an ideal time to seek advice, insight and consultation from colleagues.
- Handoff communication should attempt to be patient- and family-centered, involving patients and/or caregivers.
- Handoff communication is a skill requiring training and practice. Residency programs often include this competency in their curriculum development, and practicing physicians and advanced practice providers are likely to benefit from ongoing training.
- Time and administrative support for handoffs should be included in practitioners’ working hours.
- Studies comparing handoff models are encouraged. Standardized, validated process and outcome metrics are recommended to evaluate the effectiveness of processes of care.
Dr. Gross is a lead author of the policy statement and a member of the AAP Committee on Pediatric Emergency Medicine. Dr. Jewell is lead author of the clinical report and chair of the AAP Committee on Hospital Care.
