The ED is usually the only part of the hospital that has multiple doctors and nurses working at full speed 24 hours/day. A night shift as an ED registrar rarely allows for a wink of sleep, and we are constantly chopping and changing between day and evening shifts when not on night duty, punishing our bodies. Finishing work on time is essential to maintain any routine (and sanity!) in your life as an ED doctor.

Therefore, we buy into the shiftwork mentality – it is the clock that dictates when we leave work, not how long our list of patients is.

Despite the transiency of our patient ‘ownership’ (most go home, and those that are admitted usually get rushed upstairs so that the ‘4-hour target’ is adhered to – certainly in the UK, increasingly so in Australia), a consequence of shiftwork culture in the ED is that an undeniably large part of our job is ‘handover’.

What is ‘handover’?

‘Handover’ (or ‘signout’ /’handoff’ in the US) is a process that occurs at shift change where a doctor finishing their shift transfers the responsibility of his/her patients to a receiving doctor who is starting.

Multiple pieces of information require transmission from one brain to another:

• Patient demographics
• Working diagnosis/differential
• Background
• Physical examination/investigations/referrals made
• Plan/likely disposition
• Expectations of near future – flag management priorities if any deviation from expected clinical path

The process of handover varies significantly depending on institution:

The people involved:

• One-on-one meeting/conversation between two doctors.
• Formal doctors meeting (often called ‘handover’), where cases are discussed by the whole group before the responsibility of a patient is allocated to a receiving doctor – usually overseen by a consultant.
• Other members of the multidisciplinary team can be present at handover (nurses, pharmacists, physiotherapsists)

Where in the process occurs:

• In the central clinical area, usually beside computers.
• In a separate area of the department – away from the busy, chaotic clinical area.
• At the bedside.

Structure:

• Oral only, with perhaps occasional jotting on scrap paper.
• Oral and written (either handwritten, or electronic medical record).
• Written only.
• Use of handover mnemonic (SBAR, I-PASS, SIGNOUT etc).

Is handover a source of error?

A sentinel event is ‘any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness’. A sentinel event occurs as a result of an error from a healthcare professional.

The Joint Commission in the US report that 70% of sentinel events are caused by communication breakdown. Of these, 50% occur during the transition of care from one healthcare professional to another – i.e. during handover (1).

Inadequate handover occurs as a result of failure to include critically important information, failure to accurately portray severity of illness, or transferring erroneous information. Clearly, all can all have devastating consequences.

What contributes to poor handover in the ED?

Departmental Factors

The ED is a chaotic working environment with frequent interruptions. It has been estimated that consultants are interrupted on average every 9 minutes during the course of a shift, and residents every 14 minutes (2).  An unpredictable, loud, and disruptive environment is suboptimal for the sensitive handover process.

When the department is particularly busy, there is increased pressure on doctors to ‘pick up’ patients. The more patients a doctor is taking care of (particularly late in a shift), the more information they’ll have to handover – more opportunity for error (especially if that doctor is desperate to leave on time).

The culture of the department may dictate that handover is viewed as an informal process. This creates a fertile environment for error:

• Handover may not receive an appropriate amount time or effort.
• Despite taking nominal responsibility of a handed patient, receiving doctors may not invest as much time/energy as that patient is ‘second hand’ – how many times have you heard a colleague being grilled by a boss about a patient, and defensively responding with ‘well it was a handover..’ – as if that is an acceptable excuse for not knowing all the important details regarding a sick patient they are responsible for.
• The hierarchy of a department might dictate that juniors handover to other juniors without senior supervision.
• Lack of MDT involvement: this can lead to nursing staff not knowing which doctor has the responsibility of the patient at a certain point in time – ‘ambiguous moment of transition of care’ (3).

Individual Factors

Task saturation/multitasking is commonplace in a busy ED. Individuals may be so busy that they may not allocate enough time to give/take adequate handover. A departmental culture with a lax attitude towards handover compounds this problem.

An individual may be desperate to finish a shift for personal reasons, and rush the handover process. Again, this problem can be facilitated by suboptimal departmental culture.

Individual cognitive bias can play a role in faulty handover leading to error:

• Receiving doctor trusting erroneous information – ‘diagnosis momentum’.
• Receiving doctor misinterpreting information due to their own biases. ‘Anchoring’occurs – focusing on one aspect of the presentation (and ignoring others) because that particular element was important in previous memorable cases (3).

Doctors may not use a standardized approach:

• Individual preference/style is often preferred (particularly by senior clinicians who have practiced in a certain way for many years). This creates unpredictable and variable handover content, which can obstruct the transmission off vital information.
• Too much information may be handed over – overwhelming; more difficult to elicit key elements that will potentially require action.
• Poor communication techniques:
  • No ‘closed-loop’/’repeat back’ communication.
  • ‘Unidirectional’ communication (i.e. not bidirectional, where the receiving doctor asks questions and clarifies content) (3, 4).

Wider issues

An ethos within medicine, particularly within EM, is to rule out the worst-case scenario for a given presentation, and then work backwards. We like to hunt for ‘red flags’ that highlight potentially high-risk patients with a worrying underlying diagnosis. We know what the red flags are when considering a patient presenting with back pain or dyspnoea, but we don’t know what the red flags are when considering a handover. Perhaps a patient who has required consultant input, or has pending imaging should be flagged as higher risk to the receiving doctor. No evidence currently exists that shows certain elements of a handover to represent a high-risk scenario.

Handover technique is not in the medical school curriculum. We learn how to take a detailed history, perform a physical exam, and then present our findings to a senior doctor, but we don’t learn how to succinctly structure a handover. This leads to the common problem of very junior doctors overwhelming a receiving doctor with information (see above).

So… The Paper

“Changes in Medical Errors after Implementation of a Handoff Program”

http://www.ncbi.nlm.nih.gov/pubmed/25372088

This paper from the New England Journal came to my attention by being named a ‘Hall of Famer’ in Research and Reviews in the Fast Lane.

It was also reviewed by Ryan Redecki over at Emergency Medicine Literature of Note – ‘It’s a Patient Handoff Miracle’.

What were they Pondering?

• Will implementation of a standardised handoff (handover) program reduce medical errors/adverse events/miscommunication?
• Will this program increase the workload of residents?

What type of study was it?

• Multi-centre prospective intervention study.
• Pre-intervention data was collected for a 6-month period. Then there was a 6-month period of implementing the intervention. Then post-intervention data was collected for a further 6-months.

Who were they studying?

• They were studying the residents at nine paediatric residency programs in the US and Canada.
• None of the sites studied had a standardized handover procedure in place.
• 875 residents participated.

What was the intervention?

Implementation of the ‘I-PASS Handoff Bundle’ – 7 elements:

1. Introduction of the I-PASS mnemonic
2. 2-hour workshop
3. 1-hour role-playing and simulation session (practicing skills from the workshop)
4. Computer module for independent learning
5. Faculty development program
6. Direct-observation tools for faculty to provide feedback to residents
7. Departmental culture-change campaign (logo, posters etc)

The I-PASS structured handover tool was integrated into verbal and written handovers at all sites. Both verbal and written handovers were expected for every patient.

What was the Primary Outcome?

2-component primary outcome:

• Rates of medical errors (overall errors)
• Rates of preventable adverse events (errors that led to patient harm)

What else was being looked at?

The quality of written and verbal handovers was evaluated. This was performed by recording the inclusion of key quality elements before and after the intervention.

Key quality elements for handover:

• Illness severity assessment
• Patient summary
• To do list
• Contingency plans
• Readback by receiver (oral handover only)

Resident workflow patterns were evaluated. Did the intervention increase the amount of time residents spent handing over, and therefore, reduce the time they spent with patients?

How were medical errors identified?

10, 740 patient admissions (5516 pre-intervention and 5224 post-intervention) were reviewed for the presence of medical error.

Possible errors were identified by a research nurses reviewing medical records, formal incident reports, or solicited reports from nurses/residents in postshift surveys.

2 physician investigators interrogated each suspected error and classified it into:

• An adverse event (patient harm due to medical care) – further classified into preventable (due to medical error) and non-preventable.
• A non-harmful error (or ‘near miss’).
• Neither (excluded).

Subtypes of error

• Errors related to diagnosis (incorrect, delayed, omitted)
• Errors related to therapy other than medication or procedure
• Errors related to history/physical examination
• Multifactorial errors
• Medication-related errors
• Procedure-related errors
• Falls
• Nosocomial infections

 The results…

Overall errors?

• There was a 23% relative reduction in the rate of all medical errors (before vs after the intervention, 24.5 vs. 18.8 errors per 100 admissions, P<0.001).
• Significant error reductions were seen in 6 of the 9 sites.

Adverse events?

There was a 30% relative reduction in the rate of preventable adverse events (4.7 vs. 3.3 events per 100 admissions, P<0.001).

Non-harmful medical errors?

There was a 21% relative reduction the rate of non-harmful medical errors (19.7 vs. 15.5 non-harmful errors per 100 admissions, P<0.001).

What subtypes of error were reduced?

There were significant reductions in:

• Diagnostic errors
• Errors related to history/examination
• Errors related to therapies other than medication/procedure
• ‘Multifactorial errors’

Did the quality of handovers improve?

Significant improvements were found in the quality of written and oral handovers.

All key quality elements for written and oral handover saw a significant improvement in their inclusion.

Did resident workflow patterns change?

No significant change in mean duration of oral handover sessions.

No significant change in the percentage of time in a 24-hour period spent in contact with patients and families, and performing handover (written and oral).

Stengths of this study…

It was a multi-centre trial.

Pre-intervention and post-intervention data was collected at the same time of year – safeguards against time-of-year confounding (i.e. difference in resident experience; patient population).

The physician investigators who categorized the suspected errors were blinded (however the nurses collecting the initial data were not).

A single-centre study was performed beforehand as an exploratory study – this saw similar improvements in error reduction.

Key differences in the exploratory study intervention bundle:

• SIGNOUT mnemonic used instead of I-PASS
• As part of the intervention bundle, a team-based handover structure was implemented– all handovers took place in the presence of the whole team, in a quiet room.
• Did not include role-playing/sim session, computer module, faculty development program, direct-observation tools for faculty, or a culture-change campaign.
• There is a ‘Paper Chase’ on EM:RAP discussing this paper.

Limitations…

This study was performed in the paediatric setting. It is difficult to know whether we can extrapolate the results to the EM/critical care setting.

The study focuses on one-to-one handovers. It doesn’t introduce a team-based handover structure in the intervention bundle (unlike the exploratory study).

The two physician investigators had only a 70% agreement (Kappa score 0.47) when classifying incidents into an adverse event/non-harmful error/exclusion; and only a 72% agreement (Kappa score 0.44) when further classifying adverse events into preventable/non-preventable. There was, therefore, a considerable amount of disagreement between the investigators, which makes the data less reliable.

• A ‘Kappa score’ is a statistic that removes the percentage agreement that would occur by chance, and calculate true inter-rater agreement.
• Kappa scores of 0.47/0.44 indicate, at best, a moderate inter-rater agreement.

The ‘I-PASS handoff bundle’ was a multi-pronged intervention. It is, therefore, difficult to tease out which elements of the bundle made the difference. Was it the introduction of the I-PASS mnemonic? Was it the various educational interventions? Was it the overall change in departmental culture as a result of participation in this study?

By virtue of participating in this study, the handover process will have been in the spotlight at each of the participating sites, which may have contributed to the results. Will the observed error reductions be maintained when research is no longer being conducted?

Final thoughts

Handover is a massive part of our daily practice as ED doctors.

A suboptimal handover process (no standardization, informal departmental attitude, minimal senior input) creates an environment that is extremely vulnerable to error.

It has been shown in this study that standardizing the process and educating doctors/raising awareness of the importance of handover safeguards against medical error– i.e. An overall shift in departmental culture is the key.

Instead of a minefield for medical error, perhaps a healthier way to view handover is as an opportunity to take a step back, review the case and collaborate with the receiving doctor who has a fresh perspective. It is also a fantastic platform for case-based teaching from seniors.

References

1. “Changes in Medical Errors after Implementation of a Handoff Program” http://www.ncbi.nlm.nih.gov/pubmed/25372088
2. ”The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care.” http://www.ncbi.nlm.nih.gov/pubmed/17059892
3. ”Improving Handoffs in the Emergency Department” http://www.ncbi.nlm.nih.gov/pubmed/?term=improving+handoffs+in+the+emergency+department+kelly
4. ”Reducing Error in the Emergency Department: A Call for Standardisation of the Signout Process” http://www.ncbi.nlm.nih.gov/pubmed/?term=impReducing+Error+in+the+Emergency+Department%3A+A+Call+for+Standardisation+of+the+Signout+Process
5. ”Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.” http://www.ncbi.nlm.nih.gov/pubmed/?term=Rates+of+Medical+Errors+and+Preventable+Adverse+Events+Among+Hospitalized+Children+Following+Implementation+of+a+Resident+Handoff+Bundle