Just another initiative?
Did you run track in high school or college? If so, there is a chance you were in a relay. Relays required skill not just in running but also in the method of transferring the next leg of the race to a teammate. You learned to pass the baton. If you dropped the baton the consequences were obvious and immediate.
Handoffs have become another initiative in hospitals. Taking a cue from sports, hospitals and professional organizations are launching handoff strategies in various clinical areas. Just as an athlete transfers responsibility for the next leg of the race when they handoff the baton, clinicians, nurses and doctors transfer responsibility for care of their patients when they leave the clinical area. In addition, we must also transmit important information about our patients, in other words we “sign out”.
The spotlight is on handoffs as an important process to prevent errors and improve patient safety. The problem is the underlying debate about implementing major initiatives, such as handoffs, when there is not strong evidence to support their actual ability to bring about important improvement. Two Systematic Reviews show considerable variation in study methodology, making it difficult to inform clinical practice. Both the strategies of handoffs and tools used to support handoffs lack good evidence and future research is suggested.
Does insufficient evidence mean we should not consider handoffs as a process to improve opportunity for safe care?
Let’s look in on Mr. Jones:
Mr. Jones is in your ED waiting for an inpatient bed. He’s 84 years old, lives alone, and has CHF as well as Type II diabetes. His eyesight is failing due to macular degeneration. He smiles to reassure you that he understands what you are saying.
You are the ED “doc”, pressed to evaluate another patient before your shift ends. This same challenge faces the nurse, who has two IVs to start and another patient to assess prior to the next nurse taking over. The nurse has just learned Mr. Jones is very anxious about his dog, which he left alone in the house. How does this handoff play out in a hospital that has no formal process?
I suggest some readers of this post have experienced a sinking feeling when faced with the need to “wing it” in this situation. The infrastructure is not in place to see that some process is followed to assure effective communication crosses over to the oncoming shift. The culture is not in place for systematic methods in caring for patients.
Mr. Jones needs continuity throughout his transfer from the ED to an inpatient bed. If there is no effective sign out process in place for both of these clinicians what can happen to Mr. Jones? When the new nurse takes over and Mr. Jones is moved to his bed, is there clarity in the plan of care and medication reconciliation? What about his anxiety related to his unfed and lonely dog?
There may be insufficient evidence to identify specific methods in handoffs and demonstrate their effectiveness on improving outcomes, but “winging it” is not an option in the complexity of caring for patients today. Lay publications point to national initiatives such as the Safer Sign Out protocol for patient-centered methods of team communication.
Stewardship for patients
If we are to be good stewards of limited resources and be the professionals we want to be, then adopting systematic ways to share information about our patients is essential. Building a framework for handoffs and sign outs can be the roadmap within an organization. Establish the outcome measures for a protocol, be consistent, and be patient centered. The process does not need to be elaborate, keep it simple and set the expectation that it is part of the culture of care in your organization.
Mr. Jones will be less anxious, which helps his clinical condition, when the clinicians go to his bedside, make eye contact, introduce themselves and, while making a transfer of his care, seek his input. Likely this man will only ask about his dog, which means more time from one of these clinicians. This is not easy when you’re tired and overextended, but this is topic for another post about interdisciplinary interdependence as our opportunity to push the industry toward clinical-patient partnership.