BACKGROUND

Previous studies reveal that ineffective communication contributes to patient-safety events. Structured handoffs improve communication during shift change and transfers from outpatient clinics to emergency departments. We aimed to improve the perceived quality of admission handoffs from a baseline of 22.2% to 50% by the end of the study period through use of a standardized template between urgent care (UC) and inpatient providers.

METHODS

We used quality improvement methodology to identify key themes (clarity in illness severity, organization, completeness, and pace) that contribute to decreased quality communication. A survey to evaluate the perception of communication and key themes between the groups was administered. During the 15-month quality improvement study at a tertiary pediatric institution, we implemented a handoff tool with visual aids. Givers of information received formal training. Participants received iterative performance feedback. A control chart was used to monitor fidelity to the handoff tool. We used statistical analyses to compare changes in perceived communication between provider types before and after implementation of the handoff tool.

RESULTS

Both UC and inpatient providers had an increased rate of positive perceptions in the overall quality of communication after 12 months of using the admission handoff tool (22% vs 67.3%; P = .01). Complete fidelity to the admission handoff tool increased over time. There was no change in mean duration of handoff (4 minutes) after implementing the structured handoff.

CONCLUSIONS

A structured handoff during admission of pediatric patients from an off-site UC to inpatient setting improved the perception of the quality of admission handoff communication.

Ineffective handoff communication is recognized as a critical patient-safety problem in health care. Errors in communication result in increased patient morbidity and mortality and play a significant role in malpractice claims.1  An estimated 80% of serious medical errors involve miscommunication between providers during the transfer of patients from one medical provider to another with change of shift or change of care setting.2 

Results of previous studies support the use of structured handoffs to decrease medical errors and preventable adverse events without negatively impacting workflow during shift changes.3,4  In addition to improving patient care and safety during shift changes, implementation of a structured handoff during emergency department to inpatient admissions results in increased staff satisfaction5  and improved communication during interdepartmental transfers within a hospital setting.6 

Transitioning care of a patient from a location that is geographically separate from the next care team adds another level of complexity. This type of transfer requires effective communication to ensure the patient arrives safely to the appropriate unit and the accepting care team is prepared for the patient’s arrival. Huth et al describe how structured handoffs improve communication during transfer of care from off-site outpatient clinics to the emergency department.7  However, to our knowledge, the use of a structured handoff to improve communication for direct admission to an inpatient setting for pediatric acute illness or injury from an urgent care (UC) center has not been described.

We aimed to improve the percentage of positive perceptions of overall quality of the verbal admission handoffs between UC providers to inpatient-receiving physicians from a baseline of 22.2% to 50% by the end of the study period. To achieve our goal, we implemented multiple plan-do-study-act (PDSA) cycles to increase the use of an admission handoff tool to structure the handoff communication during the admission of pediatric UC patients to a geographically separate inpatient setting.

The receiving facility was a tertiary care pediatric medical center with ∼186 medical-surgical beds8  across 2 freestanding pediatric hospitals with general inpatient units. The general inpatient units are staffed by pediatric hospital medicine (PHM) teams and separate resident physician teams. Inpatient physicians use illness severity, patient summary, action list, situation awareness, and synthesis by receiver. Inpatient physicians use an evidence-based template developed by Starmer et al9  as the standard format for handoffs during shift changes on the general inpatient units.

The organization also has 3 pediatric UC centers located throughout the metro area in which the index admissions were generated. These UC centers are staffed by general pediatricians and advanced practice registered nurses (APRNs) who together complete >90 000 encounters a year, of which ∼1% require admission.10  UC providers directly admit patients to the inpatient units. Because of the geographical separation between the UC centers and inpatient units, all admission handoffs occur via telephone between the admitting UC provider and accepting inpatient provider. All admission handoffs are recorded and stored for 10 years in a secure database.11  A PHM physician triages admissions from outside facilities to help determine patient placement. However, when a triage physician is not available, the admitting provider delivers the handoff directly to the PHM or resident team. Before the study period, there was no standard format for admission handoffs.

Before the start of the intervention, a team of UC and PHM physicians completed a fishbone diagram to identify key themes that contributed to admission handoff communication quality: clarity, completeness, organization, and pace (Fig 1). After identifying the key themes, the team developed a Research Electronic Data Capture (REDCap) survey (Supplemental Table 2) that was sent to all UC and PHM providers in July 2018.12,13  This survey was used to measure the impact of the key themes, as well as obtain a baseline perception of the overall quality of communication during admission handoffs between UC and inpatient providers. A free-text box at the end of the survey captured additional comments used to craft interventions. Provider perceptions of handoff communication were again assessed by using the same REDCap survey 12 months postimplementation (July 2019), and results were shared with the providers via e-mail and division meetings. We excluded resident physicians from the survey because the UC provider typically interacted with the PHM triage physician to communicate the admission handoff.

With the key themes (Fig 1) in mind, the team collaborated to develop essential elements that should be included during an admission handoff. Because PHM physicians used illness severity, patient summary, action list, situation awareness, and synthesis for handoffs during shift change, this format was used as the template for the admission handoff tool between UC and inpatient providers. We added elements to each component to include information essential to the safe handoff of care from the off-site outpatient setting to inpatient (Fig 2A).

We completed multiple PDSA cycles during the study period. We launched the handoff tool July 1, 2018, via a campaign with educational presentations to UC and PHM providers. We displayed visual aids in UC and PHM work areas. UC providers participated in an interactive workshop in October 2018 in which they practiced using the handoff tool to deliver information from mock scenarios of common pediatric UC admissions. We modified the admission worksheet that PHM physicians used to take notes during handoffs in January 2019 to mirror the order, information, and cadence of the admission handoff tool. The project leader emailed UC providers individualized quarterly feedback on their admission handoffs. This included the percentage of complete fidelity to the handoff tool and the percentage of each component delivered. PHM physicians received quarterly feedback on their division’s overall performance by the PHM champion either by e-mail or during division meetings. By using feedback received from PHM and UC providers during the first 12 months of the intervention, the visual aid that was displayed in the work areas was updated for the final quarter of the intervention (Fig 2B).

We evaluated all handoffs between core UC providers (physicians and APRNs) to PHM physicians and inpatient residents for patients who were successfully admitted to the general inpatient unit during the baseline (May 1, 2018, to June 30, 2018) and the intervention period (July 1, 2018, to September 30, 2019). We excluded the handoff if the patient was admitted to intensive care or a subspecialty team. Handoffs provided by moonlighting providers, whose primary employment was outside of the UC division, were excluded. We also excluded handoffs that did not result in admission (ie, deferred to emergency department, discharged from the hospital, or underwent further evaluation or in the UC before acceptance of the admission) because the decision to defer admission was often made before completion of the handoff.

In addition to the project leader, 15 study team members received instruction on how to review the admission recordings and record data during a training workshop. During the workshop, team members reviewed sample admission handoffs and discussed whether the handoff included each component. The team agreed that a handoff was considered to have a component of the tool if the provider mentioned at least 1 element from the description (Fig 2) of that component.

For each admission handoff recording, reviewers collected data variables, including UC provider type (physician or APRN) and inpatient physician type (PHM attending or resident), duration of handoff, and components of the handoff. The reviewers listened to recordings of the handoff admission phone call and entered the results into a REDCap database.12,13  To provide feedback, reviewers of the handoff recordings were not blinded to the identities of the givers or receivers. To evaluate for interrater variation, the project leader (A.N.) audited 10% of recordings for concordance of findings, and no discrepancies were found.

Our primary outcome measure evaluated the percentage of positive perceptions on the overall quality of the communication during admission handoffs. Our secondary outcome measures the percentages of positive perceptions of individual handoff themes: clarity of illness severity, pace, organization, and completeness. We obtained these by surveying UC providers and PHM physicians before and after the intervention period. We used a 4-point Likert scale to evaluate the perceived overall quality of admission handoffs. We used a 5-point Likert scale to measure the perceived clarity of illness severity, organization, completeness, and pace of handoffs.

Our primary process measure evaluated the percentage of handoff admissions that included all 5 components. As secondary process measures, we evaluated the percentage of each individual component included in the handoff to identify which components were omitted most often. These guided improvement opportunities for subsequent PDSA cycles.

We monitored duration of handoff as a balancing measure. We measured handoff time in minutes and rounded to the nearest whole integer. The measurement started from the initiation of the conversation to the last exchange between the 2 providers on the recording.

To evaluate the percentage of positive perceptions on the overall quality of the admission handoff, we compared survey results from baseline to 12 months after introduction of the handoff tool. For this analysis of our primary outcome, we defined positive perception of quality in the handoff as above average or excellent. For the secondary outcome measures, we defined positive perceptions of clarity of illness severity, pace, organization, and completeness of handoff as most times or almost always. We calculated the frequencies of positive perception responses for preintervention and postintervention periods and compared differences in proportion (difference-in-difference). We used the Breslow-Day test for homogeneity to compare changes in perceived communication (baseline versus 12 months) between provider type. We defined statistical significance as a P value <.05.

For our primary process measure, we evaluated the percentage of handoffs that included all 5 components of the structured tool using a p-chart. This allowed us to account for variation in the number of monthly admissions. We evaluated the percentage of the individual components as a monthly run chart of the aggregate data. The average duration of handoff in minutes was compared across sites within each quarter and across the duration of the intervention period by using analysis of variance. Pearson’s χ2 test was used to evaluate differences across UC sites for each quarter.

This study was deemed nonhuman subject research by our institutional review board.

We distributed the preintervention and postintervention survey to 81 providers. We had 45 (55.6%) respondents to the preintervention survey (22 PHM and 23 UC providers). For the postintervention survey, sent 12 months after the start of the admission handoff tool, 46 providers (56.8%) responded (19 PHM and 27 UC).

The overall perception of quality of communication for all surveyed respondents increased from 22.2% at baseline to 67.3% (P = .01) after 12 months of implementing an admission handoff tool. Before the study period, UC providers were significantly more likely to report the quality of communication during admission handoffs to be above average or excellent when compared with PHM physicians (39.1% vs 4.6%; P = .01). Results of the 12-month postsurvey continued to reveal that a higher percentage of UC providers have a more positive perception on the quality of admission handoffs than PHM physicians. However, the difference was no longer significant (74.1% vs 57.9%; P = .34) (Table 1).

Before the intervention, a higher percentage of UC providers had positive perceptions on the organization (47.8% vs 9.1%; P = .01) and pace of the admission handoff compared with PHM physicians. The percentages of positive perception of completeness and clarity of illness severity were not statistically different between UC and PHM providers.

After the intervention, UC providers continued to have a higher percentage of positive perceptions for all key themes of communication (Fig 3). However, after 12 months of using an admission handoff tool, the only statistically significant difference between UC and PHM providers that persisted was the percentage of positive perceptions on clarity of illness severity (100% vs 73.7%; P > .01) (Table 1).

There were 57 admission handoff recordings reviewed during the 2-month baseline period. During the 15-month study period, there were 911 admission handoff recordings screened for inclusion criteria. Admissions by moonlighting UC physicians (97) and admissions to subspecialty or critical care (92) were excluded. An additional 41 were excluded because of technical errors, in which the recordings terminated prematurely. The remaining 681 admission handoffs were included (Supplemental Fig 5).

Before implementation of the admission handoff tool, no admission handoffs included all 5 of the components. During the intervention period, the percentage of handoffs that included all components of the structured handoff increased 31.0% (95% confidence interval 17.8%–44.2%) from 47% during the first quarter (July to September 2018) to 78% during the final quarter (July to September 2019) of the intervention period (Fig 4A). Patient summary, which was 100% at baseline, remained essentially unchanged (99.8%) during the intervention period. Synthesis by receiver was omitted most frequently. When compared with the baseline period, communication of illness severity, situation awareness, and synthesis by receiver increased significantly (Fig 4B). No significant difference in handoff duration occurred across sites within each quarter or throughout the study period (P = .40).

The implementation of a structured admission handoff tool for admissions from an off-site outpatient setting to the general pediatric inpatient unit was successful in improving the perception of communication between UC and inpatient providers. Implementation of a structured admission handoff tool was associated with a significant improvement in PHM and UC providers’ perceptions of the organization and quality of communication during this critical point in patient care. PHM physicians’ positive perceptions of completeness also increased after implementation of the structured admission handoff. Aligning with the perception of improved communication during the study period, inclusion of all components of the structured handoff increased over time.

Omitted information has been identified as the root cause of most errors during transfers of care.14  Before the intervention, 83% of UC providers perceived that all pertinent details were discussed most times or always. However, only 55% of PHM physicians surveyed at baseline scored the completeness of the handoff with a positive perception. Although most handoffs in our study included patient summary (100%) and action list (91%) at baseline; providers often omitted the other components. Although we saw improvement in complete fidelity to the admission handoff tool after displaying visual aids and providing education, the greatest improvement occurred after an interactive workshop for UC providers that allowed for observed practice handoffs with real-time iterative feedback. Inclusion of synthesis by receiver increased when we modified the PHM admission worksheet to remind PHM physicians to provide a synthesis as the receiver of the handoff. This improvement is consistent with a previous study that revealed receiver-driven handoff communication interactions are effective in including more essential components of a handoff.7 

Although our results support the use of a structured handoff during admission from an off-site location to an inpatient setting, postsurvey free-text comments from both UC and PHM providers noted the subjectivity of the terms used to describe illness severity (stable, watcher, and unstable). These terms are interpreted differently in the outpatient setting compared to the inpatient setting. Anecdotally, UC providers often described patients they admitted as watcher or stable watcher because, in the UC setting, patients who were stable are usually discharged from the hospital. This difference in interpretation of illness severity likely accounts for the persistent difference in perceptions between UC providers and PHM physicians. The next intervention will focus on clarity by making illness severity descriptions more objective.

Our preintervention and postintervention survey results are consistent with previous studies in which it is indicated that givers of information perceive communication to be better than the receivers of that information.15  UC providers perceived the handoffs to be more complete, organized, and overall better quality than did PHM physicians in both survey periods. Despite the persistent discrepancy between the givers and receivers of information, after the implementation of a structured admission handoff tool, there was a balanced increase in positive perception of communication in both groups. This finding is consistent with other studies that have revealed improved perception in communication after implementation of a structured handoff.37,1517 

This study was limited by implementation at a single institution. Although we implemented this project across 3 UC centers and 2 freestanding hospitals located in 5 different geographic locations within a large metro area, the generalizability of these results may be limited. The receivers were already familiar with the framework, which may have accelerated the successful launch of the intervention. In addition, providers were aware their handoffs were being reviewed, which may have altered their behavior.18  Those who reviewed the admission handoff recordings were not blinded to the identity of the giver or receiver, which may bias the results; however, no discrepancies were found during the audit.

The presurvey and postsurvey was limited to UC core providers and PHM physicians although these groups interact with UC moonlighters and pediatric residents. Although PHM physicians and core UC providers account for the majority of admission handoffs, interactions with resident physicians and moonlighters who did not have consistent exposure to the interventions may have influenced the survey responses. Surveys were only distributed twice during the study period because of the feasibility of asking providers to complete multiple surveys. Therefore, we cannot determine which intervention drove the greatest change to our outcome measures. We did not evaluate direct patient-safety metrics. However, because breakdown in communication is the most common factor in sentinel safety events, our improvements in the perception of communication during transfer from one facility to another is an important factor in patient safety.

Inpatient providers must receive clear and complete information to effectively assume care of admitted patients. Our study adds to the existing body of evidence revealing that structured handoffs improve interdepartmental communication.6,7  Inpatient providers can collaborate with outlying acute care facilities and primary clinics to identify essential elements that should be included in admission handoffs. Future interventions for our project include using an objective illness severity score to improve clarity. As more data are available, clinical outcomes of admitted patients can be compared to variation in adherence to the admission handoff tool.

We thank the divisions of UC and Hospital Medicine at Children’s Mercy Kansas City for their participation and feedback throughout the project. We acknowledge Mike Weckwerth and the Children’s Mercy Transport Center for their help in accessing the recordings for review. We also would like to thank the Medical Writing Center at Children’s Mercy Kansas City for editing this article.

FUNDING: Supported by Children’s Mercy Kansas City. There was no external funding for this article. The funder/sponsor did not participate in the work.

Dr Nedved conceptualized and designed the study, analyzed and interpreted the data, drafted the initial manuscript, and supervised the approval of the final manuscript; Dr Berg assisted in study design and critically reviewed the manuscript; Dr Lee provided data interpretation, assisted in data analysis, and critically reviewed the manuscript; Dr Montalbano mentored Dr Nedved throughout the project, from project design through methods, aided in data collection, management, and interpretation, and critically reviewed the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Deidentified individual data will not be made available.

1.
CRICO Strategies
.
Malpractice Risk in Communication Failures: 2015 Annual Benchmarking Report
.
Boston, MA
:
The Risk Management Foundation of the Harvard Medical Institutions, Inc.
;
2015
2.
Joint Commission
.
Most commonly reviewed sentinel event types
.
3.
Starmer
AJ
,
Sectish
TC
,
Simon
DW
, et al
.
Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle
.
JAMA
.
2013
;
310
(
21
):
2262
2270
4.
Starmer
AJ
,
Schnock
KO
,
Lyons
A
, et al
.
Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow
.
BMJ Qual Saf
.
2017
;
26
(
12
):
949
957
5.
Bigham
MT
,
Logsdon
TR
,
Manicone
PE
, et al
.
Decreasing handoff-related care failures in children’s hospitals
.
Pediatrics
.
2014
;
134
(
2
):
e572
e579
6.
Breuer
RK
,
Taicher
B
,
Turner
DA
,
Cheifetz
IM
,
Rehder
KJ
.
Standardizing postoperative PICU handovers improves handover metrics and patient outcomes
.
Pediatr Crit Care Med
.
2015
;
16
(
3
):
256
263
7.
Huth
K
,
Stack
A
,
Hatoun
J
, et al
.
Implementing receiver-driven handoffs to the emergency department to reduce
.
BMJ Qual Saf
.
2021
;(
3
):
208
215
8.
American Hospital Directory
.
Identification and characteristics
.
9.
Starmer
AJ
,
Spector
ND
,
Srivastava
R
,
Allen
AD
,
Landrigan
CP
,
Sectish
TC
;
I-PASS Study Group
.
I-pass, a mnemonic to standardize verbal handoffs
.
Pediatrics
.
2012
;
129
(
2
):
201
204
10.
Children’s Mercy Kansas City
.
Children’s Mercy Annual Report 2017
.
11.
ASC
.
Search & replay
.
Available at: https://www.asc.de/english/search_replay.html. Accessed May 26, 2021
12.
Harris
PA
,
Taylor
R
,
Thielke
R
,
Payne
J
,
Gonzalez
N
,
Conde
JG
.
Research Electronic Data Capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support
.
J Biomed Inform
.
2009
;
42
(
2
):
377
381
13.
Harris
P
,
Taylor
R
,
Minor
B
, et al
;
The REDCap consortium
.
Building an international community of software partners
.
J Biomed Inform
.
2019
;
95
:
103208
14.
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
(
6
):
401
407
15.
The Joint Commission Center for Transforming Healthcare
.
Improving Transitions of Care: Hand-Off Communications
.
Oakbrook Terrace, IL
:
The Joint Commission
;
2014
16.
Sheth
S
,
McCarthy
E
,
Kipps
AK
, et al
.
Changes in efficiency and safety culture after integration of an I-PASS-supported handoff process
.
Pediatrics
.
2016
;
137
(
2
):
e20150166
17.
Starmer
AJ
,
Spector
ND
,
Srivastava
R
, et al
;
I-PASS Study Group
.
Changes in medical errors after implementation of a handoff program
.
N Engl J Med
.
2014
;
371
(
19
):
1803
1812
18.
McCambridge
J
,
Witton
J
,
Elbourne
DR
.
Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects
.
J Clin Epidemiol
.
2014
;
67
(
3
):
267
277

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no relevant potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.