A wide range of health IT tools and systems are helping to improve patient care and efficiency but face-to-face communication still goes a long way. Transitions in patient care, added to The Joint Commission’s list of national patient safety concerns in 2006, require a good balance of high tech and high touch to avoid miscommunication.

Complexity & volume

Patient handoffs have become more challenging for several reasons. “The information that has to be handed off has gained in complexity and volume,” says William B. Munier, MD, MBA, director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality (AHRQ).

Another factor is that the limitations put on training physicians regarding duty hours means more frequent patient handoffs. “More people are taking care of patients in a 24-hour day.” While it’s good that exhausted residents aren’t treating patients, more handovers allow for more miscommunication.

Handoffs occur both when a patient is moving from one place to another and when shift changes result in a new care team.

Studies ranking the causes of adverse events and tracking the rates of the difference causes have found communication to be the primary cause, he says. Patient handoffs are a type of communication.

AHRQ is working on common reporting formats that allow for uniform reporting of adverse events. “We’re also working on a surveillance version that will be able to establish rates,” Munier says. “Over time, that will allow hospitals to classify events in a consistent way including whether there was a problem with handoffs.”

Communication bundle

Boston Children’s Hospital has piloted a standardized communication bundle to aid in patient handoffs and findings show a dramatic improvement. The system consisted of three key components: standardized communication and handoff training, a verbal mnemonic and a new team handoff structure.

The study followed 1,255 patient admissions to two separate inpatient units and found that after implementation of the three components, providers spent more time communicating face-to-face in quiet areas conducive to conversation. There were fewer omissions or miscommunications about patient data during handoffs and medical errors decreased by 45.8 percent. Most errors caused no harm or were later intercepted, but the most serious category—preventable adverse events—decreased from 3.3 to 1.5 per 100 admissions, a 54.5 percent drop.

“We believed these systems would lead to a reduction in medical errors, but didn’t expect to see a change of this magnitude,” says Amy Starmer, MD, MPH, lead author of the study.

Participating clinicians attended an interactive workshop where they practiced giving and receiving handoffs under different clinical and real-world scenarios. The workshop was based on best practices for handoffs using elements of the TeamSTEPPS communication program, which was developed by the military and AHRQ.
Participants also adopted a mnemonic to help them remember all the relevant information to verbally pass on during handoffs. Face-to-face handoffs were restructured to involve all team members and moved to quiet areas to minimize interruptions and distractions. 

The researchers worked with the hospital’s informatics teams to create a structured tool to document patient information in written form. The forms, integrated with EHRs, self-populate with standard patient information. Previously, those data had to be entered and re-entered manually in a word processing document. The new tool eliminates that task and also prompts users to make sure all important information has been entered, serving as an additional safety net.

After the success Boston Children’s experienced with the standardized communication across more than 1,200 admissions, the pilot was expanded to other facilities and is now known as the I-PASS Handoff Program. The program includes the following mnemonic designed to standardize the verbal and written handoff process:

I – Illness severity
P – Patient summary (standard clinical summary)
A – Action list for the next team
S – Situation awareness/contingency plans (ie, If the patient begins to X, the best course of action would be Y.)
S – Synthesis (An opportunity for the provider being briefed to read back the information to help ensure all parties are on the same page.)

“You have to come at this problem from multiple angles,” says Starmer. As a result of their efforts, the pilot is one of the first to offer “rigorous data showing that, by addressing the issue, there can be an associated reduction in error rates,” she adds. “It certainly makes sense to address this problem, not just in residency training but with other types of professions such as nurses and other care team members, as well as at different stages of training.”

‘Accurate, easy process’

Methodist Hospital in Houston has addressed the patient handoff problem as well. The facility had some unique handoff challenges to address, including numerous detailed reports to produce for every patient. Sometimes the reports were illegible. Plus, the PACU would call a nursing unit to begin a patient transfer but there wasn’t always a nurse available to take the call, explains Janet Gilmore, RN, nursing director. “We had phones all over the PACU on speaker waiting for someone to pick up.”

The nurses wanted an accurate, easy process, says Gilmore. They partnered with their colleagues to learn what information was most important for the receiving unit to know about a transferring patient.

The PACU worked with the IT department to develop an electronic solution. The new process extracts patient information from the PACU EHR using SBAR (Situation-Background-Assessment-Recommendation) methodology and sends that information directly to the receiving unit’s printer. After time to review the report and to close the loop, the nurse or unit clerk calls to verify receipt and ask whether there are any questions.

Now, the “receiving nurses get the information they need but still have an opportunity to ask questions.” Nurses often use the tool to hand off to the next shift because it tells the whole surgical story, explains Gilmore.

Despite the easier new process, some still resisted, she says. “We still had a lot of pushback from nurses because it was change. Change is hard.” But, after some time and realizing they could still physically talk to each other whenever they felt the need, the nurses all adapted.

Gilmore recommends working on the process together rather than trying to force a new process on employees. “We built something that filled their need.”

Improving care for complex patients

Another children’s hospital has been working hard to improve transitions of care—North Carolina Children’s Hospital’s pediatric congenital heart surgery patients have complex conditions, spend time in many different hospital units and interact with several multidisciplinary care teams.

To improve communication, along with patient safety and patient outcomes, the organization launched Project TICKER (Teamwork to Improve Cardiac Kids’ End Results) in 2010 to implement a safe practice infrastructure by breaking down operational silos to facilitate collaboration across disciplines.

Tina Schade Willis, MD, pediatrician and associate director of University of North Carolina Institute for Healthcare Quality Improvement, is the principal investigator of the project funded by the Agency for Healthcare Research and Quality. She and her team focused on two areas they knew needed improvement—operating room (OR) to intensive care (ICU) and neonatal ICU to pediatric ICU/cardiac ICU. The toolkit they developed, along with TeamSTEPPS coaching and communication initiatives, describes the communication and steps leading up to the receiving care team’s acceptance of responsibility and includes a handoff template outlining team roles and activities.

During a handoff, care of a patient and pertinent information about the patient’s state are transferred across the care continuum in a structured communication format. An effective handoff provides both parties with an opportunity to ask questions and clarify/confirm the transfer of responsibility and accountability, Willis says.

The patient handoff tools include a process flow diagram using a format known as SBARq (Situation, Background, Assessment, Recommendation, Questions), and a nurse handoff/communication form with a more detailed SBARq.

It’s too early for thorough findings based on the results of the intervention but median length of stay for some conditions have decreased and OR team members participating in the post-intervention AHRQ Hospital Survey on Patient Safety Culture reported a positive increase from baseline in perception of patient safety during handoffs and transitions.

Multipronged approach

Old-fashioned face-to-face communication combined with the electronic tools possible through health IT are helping providers improve care transitions. “We can’t expect an EHR to solve the problem,” says Munier, “but I think IT can certainly assist by standardizing the information that’s supposed to be handed over.”

Standardized electronic and verbal communications are “mutually reinforcing,” says Starmer. “You have to think about all the different pieces of information and how they are best transferred.” Having reports, EHRs and verbal communication processes are needed to catch everybody involved in patient care.

“It kind of makes me shudder to think of the additional problems we’ve introduced by the fact that doctors don’t necessarily ‘own’ the patients the way they used to,” says Munier. “On the other hand, we don’t have tired doctors. Medical care is complicated. Sometimes, we solve one problem and create another.”