Since completing residency in 2012, I’ve worked at large academic centers like UCSF, Brigham and Mount Sinai, at community hospitals like Jefferson Cherry Hill and I’ve also done short locum tenens assignments at tiny remote hospitals like Franklin Memorial Hospital in Maine.
Regardless of where I’ve worked, handoff between physicians at change of shift remains one of the most challenging tasks that no one has seemed to figure out completely. To outsiders it would seem that otherwise meticulous healthcare professionals seem to engage in a very brief exercise that is prone to errors and omissions. During the changeover from day to night shift (or vice versa) the handoff conundrum is evident – exhausted healthcare professionals are trying to get home to their families and yet they must stay behind and pass on important information about patients to the next caretakers.
I’ve noticed that our nurse colleagues seem to spend 15-30 minutes going from room to room and eyeballing patients with the new oncoming RN and discussing the base. Often they’re each covering 3-6 patients and it makes this ritual sustainable. This system doesn’t work for most physician services like hospital medicine, which have 15-20 patients per doctor and a dozen doctors (some services have 100+ patients on the list). Usually, the team simply updates a section of the EMR with a summary and clinical course and then a to-do list or checklist of what the oncoming overnight physician must get done is passed off like a baton during a relay. In rare instances I have seen a system where there is no hand off at all and the night time doctors act like firefighters all shift!
Physician group staffing ratios change dramatically from days to nights. For example – in a hospitalist service of 5-10 daytime doctors, you may only have 1-3 night physicians and/or PA/NPs covering the service. It’s rare that you’re signing out one clinician list to another clinician, it is always many to one. The night team responsibilities are obviously different too, they’re usually responding to emergencies and doing new admissions, rather than rounding and discharging existing patients. They don’t have to necessarily know every little detail on every single patient, but they do need clinically relevant and updated information.
It seems historically that the culture of medicine has placed a high value on individual responsibility and autonomy, which can sometimes lead to a reluctance to rely on others for information or decision-making. Patients may have noted that the ER doctor, the admitting doctor and then consultants ask them similarly identical questions. This is because the electronic record may be filled with bloat and also copied forward incorrect information.
However, in recent years, there has been increasing recognition of the importance of effective communication and handoff protocols in ensuring patient safety and continuity of care. Many healthcare organizations have implemented formal sign-out procedures to help ensure that critical information is communicated clearly and accurately between healthcare providers. These procedures may include standardized forms, checklists, and specific protocols for who should be involved in the sign-out process. The better ones have integrated tools in their electronic medical records.
Despite these efforts, there is still variability in the implementation of sign-out procedures across healthcare organizations and individual physicians. This may be due to a lack of consistent training and education on effective communication and handoff protocols, as well as cultural and organizational barriers to change. However, the recognition of the importance of effective sign-out procedures is growing, and efforts to standardize these processes are likely to continue in the future.
There are many ways to improve physician handoff at change of shift. Here are a few suggestions (obviously these don’t work for all specialties/groups):
Use a structured handoff format. A structured handoff format helps to ensure that all important information is communicated. There are many different structured handoff formats available
I-PASS mnemonic is defined as illness severity, patient information, action list, situational awareness and contingency plans, and synthesis by receiver.
SBAR (Situation, Background, Assessment, Recommendation)
I-ABCDE (Illness or Injury, Allergies, Background, Current Medications, Diagnosis, Disposition, Estimate)
TEACH (Transfer of Care, Education, Assessment, History, Communication)
RATS (Reason for transfer, Assessment, Treatment plan, Summary)
These formats are all designed to help ensure that all important information is communicated during a handoff. They can be used in any setting, including hospitals, clinics, and nursing homes. It is important to choose a format that fits your needs and the needs of your team. You may also want to consider using a combination of formats. For example, you could use iPass for the main body of the handoff and then use SBAR to summarize the key points.
Conduct handoffs in person. Face-to-face handoffs are more effective than phone or electronic handoffs. This is because they allow for better communication and understanding.
Allow time for questions. The handoff should be followed by a period of time for questions. This allows the receiving team to ask any questions they have about the patient. Electronic handoffs obviously leave no opportunity to ask questions. It’s just simply one way communication.
Document the handoff. The handoff should be documented in the patient’s medical record. This ensures that the information is not lost.
Be clear and concise. When giving the handoff, be sure to speak clearly and concisely. Avoid using jargon or medical terms that the receiving team may not understand.
Be specific. When providing information about the patient, be as specific as possible. This includes the patient’s diagnosis, medications, allergies, and any other relevant information.
Use technology to support handoffs. There are a number of technologies that can be used to support handoffs. These technologies can help to improve the efficiency and accuracy of handoffs.
By following these suggestions, you can improve physician handoff at change of shift and help to ensure that patients receive safe and effective care.
Varun Verma M.D. is a board-certified internal medicine physician, entrepreneur, patient advocate and author. He is the co-founder of Andwise – a platform designed to empower physicians with the financial knowledge and resources they need to make smart financial decisions.