Preparation, Exchange, and Utilization: A Three-Phase Approach Toward Improving Resident Physician Handoffs

In hospitals, failures in communication have been linked to medical errors, adverse events, and account for 60% of the root causes of unexpected occurrences involving death or serious physical or psychological injury reported to The Joint Commission. Beginning in 2003, the Accreditation Council for Graduate Medical Education (ACGME) released the first in a series of successive duty hour restrictions for resident physicians. Duty hour restrictions have necessitated more frequent shift changes for residents, an increase in the frequency of patient care handoffs and thus, more opportunities for miscommunication. Ideally, the handoff provides residents the opportunity to relay to incoming residents information which may not be accessible once members of the outgoing care team are gone, synthesize and organize patient information, develop and clarify care plans, ask questions and collaboratively solve problems, and in general, mitigate the chance of errors during patient care.

Handoff is conceptualized as a three phase process in this work beginning with the preparation for handoff both incoming and outgoing residents and followed by the communication and exchange of patient information between the two shifts of residents during the handoff. The third phase encompasses the majority of the shift and is seen as a utilization phase in which residents have an opportunity to employ the information communicated during handoff in patient care activities. This work seeks to understand the characteristics and role of patient information as it exists and flows across the three sequential phases of the handoff. Research to date has yet to provide an empirical basis for what information should be exchanged during handoff, measure the impact of the information exchanged on patient care activities after handoff, or assess the effect of training residents to discuss critical information during handoff on what information is ultimately discussed. This work addresses these gaps by examining the relationship between the information residents exchange during handoff and the information they utilize in responding to the information requests of other care providers and investigates the effect of training on the information residents communicate during handoff. As an ancillary objective, this work also discusses the benefits of user-centered design principles in the development of an information system to support the handoff process.

The results of this work suggest that discussing the plan of care for patients during the exchange phase is critical information that is frequently requested by nurses, interns, and other care providers who may not have been involved when the initial care plan was formulated. Furthermore, results suggest that residents’ ability to respond to information requests from other care providers may be heavily determined by the type of information which is requested and the depth of the discussion of that information during handoff. Results of a behavioral evaluation of the impact of training on the information residents discuss during handoff suggest that training is influential primarily in reducing redundancy and ensuring completeness of the information discussed for each patient. Training residents to discuss a core set of information components for each patient generally resulted in a significant increase in the proportion of patients for which residents discussed all critical information components for each patient. In general, simply training a minimum core set of information to discuss at handoff may be a successful strategy for mitigating errors and reducing the frequency of adverse events related to miscommunicated or incompletely communicated patient information during handoff.

Clearly understanding the phases of a process and developing requirements that support each phase of that process are critical when designing a computerized process support tool. With respect to handoff, involving resident physicians early in the design process helped to gain their interest. Collaboration throughout the development stage resulted in feedback from residents that increased the flexibility of the system to support processes other than handoff as well. While hand-off information systems are not necessarily meant to completely scaffold decision making or devalue verbal communication, there is certainly an opportunity for these systems to reduce and filter information in order to direct physicians toward a discussion of a particular set of unusual or hard to find data. In particular, verbal exchange of abstract information during handoffs such as a patient’s plan of care appear to influence residents’ ability to inform other care providers as well as to accomplish their own responsibilities related to patient care.