- Vineet Arora, MD, MAPP
Vineet Arora, MD, MAPP
- Associate Professor
- University of Chicago
- Jeanne Farnan, MD, MHPE
Jeanne Farnan, MD, MHPE
- Associate Professor, University of Chicago
The increasing fragmentation of health care has the unintended consequence of more care transitions. Transitions of patient care between providers occur frequently and require providers to transmit critical clinical information. If information is omitted or misunderstood, there may be serious clinical consequences [1,2]. Several studies have shown that handoffs are often variable and represent a major gap in safe patient care [3-5].
In addition to care transitions into and out of the hospital (extra-hospital handoffs), hospital care itself has become increasingly fragmented due to the increase in number of resident handoffs secondary to duty hour regulations  and the adoption of the shift-work type systems utilized by hospitalists. In-hospital handoffs are common in hospitals and represent a vulnerable time during patient care. For example, hospitalized patients are often passed between doctors an average of 15 times during a single five-day hospitalization . Poor handoffs lead to uncertainty during clinical decision-making, which then leads to potential harm (near misses) and inefficient work in both resident and hospitalist service changes .
This topic will discuss patient handoffs that occur in the hospital. Transitions of care focused on hospital discharge are discussed elsewhere. (See "Hospital discharge and readmission".)
The sender provides the information for the handoff and the receiver receives the information and then assumes care of the patient. Other terminology used to describe patient handoff include:
●Shift change – This is the transfer of responsibility that occurs when one clinician ends and another one begins their shift.
- Jagsi R, Kitch BT, Weinstein DF, et al. Residents report on adverse events and their causes. Arch Intern Med 2005; 165:2607.
- Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med 2004; 79:186.
- Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med 2006; 166:1173.
- Arora V, Johnson J, Lovinger D, et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 2005; 14:401.
- Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern Med 2008; 168:1755.
- Nasca TJ, Day SH, Amis ES Jr, ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med 2010; 363:e3.
- Vidyarthi AR, Arora V, Schnipper JL, et al. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med 2006; 1:257.
- Hinami K, Farnan JM, Meltzer DO, Arora VM. Understanding communication during hospitalist service changes: a mixed methods study. J Hosp Med 2009; 4:535.
- Lyons PG, Arora VM, Farnan JM. Adverse Events and Near-Misses Relating to Intensive Care Unit-Ward Transfer: A Qualitative Analysis of Resident Perceptions. Ann Am Thorac Soc 2016; 13:570.
- Ong MS, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf 2011; 37:274.
- Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ 2000; 320:791.
- Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf 2006; 32:646.
- Gibson SC, Ham JJ, Apker J, et al. Communication, communication, communication: the art of the handoff. Ann Emerg Med 2010; 55:181.
- Cohen MD, Hilligoss B, Kajdacsy-Balla Amaral AC. A handoff is not a telegram: an understanding of the patient is co-constructed. Crit Care 2012; 16:303.
- Sharma N. Sensemaking handoff: When and how? Proceedings of the American Society for Information Science and Technology 2008; 45:1.
- Arora VM, Johnson JK, Meltzer DO, Humphrey HJ. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care 2008; 17:11.
- Mardis M, Davis J, Benningfield B, et al. Shift-to-Shift Handoff Effects on Patient Safety and Outcomes. Am J Med Qual 2017; 32:34.
- Davis J, Riesenberg LA, Mardis M, et al. Evaluating Outcomes of Electronic Tools Supporting Physician Shift-to-Shift Handoffs: A Systematic Review. J Grad Med Educ 2015; 7:174.
- Foster S, Manser T. The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research. Acad Med 2012; 87:1105.
- Starmer AJ, Spector ND, Srivastava R, et al. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics 2012; 129:201.
- Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014; 371:1803.
- Van Eaton EG, Horvath KD, Lober WB, Pellegrini CA. Organizing the transfer of patient care information: the development of a computerized resident sign-out system. Surgery 2004; 136:5.
- Van Eaton EG, Horvath KD, Lober WB, et al. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg 2005; 200:538.
- Payne CE, Stein JM, Leong T, Dressler DD. Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. BMJ Qual Saf 2012; 21:925.
- Arora VM, Manjarrez E, Dressler DD, et al. Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med 2009; 4:433.
- Chang VY, Arora VM, Lev-Ari S, et al. Interns overestimate the effectiveness of their hand-off communication. Pediatrics 2010; 125:491.
- Philibert I. Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. Qual Saf Health Care 2009; 18:261.
- Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004; 13 Suppl 1:i85.
- Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff mnemonics literature. Am J Med Qual 2009; 24:196.
- Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007; 297:831.
- Pucher PH, Johnston MJ, Aggarwal R, et al. Effectiveness of interventions to improve patient handover in surgery: A systematic review. Surgery 2015; 158:85.
- Bhabra G, Mackeith S, Monteiro P, Pothier DD. An experimental comparison of handover methods. Ann R Coll Surg Engl 2007; 89:298.
- Rosenbluth G, Bale JF, Starmer AJ, et al. Variation in printed handoff documents: Results and recommendations from a multicenter needs assessment. J Hosp Med 2015; 10:517.
- Arora VM, Reed DA, Fletcher KE. Building continuity in handovers with shorter residency duty hours. BMC Med Educ 2014; 14 Suppl 1:S16.
- Martin K, Frank M, Fletcher KE. Intrateam coverage is common, intrateam handoffs are not. J Hosp Med 2014; 9:734.
- Phillips AW, Yuen TC, Retzer E, et al. Supplementing cross-cover communication with the patient acuity rating. J Gen Intern Med 2013; 28:406.
- Gregory S, Tan D, Tilrico M, et al. Bedside shift reports: what does the evidence say? J Nurs Adm 2014; 44:541.
- University HealthSystem Consortium (UHC). UHC Best Practice Recommendation: Patient Hand Off Communication White Paper, May 2006. Oak Brook, IL: University HealthSystem Consortium; Healthcare Communications Toolkit to Improve Transitions in Care.
- Apker J, Mallak LA, Gibson SC. Communicating in the "gray zone": perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med 2007; 14:884.
- Barenfanger J, Sautter RL, Lang DL, et al. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol 2004; 121:801.
- Greenstein EA, Arora VM, Staisiunas PG, et al. Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist. BMJ Qual Saf 2013; 22:203.
- Pothier D, Monteiro P, Mooktiar M, Shaw A. Pilot study to show the loss of important data in nursing handover. Br J Nurs 2005; 14:1090.
- Englander R, Flynn T, Call S, et al. Toward Defining the Foundation of the MD Degree: Core Entrustable Professional Activities for Entering Residency. Acad Med 2016; 91:1352.
- Weiss KB, Bagian JP, Wagner R, Nasca TJ. Introducing the CLER Pathways to Excellence: A New Way of Viewing Clinical Learning Environments. J Grad Med Educ 2014; 6:608.
- The core competencies in hospital medicine: a framework for curriculum development by the society of hospital medicine. J Hosp Med 2006; 1 Suppl 1:2.
- Wohlauer MV, Arora VM, Horwitz LI, et al. The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med 2012; 87:411.
- Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf 2010; 36:52.
- Horwitz LI, Dombroski J, Murphy TE, et al. Validation of a handoff assessment tool: the Handoff CEX. J Clin Nurs 2013; 22:1477.
- Arora VM, Berhie S, Horwitz LI, et al. Using standardized videos to validate a measure of handoff quality: the handoff mini-clinical examination exercise. J Hosp Med 2014; 9:441.
- Bates KE, Bird GL, Shea JA, et al. A tool to measure shared clinical understanding following handoffs to help evaluate handoff quality. J Hosp Med 2014; 9:142.
- Nagpal K, Abboudi M, Fischler L, et al. Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Ann Surg 2011; 253:831.
- Feraco AM, Starmer AJ, Sectish TC, et al. Reliability of Verbal Handoff Assessment and Handoff Quality Before and After Implementation of a Resident Handoff Bundle. Acad Pediatr 2016; 16:524.
- Martin SK, Farnan JM, McConville JF, Arora VM. Piloting a Structured Practice Audit to Assess ACGME Milestones in Written Handoff Communication in Internal Medicine. J Grad Med Educ 2015; 7:238.
- Doers ME, Beniwal-Patel P, Kuester J, Fletcher KE. Feedback to achieve improved sign-out technique. Am J Med Qual 2015; 30:353.
- Bump GM, Jacob J, Abisse SS, et al. Implementing faculty evaluation of written sign-out. Teach Learn Med 2012; 24:231.