Article review: Handoffs in the Emergency Department

One shared experience amongst all emergency physicians is the “handoff” or “signout” of patients at the end of your shift to the oncoming physician. A recent article in Annals of Emergency Medicine explores and explains how this process can often lead to delays and errors in patient management. Just envision ED handoffs as a high-stakes game of Telephone, which you played as a child.

Sentinel events involving medical errors often can be traced back to errors in communication. A particular high-risk window is during patient handoff. Interestingly, poor handoffs were at the root cause of 24% of malpractice claims in the ED. In 2006, the Joint Commission actually published a National Patient Safety Goal paper recommending a standardized approach to handoffs for this very reason.

There are 4 phases in handoff practices:

1. Pre-turnover time – Physician A getting ready to go off-shift
2. Arrival – Physician B arrives for shift
3. Meeting – Exchange of info between physicians
4. Post-turnover time – Physician B assumes care of patients

The ED especially is a hotbed for handoff errors. Examples provided include:

• Signal-to-noise ratio: In a chaotic environment, it is often to discern the important information from the less important during signout rounds.
• No standard approach: Everyone has a different way of signing out. Lack of standardization may make it more difficult for one physician to communication with the other effectively.
• Cognitive bias: The oncoming physician may misinterpret or disproportionately rely too heavily on one piece of information during the handoff process. This “anchoring” bias can sometimes lead to patient management delays and errors.

Standardizing handoffs, however, is easier said than done. No single template fits the spectrum of patient presentations. There are important concepts behind handoffs, which are good to know about to optimize your handoff practices:

• Reduce the number of unnecessary handoffs
• Limit distractions during signout rounds: Find a quieter central place to round
• Provide a succinct overview: Don’t make the critical points hard to discern. It’s not meant to be a needle in a haystack.
• Communicate outstanding tasks, anticipated changes, and clear plan
• Make info readily available for direct review
• Encourage questioning and discussion
• Account for all patients: Don’t forget to sign out the patient who is temporarily in dialysis or ophthalmology clinic.
• Signal a clear moment in transition of care

Because there is little evidence in the area of handoffs, this topic is a rich area for new research. Researchers should not only include emergency physicians but also communications experts, pyschologists, and behavioral scientists.

My 2 cents

I have been the giver and receiver of sub-optimal handoffs for a variety of reasons outlined above. Distractions, anchoring biases, and missing data elements have all been contributors (sometimes all concurrently). Here are my thoughts about handoffs:

• I keep handoffs extremely short where I have signed the bottom line of the chart – those whom I have discharged or admitted to the hospital. A simple diagnosis, plan, and potential questions that might come up from the patient.
• I provide a much more detailed presentation for undifferentiated patients. I spend extra time on higher-risk patients so that the oncoming physician has no questions. I consider higher-risk undifferentiated patients as: chest pain, febrile, or age older than 65.
• I present as much of a concise and algorithmic plan at the end. Specifically, I include some version of “if all the tests are negative, I would… “. However, if I am still unsure, I would state that instead. It’s far worse to provide premature closure to the patient’s workup for the sake of handoff.
• When receiving a patient handoff, I very, very, very rarely change the workup plan. For instance, I recently had a student who asked about canceling an abdominopelvic CT scan for a patient with RLQ abdominal pain because she was feeling much better. It was true – she only had minimal tenderness on exam. However, because the prior physician was impressed enough by the initial tenderness to order imaging, we continued the plan. The CT scan showed perforated appendicitis.

What are your handoff pearls?

Reference
Cheung DS, Kelly JJ, Beach C, et al; American College of Emergency Physicians Section of Quality Improvement and Patient Safety. Improving Handoffs in the Emergency Department. Ann Emerg Med. 2009 Oct 1. [Epub ahead of print]

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